UC SOUTHERN REGIONAL LIBRARY FACILITY 
 
 G 000 005 785 1
 
 THE LIBRARY 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 THE NEW SYDENHAM SOCIETY. 
 
 Instituted MDCCCLVIII. 
 
 VOLUME CIX.
 
 CLINICAL LECTUEES .i • 
 
 PRACTICE OF MEDICINE. 
 
 BY THE LATE 
 
 ROBERT J. GRAVES, M.D., F.R.S., 
 
 PROFESSOR OF THE INSTITUTBS OF MEUICINE IN THE SCHOOL OF PHYSIC IN lEELAND. 
 
 TO ■W^ICH IS PREFIXED A CRITICISM BY 
 
 PROFESSOR TROUSSEAU. 
 
 Jn Ctoo Volumes. 
 VOL. I. 
 
 Reprinted from the Second Edition, 
 [EDITED BY THE LATE DR. NELIGAN. ] 
 
 THE NEW SYDENHAM SOCIETY. 
 
 MDCCCLXXXIV.
 
 538
 
 Ubrat/ 
 
 joo 
 
 RIGHT HONORABLE WILLIAM, EARL OF ROSSE, K.P.,. 
 
 13rf6ilrcnt of t^c Kogal SorietB, 
 THIS, THE SECOND EDITION OE A TREATISE 
 
 ON 
 
 CLINICAL MEDICINE, 
 
 IS RESPECTFULLY DEDICATED BY HIS FRIEND, 
 
 THE AUTHOR. 
 
 9S18i
 
 ADVERTISEMEl^T. 
 
 41, Grafton Street, 
 
 Dublin, January, 1864. 
 
 The Clinical Lectures of the late Dr. Graves have been for some 
 time out of print ; and the constant demand for them has been 
 such as to induce the publishers to issue this reprint of the 
 second edition, edited, in Dr. Graves' lifetime, by the late 
 Dr. Neligan. 
 
 They have much pleasure in annexing, from the Medical 
 Times and Gazette, the following translation of the Introduction 
 to the French edition of this work, from the pen of Professor 
 Trousseau, of Paris : — 
 
 "to the translator. 
 
 " Sir and honored Confrere, 
 
 " For many years I have spoken of Graves in my 
 clinical lectures ; I recommend the perusal of his work ; I 
 entreat those of my pupils who understand English to consider 
 it as their breviary ; I say and repeat that, of all the practical 
 works published in our time, I am acquainted with none more 
 useful, more intellectual ; and I have always regretted that the 
 Clinical Lectures of the great Dublin practitioner had not been 
 translated into our language. 
 
 " As Clinical Professor in the Faculty of Medicine of Paris, 
 I have constantly read and re-read the work of Graves ; I have 
 become inspired with it in my teaching ; I have endeavoured to 
 Imitate it in the book I have myself published on the Clinique of 
 the Hotel Dieu ; and even now, although I know almost by heart
 
 Vm PROFESSOR TROUSSEAU S CRITICISM. 
 
 all that the Dublin professor has written, I cannot refrain from 
 perusing a book which never leaves my study. 
 
 " Graves is an erudite physician ; while so rich in himself, 
 he borrows perpetually from the works of his contemporaries, 
 and at every page brings under tribute the labours of German 
 and French physicians. Although a clinical observer, he love& 
 the accessory sciences ; we see him frequently have recourse 
 to physiology, in the domain of which he loves to wander ; to 
 chemistry, with which he is acquainted, which he estimates 
 at its true value, and to which he accords a legitimate place. 
 He often reminds me of the greatest clinical teacher of our 
 day, Pierre Bretonneau, an able physiologist, a distinguished 
 chemist, a learned botanist, an eminent naturalist, who inces- 
 santly in his lectures and conversation at the Hospital of Tours, 
 found in all those accessory sciences, with which he was so 
 conversant, those useful ideas and ingenious views which he 
 subsequently applied with unusual felicity to the study of our 
 art. 
 
 " Shall I now say what are, in Graves' work, the most 
 remarkable and important lectures ? To be just, I ought to 
 indicate all in succession : there is not one of them, in fact, 
 which does not abound in practical deductions ; there is not one 
 which does not bear the impress of the admirable and powerful 
 faculty of observation which distinguishes the physician of the 
 Meath Hospital. The lectures on scarlatina, paralysis, pulmonary 
 affections, cough, headache, have acquired an European reputa- 
 tion, and the interest with which they inspire every attentive 
 reader is assuredly their best panegyric. 
 
 " There are, however, two points to which it is important 
 to call particular attention. Graves has devoted a great many- 
 lectures to typhus fever, which so cruelly decimates Ireland. It 
 might be supposed, at first sight, that the study of this portion 
 of his work is not of so much importance to us, French 
 physicians, who, fortunately, have not to contend with the 
 formidable malady in question. This is a mistake. All the
 
 PROFESSOR TROUSSEAU S CRITICISM. IX 
 
 precepts of the author upon the treatment of tins pyrexia are 
 so applicable to the severe forms of our typhoid fever, that ^^e 
 shall with the greatest advantage consult this remarkable work. 
 Moreover, the maxims relating to regimen have become the 
 guide of the practitioners of all countries : it is they which now 
 direct us in the treatment of putrid fever. And, nevertheless, 
 when he inculcated the necessity of giving nourishment in long- 
 continued pyrexias, the Dublin physician, single-handed, assailed 
 an opinion which appeared to be justified by the practice of all 
 ages ; for low diet was then regarded as an indispensable 
 condition in the treatment of fevers. Had he rendered no other 
 service than that of completely reversing medical practice upon 
 this point, Graves would by that act alone have acquired an 
 indefeasible claim to our gratitude. 
 
 " On the other hand, I cannot sufficiently recommend the 
 perusal of the lectures which treat of paralysis ; they contain a 
 complete doctrine, and this doctrine has decisively triumphed. 
 The sympathetic paralyses of Whytt and Prochaska have now 
 their place assigned in science, under the much more physiological 
 name of reflex paralyses, and the Dublin professor is the first 
 who has studied with exactness their etiological conditions, as he 
 is the first who has made known their pathogenic process. 
 Anticipating by many years the admirable works of Marshall 
 Hall, he has comprehended, he has seen that anomalous 
 peripheric impressions may react upon any section of the 
 medulla, and determine at a distance disturbance of movement 
 or of sensibility ; he has, in a word, created the class of 
 peripheric or reflex paralyses, and he has clearly established the 
 relations existing between these paralyses and acute diseases. 
 
 " Unhappily, these remarkable lectures have remained a 
 sealed letter for the majority of French practitioners ; but it 
 is time to render to the physician of the Meath Hospital tbe 
 justice which is due to him ; it ought to be known that Graves 
 is the creator of this new doctrine, which has profoundly moditied 
 within a few years the pathology of the nervous system ; it is
 
 X PROFESSOR TROUSSEAU S CRITICISM. 
 
 right, in fine, to refer to its true author the suggestive theory of 
 the paralj'ses and the convulsions of peripheric origin. 
 
 " You have then, sir, done a very useful work in puhlishing 
 Graves' Lectures. You have rendered a great service, if not to 
 beginners — who will perhaps not find in them the elementary 
 ideas which are necessary to them — at least to physicians, who 
 must understand the reasons of instinct and intelligence by 
 which they ought to allow themselves to be guided in the 
 difficult paths of practice ; who are called upon to assist in the 
 doubts, embarrassments, and ^perplexities which trouble the 
 conscientious man when he is engaged in those obscure cases 
 which so frequently present themselves in the wards of an 
 hospital. 
 
 " Graves is often empirical. What true clinical observer can 
 avoid being so ? But he is so only in spite of himself. He 
 seeks, he points out the reasons which determine him ; he 
 discusses them, and he conducts his pupil, step by step, from 
 the theory, occasionally too ingenious, to the application, which 
 is always useful though often unexplained. 
 
 " Graves is a therapeutist full of resources. For the majority 
 of French physicians his medications present something unusual, 
 because the agents he employs are rather less used in France ; 
 but we learn in his lectures the medicine of our neighbours at 
 the other side of the Channel — a medicine strange to us, as ours 
 is to them. We learn in them the methods most relied upon 
 in the United Kingdom, and the remedies to which our English 
 colleagues give the preference. I freely confess that I had some 
 difficulty in accepting, notwithstanding the imposhig authority 
 of Graves, what he states of the influence of certain remedies, 
 such as mercurials, essence of turpentine, spirituous preparations, 
 nitrate of silver, Sec. ; but the Dublin professor speaks with so 
 much conviction that I ventured to follow his precepts, and I 
 must say that my early trials very soon encouraged me to adopt 
 unreservedly what at first I accepted only with misgiving. There 
 is not a day that I do not in my practice employ some of the
 
 PROFESSOR TROUSSEAU S CRITICISM. XI 
 
 modes of treatment wbicli Graves excels in describing with the 
 minuteness of the true practitioner, and not a day that I do not, 
 from the boLtom of my heart, thank the Dublin physician for the 
 information he has given me. 
 
 " Graves is, in my acceptation of the term, a perfect clinical 
 teacher. An attentive observer, a profound philosopher, an 
 ingenious artist, an able therapeutist ; he commends to our 
 admiration the art whose domain he enlarges, and the practice 
 of which he renders more useful and more fertile. We shall, 
 therefore, all be much indebted to you, my dear confrere, for 
 having rendered familiar to us an author unfortunately too little 
 known among us. 
 
 "A. TROUSSEAU."
 
 THE EDITOE'S PEEFACE. 
 
 Having, at the request of Dr. Graves, undertaken to edit the 
 present edition of his work on Clinical Medicine, my chief aim 
 has been to improve its truly practical character, and thus render 
 it if possible more useful to the profession. With this view I 
 have altered and re-arranged the Contents, classifying the various 
 diseases and subjects treated of, and throwing the entire into the 
 more suitable form of lectures. This, so far as related to the 
 Second Part — which in the first edition consisted of miscellaneous 
 essays — I found but little difficulty in doing ; for the author 
 having been always in the habit of dictating to a shorthand 
 writer, his style naturally assumed a colloquial character, and 
 therefore required but very little alteration to reduce it to that of 
 a Lecture. 
 
 With this same object in view, whatever alterations or additions 
 I have myself made, I have incorporated with the text ; know- 
 ing practically the great inconvenience and distraction of mind 
 to the reader, which editorial notes or matter inserted between 
 brackets produce. Moreover, I have been differently circum- 
 stanced from most other editors, having had all through the 
 zealous co-operation of the author and his approval of the 
 alterations and additions made. 
 
 The reader will perceive that I have introduced into this 
 Edition several of the author's essays which were omitted from 
 the first : of these I wish to call especial attention to his 
 observations on two subjects — the Pulse and Cholera. The 
 greater part of the former, which now constitutes the fourth 
 lecture, was originally published in the Dublin Hospital Keports
 
 THE EDITOR S TREFACE. XIU 
 
 nearly five and twenty years since, and contains an account of 
 the first accurate experiments which were made as to the efllects 
 of posture on the frequency of the pulse ; — an inquiry which has 
 been since then carefully investigated by Knox, Guy, and others, 
 with the effect of stamping with correctness the original 
 observations of Dr. Graves, and proving their practical value. 
 
 The subject of the Cholera is just at present an all-important 
 one, when this pestilence is ravaging a great portion of the 
 globe, and those countries which have been once and but once 
 before afflicted with it are again threatened with a visitation. 
 Shortly after the cessation of the previous epidemic, Dr. Graves 
 read an essay before the College of Physicians on its origin and 
 progress, chiefly with the view of proving its contagious character ; 
 this essay, which was published at the time in the DiihUii 
 Journal of Medical Science, is now remodelled, and a short 
 history of the present epidemic, as far as it had advanced at the 
 time those lectures were going through the press added. 
 
 The lectures on Fever, which constitute so large and so 
 valuable a portion of the first volume,* will be found to be much 
 altered as regards arrangement ; and the causes and mode of 
 diffusion of the late epidemic Avith which this country was visited 
 have been noticed. 
 
 Although many years have elapsed since several of the author's 
 views on the physiology, pathology, and treatment of diseases 
 were first published, and the science of medicine has been since 
 extraordinarily advanced by the aid of the chemist and the 
 histologist, but few alterations or omissions have been required 
 to adapt them to the present state of knowledge. Indeed, it 
 is singular how many of his observations, which, when first 
 promulgated, were from their novelty either doubtingly received 
 or altogether rejected, have been corroborated by the investiga- 
 tions of more recent inquirers. Of these I would particularly 
 notice his views " on the Capillary Circulation, and on the 
 
 * In perusing this and the Author's Preface, the reader is re juested to observe tha" 
 the second edition was in two volume!".— [fui. of Reprint. 1
 
 xiv THE EDITOE S PREFACE. 
 
 Doctrines of Inflammation," confirmed by the most recent 
 microscopical investigations; "on the Circulation of the Blood 
 within the Cranium," confirmed by Dr. Burro wes' experiments ; 
 "on the Pathology of Paralysis," so remarkably in accordance 
 with the Cerebro-spinal Pieflex Theory ; " on the Pathology of 
 Tubercle;" and "on the Nature of the Acid in the Human 
 Stomach." 
 
 In conclusion, I have only to add that these volumes, as now 
 presented to the reader, contain the results of Dr. Graves' 
 additional experience during the five years which have elapsed 
 since the first edition was published. 
 
 J. MOORE NELIGAN.
 
 THE AUTHOll'S PliEPACE. 
 
 This Work first appeared in 18 i3, and its publisher informed me 
 last year, the sale had been so rapid that he expected the whole 
 edition would be soon disposed of. The event more than 
 justitied his anticipations, and consequently he requested me to 
 prepare a second edition for the press, a request I felt bound to 
 comply with, particularly as I was conscious that much might be 
 done to render the work more deserving of the approbation which 
 my brethren and colleagues in all parts of the world had so kindly, 
 and to me so unexpectedly, bestowed on it. 
 
 On revising the volume as before printed, I detected so many 
 faults and errors, that I at once resolved to remodel the whole, 
 and accordingly I applied myself to the accomplishment of this 
 object, with a sincere desire to render my Clinical Medicine still 
 more useful to the profession. I soon found, however, that my 
 task was a very difficult one. The original work contained so 
 much which a maturer reflection and experience disapproved of, 
 that the sections to be omitted soon swelled to a formidable 
 bulk ; while, on the other hand, a closer review of the matters 
 discussed suggested the necessity of inserting many lectures that 
 had been formerly left out. 
 
 The occupations of a laborious profession so encroached on 
 my time, that I found my plans could not be executed, without 
 associating myself with some other physician, in whose industry, 
 learning, and ability I reposed confidence. Having been fortu- 
 nate enough to secure the co-operation of Dr. Neligan, I felt 
 certain that the result would be satisfactory, and I placed in 
 his Lands the numerous cases I had collected from my own
 
 xvi THE author's PREFACE. 
 
 practice, and the various extracts I had made from hooks since 
 the puhlication of the first edition. To these materials Dr. 
 Neligan made many and important additions, and he has bestowed 
 so much labour on the two volumes now submitted to the 
 profession and public, that I feel confident this edition will be 
 found a great improvement on the former. 
 
 EGBERT J. GRAVES. 
 
 Merrion Square, 
 
 September, 1848.
 
 COIN TENTS OF VOL. I. 
 
 LECTURE I. PAGE 
 CumcAr. Instruction. — Objects of Hospital Attendance. — Importance of study- 
 ing Chronic Diseases. — Edinburgh Clinic— French Clinic— German method 
 of giving Clinical Instruction. — Its superiority. — Plan adopted by the Author. 
 — Defective system of instruction required by the London University 1 
 
 LECTURE II. 
 Utility of German method of Clinical Instruction. — Requisites from the Stu- 
 dents. — Preliminary Education. — Age for commencing the study of ^Medicine. 
 —The study of Botany.— Botanical Nomenclature.— The study of Chemistry.— 
 Inconvenience arising from changing the names of Medicines. — The progress 
 of Physiology and Pathology in some instances retarded by the researches 
 of Chemists. — Liebig's theories of Poisoning and Contagion refuted. — Liebig's 
 theories of Heat disproved. — Facts wholly inconsistent with his views. — Great 
 responsibility of a teacher of Clinical Medicine in Great Britain and Ire- 
 land. — The profession of Medicine ^^ 
 
 LECTURE III. 
 The proper Mode of studying Physiology and Morbid Anatomy.— The study of 
 Physiology. — The connexion of Morbid Anatomy with Practical Medicine. — 
 Errors of Nosologists.— The utility of Morbid Anatomy.— The difficulties 
 attending its study.— How to be avoided. — The Dublin Pathological Society. 
 — Irish Medical Literature 40 
 
 LECTURE IV. 
 The Pulse,- Effects of Posture on the frequency of the Pulse.— Difference in 
 diiEerent positions of the body in healthy persons. — The Cerebral Circulation. 
 -Effect of the inverted posture on the Pulse. — Effects of change of posture 
 on the Pulse in disease. — In Hypertrophy of the Heart with dilatation. — 
 Results of numerous observations. — Relation which the Pulse and Respiration 
 bear to each other. — A Dicrotus Pulse in Fever. — In Hemorrhages. — Effects of 
 Digitalis on the Pulse. — The position of the Egg during Incubation 53 
 
 LECTURE V. 
 Inflammation. — The general laws of Inflammation. — Opinions of various 
 Physiologists : of Dr. Marshall Hall. — Refutation of his views,— The circula- 
 tion of the Blood. — Minute Blood Vessels. — Capillary Circulation. — Forces by 
 means of which the Circulation of the Blood is accomplished. — The Vascular 
 System in the Foetus. — The Circulation in the Impregnated Womb. — Dr. 
 Houston's case of an Acardiac Foetus. — A proof of the independence of the 
 Capillary Circulation. — Dilatation of Arteries and Veins in inflamed parts not 
 passive. — Dr. Williams' views refuted. — Dr. Weatherhead's conclusions. — 
 Miiller's hypothesis on the motion of the Blood in the Capillaries un- 
 tenable. — Increase of size in the Arteries. — Proofs of the power which the 
 
 Capillaries possess of drawing Blood to themselves 61 
 
 VOL. I. h
 
 XVili CONTENTS. 
 
 LECTURE VI. PAGE 
 Inflammation continued.— Proofs of the capillary jjower drawn from the Vegetable 
 Kingdom.— Hales and Dutrochet's experiment. — The Circnlation of some of 
 the lower tribes of Animals.— Dr. Hastings' and Dr. Philip's views as to the 
 state of the Capillaries in Inflammation.— Case of deficient circulation in the 
 legs. — Dr. Carpenter's opinions, — Dr. Holland's views, — Extract from Adelon's 
 Physiology on the Capillary Circulation.— Concluding remarks on In- 
 flammation 83 
 
 LECTUEE VII. 
 Fever. — Typhus Fever endemic in Ireland. — Dependent on some general At- 
 mospheric Change. — Not of Malarious origin. — Effects of Cultivation and 
 Drainage on Health. — Mr. Chadwick's investigations. — No notable diminution 
 of Fever in Ireland to be expected from Drainage, improved habits of Clean- 
 liness, or increased Comforts. — Effects of the Weather on the Public Health. 
 — Fatality of Fever in Ireland. — Dr. Cowan on the frequency of Fever in 
 Britain. — On Epidemics among Cattle simultaneous with Human Epidemics. 
 — Epidemic of 1847. — Its causes. — Connexion between Famine and Fever.— 
 Dr. Lalor's observations. — Overcrowding as a cause of Fever. — The Work- 
 houses. — Dr. Dillon's letter. — Fever in Cork. — Effects of sudden change in 
 Diet. —Proofs of the Contagiousness of Typhus Fever. — Fever of the Ameri- 
 can Emigrants in 1817. — Outbreak of Fever in Galway Gaol 96 
 
 LECTURE VIII. 
 General Observations on Fever. — How the contagion of Fever influences the 
 System. — Different Theories of Fever. — Cheyne and Barker on the Epidemic 
 of 1817-18. — The Author's Theory of Fever. — Dr. Chi-istison's views of 
 Fever. — Pathology of Typhus Fever. — Classification of Irish Fever. — Contagion 
 of Fever. — Dr. Perry's observations on. — Petechial Fever not epidemic in 
 Ireland 117 
 
 LECTURE IX. 
 General Treatment of Fever. — Epidemics of 1836 — 37. — Interest and importance 
 of Fever as a disease. — The Treatment of Fever not a matter of indifference. 
 — Points to be chiefly attended to. — Necessity for a Nurse. — Fever Patients 
 should be frequently visited. — General observations. — Diet. — Patients not to 
 be allowed to die of Starvation. — Directions for the administration of Food. 
 — Drinks. — Green Tea as an expergefacient. — Flagellation. — Injurious effects 
 of the ad libitum use of Soda or Seltzer Water and effervescing draughts in 
 Fever 129 
 
 LECTURE X. 
 General Treatment of Fever continued. — Importance of a proper Regimen. — 
 Injurious effects of drastic Purgatives in the early and middle stages of 
 Typhus Fever. — Tympanitis. — Uses of Air in the Intestines. — Treatment of 
 Tympanitis by Oil of Turpentine and by Acetate of Lead. — Beneficial effects 
 of Oil of Turpentine in Intestinal Hemorrhages.— Hiccup. — Hemorrhage from 
 the Bowels in Fever 147 
 
 LECTURE XL 
 General Treatment of Fever continued. — Emetics may cut short the disease at its 
 commencement. — Directions for their administration. — The use and abuse 
 of Purgatives. — Absurdity of the idea of curing Fever by active purging. — 
 Symptoms which indicate their employment. — Their mode of administration. 
 — Bleeding. — The influence of, in checking Fever. — Circumstances which in- 
 dicate its employment. — Never to be used when Maculae are present. — Leeches 
 and Cupping in Local Inflammations 158
 
 CONTENTS. XIX 
 
 LECTURE XII. TAGE 
 General Treatment of Fever continued. — Blisters. — Answer a twofold purpose, 
 stimulants or derivatives. — Mode of application where stimulant effect is 
 required. — Cerebral symptoms in Fever should be always .■mticipated. — Two 
 classes of sj'mptoms which indicate the approach of engagement of the Heatl. 
 — Use of Blisters in both. — The state of the Respiratory Function in con- 
 nexion with Cerebral Kxcitcment. — State of the Pupils during Sleep. — 
 Application of flying Blisters as energetic stimulants. — Illustration. — Blisters 
 and Tartar Emetic Ointment to the shaven Scalp. — BUsters in the Pulmonary 
 Affections of Fever. — Mode of dressing Blisters. — Peculiar Habits and 
 Idiosyncrasies of Families 172 
 
 LECTURE XIII. 
 General Treatment of Fever continued. — The application of Cold to the Head. — 
 Cold Affusion as practised at the Charite Kraokenhaus at Berlin. — Imperfect 
 mode in which Cold Lotions are ordinarily applied to the Head in Fever. 
 — Advantages of Warm Fomentations. — Use of Mercury in Fever. — Mer- 
 curialization, not a preventive of the contiigion of Typhus.— Illustration of 
 the treatment of Delirium in Fever. — Mode of administering Tartar Emetic. 
 — State of the cerebro-spinal system in Maculated Typhus. — Subsultus ten- 
 dinum. — Vomiting and Diarrhoea in the beginning of Fever. — Scrofulous 
 Secondary Fever 187 
 
 LECTURE XIV. 
 Head Symptoms in Fever. — Dependent on opposite conditions of the Cerebral 
 Circulation. — Cerebral Symptoms must be always closely watched. — Treat- 
 ment of. — Majority of fatal cases in this country rendered so by the superven- 
 tion of Cerebral Symptoms. — They are therefore to be checked as early as 
 possible, — Illustrations. — Analogous symptoms occur under opposite conditions 
 of the Brain. — Dr. Wilson on the nature of Coup de Soleil. — Case illustrating 
 the necessity of repeatedly visiting a Fever Patient. — Use of Turpentine where 
 symptoms of Nervous Irritation exist. — Combination of Tartar Emetic, Opium, 
 Musk, and Camphor in Eruptive Typhus with alarming symptoms 199 
 
 LECTURE XV. 
 Fever continued. — Bed-sores, their prevention and treatment. — Use of a second 
 bed in the patient's apartment. — Contagion of the Epidemic of 1831. — Mercury 
 not a piophylactic of Fever. — Illustration, — Symptoms of Inflammation or 
 Congestion of the Brain in the course of Fever. — Rigors, Earache, »fec. — 
 Treatment of. — Irritability of the Stomach without Epigastric Tenderness is 
 in aU febrile complaints symptomatic of Congestion of the Brain. — Seat of 
 the Swellings of the Neck which occur in the latter stages of Fever. — Do not 
 arise from Inflammation of the Parotid or Submaxillary Gland, — Illustrated 
 by cases. — Mumps 214 
 
 LECTURE XVI. 
 Fever continued. — Tartar Emetic in the treatment of the Cerebral Excitement of 
 Fever. — Maculated Typhus with Cerebral Symptoms. — Proofs of the Author's 
 originality as to the administration of Tartar Emetic in such cases. — Tartar 
 Emetic combined with Opium in Fever. — Cases illustrating its effects. — 
 Analogy between Cerebral Symptoms in Fever and Delirium Tremens, — Dif- 
 ference in the indications as to the use of antiphlogistic measures, where 
 Cerebral Symptoms occur at the commencement, and at the termination of 
 Fever 22(j
 
 XX CONTENTS. 
 
 LECTURE XVII. page 
 
 Fever continued. — Mode in which the CDmbination of Tartar Emetic with Opium 
 acts. — The stage of Fever in which it proves most useful. — No relief to be 
 expected from Perspirations in the commencement of Fever. — Cases illus- 
 trating the efficacy of Tartar Emetic and Opium in Fever, and the form of 
 their administration. — Small quantity of Laudanum which produces Sleep 
 when thus combined.^-Other symptoms produced by Functional or Organic 
 Lesions of various Organs may prevent this combination from producing the 
 desired result. — Relative proportions of Tartar Emetic and Laudanum to be 
 used 238 
 
 LECTURE XVIII. 
 
 Fever continued. — Maculated Fever of 1834— .35. — Existence of general tender- 
 ness over the surface of the body in Fever. — Combination of primary Nervous 
 Excitement with secondary Cerebral Congestion. — Some additional remarks 
 on the Tartar Emetic and Opium plan of treatment. — Tartar Emetic in large 
 doses in Malignant Fever.— Observations of Dr. Marryatt, of Bristol, pub- 
 lished in 1788. — Illustrative cases. — Hippocrates on the danger of Convulsions 
 in Fever. — Doses of medicines must be pronounced large or small only ac- 
 cording to their effects. — Dr. Kilgour and Dr. Hudson on the Author's plan 
 of using Tartar Emetic in Fever 263 
 
 LECTURE XIX. 
 
 Fever continued. — The administration of Wine. — Dr. Stokes' views. — Author's 
 opinion that the debilitated state of the Heart in Fever depends on a general 
 prostration of the nervous energy and not on softening. — Symptoms which 
 indicate the employment of Wine and Opium in Fever. — Sequelae of Fever. 
 — Delirium. — Coming on without any premonitory symptom. — Tartar Emetic 
 combined with Musk and Opium in. — Supervention of other diseases in 
 Fever. — Swelled Leg simulating Phlegmasia Dolens and Phlebitis. — He- 
 morrhage from the Bowels in Fever 287 
 
 LECTURE XX. 
 
 Fever continued. — Nervous Fever. — Critical days in Fever. — Prognosis in Fever 
 must be in every case extremely cautious. — Illustration. — Prescriptions in 
 Fever.— Necessity for employing medicines of an expectant and temporizing 
 character. — Formulae for such. — Inflammation of the Mammae in Fever. — 
 Causes and treatment of. — Change in opinion with respect to Fever. — Con- 
 cluding remarks on Fever 309 
 
 LECTURE XXI. 
 
 YELLOViT Fevek of the British Islands. — Louis's account of the Gibraltar 
 Epidemic— Compared with the Irish Epidemic of 182(i.— Dr. Stokes' and the 
 Author's account of. — Illustrative cases from their report. — Morbid appear- 
 ances of the Stomach in Yellow Fever. — Nature of the Disease. — A variety of 
 Continued Fever.— Summary of symptoms in the Dublin Epidemic. — The 
 Dublin Fever of 182G— 7 contrasted with Louis's description. — The Scotch 
 Epidemic of 1843— 11.— Isolated cases of Yellow Fever since seen by the 
 Author 323
 
 CONTENTS. XXI 
 
 LECTURE XXII. page 
 Scarlatina. — Epidemic of 1801 — 2 — 3—4. — Original mildness of the disease. — 
 Cliange in its character. — Dr. Autenrieth's observations on the causes capable 
 of modifying diseases. — The Inflammatory constitution of disease recently 
 repUiced b}- a Typhous type. — Proved by the recent Epidemics of Influenza, 
 Cholera, and Fever. — Scarlatina continued to be of a mild type until 1831. — 
 Forms which the disease when violent assumed. — Effects of Depletion in 
 Epidemic of 1834. — Mr. O'Ferrall's communication 349 
 
 LECTURE XXIIL 
 
 Scarlatina continued. — Communications from Provincial Practitioners as to the 
 difl:'usion and type of the disease in the country districts of Ireland. — No 
 Geological or Physical peculiarities in the various localities to account for the 
 difference in the reports. — The mild form co-existed in Dublin with the most 
 virulent. — Dr. Osbrey's communication 374 
 
 LECTURE XXIV. 
 
 Scarlatina continued. — Absence of Eruption in. — Illustrative cases. — Aphthous 
 Ulceration of the Anus in. — Hemorrhage from the Nose in. — Hemorrhage 
 from the Ear in. — Dift'use Inflammation of the Neck after. — Scarlatina with- 
 out Eruption capable of communicating Infection. — A Constitutional Affection 
 may display its existence by only one or two of the numerous symptoms which 
 usually accompany it. — Dropsy after Scarlatina. — Treatment of Dropsy with 
 Albuminous Urine 390 
 
 LECTURE XXV. 
 
 Intermittent Fever.— Quartan Ague, defined. — Reasons why twelve hours 
 should be the unit employed in calculating intervals between the accession of 
 one attack and the accession of the next in Ague. — Illustrations from the 
 occurrence of Crises in Fever. — Effects of Sulphate of Quina and of Arsenic 
 in Ague. — An affection chiefly of the Nervous System. — A form of Ague in 
 which the attacks return ever}' seventh day. — Tertiana Soporosa. — Ague-cake. 
 — Congestion of internal organs during Paroxysms. — Diseases which simulate 
 Ague. — Treatment. — The Malarious Fever of Africa. — Capability of Negroes 
 of withstanding the deleterious exhalations by which it is produced. — Practical 
 deductions therefrom 408 
 
 LECTURE XXVI. 
 Intermittent Fever continued. — Relapse periods of. — Law by which they are 
 regulated applies to the free intervals between the Fits. — Case in illustration. 
 — Obstinate Ague even where accompanied by various complications may be 
 cured by Quina alone. — Best method of administering it. — Table showing the 
 quantity taken in one case 426 
 
 LECTURE XXVII. 
 Cholera. — Origin and Progress. — Difference in the course of Epidemic Cholera 
 and Epidemic Influenza.— March of Cholera from India. — Unknown in 
 Europe before the present century. — Cholera Epidemic of 1817 in India. — 
 Spread of the disease along the rivers and routes most frequented by travellers. 
 — It never travelled the ocean at a rate exceeding that of ships. — Arrival m 
 England — in Ireland 441
 
 XXU CONTENTS. 
 
 LECTURE XXVIII. PAGE 
 
 Cholera continued. — Its route in America. — Probable transmission there by 
 emigrant ships. — Dr. Jackson's account of its spread. — Deductions as to its 
 being a contagious disease. — Epidemic of 1842 in India. — Spread to Europe 
 in 1847. — Its progress in 1818. — Treatment of Cholera. — Acetate of Lead and 
 Opium in. — Treatment by Calomel. — Mode of administering Acetate of Lead 
 in Cholera. — The recent proofs of the efficacy of this remedy in Cholera in 
 India 462 
 
 LECTURE XXIX. 
 
 Influenza. — Difference in mode of spreading between it and Cholera. — Influenza 
 does not depend on mere variations of temperature. — Probably depends 
 chiefly on Telluric Influenza. — Epidemics of Influenza in the eighteenth and 
 nineteenth centuries. — Symptoms of the disease vary in different individuals. 
 — Mortality from, in Dublin in 1837 and 1847. — Nature and Symptoms of 
 Influenza.— Illustrative cases. — Dr. Greene's report of the Morbid Appear- 
 ances in fatal cases. — Treatment 484 
 
 LECTURE XXX. 
 
 Connexion between Disease^ op Different Organs. — Arthritis, Hepatitis, and 
 Urticaria.— Proofs of this connexion from the effects sometimes produced 
 on the system by eating Fish. — Venereal, Periostitic Inflammation, and 
 Hypertrophy of the Liver. — Cases in illustration. — Rationale of intermittent 
 secretion of Bile by the Liver. — Consecutive Affection of the Liver in Morbus 
 Coxse. — Curability of Hepatic Affections of this kind. — Disease of Liver pro- 
 duced by immoderate use of Mercury. — Scarlatina and Disease of the Liver. — 
 Connexion between Disease of the Heart and Hypertrophy and Disease of 
 the Liver. — Ague and Diseased Liver. — Connexion between Diseases of the 
 Spleen and General Diseases affecting the system. — Notices of, by Voight 
 and Aretseus 512 
 
 LECTURE XXXL 
 
 Gout. — Constitutional Inflammation in general. — Local Inflammations depending 
 on a Constitutional cause sometimes remarkably Fugitive and Transient. — 
 Gouty Pains or Twitches. — Gouty Tumors of the Face. — Grinding of the 
 Teeth in Gouty Habits. — Functions of the Dental Nerves. — Paralysis of these 
 Nerves has never been observed. — Gouty Neuralgia. — Illustrative cases. — 
 Gouty redness of the nose. — Premonitory symptoms of an attack of Gout in 
 the Extremities. — Exceptions to. — Gouty Bronchitis. — Gouty Inflammation 
 of the Peripheral Nerves may extend to the Spinal Marrow. — Illustrations. — 
 Treatment. — Concluding observations 528 
 
 LECTURE XXXII. 
 
 Rheumatism. — Arthritic Rheumatism.— General observations on Treatment of. — 
 Sweating in the commencement of the Disease an important Symptom. 
 — The effects of Meicury when applied locally. — Mercury and Hydriodate 
 of Potash in Rheumatic Fever. — lUu.strative cases. — Chronic Rheumatism. 
 — A very intractable disease. — Treatment. — Sciatica and Lumbago. — General 
 Treatment. — Cupphig. — Hydriodate of Potash. — Illustrative cases. — Treat- 
 ment of Chronic Sciatica 558
 
 CONTENTS. XXm 
 
 LECTURE XXXIII. page 
 
 PATHor.oGY OF Nkrvous DISEASES. — Tho Author's New Views. — An Injury of 
 the Extremities or Circumferential parts of the Nerves may cause Paralysic. 
 — Illustrative cases. — Effects of Cold on the Extremities. — The Epide'mie de 
 Paris an example of Disease of the Nervous System commencing in the Ex- 
 tremities. — Both Hemiplegia and Paraplegia may commence in the Extremities. 
 — The former rarely. — Illustration of the Author's Views from the Paralysis 
 caused by the Poison of Lead. — Spinal Neuralgia of Chronic Complaints and 
 Hj'stcrical Affections. — Additional cases in illustration of the Author's Views. 
 — Paralysis of the Insane 574 
 
 LECTURE XXXIV. 
 
 Apoplexy. — Symptoms of Cerebral Disease and Morbid Appearances do not 
 always agree. — Diagnosis therefore difficult. — Two cases of Apoplexy in illus- 
 tration. — General Opinions as to the causes of Paralysis. — The Author's 
 experience as to their truth. — Cases in illustration. — Causes of Hemiplegia. 
 — Mode of explaining the occurrence of slight Paralytic Attacks. — The 
 symptoms indicative of Ramollissement of the Brain not to be always relied 
 on. — Knowledge of the Morbid Anatomy of the Brain, how far useful. — Case 
 of Epilepsy without Organic Disease of the Brain or Spinal Man-ow 580 
 
 LECTURE XXXV. 
 
 Delirium Tremens. — Case of, complicated with several Inflammatory Diseases. 
 — Causes of Deluium in Acute Bronchitis. — Treatment of Delirium Tremens. — 
 Complication of Delirium Tremens with Acute Rheumatism. Chorea. — 
 Obstinate Case of. — Treatment which at length proved successful. — Effects 
 of water poured on the naked skin. — Treatment of Chorea by Sulphate of 
 Zinc. — Cases of Chorea occurring for the first time in advanced life. 
 Epilepsy. — Treatment of, by Sulphate of Zinc. — Case of Epilepsy depending 
 on injui-y to the Bones of the Cranium 607 
 
 LECTURE XXXVI. 
 
 Paralysis. — The obscurer varieties of Paraplegia. — Their production by Reflex 
 Action. — Exemplified by the occurrence of Tetanus from injury, and of Con- 
 vulsions from Intestinal "Worms and from Cutaneous Irritation, — Spinal 
 Tenderness in Hysteria. — Illustrative cases of Paraplegia. — Mode of exf)laining 
 the Paraplegia which occurs after Inflammation of the Bowels. — Connexion 
 between Paraplegia and Disease of the Kidneys. — Observations on Mr. 
 Stanley's cases of Paraplegia. — The Priority of the Author's Views on the 
 Pathology of Paralysis asserted 623 
 
 LECTURE XXXVII. 
 
 Paraplegia continued. — Dr. Hutton's case of Inritation of the Urinary Organs 
 causing Paraplegia. — Paraplegia occurring in the course of Fever. — Illustrative 
 Cases. — Explanation of the cause of. — Paralysis in consequence of Eiysipelas, 
 of Phlegmasia Dolens, and of injurj' to one of the Principal Nerves of a 
 Limb. — Paraplegia produced by the Action of Cold on the Lower Extremities. 
 — Illustrative case. — Causes of this form of Paraplegia. — Diagnosis between 
 it and Paraplegia dependent on Spinal Disease. — Prognosis and Treatment ... 636
 
 XXIV CONTENTS- 
 
 LECTURE XXXVIII. PAGE 
 
 Various Neuralgic Affections.— Bell's Paralysis. — May exist independent of 
 Cerebral Disease. — Illustrative cases. — Singular Aii'ection of the Muscles of 
 the Face, named by the Author Bell's Spasms of the Portio Dura. — Neuralgic 
 Affection of the Lar\-nx. — Loss of Speech may arise from apparently trifling 
 Lesions. — Case of Stammering cured by Larjmgitis. — Pathology and Treat- 
 ment of Stammering. — Neuralgia of the Mammse. — On the administration of 
 Tonics. — Neuralgia of the Testicle. — Cases of injury to the Jaws or Dental 
 Nerves simulating Tic Douloureux. — Infantile Convulsions. — Causes and 
 Treatment of. — Indigestion a special cause. — Caution in giving Opium to 
 Children.— Myelitis 652
 
 CLINICAL LECTURES 
 
 ON THK 
 
 PRACTICE OF MEDICINE. 
 
 LECTUEE I. 
 
 CLINICAL INSTRUCTIOX. 
 
 Gentlemen, — Before we commence an examination of the cases 
 at present in the medical wards of this hospital, it is necessary 
 to explain the method of instruction which I mean to adopt. 
 Employed elsewhere in learning the principles that constitute 
 the basis of medical education, you ought to be impressed with 
 a precise notion of the peculiar objects and utility of hospital 
 attendance. You come here to convert theoretical into practical 
 knowledge ; to observe the symptoms of diseases previously 
 known to you only through the medium of books or lectures ; 
 to learn the art of recognising these symptoms, and of appre- 
 ciating their relative importance and value ; to study their con- 
 nexion with morbid alterations of internal organs ; and, finally, 
 to become acquainted with the best method of relieving your 
 patients, by the application of appropriate remedies. 
 
 Such, gentlemen, are the objects you seek in coming here ; 
 and in proportion to the number and importance of these objects, 
 are the degree of responsibility attached to your clinical in- 
 structors, and of blame to yourselves, should the opportunities 
 which this institution offers for j^our benefit be neglected. 
 
 The other branches of medical education may be cultivated at 
 different times, and according to a certain order of succession, — 
 one period of your studies demanding a particular application to 
 anatomy, another to chemistry, while a third must be especially 
 devoted to materia mcdica. With the observation of disease it 
 is otherwise. From the very commencement, the student ought 
 to witness the progress and effects of sickness, and ought to 
 VOL. I. 1
 
 2 CLmiCAL MEDICINE. 
 
 persevere in the daily oToservation of disease during the whole 
 period of liis studies. 
 
 The human mind is so constituted, that in practical knowledge 
 its improvement must be gradual. Some become masters of 
 mathematics, and of other abstract sciences, with such facility, 
 that in one year they outstrip those who have laboured during 
 many. It is so, likewise, in the theoretical parts of medicine ; 
 but the very notion of practical knowledge implies observation 
 of nature ; nature requires time for her operations : and he who 
 wishes to observe their development will in vain endeavour to 
 substitute genius or industry for time. Remember, therefore, 
 that however else you may be occupied — whatever studies may 
 claim the remainder of your time, a certain portion of each day 
 should be devoted to attendance at an hospital, where the pupil 
 has the advantage of receiving instruction from some experienced 
 practitioner. A well-arranged, and sufficiently extensive hospital, 
 contains everything that can be desired by the student ; but, 
 unfortunately, his improvement is seldom proportioned to the 
 opportunities he enjoys. Whence this deficiency ? How does 
 it happen that many attend hospitals day after day, and year 
 after year, without acquiring much practical knowledge ? This 
 may be attributed to want of ability or diligence on the part of 
 the student, or to an injudicious or careless method of teaching 
 on the part of the hospital physician. It may be well to ex- 
 amine more in detail the errors to which the student and the 
 teacher are respectively most exposed. 
 
 A great number of students seem little, if at all, impressed 
 with the difficulty of becoming good practitioners ; and not a 
 few appear to be totally destitute of any prospective anticipation 
 of the heavy, the awful responsibility they must incur when, 
 embarking in practice, the lives of their fellow- creatures are 
 committed to their charge. It is by persons of this description 
 that the earnest attention, and permanent decorum, which ought 
 to pervade a class employed in visiting the sick, are so frequently 
 interrupted. Young men of the character to which I allude 
 attend, or, as it is quaintly enough termed, zvalk the hospitals 
 very regularly, but they make their appearance among us rather 
 as critics than as learners : they come not to listen but to speak ; 
 they consider the hospital a place of amusement rather than of 
 instruction. I am happy to be able to state that such characters
 
 CLINICAL INSTRUCTION. 3 
 
 are not very numerous here, for this hospital possesses no other 
 attractions, confers no special qualification beyond the knowledge 
 which may be obtained within its walls.* 
 
 Of those who are anxious to learn their profession, a great 
 number fail, and are found wanting when their studies are 
 finished ; in a few, the failure may be traced to a deficiency of 
 intellectual powers ; but in the majority it is owing to their 
 studies being erroneously directed. Thus I have known many 
 who have displayed a taste for the study of the progress and 
 treatment of acute diseases, while they paid but little attention 
 to complaints of a chronic nature. This predilection is not 
 confined to students ; professors and authors in general seem to 
 participate in this taste ; and, consequently, we find that acute 
 diseases form the favourite subjects of clinical lectures, and 
 occupy the greatest portion of medical literature — and for 
 obvious reasons ; for if the course of acute diseases, such as 
 fever and the phlegmasia, be compared with that of chronic 
 maladies, we shall find that the former begin, continue, and end 
 in a manner comparatively so regular and definite, that their 
 progress can often be accurately predicted, and their termina- 
 tions foreseen, — a circumstance which enables us not only to 
 predict the event with confidence, but obtain, by the well-timed 
 application of active remedies, relief, evidently the result of the 
 means employed, and, consequently, reflecting credit both upon 
 the physician and the art of medicine. How satisfactory are our 
 feelings on arresting the progress of pneumonia by venesection 
 or tranquillizing the mania of delirium tremens by means of 
 opium ! 
 
 Far different is the case with chronic diseases ; in their com- 
 mencement generally obscure, insidious, and irregular ; in their 
 terminations, necessarily uncertain; frequently transferrino- 
 themselves, as it were, from one part of the system to another, 
 occasioning unexpected and anomalous symptoms, and involvino- 
 in their destructive course almost every tissue of the body. 
 
 * Since this was written, the ^Mcath Hospital became for several years a privileged 
 hospital. Latterly this premium upon idleness has been again withdrawn from us 
 and I most heartily rejoice that this and other hospitals have ceased to form a sort of 
 favoured oligarchy to the exclusion of the less extensive institutions of this city; 
 everything like monopoly tends to retard the advancement of science, and I see no 
 reason why an hospital with 50 beds should be inferior to one with 100, It is not the 
 quantity of disease a teacher treats which renders his lesson instructive ; his diligence 
 and accuracy of observation are the best means of instructing the pupils.
 
 4 CLINICAL MEDICINE. 
 
 From the very length of their duration, they are also more liahle 
 to be modified by new physical and moral influences, afifecting 
 either the mind or body ; and are, in a word, more closely 
 leagued with time, the parent of mortality. In the treatment of 
 such affections, the greatest judgment and patience are requisite ; 
 there is here no room for the application of heroic remedies ; nor 
 can the physician expect, from his most persevering exertions, 
 that speedy benefit by which he acquires eclat in acute cases, for 
 it must be remembered that chronic diseases require chronic 
 remedies. 
 
 This most difficult department of medicine surely claims not 
 the least portion of your attention, and you will attach more 
 importance to this subject, on considering that a knowledge of 
 chronic diseases is essential to the surgeon, inasmuch as those 
 who labour under them remain exposed to accidents which con- 
 stitute his peculiar province.* 
 
 Many students fail from another cause : instead of studying 
 the most common, and, on that account, the most important 
 diseases, they acquire a taste for obser\dng and relating singular 
 and rare cases, as if their chief object was to obtain a store of 
 curious medical information. Let me warn you against this 
 amusing, but comparatively unprofitable employment of your 
 time. Suffer not yourselves to be misled by those who prefer 
 the gratification of an idle curiosity to the laborious investigation 
 of ordinary diseases. 
 
 Students should aim, not at seeing many diseases every day, 
 not at visiting daily numerous cases ; no, their object should be 
 constantly to study a few cases with diligence and attention ; 
 they should anxiously cultivate the habit of making accurate 
 observations. This cannot be done at once ; this habit can be 
 only gradually acquired. It is never the result of ability alone ; 
 it never fails to reward the labours of patient industry. You 
 should also endeavour to render your observations not only 
 accurate but complete ; you should follow, when it is possible, 
 every case from its commencement to its termination ; for the 
 latter often affords the best explanation of previous symptoms, 
 and the best commentary on the treatment. Did time permit, 
 I could expose many other erroneous practices calculated to 
 
 * At tlie time this lecture was written, the absurd idea that the education of a 
 surgeon should diilcr from that of ph}rfician had not bte;! altogether abandoned.
 
 CLINICAL INSTRUCTION, O 
 
 render your studies comparatively unprofitable ; but I must turn 
 from the student to the teacher — from the errors of the learner 
 to the imperfection of the mode adopted for instructing him. 
 
 I have had an opportunity of observing with attention three 
 different methods of conducting clinical instruction ; the first is 
 that practised in Edinburgh and Dublin. I shall select that of 
 Edinburgh for examination, being by far the most celebrated of 
 the British schools of physic, and much resorted to even by 
 foreigners for instruction.* Two clinical clerks, one for the 
 male, another for the female wards, are selected by the physician 
 from among the senior pupils ; their business is to write an 
 accurate history of the cases, to report the effects of medicines, 
 and record the symptoms which may have occurred since the 
 physician's last visit. All this is generally done with fidelity 
 and zeal. At his daily visit, the physician stops at the bed of 
 each patient, and having received the necessary information from 
 his clerk, he examines the patient, interrogating him in a loud 
 voice, while the clerk repeats the patient's answer in a tone of 
 voice equally loud. This is done to enable the whole audience 
 to understand what is going on ; but indeed, when the crowd of 
 students is considerable, it is no easy task ; it requires an exer- 
 tion almost stentorian to render this conversation between the 
 physician and his patient audible by the more distant members 
 of the class ; while the impossibility of seeing the patient obliges 
 all who are not in his immediate vicinity to trust solely to their ears 
 for information. i' This information is not indeed neglected, for 
 every word so attentively listened to, and heard with so much 
 difficulty, is forthwith registered most faithfully in each student's 
 case-book ; and afterwards all the observations the professors 
 make in their clinical lectures are taken down with equal care 
 and fidelity. 
 
 It is really a pity to find so much labour and diligence thrown 
 away; for it is evident that the practice of medicine canno!; be 
 thus taught or learned, as it were, by hearsay ; and it is conse- 
 qaently to be feared that many are annually dubbed doctors at 
 Edinburgh who have been scarcely ever called on to write a pre- 
 
 * I speak of Edinburgh as it was when I studied there in 1819. 
 
 t When this information was conveyed, as it formerly was at Sir Patrick Don's 
 Hospital, in Latin, the student had to encounter another barrier to the acquisition of 
 knowledge. I have called the langiuige Latin, in compliance with the generally 
 received opinion concerning its nature.
 
 6 CLINICAL MEDICINE. 
 
 sciiption. The chief objection to this mode of teaching is, that 
 however well inclined the student may be, he is never obliged 
 to exercise his own judgment in distinguishing diseases, and 
 has no opportunity of trying his skill in their cure ; and, con- 
 sequently, at the end of his studies he is perhaps well grounded 
 in the accessory sciences — is a perfect medical logician — able to 
 arrange the names of diseases in their classes, orders, and differ- 
 ent subdivisions ; he may be master of the most difficult theories 
 of modern physiologists ; he may have heard, seen, and, if a 
 member of the Medical Societ}^ he may have also talked a great 
 deal ; but at the end of all this preparation, what is he when he 
 becomes a full doctor ? — a ijractitioner wlio has never practised ! 
 I do not assert that a diligent student may not obtain a good 
 deal of knowledge by attending one or several clinical courses in 
 Edinburgh ; no doubt he will gain many useful general ideas 
 concerning the nature and treatment of disease ; and if he him- 
 self examine the patient after the physician's visit, he may even 
 acquire a certain degree of tact in recognising symptoms and 
 appreciating their value. This method of instruction is indeed 
 very useful, and nothing better can be devised for a beginner ; but 
 for the more advanced student it is by no means sufficient, nor is 
 it calculated to give him practical experience, without which all 
 other acquirements are of no avail. I say it does not give him 
 experience, because he has at no time been charged with the re- 
 sponsibility of investigating a case for himself and by himself, 
 because at no time has he been called on to make a diagnosis 
 unassisted by others, and above all, because he has never been 
 obliged to act upon that diagnosis, and prescribe the method of 
 treatment. If those who have been thus educated, and who 
 Jiave been made doctors upon so slender a foundation, were to 
 confess the truth, we should be presented with a picture calcu- 
 lated to excite dismay, if not a stronger feeling. How many 
 doubts and distracting anxieties attend such a man at his first 
 patient's bedside ? If the disease be acute, and life in imminent 
 danger, and if he shrink under this sudden and unusual load of 
 responsibility, he gains little credit for professional ability; if, 
 on the contrary, inexperienced as he is, he assumes that decision 
 of judgment, that energy of practice, which experience alone 
 can confer, it is not improbable that the result may be still more 
 disastrous.
 
 CLINICAL INSTRUCTION. 7 
 
 Gentlemen, I am not drawing a picture from my imagination 
 alone ; I have had occasion too often to shudder at the original, 
 — too often to deplore the sad effects resulting from the well- 
 meant but totally mistaken treatment employed by young men ; 
 and often have I regretted that, under the present system, 
 experience is only to be acquired at a considerable expense of 
 human life. There is, indeed, no concealing the truth, the 
 melancholy truth, that numbers of lives are annually lost in 
 consequence of mal-treatment. The victims selected for this 
 sacrifice at the shrine of experience generally belong to the 
 poorer classes of society, and their immolation is never long 
 delayed when a successful candidate for a dispensary commences 
 the discharge of his duty. The rich, however, do not always 
 escape ; nor is the possession of wealth in every instance a safe- 
 guard against the blunders of inexperience. 
 
 This charge of inexperience is not necessarily confined to the 
 beginner ; it applies equally to many an old practitioner, whose 
 errors have grown, and have increased in strength, during a long 
 succession of years ; because, from a defect in his original educa- 
 tion — from the absence of a properly directed clinical instruction, 
 he commenced practice without having previously acquired the 
 power or the habit of accurate observation ; because he had not 
 in his youth been taught to reason justly upon the facts presented 
 to his view ; because, not having learned in the beginning to 
 think accurately, he contracted a loose and careless mode of 
 examining the progress of disease and the effects of remedies ; 
 and, consequently, the lapse of time has had no other efiect upon 
 his errors than that of rendering them more inveterate. Such a 
 man has generally an overweening confidence in his own judg- 
 ment ; he never detects or is conscious of his own mistakes ; 
 and, instead of improvement, years bring only an increased 
 attachment to his opinions — a deeper blindness in examining 
 the results of his own practice ; and do not such persons abound 
 in every branch of the profession ?— are there not general prac- 
 titioners, are there not physicians, are there not surgeons, are 
 there not apothecaries, who answer to this description, and who 
 nevertheless are cheerful in their demeanour, and enjoy a good 
 repute among their clients ? Believe me, gentlemen, the quacks 
 who cover our walls with their advertisements, vend not annually 
 to the community more poison than is distributed according to
 
 8 CLINICAL MEDICINE. 
 
 the prescriptions of your routine and licensed practitioners: — 
 and yet the science of medicine is improving daily, and treatises 
 on the practice of physic are every day multiplying. Why, then, 
 is society so infested ? Many circumstances concur to produce 
 this effect ; but the most influential is undoubtedly that M'hich 
 now occupies our attention, — I mean a system of clinical in- 
 struction radically wrong, because it does not teach the actual 
 practice of medicine. Is there any other profession or art, or 
 even trade, in which any but a madman would embark un- 
 provided with a store of practical knowledge ? But enough of 
 this unpleasing subject. Let us next consider what systems 
 have been adopted in other countries, with a view of judging how 
 far it is either practicable or expedient to introduce them into 
 this.* 
 
 In France, the mode of conducting clinical instruction is very 
 similar to that which we have already described, and is con- 
 sequently attended with nearly the same advantages and defects. 
 In the French hospitals, however, no reports are dictated to the 
 clerks, and more care is taken to explain the symptoms and pro- 
 gress of each case at the bedside of the patient : in fact, these 
 explanations, answering to the original institution and design of 
 clinical lectures, are attended with many important advantages, 
 and are well worthy of imitation. By this means, the trouble 
 and uncertainty of a circumstantial and detailed description are 
 frequently avoided by a direct reference to the matter to be de- 
 scribed ; and the interest of the student is secured by a very 
 slight exertion on the part of his instructor, while the latter 
 owes many new ideas to the degree of attention which he is thus 
 forced to give each case. It is true that the duration of the visit 
 is thereby increased ; and in Italy, where the same plan is 
 pursued, it is not unusual for Tommasini to expend, in the 
 
 * As truth has obliged me to expose a fault which the Edinburgh school shares in 
 comuion with the other schools of Great Britain, I am bound in candour to acknow- 
 ledge the very great advantages which Edinburgh, in other respects, offers to students ; 
 they there find themselves surrounded by so much diligence, enthusiasm, and zeal, 
 that they can scarcely resist the impulse of improvement, and consequently many 
 learn there to think and to labour, who had been previously careless idlers. That 
 such was the case until within the last few years is undoubtedly true ; but what can 
 be said now in favour of a university in which the Professor of Pathology is not only 
 an avowed homijopathist, but has written a book with the view of proving the truth, 
 and promulgating the doctrines of that ridiculous sect of quacks, — and the Professor 
 of Chemistry a Professor of Animal Magnetism ?
 
 CLINICAL INSTRUCTION. \) 
 
 morning, more than two hours upon eight or ten cases, besides 
 the time devoted in the evening to the same purpose. When 
 the importance of the subject to be taught is so great, it is wisely 
 judged that the teachers must be laborious ; and it is thought 
 necessary to use every possible means to convey clear ideas con- 
 cerning each case to the student. His attention is not distracted 
 by seeing a great number of cases in rapid succession, nor (as is 
 too often the case in the hospitals of Dublin and London) are 
 the inquiries dictated by a laudable curiosity on the part of the 
 student suppressed by a forbidding demeanour or an uncourteous 
 answer from his teacher.* 
 
 Although the French clinic thus presents several manifest 
 superiorities over the British, yet it is liable to the chief objection 
 already urged against the latter — that the student is not supplied 
 with an opportunity of learning the actual practice of his pro- 
 fession. I am by no means disposed to join in the cant of 
 humanity ; yet I cannot overlook another disadvantage to this 
 mode of teaching. I cannot help feeling that it is scarcely 
 justifiable to lecture upon a patient's case in his presence, and 
 in his native language ; that it is cruel to explain (as must, 
 when this method is adopted, be often done) that the patient 
 is labouring under a fatal complaint. During such a lecture 
 I have often watched the worn and pallid countenance of the 
 sufferer, while he listened attentively to the record of his past 
 and present sufferings, and I have marked the settled expression 
 of despair it assumed when the prognosis thus tediously ushered 
 in, was too clearly announced. It is cruel to banish from the 
 sick man's bed his sole remaining comfort ; it is unmerciful to 
 scare away hope — his only consolation during hours of pain and 
 watching. We ought never to allow any expression to escape 
 from us which could possibly add the terrors of apprehension to 
 the weight of actual suffering. On this account, while we borrow 
 the useful part of their system from the French, we must correct 
 so glaring a defect by making use of the Latin language, when- 
 
 * In this respect our hospital physicians and surpjeons have improved much since 
 1821. I am strongly disposed to believe that the improvement was not owing to a 
 voluntary change, but to a certain salutary fear of public castigation from the weekly 
 medical press ; much, however, remains to be done, for the influence of the last century 
 has not yet entirely ceased, and there are those still lingering among us, who no doubt 
 regret the aristocratic era when an impassable gulf lay betwttn the student and his 
 teacher.
 
 10 CLINICAL MEDICINE. 
 
 ever it is absolutely necessary to make any observation that 
 might alarm the patient.* One of the most important duties of 
 a surgeon, or physician, consists in the practice of humanity ; 
 and it is vei'y doubtful whether the student does not experience 
 as much difficulty in deriving benefit, not so much from the 
 precept as the example of his seniors, in this department of his 
 profession as in any other. 
 
 Observe, gentlemen, I speak not of French, but of Irish 
 hospitals ; for, with the exception of the objection already ad- 
 verted to, the conduct of the French medical men is in every 
 respect praiseworthy. We do not find them indulging in coarse, 
 harsh, and even vulgar expressions to their hospital patients ; 
 we do not find them provided with two vocabularies — one for the 
 rich, and another for the poor.f The medical, more than any 
 other profession, requires that the better feelings of our nature 
 should be cultivated and fostered. The nature of anatomical 
 pursuits obliges us to violate many of our natural prejudices, 
 and disregard some of our strongest propensities ; let us there- 
 fore be doubly anxious to give, by means of the most diligent 
 cultivation, an additional and more vigorous growth to our better 
 feelings — to our social affections ; and if we are accused of dis- 
 respect for the dead, let us answer the accusation by our humanity 
 to the living. 
 
 But to return to our subject. The third mode of conducting 
 clinical instruction is that adopted generally throughout Ger- 
 many ; and which, in addition to the means of improvement 
 comprehended in the plan of the French and English methods, 
 possesses the advantage of allowing the more advanced students 
 to undertake the care of patients in the hospital, under the 
 direction of the attending physician. 
 
 The importance of clinical instruction is so much felt in 
 
 * This rule is always observed iu Germany, a country remarkable for the zeal and 
 humanity of the medical profession. In Italy both professors and students are less 
 scrupulous. Thus Dr. Clark relates that he has heard the case of a phthisical person 
 explained in all its bearings by the professor of Bologna, in the patient's presence : iu 
 another instance, which occurred at the same place, a female, labouring under cancer 
 uteri, burst into tears on hearing a detailed account of the nature of her complaint. 
 
 t When the above lecture was delivered, the abuse I speak of was but too frequent ; 
 and will it be credited, that many other and greater abuses had existed during the 
 preceding generation? Death, the most efficient of all reformers, had then removed 
 several of the chief actors from the scene, for which, as on most other occasions, he 
 has, I rather think, been undeservedly censured.
 
 CLINICAL INSTRUCTION. 11 
 
 Germany, that each school has three distinct medical clinics 
 attached to it, by which means the labour of teaching is divided 
 among the professors, and the number of students attending 
 each is diminished. There is one clinical hospital for the treat- 
 ment of acute diseases, and another for chronic diseases, while a 
 clinical dispensary is devoted to the care of extern patients. The 
 pupils are divided into two classes — the more advanced, who get 
 the care of patients ; and the junior students, who merely look 
 on and listen. When a patient is admitted, his case is assigned 
 to one of the practising pupils, who, when the physician is 
 visiting the ward, reads out the notes he has taken of the 
 patient's disease, including its origin, progress, and present 
 state. This is done at the bedside of the patient ; and be- 
 fore he leaves the ward, the physician satisfies himself whether 
 all the necessary particulars have been accurately reported by 
 the pupil. After all the patients have been thus accurately 
 examined, the professor and his class proceed to the lecture- 
 room, and a list of the patients and the practising j)upils is 
 handed to the professor : the cases admitted that day are first 
 inquired into, and the pupils are examined concerning the nature 
 of their diseases, their probable termination, and the most ap- 
 propriate method of treatment, each student answering only 
 concerning the patients entrusted to his special care. During 
 this examination, the pupil's diagnosis and proposed remedies 
 are submitted to the consideration of the professor, who corrects 
 whatever appears to be erroneous in either, and then the student 
 retires to write his prescriptions, while the rest of the cases and 
 pupils undergo a similar examination. At the conclusion, the 
 prescriptions written by the students are read out in order by the 
 professor, who strictly comments on and corrects any inaccuracy 
 or inelegance they may contain. When the prescriptions have 
 been revised and corrected, they are signed by the physician, 
 and handed to the apothecary to be made up and distributed. 
 In some clinics, the price of each medicine is affixed to the 
 bottle or box containing it, in order that the students may 
 become acquainted w'ith the comparative expense of various 
 prescriptions, and may thus be enabled, in private practice, to 
 accommodate, as far as possible, the expense of the remedies to 
 the circumstances of their patients. The clinic for extern patients 
 is conducted on the same principles : patients who are able to
 
 12 CLINICAL MEDICINE, 
 
 attend, are examined at the dispensary ; those M'ho cannot leave 
 their homes, are visited by the senior practising students, who 
 always seek the advice of the professor when the case is urgent 
 or the treatment doubtful. 
 
 Nothing, gentlemen, can be better adapted than this plan of 
 clinical instruction for the improvement either of the beginner, 
 or of the more advanced student ; this daily deliberation and 
 anxious discussion concerning the nature and treatment of each 
 case is peculiarly interesting, and serves to accustom the be- 
 ginner to habits of accurate examination, whereby he is taught 
 to interrogate nature for himself, and learn the history and 
 treatment of disease, not from books and descriptions, but from 
 direct observation. The advantages gained by the practising 
 pupils are too obvious to require comment : being obliged to 
 give reasons for every plan of cure that they propose, they are 
 accustomed to a rational and careful investigation of disease ; 
 and enjoying the most important of all advantages — the early 
 correction of their errors — they commence private practice with a 
 sufficient degree of experience to render them unlikely to commit 
 any very serious mistakes. 
 
 It is evident that, according to the German method, no 
 regular clinical lectures are necessary, as the pupil becomes 
 accurately acquainted with the physician's views of each case, 
 and no step is taken in the treatment without the reasons for 
 it being given. This is the best sort of clinical lecture ; the 
 pupils have their doubts solved, and their erroneous views cor- 
 rected, while the professor is enabled to mention, as the disease 
 proceeds, everything which he thinks illustrative of its nature. 
 
 Eleven years' experience, since I first delivered the foregoing 
 observations, enables me strongly to recommend the method of 
 instruction pursued in Germany. Since my appointment to the 
 Meath Hospital I have had extensive opportunities of observing 
 its good effects. Not a session has elapsed without furnishing 
 proofs in its favour. This system, however, at first met with 
 much opposition, and its introduction was ridiculed in every 
 possible manner ; even now it may be doubted whether its well- 
 wishers are as numerous as might be expected. It is still opposed 
 by several narrow-minded persons, whose opinions have much 
 weight with the pupils.
 
 CLINICAL INSTRUCTION. 13 
 
 I remember perfectly ^Yell having only two practising pupils 
 iu one class, but I was not discouraged ; and although we 
 have had many numerous classes in the Meath Hospital, I 
 doubt if any of them contained more talent and worth than 
 was shared between my two pupils, Dr. Townsend and Dr. 
 Stokes. 
 
 Since the latter, from being my pupil, has become my col- 
 league, he has evinced the most indefatigable zeal in co- 
 operating with me in instructing the pupils of the Meath 
 Hospital ; and I am sure he joins me in testifying the constant 
 gratification we have received from observing that our efforts 
 have been so far successful, that no season elapses without 
 bringing under our immediate observation several pupils whose 
 diligence, zeal, and moral worth insure our warmest approba- 
 tion. Many of these gentlemen have already distinguished 
 themselves, and will always carry with them the best wishes 
 of myself and my colleague. 
 
 Six and twenty years have now elapsed since the foregoing 
 part of this lecture was delivered in the old Meath Hospital, and 
 my subsequent experience has amply verified the opinions therein 
 expressed. I regret to say that however influential these 
 opinions may have proved in this city, their promulgation has 
 produced but little benefit in causing any alteration iu the mode 
 of instruction pursued in the medical schools of the United 
 Kingdom at large. So far indeed from the mode of conduct- 
 ing medical education being improved, it has decidedly been 
 altered for the worse. This assertion may appear para- 
 doxical, nay almost incredible, when it is recollected how 
 many new Universities and Schools have arisen since the year 
 1821, and how many novel medical professorships have been 
 founded. 
 
 But if we carefully examine into the instructions given, and 
 the qualifications required in the first and most recently 
 organised medical school of the day, viz., that of the London 
 University, it would readily appear that a very small part of 
 the student's time and attention is directed to acquire a know- 
 ledge of how disease is to be actually treated and cured — unless, 
 indeed, we admit that a knowledge of Greek and Latin, of 
 mathematics, algebra, and optics, of i)hysics, botany, and
 
 14 CLINICAL MEDICINE. 
 
 chemistry, is necessary for this purpose. That this multiplicity 
 of subjects distracts every student, is sufficiently evident a 
 priori. And my own experience, from opportunities as a 
 public teacher for many years, has satisfactorily convinced 
 me that the practical parts of medicine are not taught so Avell 
 now as formerly. 
 
 It is not intended to assert that pupils now hear fewer clinical 
 lectures, or attend a shorter time in the hospital, but it may be 
 confidently affirmed that what they hear in these lectures, or 
 see in the hospital, does not rivet attention or excite reflection 
 now as formerly. For the pupil's avocations are so numerous, 
 that he is hurried from one to the other, and has no time to 
 devote to serious reflections upon what he has seen. 
 
 In Edinburgh, the engrossing subject of conversation amongst 
 students used to be the nature of the diseases of the clinical 
 patients, and the eff'ects of remedies employed ; the clinical 
 ward afforded constant themes for discussion, and its contents 
 were constantly before the thoughts of the student. Such was 
 Edinburgh in 1819, how it may be now, I cannot tell ; but be it 
 changed for the worse, which I hope is not the case, it must 
 result from a change in the system, and not a deterioration in 
 the professors, whose unwearied diligence in the promotion of 
 medical science daily brings forth fruit not unworthy of the best 
 era of their predecessors. 
 
 When so many seductive subjects are successively placed 
 before the student, it cannot be expected that he will think 
 almost exclusively on what is practical. On the contrary, the 
 chances are that the chief energies of his mind will be mis- 
 spent on the fascinating experiments and doctrines of chemistry, 
 electricity, magnetism, and the polarization of light, to the 
 exclusion of the less fascinating but all-necessary subject of 
 disease and its treatment. In truth, the very rapid advances in 
 the so-named collateral sciences have, of late years, seemed to 
 render the practical improvement of the student less probable, 
 and every day it becomes more unlikely that he will attain to the 
 simple goal that he ought to hold in view, but will be diverted 
 from the pursuit of the one indispensable object by the very 
 means which he is taught to believe are necessary for its 
 attainment. To this subject I shall recur in the following 
 lecture, concluding this with an expression of satisfaction
 
 CLINICAL INSTRUCTION. 15 
 
 that since the first publication of my views upon medical 
 education, they have been brought forward and enforced in 
 several leading articles by the able editor of the Medical 
 Gazette ,- and they have had, I have reason to hope, a favour- 
 able effect upon the manner in which medical education is 
 conducted in my native city.
 
 IG 
 
 LECTUEE II. 
 
 pkeliminary education. modern nomenclature. 
 
 liebig's theories. 
 
 Having now explained the advantages of this, the German mode of 
 clinical instruction, I shall content myself with remarking that we 
 have had many years' experience of its beneficial effects in the 
 Meath Hospital, where it was introduced by myself in 1821 ; I 
 must remind you, however, that even its utility is necessarily 
 proportioned to the diligence of the student. There is no system 
 capable of communicating information to the indolent ; every 
 man must depend chiefly on his own assiduity, and all the 
 teacher can do is to facilitate the means of acquiring knowledge, 
 and afford an example of punctuality and attention. I would 
 seriously recommend everyone who undertakes the management of 
 cases, to set out with a fixed determination to persevere throughout 
 the whole session. Few things give me more concern than to 
 find 3'oung men, who have commenced with ardour, becoming by 
 degrees less and less industrious, until their hospital attendance 
 degenerates into an irksome task, imperfectly performed, and at 
 last wholly neglected. One of the most valuable things which 
 the student can acquire, is a habit of daily diligence. The know- 
 ledge requisite for the efiicient discharge of our professional 
 duties is not to be acquired by sudden starts of intense applica- 
 tion, or by the overwrought strivings of desultory exertion ; it 
 demands a daily and hourly attention, a steady, constant, and 
 accurate course of observation, continued uninterruptedly for 
 years. 
 
 I think students are very much misled as to the best mode 
 of becoming good practitioners. This is an age of ambitious 
 acquirement, and professional men seem to be ashamed unless 
 they have the character of universal knowledge. Everybody 
 studies everything, and the consequence is that few know any- 
 thing well. We live amidst the din of declamations in favour of
 
 PRELIMINARY EDUCATION. 17 
 
 general education ; and are everywhere assailed by tlie ceaseless 
 competition of those who vend cheap knowledge in the form 
 of penny periodicals, lectures innumerable, and hosts of rival 
 enc3'clopaxlias ; but ours is not an age of calm unpretending 
 acquirement and severe precise study, without which the 
 effort to become good physicians and surgeons must prove 
 vain and fruitless. 
 
 Can anything be more embarrassing than the multitudinous 
 array of studies presented to the young student who comes to 
 London or Dublin with the view of educating himself as a gene- 
 ral practitioner '? So many departments of knowledge are spread 
 before him, and so numerous are the exhortations to study each 
 with particular care, that he feels at a loss where to begin. The 
 merits, advantages, and necessity of his own branch, are insisted 
 on by the respective teachers, with all the force of impressive 
 eloquence ; and after running the round of introductory lectures 
 — an initiatory penance duly performed by all beginners — he 
 returns in the evening to his home, puzzled and dispirited. 
 He finds that it will be necessary for him to become an excellent 
 botanist, an able and scientific chemist, and a profound anato- 
 mist ; that he must have some knowledge of zoology, be well 
 versed in comparative anatomy, know how to detect poisons with 
 accuracy, and study the legislative enactments which bear on 
 questions of medical jurisprudence. Physiology, materia medica, 
 therapeutics, nosology, morbid anatomy, the principles and practice 
 of surgery, medicine, and midwifery, claim, all and each, his especial 
 attention ; nay, many teachers insist upon the necessity of his be- 
 coming master of several languages — Greek, Latin, French, and 
 German ; while others assure him that he never can prosecute 
 scientific medicine with success, unless he studies physics as 
 well as physic ; some are there even who encourage him to culti- 
 vate mineralogy and geology, as if forsooth a knowledge of these 
 sciences could teach the laws that regulate diseased action, or 
 the indications which should govern the exhibition of remedies. 
 In a lecture published by Mr. Hayden, I find it remarked " that 
 to keep pace with the modern race of intellect, we should get on 
 a railroad of literature ; mathematics, natural philosophy, the 
 art of drawing, and, above all, logic, will be indispensable." Dr. 
 EUiotson would no doubt add metaphysics, animal magnetism, 
 and phrenology, sciences he has cultivated with success, and taught 
 VOL. I. 2
 
 18 CLINICAL MEDICINE. 
 
 with perspicuity ! Dr. Latham, who has had sufficient courage 
 to put forth his opinions on this subject, has demonstrated, with 
 much truth and force, the injustice and folly of attempting to 
 impose so many burthens on the minds of students, and has 
 shown clearly the bad consequences resulting from such a mode 
 of proceeding. 
 
 No profession requires a sounder preliminary education than 
 ours, and in none ought education be more studiously directed 
 to promote the activity and development of the mental powers, 
 especially those connected with the hahit of ohservation as well as 
 with the judgment and memory. The latter faculty should be 
 cultivated from the earliest period, and the boy should be taught 
 the chief anatomical names, as those of the different parts of 
 the muscular, nervous, and vascular systems, which names he 
 will of course find no difficulty in retaining when a man, and it 
 will then be only necessary to learn the qualities of the things to 
 which they belong. If, in addition to this, boys were taught the 
 scientific names of the chief articles of the materia medica, and 
 the technical terms and classifications of botany and chemistry, 
 much trouble would be saved them in after life ; and their 
 memories, while in the state of greatest activity, would be much 
 better employed than in attaining the rules and terms of syntax, 
 prosody, mythology, and ancient geography. 
 
 I would not recommend any one to commence the actual study 
 of medicine and surgery until the age of nineteen. Before that 
 period the mind is not sufficiently ripe for practical observation, 
 nor sufficiently stored with that knowledge — only to be gained 
 by the daily intercourse of life — which teaches us to estimate the 
 effects of moral or physical causes on the human system, imparts 
 to us the power of weighing conflicting evidence, and detecting 
 the too frequently incorrect and erroneous statements of our 
 patients. A certain knowledge of the world is indispensable to 
 the physician ; and it is only loss of time — yes, of precious time 
 — to employ boys in trying to learn what can only be acquired 
 hymen. Those who attend hospitals at too early an age are very 
 apt to acquire careless habits of observation ; all the interest 
 which disease presents, when observed for the first time by 
 matured minds, is lost to them, and all the attractions of novelty 
 have ceased long before they possess that tact and experience 
 which enable the adult to understand the meaning of symptoms.
 
 PRELIMINARY EDUCATION. 19 
 
 the progress and phases of morbid phenomena, and the effects 
 of therapeutic agents. 
 
 It is then the duty of parents, guardians, teachers, and all who 
 superintend the education of youth, to see that those who are 
 destined for the medical profession should have their minds pre- 
 pared and strengthened by diligent cultivation during early 
 youth, not only by the attainment of extra-professional knowledge 
 suited to their means and opportunities, but also by instruction 
 in those portions of anatomy, materia medica, botany, and che- 
 mistry, which may be readily comprehended at that age. Especial 
 care should be taken to impart to them some knowledge of the 
 physical qualities of medicinal substances. All this being done, 
 when the student, arrived at maturer years, comes to grapple 
 with the practical departments of his profession, he will find 
 many difficulties easily surmounted, and at this period he should 
 disengage himself from too devoted an attention to the accessory 
 sciences. But he need not wholly detach himself from them ; 
 some one of them may be cultivated along with his more serious 
 pursuits. He may devote one session to lectures on chemistry, 
 another to those on botany, a third to physiology, and so on of 
 the rest. But his main object must now be the acquisition of 
 practical knowledge, and consequently the greater portion of his 
 time and energies must be devoted to the clinical wards and dis- 
 secting-room of an hospital, to the study of materia medica and 
 pharmacy in an apothecary's shop, and to practical anatomy. 
 
 Five or six years' attendance on an hospital will be little 
 enough to qualify you to enter with propriety and confidence on 
 the discharge of your professional duties. Bear in mind, gentle- 
 men, that when you come to treat disease, you approach the 
 bedside as physicians or surgeons, and not as chemists, botan- 
 ists, or anatomists. This is the character in which you are to 
 appear; and, to the acquisition of knowledge which will prepare 
 you for the discharge of its duties you ought to apply your 
 chief attention. 
 
 Some of you, gentlemen, may think that it ill becomes a 
 teacher to narrow the limits of your exertions, or circumscribe 
 your pursuits. But let me be understood. What I wish to 
 impress upon your attention is, that you ought to address your- 
 selves mainly to the acquirement of what is really useful, and 
 should store up chiefly what is most important and available.
 
 20 CLINICAL MEDICINE. 
 
 And in furtherance of this object I think it my duty to warn you 
 against the well-meaning but injudicious representations of those 
 who would turn you from the study of practical matters to the 
 cultivation of their favourite sciences — sciences connected with 
 and ancillary to medicine, but in which medical students are too 
 often encouraged to engage with an ardour that indirectly but 
 certainly leads to a less zealous and efficient attention to more 
 important matters. Take, for instance, two of the most popular 
 of the adjunct sciences — two usually regarded as most intimately 
 connected with the study of medicine — botany and chemistry. 
 Both are extremely valuable in themselves, and a certain ac- 
 quaintance with them is undoubtedly desirable; but to the 
 student in medicine their utility has been greatly overrated. 
 Botany is an extremely interesting and useful science ; but I 
 believe you might be very good practitioners without knowing 
 the classes of Linnoeus, or the families of Jussieu. To be sure, 
 if you had the misfortune to practise in localities separated from 
 the ordinary channels of commerce ; if you were suddenly bereft 
 of the numerous stores which maritime enterprise pours into the 
 lap of medicine, and obliged, like the herbalists of old, to search 
 the woods and fields for your materia medica, you would certainly 
 be often at a loss, and might make some serious mistakes, unless 
 you were adepts in practical botany. But this labour, fortunately 
 for us and for every European practitioner, is quite unnecessary. 
 A small capital will bring the vegetable productions of the most 
 distant countries to your door; and any respectable druggist 
 will for a trifling sum i)rovide you with all the medicinal sab- 
 stances derived from plants, carefully selected, and accurately 
 prepared. 
 
 Those who boast the most loudly of their acquisitions in 
 botany, and who lay most stress on its importance, know very 
 well that to the physician it is of little or no practical value. 
 Take one of the best of our English or Irish botanists, and see 
 how meagre a knowledge he possesses, after all, of many of the 
 plants whose products are employed so largely every day in the 
 treatment of disease. Transport him suddenly to the East or 
 West Indies, to Africa, or South America, ask him to show you 
 the camphor or the cinnamon-tree, the cajeput, the croton, or 
 the gnaiacum : I doubt very much whether he would be able to 
 recognise logwood, or even ipecacuanha, growing in their natural
 
 PRELIMINARY EDUCATION. 21 
 
 situations. Again, there arc a great many vegetable productions 
 used every hour in medicine, of which it may be said that no 
 two botanists are agreed as to the precise description of plant 
 from which they are derived. There is no substance in such 
 common use as gum arable, and yet, notwithstanding all that 
 has been written on the subject, it is not clear from what par- 
 ticular plants it is derived. Nor do I think it necessary to know 
 whether the gum we use in compounding a cough medicine comes 
 from the Acacia vera or Acacia arabica. In like manner, the 
 plants which furnish cardamoms and many other substances in 
 common use are by no means determined. How many disputes 
 have there been with respect to the genus cinchona ? And what 
 has been the result of all our investigations concerning the plant 
 which produces this great remedy ? Listen to what my late 
 learned friend Andrew Duncan says, in the supplement to the 
 Dispensatory: "Notwithstanding that all the British colleges 
 agree as to the botanical species of cinchona from which the com- 
 mercial varieties of bark are derived, there is no satisfactory 
 evidence that they are right ; on the contrary, it is almost certain 
 that in regard to some of them they are wrong." How many 
 years were calumba and many other similar productions employed, 
 before scientific botanists knew anything of their true history ? 
 In 18'29 a paper was read by Dr. Hancock, on the tree which 
 yields the Angostura bark ; it appears that even Bonpland and 
 Humboldt had described the wrong tree, and consequently it has 
 been called for many years a Bonplandia ; whereas it belongs, it 
 now appears, to another genus, named Galipea. Dr. Hancock 
 has also proved that the Smilax syphilitica of Wildenow is not 
 the true sarsaparilla, but that it is obtained from other plants : 
 and at what conclusion does Dr. Hancock, who spent many years 
 in South America, arrive ? Why, that the only criterion for 
 knowing good sarsaparilla is its taste when chewed ! In proof of 
 the uncertainty which still prevails concerning the determination 
 of species used in medicine, I have only to refer 30U to the 
 admirable lectures of Mr. Pereira in the Medical Gazette, and 
 those of Dr. Sigmond, published in the Lancet* 
 
 * In the number of the Quarterly Review for June, 1842, we find some very pertinent 
 observations upon the ridiculous names given to many flowers, and the inconveniencee 
 Kkely to arise from the frequent changmg of them. 
 
 The Reviewer says, '■ Before we have done with the florists and botanists, we must 
 Bay one word about their nomenclatures. As long as the extreme vulgarity of the
 
 22 CLINICAL MEDICINE. 
 
 I do not wish to undervalue botany as a part of general educa- 
 tion. Few sciences are more attractive, and few are more likely 
 to become an object of enthusiastic pursuit ; but it is the very 
 enthusiasm it is so likely to generate that I wish to warn you 
 against. Botany is an excellent exercise for the minds of 
 youth : it gives habits of accuracy of observation, and tends to 
 strengthen the memory. It leads to healthy occupation, and 
 affords a source of innocent enjoyment. As productive of so 
 much good, let it form a part of the education of young persons 
 in general ; sure I am that its cultivation would give a healthier 
 tone to both mind and body, than is to be obtained from many 
 of the studies with which boys are now tortured in the schools. 
 But let botany be restricted within its proper limits ; and when 
 once young men have seriously engaged in the acquirement of 
 medical and surgical knowledge, let them not entertain the 
 ambition of becoming accomplished botanists. 
 
 Speaking of botany, I may observe that it is much to be 
 regretted that the names of plants should undergo so many 
 
 one and the extreme pedantry of the other continue, they must rest assured that they 
 will scare the majority of this fastidious and busy world from taking any great interest 
 ia their pursuits." 
 
 After objecting to many modern names, he adds, " Surely there is marked character 
 enough about every plant to give it some simple Englhh name, without drawing either 
 upon living characters or dead languages. It is hard work, as even Miss Mitford has 
 found it, to make the maurandias, and alstrjemerias, and escholtzias — the commonest 
 flowers of our modern gardens — look passable even in prose : they are sad dead letters 
 in the glo^^ing description of a bright scene in June. But what are these to the 
 pollopostemonopetelEe and eleutheromacrostemones of Wachendorf, with such daily 
 additions as the native name of iztactepotzacuxochitl icohuej o, or the more classical 
 ponderosity of Erisymum Peroft.kyanum ? 
 
 " Like the Verbum Grsecum 
 Spermagoraiolekitholakanopolides, 
 Words that should only be said upon holidays, 
 When one has nothing else to do. 
 
 " To make confusion worse confounded, our botanists are not satisfied 
 
 ■with their far-fetched names ; they ihust ever be ch.anging them too. Thus it is a 
 mark of ignorance in the world of flowers, to call our old friend Geranium otherwise 
 than Pelargonium ; the Glycine (G. sinensis), the well-known specimen of which, at 
 the Chiswick Gardens, produced more than 9,000 of its beautiful lilac, laburnum-like 
 racemes from a single stem, is now to be called Wistaria ; the new Californian annual 
 iEnothera is already Godetia ; while the pretty little red Hemimeris, once a Celsia, is 
 now (its third designation) an Alonaoa ; and our list is by no means exhausted. Going 
 on at this rate, a man might spend the morn of his life in arriving at the present state 
 of botanical science, and the rest of his days in running after its novelties and changes. 
 We are only too glad when public sanction triumphs over individual whim, and, aa in 
 the cases of Georgina proposed for Dahlia, and Chryseis for Escholtzia, resists the 
 attempted change."
 
 PRELIMINARY EDUCATION. 23 
 
 mutations. Wliat was formerly called Stilozobium has suc- 
 cessively become Doliclios and Mucuna ; while Iceland moss 
 has been changed from Lichen into Cetraria, and Secale cor- 
 nutum into Acinula clavus. Uva ursi is now preceded by the 
 prtenomen Arctostaphylos ; and our old acquaintance jalap, 
 deprived of its euphonious prefix Convolvulus, has degenerated 
 into Ipoma3a, still further converted, more recently, into Exo- 
 gonium. All these changes are useless or injurious, and entail, 
 as a necessary consequence, that the young, the middle-aged, 
 and the advanced in life, use a different medical vocabulary. 
 The materia medica too, as now taught by scientific professors, 
 presents a serious stumbling-block to students. Teachers do 
 not confine themselves to showing the different drugs and pre- 
 parations, but they enter into very minute details of their 
 natural history and characters ; so that the student cannot 
 learn the properties of bees' wax without being entangled in 
 the ditficulties of entomology, or the nature of isinglass, with- 
 out learning the hard names used in ichthyological classification. 
 The same observations apply to chemistry. It is a science 
 fully as attractive as botany, and medical men are apt to spend 
 too much time in its pursuit. Some very pertinent observations 
 on this subject have at different periods appeared in the Medical 
 Gazette, to which I refer you : they are conceived in a spirit of 
 good sense and sound judgment, and you will find them well 
 Avorthy of an attentive perusal. I grant that it may appear very 
 like a paradox to say, you need not know much practical 
 chemistry. But if you go to a reputable druggist with money 
 in your pocket, he will furnish you with all the chemicals you 
 have need of, excellent in their kind, and prepared with 
 scrupulous exactness. So far as chemicals are required for 
 medicinal uses, you can have them all of the best description. 
 But it will be said, that without an accurate and extensive 
 knowledge of chemistry you cannot prescribe. This is an 
 assertion to which I cannot assent. A very limited knowledge 
 indeed of chemistry will enable you to ascertain what sub- 
 stances are compatible with each other, and a small share of 
 attention will prevent you from making any important mis- 
 takes. Besides, you are all aware that many of our best 
 prescriptions contain incompatible ingredients ; and that many 
 compounds, which would be sneered at by the mere chemist as
 
 24 CLINICAL MEDICINE. 
 
 heterogeneous and absurd, prove decidedly efficacious in medi- 
 cine. Granting that a certain degree of chemical knowledge is 
 requisite, it does not follow that you should be scientific and 
 accomplished chemists. It is not necessary that you should 
 dive into all the arcana of the science, or have your memories 
 loaded with atomic numbers, symbols, and equivalents. 
 
 Let me repeat with respect to chemistry what has been 
 already observed concerning botany. Students should attend 
 one or two courses of this science as preparatory to the study of 
 medicine, and during the period of that study they may attend 
 another, in order to keep up and improve their knowledge ; but 
 they should never allow chemistry to cause them to absent 
 themselves from the hospital for a single day. Theoretical and 
 philosophical call for your attention, less than animal and 
 pharmaceutical chemistry. 
 
 But you are told that you may be called on to decide questions 
 of medical jurisprudence, which demand an accurate knowledge 
 of chemistry; that you will be required to test poisons, and 
 detect them when accidentally or purposely mixed with food or 
 drink. What should you do in such cases ? Why, do not 
 undertake any investigations of the kind, refuse to make them, 
 refer them to those who are competent to the task. Where 
 will you find a man engaged in the practice of physic fully 
 capable of deciding such questions ? What practising physician 
 or surgeon is competent to enter at once upon an investigation 
 of this nature ? I have lectured some three or four years on 
 medical jurisprudence, and have bestowed a good deal of atten- 
 tion on the subject, and yet if called on to decide a case of 
 poisoning, I would refuse, and say I was incompetent to the 
 task. What then is to be done under such circumstances ? 
 This is a matter of deep importance to society. It is of the 
 utmost consequence that the wretch who poisons should not 
 escape, and that the innocent should not sutler. It therefore 
 behoves the Government to employ and pay persons capable of 
 deciding such questions. Then, and not till then, will the task 
 be duly performed, and the decisions be such as the public can 
 look up to with respect and confidence. 
 
 So far with respect to a knowledge of chemistry as connected 
 with the choice and prescription of medicines, or the analysis of 
 poisons. As to any benefits derived from analytical chemistry
 
 PKELIMINARY EDUCATION. 25 
 
 in solving the problems of vital action, or elucidating the functions 
 of the various organs in health and disease, they may be said to 
 be few and unimportant, and inconclusive. Few and scanty, 
 indeed, are the rays of light which chemistry has flung on the 
 vital mysteries. I am not aware that it has revealed any of the 
 master secrets of the organism, or detected the sources of those 
 important aberrations from normal action which we are called on 
 to study every day and every hour. Chemistry has failed most 
 remarkably in revealing the arcana of life ; and notwithstanding 
 all her boasted discoveries, we are still very little in advance of 
 those who practised the healing art some centuries ago. Chemists, 
 the ablest of their class, have bestowed the most minute and 
 unwearied attention on the analysis of fibrin, and gelatin, and 
 albumen ; and what have they discovered ? Simply this : that 
 substances so apparently distinct in their vital relations, and 
 so difterent, or even opposed, in their physical properties, are 
 analogous compounds ; that there is scarcely any difference in 
 their elementary composition ; and that their atomic constitu- 
 tion is nearly identical. How long have chemists laboured in 
 attempting to detect the cause of animal beat ! How" many 
 experiments have been made for the purpose of ascertaining the 
 eflect produced on the air by respiration ! How many able and 
 ingenious men have sought a chemical explanation of the 
 difference in point of colour between arterial and venous blood ! 
 All these investigations have proved indirectly useful, but none 
 of them have revealed the secrets sought ; and we are still in 
 profound ignorance of the powers which direct and modify the 
 unceasing operations of the laboratory over which life presides — 
 that mysterious influence, which, like the Deity from whom it 
 emanates, is invisible, inscrutable, incomprehensible. 
 
 So much for the light which chemistry has shed on the vital 
 actions, and on the nature of organised compounds. There are, 
 to be sure, one or two instances in which a rough examination 
 of some organic products is necessary — as, for example, of the 
 urine, in certain cases of gout, gravel, and dropsy. But even in 
 these instances a few simple rules will suffice, and sufficient 
 information may be obtained by one moderately acquainted with 
 chemistry. Generally speaking, the chemical knowledge requi- 
 site for the study of disease is very limited ; and those who are 
 engaged in the practice of medicine are well aware, that cases
 
 26 CLINICAL MEDICINE. 
 
 demanding an accurate or extensive knowledge of chemistry are 
 of extremely rare occurrence. 
 
 Let me now advert to a serious inconvenience which the 
 chemists have imposed upon the medical world. They have, it 
 appears, not only assumed to themselves the privilege of naming 
 our medicines, but also of changing those names every five or 
 six years. One of my ablest and most diligent pupils (Mr. 
 Moore) has taken the trouble of drawing up a table, showing the 
 various names which have been successively bestowed on each 
 substance since the days of Lavoisier. I have the table here 
 before me, and I find that most chemical substances have, in 
 the space of fifty years, undergone at least five changes. Of 
 course, as the march of chemistry progresses with accelerated 
 speed, we may give our nomenclators credit for an increased 
 tendency to revolutionize the chemical vocabulary, and conclude 
 that they will change them five times within the next fifty years. 
 In 1890, how will a man be able to recognise a substance whose 
 name has undergone ten mutations ? I am anxious to dwell on 
 this defect as being pregnant with perplexity and confusion. It 
 would almost seem as if some enemy to our profession had 
 invented the chemical nomenclature for the purpose of retarding 
 the advance of practical medicine. Of what use will a practice 
 of Physic, published in 1800, be to the reader who peruses it in 
 1900 ? We all know how easily the mind of man is deterred 
 by difficulties ; how few there are who wdll submit to the labour 
 of becoming genealogists in chemical names. 
 
 Many and able men foresaw this difficulty from the beginning, 
 and raised their voices against the adoption of names meant to 
 convey a knowledge of the chemical composition of mineral and 
 saline medicines. Bostock and Murray have both written ably 
 on this subject, and I regret much that their advice has not been 
 duly weighed and considered. In practice, many serious incon- 
 veniences arise from this vacillating state of chemical nomen- 
 clature. Every apothecary knows that mistakes occur from day 
 to day, owing to the shifting character of chemical nomenclature, 
 and I think it is time for us to bestir ourselves, and make a 
 stand against the useless and dangerous innovations of the 
 chemists. We should come forward boldly, and declare that we 
 will not be made the slaves of names. Compare our last 
 Pharmacopoeia with its immediate or penultimate predecessor,
 
 PRELIMINARY EDUCATION. 27 
 
 and the difficulties a physician has to encounter will he ohvious. 
 Are we to be perpetually called on to learn new names ? Must 
 an artificial method of forgetting become even more necessary 
 than a memoria technica !^ Must my prescriptions of 1818 
 be translated into a new language, if I wish to employ them 
 now ? It is time, then, to protest seriously against having our 
 memories loaded with a polyglot vocabulary, and our ideas con- 
 fused by a perpetual alteration of names. I do therefore assert 
 boldly, that much benefit would accrue from reverting to the old 
 system, and employing names which have no direct reference to the 
 substances. I do not see any reason why we should not continue 
 to call calomel, calomel ; nor do I see any advantage in giving it 
 any of the numerous modern appellations supposed to indicate 
 its chemical constitution. I am glad to find that this view of 
 the subject has the able support of Dr. Sigmond. He quotes 
 Professor Brande as being of opinion that " it is very inconvenient 
 to alter pharmaceutical terms according to the changes in 
 chemical nomenclature ; and as physicians in practice have not 
 come to accord in this particular, I can see no objection to the 
 term calomel for one substance, and corrosive sublimate for the 
 other, pharmaceutically speaking. It is a subject of deep regret," 
 adds Dr. Sigmond, " that the attempt should be made, because 
 it never can be successful ; for some chemists will call calomel 
 jjrotocliloride, others chloride, and some denominate sublimate 
 ■percldoride, others deutochloridc, and others again, as does the 
 Koyal College of Physicians, bichloride.'' How remarkably cor- 
 roborated is the truth of these remarks by the fact, that at 
 present nearly all chemists agree in considering calomel a 
 suhchloride, and corrosive sublimate a chloride of mercury ! 
 
 "What is the use of a name ? To designate a thing — to point 
 out any substance, so that when we call for it we may get it, and 
 nothing else. This is all that is necessary. When you tax a 
 name beyond this, you exceed the limits of ordinary language, 
 and demand too much. The old names for our medicines are 
 not inferior, in this respect, to the modern ones imposed on us 
 by chemists. Tartar emetic is a good and significant name, 
 and yet I perceive it has been altered several times before, and 
 again in the last edition of the Loudon Pharmacopoeia. Why is 
 it that the preparation of bismuth used in pyrosis has been three 
 times changed in my own memory ? What alterations have not
 
 28 CLINICAL MEDICINE. 
 
 the carbonates of iron and of alkalies undergone ? As for Fowler's 
 solution, corrosive sublimate, Mindererus' spirit, and ^thiop's 
 mineral (all good standard names), they are now nearly extinct, 
 and have been superseded by a new generation likely to prove as 
 unstable as their predecessors. Many other substances have 
 undergone the same fate. Where will the revolution stop ? 
 Indeed we seem, at the present moment, as far removed as ever 
 from the establishment of a stable system of chemical names. 
 The progress of investigation discloses almost daily new views of 
 the mutual relations between the elements constituting compound 
 bodies ; the atoms associated together are divided and subdivided 
 into new groups, and, consequently, the symbolical representa- 
 tion of every compound assumes a new configuration, and is 
 subdivided by brackets, altering their places with each successive 
 advance of science. The labours of Bornsdorff and Hare already 
 threaten the nomenclature of Berzelius, and the chlorure jjlf^tino- 
 sopotassiqtie of the latter, now considered as a compound of 
 chloroplatinous acid and the chlorobase of potassium, must then 
 be called chloroplatinite of potassium. 
 
 In a retrospect of the progress of chemistry for the years 1846 — 7, 
 published by Mr. Sullivan in the number of the Dublin Quarterly 
 Journal of Medical Science for February, 1848, at page 243 is the 
 following paragraph: — "Thus,NaO, SO3 + lOAq, would be natan- 
 qfimvasue ; 2NaO, HO. PO5 + 24 Aq, would' be jenatan-alan- 
 apun-weso; NH4 0, AL O3, 4SO3 + 24Aq, one of the most com- 
 plicated formulge, would be atolan-telmin'OJaJin-iDeso, a word 
 which is certainly longer than ammonia-alum, but shorter than 
 crystallized sulphate of ammonia and alumina, and even than 
 the formula, which has eighteen syllables when read, while the 
 new name has only ten." If such names be ever introduced into 
 our Pharmacopoeia, I fear we must get over some of the abori- 
 gines of the South Sea Islands to teach us hosv to pronounce 
 them ! 
 
 If chemical names are still to be formed with the view of 
 expressing chemical composition, there is no end to the compli- 
 cation and length at. which they must arrive. If they express 
 composition, it is worse than useless were they to do so incom- 
 pletely. A name whose structure designates the nature of the 
 thing named must, in chemistry, to be serviceable, designate it 
 with perfect accuracy. Professor Kane has analysed, in one of
 
 PRELIMINARY EDUCATION. 29 
 
 his very able papers, a crystalline substance obtained by boilinf^ 
 the white ammonia subnitrate of mercury with solution of 
 ammonia. Suppose this substance to be introduced into the 
 Pharmacopoeia, how can it be named in conformity with the 
 principle which attempts to make each name expressive of the 
 composition of the matter named *? Its composition is stated by 
 Professor Kane to be — one atom of nitrate of the oxide of mer- 
 cury, _2)Z«s two atoms of oxide of mercury, j;^«s one atom of amide 
 of mercury, plus two atoms of the nitrate of the oxide of ammo- 
 nium, 2^1 lis two atoms of the oxide of hydrogen. Even if the 
 ingenuity of chemists had surmounted the difficulty of inventing 
 a name capable of expressing the nature, number, and mode of 
 aggregation of the above elementary atoms, is it probable that a 
 name, so gifted, would be of a length manageable by either the 
 tongue or the memory ? Is it certain that future experiments 
 may not unfold new views concerning the arrangement of the 
 constituent atoms, and thus nullify the old, by requiring the 
 adoption of a new designation ? 
 
 The following apposite remarks on this subject are extracted 
 from a review of Dr. Gregory's Chemistry, in the London 
 Medical Gazette for October 3, 1845. The reviewer, in noticing 
 some of the new organic substances described, and the meta- 
 morphoses which they undergo, says, " Clever as this exposition 
 is, we fear that it will be as unintelligible as Coptic or Sanscrit, 
 not only to practitioners, but to the present race of students, 
 who are apt to look very closely to what concerns them in their 
 examinations. There is, however, this consolatory reflection, 
 that the examiners would themselves have to go to school a"^ain 
 before they attempted to ask questions upon one half of the 
 subjects introduced into this volume on Organic Chemistry. 
 Without intending any disrespect to the examiners of the Uni- 
 versity of London, or the Apothecaries' Society, we do not think 
 that there is one among the whole body who could describe 
 oft*-hand the symbolical differences between the Oxalate and 
 Oxamate of the Oxide of Methylc (p. 397), the composition of 
 chloro-phrenisic acid (p. 511), or the construction of cinnamic 
 acid from cinnamyle ! The candidates for the diploma are 
 therefore safe for the present ! 
 
 " We agree with the author that scientific chemistry has been 
 too much neglected in this country ; but it is questionable whether
 
 30 CLINICAL MEDICINE. 
 
 a taste for it can be revived by the introduction of a cumbrous 
 nomenclature founded on hypothetical postulates — -whether, 
 indeed, the student will not be discouraged by finding the pi»o- 
 perties of substances drowned in symbols and formula?. This 
 appears to us to be a defect in the work before us. We turn 
 over the pages, and we continually meet with rows of symbols 
 and formulae, as well as names, with which it would be a matter 
 of despair to charge the memory. Dr. Prout long since entered 
 a protest against the barbarism of Liebig and Wohler's new 
 terms, and he expresses himself by no means satisfied that the 
 doctrines on which they are founded are satisfactorily established. 
 The remarks on this subject made by another eminent English 
 chemist (Brande) are so apposite that we shall here quote them. 
 ' The nomenclature which, among the continental chemists, is 
 creeping into organic chemistry cannot, I think, be too strongly 
 protested against by all who are engaged in teaching chemistry. 
 Neither arrangement nor nomenclature are of much importance 
 to those who have advanced far into, and are familiar with, the 
 more complicated details of the science ; but to the student, the 
 capricious and hypothetical terms which are in vogue are either 
 unintelligible, or, what is worse, are calculated to mislead and 
 embarrass.' " 
 
 In order to exemplify how much physiology and pathology 
 are indebted to the researches of chemists, I beg to quote at 
 length from the Quarterly lleview, June, 1842 (pp. 99 and 
 121). 
 
 " Professor Liebig applies the name of metamorplwsis to 
 those chemical actions in which a given compound, by the 
 presence of a peculiar substance, is made to resolve itself into 
 two or more compounds, e.g., sugar by presence of yest, into 
 alcohol and carbonic acid. 
 
 "Now, putrifying animal matters will cause sugar to ferment 
 as well as yest : explanation, the ferment or exciting body is 
 invariably a substance in an active state of decomposition, and 
 therefore its particles in motion ; this motion is communicated 
 to the particles of the body to be metamorphosed, and is sufficient 
 to overturn their very unstable equilibrium, and .to cause the for- 
 mation of new and more stable compounds. Liebig explains the 
 action of certain medicines and poisons on the human body in 
 the same way — thus there are many medicines and poisons
 
 PRELIMINARY EDUCATION. 31 
 
 which produce a very marked efi'oct without their elements 
 taking a direct share in the changes which ensue ; those hodies 
 originate, as it were, in action, which is subsequently propagated 
 from particle to particle ; they are uniformly substances in a 
 state of change, and appear to act on the blood as j-est does on 
 a solution of sugar. In this class appear miasms, contagions, 
 and the similar sausage poison of Wiirtemberg ; the latter is 
 an excellent example. Sausages, made in a peculiar way, 
 are much used in that country; when ill-prepared, they 
 become poisonous, and their effects are invariably fatal : the 
 patient gradually dries up into a sort of mummy, and after 
 weeks or months of misery death closes the scene ; but there is 
 no poisonous substance to be detected in the sausage. It is, 
 according to Liebig, in a peculiar state of fermentation, which 
 is not checked by the action of the stomach, and which, unfor- 
 tunately, is communicated to the blood ; it never ceases until 
 every part capable of solution has been destroyed, and death of 
 course must follow. Miasms and contagions act on the very 
 same principle, and the reason that all are not affected by them 
 seems to be, that they require the presence of a peculiar com- 
 pound in the blood, which enters into decomposition, and when 
 the whole of this peculiar matter is destroyed, the disease dis- 
 appears. If there be much such matter, the case is severe ; if 
 little, the case is mild; and apparently in many contagious 
 diseases, the jjcculiar decomposable matter, once destroyed, can 
 never he renewed, so that these diseases occur hut once." 
 
 Such is Professor Liebig's theory of poisoning and contagion 
 — a theory which, though it comes to us recommended by the 
 abilities of the first organic chemist of the ago, and sanctioned 
 by his anonymous but able reviewer in the Quarterly, can 
 nevertheless be easily proved to rest on almost as many assumed 
 as proven facts. Thus how can Liebig so positively assert that 
 there is no poisonous substance in the fatal sausages ? True it 
 is that no chemist has yet insulated such a substance; but 
 Liebig knows better than any one else, how profoundly con- 
 cealed any particular animal principle may be, by being mixed 
 with a great variety of other animal principles. Thus how long 
 did sugar, in the blood of diabetic patients, elude the searches 
 of chemists ? and yet they were looking for a principle with 
 whose chemical qualities they were already accurately acquainted.
 
 32 CLINICAL MEDICINE. 
 
 How mncli more difficult of detection must the poisonous prin- 
 ciple be, which exists in so compound a body as a Wlirtemberg 
 sausage ? Besides, what chemist was ever sure that he was 
 actually analysing a poisonous sausage ? Here a special diffi- 
 culty lies, for hitherto there has been discovered no a priori 
 method of distinguishing a poisonous from a wholesome sausage 
 until both have been eaten ; that is, too late for analysis. How 
 long has the poisonous quality of ergot of rye been known ? and 
 yet the principle to which its effects are owing, though often 
 sought, has been only lately insulated. 
 
 It is obvious, therefore, that Professor Liebig's main example 
 of his new pathological explanation is not by any means proven, 
 and consequently it is unnecessary to follow him into the regions 
 of fancy where he has been enticed by a specious and seductive 
 analogy. Pathology will cease to be a science when the study 
 of facts gives i:)lace to such reveries as the above-cited passage 
 contains — relative to miasms, contagions, mild cases, severe 
 cases, diseases occurring but once in life, &c., &c., &c. And 
 yet I am sorry to say that one of our most distinguished lec- 
 turers. Dr. Watson, has, in his published lectures on the 
 Practice of Physic (volume 2, p. 667, 1st edition), fully adopted 
 these opinions. 
 
 In order to give the reader some idea of what Dr. Watson 
 considers to be "distinct conceptions," and "lights supplied by 
 a theory,'^ I beg leave to quote from the doctor's lecture the 
 following paragraphs : — • 
 
 " Moreover, the light supplied by this theory gives distinct- 
 ness to our conceptions respecting certain deviations from the 
 regular course and type of these diseases ; which deviations are 
 not uncommon. 
 
 '* Thus the symptoms which precede and usher in the erup- 
 tion are sometimes slow, halting, and irregular in their progress ; 
 appear, and then recede, and re-appear, so that we are in doubt 
 what is about to happen, until at length the disease declares 
 itself in its decided and authentic form. 
 
 "We may suppose this to depend upon some tardiness or 
 interruption of tlie process whereby the virus is (to use the 
 ancient term) concocted. 
 
 "Again, the series of combination of symptoms that mark 
 the specific disease is sometimes, as I stated before, incompleie.
 
 PRELIMINARY EDUCATION. 33 
 
 We have the eruption of measles without the catarrhal symptoms ; 
 the sore throat without the rash of scarlet fever. Anil experience 
 has found that, where the malady is thus imperfectly developed, 
 the protection it confers against its own recurrence is also in- 
 complete. To explain this douhle failure, we may reasonably 
 infer a corresponding defect in the series of changes which the 
 poison tends to produce in the mass of the blood. 
 
 " Glandular enlargements and chronic abscesses are frequent 
 sequeUe of these exanthematous disorders. They may be con- 
 sidered to represent the dregs of the reproduced virus, which 
 has been imperfectly eliminated from the system by the usual 
 channels." 
 
 Very few observations are called for by these surmises of Dr. 
 Watson ; and certainly the learned doctor is rather guarded in 
 his expressions, thus admitting that though he has given his 
 adhesion to Liebig's theory, yet he seems to view the deductions 
 to which it leads with considerable distrust. Indeed it is diffi- 
 cult to rest satisfied with reasoning which not only assumes 
 gratuitously a certain thing to be the cause of a certain effect, 
 but considers it a corroboration of that assumption, that whereas 
 the effect is irregular in its progress, ive may suppose the cause 
 is so likewise. 
 
 It is still a greater triumph of logic to infer that, because a 
 disease is incomplete, we gain anything towards the establish- 
 ment of the true nature of its cause, by saying that we may 
 reasonably infer a corresponding defect exists in the cause 
 itself. To me the whole line of argument appears delusive ; 
 and as to the last paragraph, concerning glandular enlargement 
 and chronic abscesses, it seems that Dr. Watson's conclusion 
 involves a contradiction, for he attributes to the virus itself, and 
 that by virtue of its chemical action, the production of several 
 exanthematous diseases, each specifically distinct, and indeed as 
 different from each other as an acid from an alkali, while to the 
 dregs of the reproduced virus he attributes sequelae — those 
 glandular enlargements and chronic abscesses which so fre- 
 quently appear after small-pox, scarlatina, or the measles. 
 According to this hypothesis, three different animal poisons, 
 all acting chemically, produce at first three difi'erent diseases, 
 and at last the same disease. With regard to this hypothesis, 
 I may further remark, that when a brewer takes a certain 
 
 VOL. I. 3
 
 34 CLINICAL MEDICINE. 
 
 quantit}' of sweet wort, puts it in a vessel, and adds a given 
 portion of yest* to it, he knows that if be simultaneously fills in 
 the same way fifty similar vessels, the process of fermentation 
 will produce in each thirty times as much yest as was originally 
 added to the wort. But when the virus of small-pox is intro- 
 duced into the blood of fifty individuals, is a multii^lication of 
 the small-pox matter thus proportioned to the quantity of blood 
 in each ? It certainly is not ; a fact conceded by the sup- 
 porters of Liebig's hypothesis, but which they try to evade by 
 saying that the particles of the blood which are susceptible 
 of this particular decomposition and metamorphosis exist in 
 different proportions in different individuals. 
 
 This method of ratiocination is as inconclusive as it is novel, 
 and may be aptly termed, arguing not in but outside of a circle. 
 
 The following quotation, taken from the Provincial Medical 
 Journal, contains a condensed but very accurate analysis of 
 Liebig's theory of heat, and the pathological inferences which 
 necessarily appear to flow from it : — 
 
 " The carbon and hydrogen of food, in being converted by 
 oxygen into carbonic acid and water, must give out as much 
 heat as if they were burned in the open air. The only difference 
 is, that this heat is spread over unequal spaces of time ; but the 
 actual amount is always the same. The temperature of the 
 human body is the same in the torrid as in the frigid zone. 
 But as the body may be considered in the light of a heated vessel, 
 which cools with an accelerated rapidity the colder the sur- 
 rounding medium, it is obvious that the fuel necessary to retain 
 its heat must vary in different climates. Thus, less heat is 
 necessary in Palermo, where the temperature of the air is that 
 of the human body, than in the polar regions, where it is about 
 90° lower. In the animal body, the food is the fuel ; and, by a 
 proper supply of oxygen, we obtain the food given out during 
 its combustion in winter. When we take exercise in a cold 
 atmosphere, we respire a greater amount of oxygen, which implies 
 a more abundant supply of carbon in the food ; and, by taking 
 this food, we form the most efficient protection against the cold. 
 
 * We are glad to find Dr. Watson adhering to the old spelling of this word. He 
 spells it as De Foe spells it in his Robinson Crusoe. ; this authority is probably as 
 good as any the writer in the Quarttrly Jievltiv could bring forward in support of his
 
 PRELIMINARY EDUCATION. 35 
 
 A starving man is soon frozen to death : and every one knows 
 that the animals of prey of the arctic recjions are far more vora- 
 cious titan those of the torrid zone.^^ Our clothing is merely an 
 equivalent for food ; and the more warmly we are clothed, the 
 less food we require. Were we to go destitute of clothes like 
 certain savage tribes — or if, in hunting or fishing, we were 
 exposed to the same degree of cold as the Samoyedes — we could 
 with ease consume 10 lbs. of flesh, and, perhaps, a dozen tallow 
 caudles into the bargain, as warmly clad travellers have related 
 with astonishment of those people. Then could we take the 
 same quantity of brandy or blubber of fish without bad effects, 
 and learn to appreciate the delicacy of train oil. 
 
 " We thus perceive an explanation of the apparently anomalous 
 habits of difterent nations. The maccaroni of the Italian, and 
 the train oil of the Greenlander and the Eussian, are not 
 adventitious freaks of taste, but necessary articles fitted to 
 administer to their comfort in the climates in which they have 
 been born. The colder the region, the more combustible must 
 the food be." 
 
 It is, I must confess, quite new to me that our clothing is 
 merely an equivalent for food, and the more warmly we are 
 clothed the less food we require. Take the well clad and 
 warmly clothed country squire, and compare the quantity of 
 food he devours with that which is consumed by his ragged 
 labourers, and it may be asserted that the balance will be as 
 much in favour of the squire's food as of his raiment. The 
 voracious Samoyedes referred to, however barbarous in their 
 manners, are an extraordinarily warmly clothed race, and the 
 semi-putrid fat and blubber of whales agrees with the stomach 
 
 * I cannot guess how everybody comes to know all this ; for my own part, I think 
 it may be maintained that a Bengal tiger, or Cape hyssua, requires, in proportion to 
 its size, quite as abundant rations as any of the arctic carnivora ; and as to the vultures 
 of Hindostan and Persia, where on earth, in air, or in water, can be found such glut- 
 tons ? Neither do I think that any one (not to say everybody) would be prudent in 
 counting on the abstinence of a shark, even within the tropics ! Although religious 
 ordinances prevent the Hindoos from eating beef, yet both they and the Arabs 
 occasionally devour mutton in astonishing quantities. Those who ride over the 
 Pampas, in South America, at the rate of luO miles a day, exposed to a burning sun, 
 subsist entirely on boiled beef and water, without a particle of vegetable food of any 
 kind, and yet they attain to an extraordinary condition, and capability of enduring 
 violent and long continued exertion. Liebig"? theory must be very ductile, if it can 
 explain how it happens that an exclusively animal diet agrees with man quite as well 
 at the equator as within the arctic circle.
 
 36 CLINICAL MEDICINE. 
 
 of the Laplander as well in the heat of summer as in winter. 
 In the arctic and cold regions of the earth man is driven by 
 necessity to subsist on animal food, which is supplied to him by 
 the unfrozen depths of the ocean, for in those inhospitable regions 
 vegetable life is almost a stranger, and therefore it is that the 
 Laplander, the Greenlander, and the Samoj^ede subsist almost 
 exclusively on animal food. In the expeditions of Franklin, 
 Parry, and Boss, our countrymen braved all the rigours of an 
 arctic Avinter on the same food which they were in the habit of 
 consuming in milder climates ; and if it be true, as stated in the 
 above passage, that in the animal body the food is the fuel, and, 
 by a proper supply of food, we obtain the oxygen given out by 
 its combustion in winter ; if this be true, it is strange that there 
 is no record of its being found necessary to give our sailors more 
 food during the extreme cold than at other periods. 
 
 Facts are wholly inconsistent with many of Liebig's allega- 
 tions. All hunting tribes of mankind, whether in northern, 
 temperate, or tropical regions, subsist chiefly on animal food. 
 This is true of the North and South American Indians, and it is 
 true of the Hottentots, and indeed our travellers relate prodigies 
 of gluttony enacted by the latter ; for when, after a long fast, 
 they suddenly obtain abundance of game, they will sit up the 
 whole night occupied in cooking and devouring steak after steak 
 unaccompanied by a morsel of vegetable food, and at such times, 
 so indefatigable are they in the business of eating, that the party 
 which over night had tightened their famine girdles to the last 
 hole, have enormously distended abdomens on the following 
 morning, — this, too, in the heat of Africa, where certainly no 
 additional fuel was required for supporting the animal tempe- 
 rature. If Liebig's theory be correct, that animal food is 
 peculiarly adapted to cold climates, how comes it that the most 
 voracious carnivorous animals abound in the hottest regions of 
 the earth ? The Bengal tiger, and the African lion, and the 
 boa constrictor of South America, together with alligators and 
 crocodiles of the Nile, the Ganges, and the Oronooko, all subsist 
 solely upon animal food; and, on the other hand, among the 
 whale tribe it is observable that they abound in every variety of 
 oceanic temperature, where the appropriate animal food occurs, 
 and the same observation applies to fishes in general. Take the 
 antelope and the gazelle of Africa, which would shiver from cold
 
 PRELIMINARY EDUCATION. 37 
 
 (luring the warmth of an English summer, and comjiare them 
 Avith the reindeer, that bears with impunity, and that for months 
 together, a temperature far below zero, and how can we explain 
 the difference by Liebig's theory, for they both subsist on 
 vegetable food ? Facts such as these are not merely irreconcil- 
 able with, but destructive of, that theory. 
 
 I would not be understood here as wishing to depreciate any 
 department of human knowledge. Far be it from me. Besides, 
 the attempt would be useless. But I am anxious that you 
 should concentrate all your energies on the proper objects of 
 medical pursuit, and devote the largest share of your attention 
 to those requirements which will render you good practitioners. 
 I have seen students led astray by false notions, wasting half of 
 the time which should be spent in hospital and by the sick-bed, 
 in wandering through the fields on botanical excursions, or 
 working in the laboratory, engaged in the solution of some un- 
 important problem. Now this is not what will teach them to 
 relieve suffering and cure disease. When I look round me, and 
 behold so many young gentlemen entering upon an honourable 
 and important profession, I feel that my responsibility is great. 
 I consider j'ou all as instruments of good or evil, and cannot 
 help being conscious that I should be guilty of a great crime, 
 did I not use every means in my power to render you able and 
 efficient practitioners. The teacher of clinical medicine, gentle- 
 men, occupies in every nation a post of heavy responsibility. 
 But when he happens to preside over the medical education of 
 those who resort to the wards of a metropolitan hospital — when 
 the metropolis is a British one, and the hospital destined to 
 send forth annually practitioners to every quarter of the globe — 
 to North and South America, to New Holland, to the Cape of 
 Good Hope, to the East and West Indies, and the countless 
 isles which, in either hemisphere, are visited by the British 
 flatr, then indeed does that teacher become himself an instru- 
 ment of good or evil to an extent which it is fearful to con- 
 template. 
 
 He who gives instruction to a clinical class in Berlin, Stock- 
 holm, Vienna, or Paris, has much to answer for, if he discharge 
 not his duties with zeal and diligence. Yet if he fails to make 
 his pupils good practitioners, their errors, however deplorable, 
 are circumscribed within comparatively narrow bounds, and
 
 38 CLINICAL MEDICINE. 
 
 limited in a great degree to their own countrymen. But the 
 British teacher sits in the centre of a circle far wider than 
 Sweden or Prussia, Austria or France ; his pupils are to be met 
 with practising in every climate, exercising their art in almost 
 every habitable region of the globe, and dispensing the blessings 
 of health to all races of mankind : — to the hardy white settlers 
 of Canada, the aboriginal red- skins of North America, the 
 Negroes of Jamaica, the Hottentots and Caffres of Africa, and 
 the countless tribes of Hindostan. 
 
 In truth, gentlemen, the British teacher of practical medicine 
 exercises an influence without parallel in importance and extent, 
 and his opportunities of benefiting or injuring his fellow-men 
 are incalculably great. If he neglect his duty, if he teach 
 erroneously, his negligence and his errors in practice are multi- 
 plied indefinitely, by means of those whom he ought to have 
 better instructed; the scene of his guilt — for it deserves no 
 better name — becomes fearfully enlarged, for there is no country 
 so remote that it may not contribute victims to the incapacity 
 of his pupils. But if, on the contrary, he works with zeal and 
 diligence ; if he labours conscientiously and perseveringly in 
 performing the important task he has undertaken, a compensa- 
 tion awaits him to which scarcely any member of any profession 
 can attain. Can any reward exceed in value the reflection that 
 he has assisted, materially assisted, in imparting practical 
 knowledge to multitudes of enterprising young men, who, year 
 after year, leave our hospitals to engage in the sacred duties of 
 the medical profession, throughout the M^orld ? Is it not a high 
 privilege to be enabled to combat death and conquer disease, as 
 it were by proxy, in so many different localities ? Can man 
 enjoy a purer, prouder, more gratifying reflection ? When I 
 hear that a favourite pupil who has acquired a solid stock of 
 practical knowledge in this hospital, has settled in any par- 
 ticular town or district, I cannot help feeling, on the part of my 
 colleagues and myself, that we have been the humble means of 
 conferring a blessing on the people entrusted to his care ; and I 
 cannot refrain from congratulating myself upon holding a situa- 
 tion which multiplies a thousand-fold our efforts to be useful, 
 and enables us to stretch forth our hands to heal men of all 
 nations and languages. The hero and the despot may extend a 
 sovereignty over distant regions — may exert an unlimited con-
 
 PRELIMINARY EDUCATION. 39 
 
 trol over millions of vassals — may dispense honours and rewards, 
 or inflict punishment and death : they may, like Alexander, 
 grieve at the narrow limits of a conquered world, and sigh for 
 other scenes of glory, hut they cannot chase away pain ; they 
 cannot bid the burning thirst to cease, or give back repose to 
 the sleepless ; they cannot impart feeling or motion to the 
 paralysed, or sight to the blind ; and, above all, they cannot 
 imitate that almost godlike function of the healing art, by which 
 man is enabled to recall to his fellow-man reason long banished, 
 and restore to society the hapless victim of insanity. 
 
 Gentlemen, the profession we have embraced is the noblest 
 that can engage the mind of man, — when diligently cultivated 
 and conscientiously practised ; but it requires great and perse- 
 vering industry to enable the student to master all the diffi- 
 culties that beset his path. Feeling this strongly, I have 
 trespassed perhaps too long on your attention ; but I thought it 
 my duty to lay before you, as fully as I could, those views which 
 I deemed best calculated for your adoption in the acquirement of 
 practical knowledge.
 
 40 
 
 LECTURE III. 
 
 ON THE PKOPER MODE OP STUDYING PHYSIOLOGY AND 
 MORBID ANATOMY. 
 
 It is quite evident that a knowledge of the functions and struc- 
 ture of the body in health is essential to him who undertakes 
 the treatment of disease, and hence physiology has always occu- 
 pied the attention of physicians. Physiology, however, may be 
 studied in very different ways, and with very different objects, 
 and, until lately, all those who were engaged in the cultivation 
 of this fascinating science, not contented with observing the 
 state of the different parts and tissues during health, the nature 
 and quality of the secretions, the mechanism and operation of 
 the different organs, sought to ascend from a knowledge of 
 effects to an investigation of causes, and after they had classi- 
 fied the more obvious phenomena of living bodies, endeavour to 
 ascertain, if not the very principle of life, at least those motions 
 and causes of motion which result immediately from the action 
 of the living principle. Having thus, as they conceived, obtained 
 •a more accurate knowledge of the conditions of health, they 
 proceeded to form general explanations of the causes of disease, 
 and frame general rules for their removal. This method, ap- 
 parently so philosophical, and possessing so many attractions 
 from the generality and simplicity of its application, has more 
 than any other circumstance contributed to retard the progress 
 of medicine. 
 
 Gentlemen, this is not only an ancient, it is also a modern 
 evil. We live among systems. It is true that the practice 
 founded on the mechanical, mathematical, chemical and humoral 
 physiologies, has been long since abandoned ; but the destruc- 
 tive system of Brown has but lately quitted the stage, where its 
 place is occupied on the Continent by those of Broussais and 
 Rasori, and in Great Britain by the system which derives all 
 diseases either from derangement of the digestive function, or 
 from inflammation.
 
 THE STUDY OF MORBID ANATOMY. 41 
 
 Physiology does not legitimately embrace the study of vital 
 actions, but merely aims at ascertaining and arranging their 
 effects. The important facts, which its study discloses, are per- 
 haps infinite in number. As long as we confine ourselves to 
 these, we advance at every stej?, and all is clear and intelligible ; 
 but the moment we attempt to inquire into the causes and modes 
 of vital action, we begin to retrograde, and all becomes hypo- 
 thesis and confusion. Thus, an examination of the organ of 
 sight, discovers a wonderful and beautiful optical arrangement, 
 calculated to form on the retina a picture of external objects, 
 exact both in its colouring and outline. The physiologist, ex- 
 amining with attention the different parts of the eye, and the 
 laws of their respective refractions, investigates the means by 
 which distinct vision is secured at different distances ; he com- 
 pares the human eye and its appendages with that of animals 
 Avhich live in water, those which soar into the highest regions of 
 the atmosphere, and those which burrow under ground. He 
 considers the eye of the mole — feeble, but protected against 
 injuries likely to be encountered in carrying on its subterrane- 
 ous works ; of the eagle — which, poised high in mid-air, selects 
 its victim from the distant pasture ; of the fly — whose micro- 
 scopic organ, with a range of vision scarcely exceeding the limits of 
 contact, distinguishes objects the most minute; and in all, he finds 
 variations in the optical instruments at once curious and intel- 
 ligible. But when he endeavours to advance further in his inquiry, 
 and tries to explain how an image painted on the retina produces 
 vision, whether by the means of undulations arising from the 
 rays of light and propagated along the optic nerve to the brain, 
 or whether because the retina is a nervous expansion, highly 
 organised and framed, so as to feel the coloured image painted 
 on it ; he is at once arrested in his progress by the barrier which 
 is everywhere interposed between physical and vital actions — 
 between the mechanism of the organs of sense and the mode in 
 which they produce ideas between body and mind. 
 
 But has he, therefore, gained no real knowledge applicable to 
 practical purposes, or has his time been merely spent in a pleas- 
 ing but useless study ? By no means. Being acquainted with 
 the mechanism and arrangement of the optical instrument, he is 
 often enabled to remedy its accidental derangements. By means 
 of a concave glass he corrects a too speedy, by a convex a too
 
 42 
 
 CLINICAL MEDICINE. 
 
 tardy, concentration of the rays of light. When the crystalline 
 lens becomes opaque, his knowledge of its connexions, nature,. 
 and position enables him either to remove it altogether, displace 
 it from the axis of vision, or to promote its absorption, and in 
 order to effect the latter purpose, he mechanically irritates it, 
 knowing by experience, that after such an irritation, the process 
 of absorption commences, although he is quite ignorant of the 
 connexion between mechanical irritation and this vital process. 
 He who inquires into the physiology of the brain and spinal 
 marrow can never discover the nature of nervous influence, or 
 the manner in which pressure on these organs destroys, or irri- 
 tation deranges, the motions of the voluntary muscles ; and yet 
 the entire treatment of cerebral or spinal diseases, whether spon- 
 taneous, or from the efiects of injury, is grounded on a knowledge 
 of this physical fact : without it, we could not estimate the value 
 or effects of morbid changes in the brain or spinal marrow. On 
 this reposes the rationale of the treatment of all convulsive, 
 paralytic, and apoplectic affections. 
 
 Although we know not the manner in which the eighth pair 
 of nerves superintends the respiratory process, although we 
 understand not how the phrenic nerves influence the motion of 
 the diaphragm, yet a knowledge of these facts led to a means of 
 relief for spasmodic asthma, and to the recovery of persons ap- 
 parently asphyxiated, by means of the galvanic stimulus passed 
 along the course of these nerves. Knowing that some of the 
 nerves, distributed to the face, are destined for sensation, while 
 others serve for muscular motion, in cases of tic-douloureux we 
 divide the sentient and not the motive nerves. In these, and a 
 thousand other instances, physical physiology supplies us with 
 information at once interesting and practical ; it would be still 
 easier to prove, as in the cases of Brown and Broussais, that 
 vital physiology, by involving us in the discussion of subjects 
 beyond the powers of our reason, never fails to entangle its 
 votaries in a labyrinth, amidst whose mazes they move without 
 progressing, and consume in idle speculations that time and 
 labour they ought to spend in the acquisition of useful know- 
 ledge. But I trust the period has at length arrived when 
 this error will be avoided ; for, on the whole, it must be 
 confessed that, in consequence of a wrong method of studying, 
 and a misconception of the true objects of physiology, this
 
 THE STUDY OF MORBID ANATOMY. 43 
 
 science has in many instances retarded the progress of practical 
 medicine. 
 
 Let us next consider the connexion of morbid anatomy with 
 practical medicine. Many have mistaken the end and object of 
 morbid anatomy, and there are not wanting some who even deny 
 its utility, while others again, in their zeal for its improvement, 
 have endeavoured to extend its limits so as to make it comprehend 
 and embrace in the explanations it affords, all the phenomena of 
 disease. It is not easy to determine which of these parties has 
 most injured the cause of practical medicine. Morbid anatomy 
 comprehends not merely decided and permanent structural altera- 
 tion, but embraces, so far as they are capable of being detected, 
 even temporary physical changes in internal organs. In order 
 justly to estimate its importance, we should recollect that the 
 hrst alteration in the texture of a part is not the cause but the 
 consequence of disease, for in every healthy organ the texture is 
 natural, and as every change of texture is produced in consequence 
 of derangement in the vital action of the vascular system of the 
 part, it is obvious that structural alteration must in the first 
 instance be always produced by functional derangement. Thus 
 the physical alterations which attend external inflammation, the 
 tumefaction, the heat, the redness are not the causes but the 
 consequences of disease. But in thus reducing them to the rank 
 of symptoms, do we diminish their importance ? Certainly not. 
 For being immediately connected, as effects, witJi the primary 
 cause, they prove the most useful of all symptoms, in enabling 
 us to ascertain the seat and progress of diseased action. In this 
 respect they possess a manifest advantage over the general or 
 constitutional symptoms. Thus, in cases of spontaneous gan- 
 grene, phlegmonous inflammation, or erysipelas, what practitioner 
 would be contented to draw his indications from the general 
 symptoms, disregarding the appearance of the affected part? 
 And yet this is exactly what those persons do, who refuse the 
 aid of morbid anatomy in the treatment of internal disease. 
 
 In external diseases, most of the physical changes in the 
 affected part can be at once recognised ; their diagnosis is there- 
 fore comparatively easy, and their treatment well established. In 
 internal diseases, the case is widely different, the physical altera- 
 tions are here beyond the cognizance of our senses ; and, in order 
 to ascertain their nature and situation, we must carefully com-
 
 44 CLINICAL MEDICINE. 
 
 pare the morbid appearances of internal organs, as revealed to us 
 by dissection, with the symi^toms during life. 
 
 Although alteration of structure is in the first instance pro- 
 duced by a disease in the vital action of the part, yet this struc- 
 tural alteration may itself become a new cause of mischief. Thus 
 the vascular system of the lungs, from some unknown cause, 
 assumes such a change of action as produces a deposition into 
 the pulmonary texture of various fluid and solid products, by 
 which the entrance of the air into its vesicles is prevented, and 
 the respiratory function, one of the most important of the body, 
 is thus considerably deranged. Again, whatever be the original 
 vital derangement which causes scirrhus of the pylorus, the 
 obstruction thus formed is a secondary cause of new and important 
 symptoms. 
 
 Another consideration, which enhances the value of morbid 
 anatom}^, arises from the fact, that when diseased action fixes 
 itself in any part of the bod}^ whether external or internal, and 
 there gives rise to physical alterations, experience teaches us that 
 the progress of the disease may be often arrested by removing 
 its effects. Thus, to recur to the example of external inflamma- 
 tion, the redness, the swelling, the heat of the part, are but 
 symptoms, and yet we find great benefit from the applications of 
 remedies capable of diminishing them : hence we leech, and 
 apply cold lotions, &c. 
 
 From all these considerations it is evident, that whenever 
 disease is attended Avith either a temporar}^ or a permanent 
 alteration in the tissue of an internal organ, it will be of the 
 greatest practical importance to ascertain the nature and extent 
 of that alteration, and the progress of practical medicine will be 
 exactly jw'oportioned to the accuracy with which this can be 
 accomplished. Thus, how much has the treatment of pectoral 
 diseases been improved by the application of auscultation and 
 percussion, — means which are only useful by enabling us to 
 ascertain the physical alterations induced by the disease, or, in 
 other words, the morbid anatomy of the afl'ected organ. Without 
 their aid, how trace the progress and follow the increase or 
 diminution of pulmonary inflammation ? — how demonstrate the 
 existence of dropsical or pleuritic effusion within the chest ? — 
 how detect latent pneumonia ? — how distinguish Avith certainty 
 pleurodjne from pleurisy ? I could prove the utter impossibility
 
 THE STUDY OF MORBID ANATOMY. 45 
 
 of distinguishing many cases of broucliitic from tubercular 
 phthisis without their assistance. I might refer to chronic 
 emphysema of the puhuonary tissue, a disease of great import- 
 ance, but actually unknown before the time of Laennec, who iirst 
 accurately described it in the dead body ; indeed, before the appli- 
 cation of percussion and auscultation, a perfect knowledge of this 
 derangement of the pulmonary structure in the dead body would 
 not have assisted our diagnosis, for how recognise it during life ? 
 I might bring forward dilatation of the bronchial tubes, another 
 disease wholly unknown before Laennec's time, and which, before 
 bis discovery, could not be recognised by the common method of 
 observation. I might enlarge on the great utility of attending 
 to the changes which take place within the chest in measles and 
 scarlet fever ; but the benefit resulting from an accurate ac- 
 quaintance with the morbid anatomy of the thoracic cavity is 
 now so generally acknowledged, that I shall rather choose my 
 illustrations from other classes of diseases. 
 
 Nosologists, until very lately, were agreed in attributing con- 
 siderable frequency to those cases of apoplexy and paralysis 
 which arise from serous effusion in the brain, or from a mere 
 functional inaction or debility of the cerebral and nervous 
 systems. This opinion was founded partly on speculative 
 grounds, and partly on inadequate and imperfect post-mortem 
 examinations, and in practical books, the symptoms supposed to 
 announce sanguineous, serous, and nervous apoj^lexy, were 
 dogmatically laid down. What was the consequence ? Most 
 disastrous, as I have had occasion to witness in some parts 
 of the Continent, where the elderly practitioners still adhered 
 to the practice founded on this false pathology. What can be 
 more melancholy than to see time wasted or misemployed in the 
 exhibition of .diuretics, given to promote absorption of serum 
 effused into the brain, or of strong exciting remedies, such 
 as arnica, camphor, &c., to overcome the nervous debility, in 
 cases where copious depletion by the lancet and purgatives were 
 urgently necessary. I do not deny that in some rare cases 
 serous effusion into the brain is the cause of death from apoplexy. 
 I have seen such an event supervene in chronic dropsy, but there 
 the termination was very sudden, and the previous history left 
 no doubt as to the cause ; but in the majority of the cases 
 formerly treated as serous or nervous apoplexy, a more careful
 
 46 CLINICAL MEDICINE. 
 
 examination would have detected marks of vascular excitement 
 or local inflammation, a subject I shall treat at large when on 
 the pathology of the brain. A similar error in morbid anatomy 
 led to a similarly erroneous practice in the treatment of hydro- 
 cephalus, and many cases of general and local dropsy. The 
 effusion occupied the sole attention of pathologists ; the marks 
 of preceding vascular excitement or inflammation escaped their 
 notice. 
 
 Time will not permit me to enlarge upon the light which 
 morbid anatomy, rationally pursued, has shed upon diseases of 
 the brain. It is sufficient to remark, that some of the most 
 important modifications of inflammation in that organ have been 
 only lately discovered, and it is only lately that a minute and 
 extensive examination of the different changes the brain under- 
 goes in disease, has begun to introduce a certain degree of 
 regularity and precision into a department where all before was 
 confusion and inaccuracy.^ 
 
 Examples of the utility of morbid anatomy might be brought 
 forward without number : — the discovery of local inflammation 
 being at times the cause of a disease in most of its symptoms 
 resembling common ague ; the use of the lancet in the cold 
 stage of ague, a practice which may be advantageously resorted 
 to in cases where each return of the fit is accompanied by a 
 recurrence of inflammation in a vital organ, as the lungs or 
 brain ; the connexion between inflammation of the mucous 
 membrane of the stomach, and some of those s^-mptoms of 
 fever formerly attributed to mere debility; the influence of 
 cerebral inflammation and congestion, in producing the symp- 
 toms formerly vaguely denominated typhus ; the low character 
 which fever assumes when accompanied by pneumonia (and 
 that, too, often latent) ; the symptoms which are produced by 
 follicular ulceration of the intestines, which so frequently occurs 
 in the course of fever ; the diagnosis between the pain produced 
 by neuralgia of the abdominal nerves, and that resulting from 
 structural diseases of the intestinal canal ; a more accurate 
 knowledge of the state of the mucous membrane in the diarrhoea 
 of phthisis, and in intestinal tympanitis ; the numerous improve- 
 ments in the treatment of diseases of the ear, which followed 
 Itard's investigations concerning the morbid anatomy of that 
 organ ; — these and many other discoveries, all replete with
 
 THE STUDY OF MORBID ANATOMY. 47 
 
 practical advantages, are the results of the attention of our 
 contemporaries to morbid anatomy. And, were I to appeal to 
 the records of surgery, I might bring forward examples, if not 
 more important, perhaps more evident and striking ; for the 
 invention and success of most capital operations depend on a 
 perfect knowledge of the structural derangements, the removal 
 or cure of which is attempted. Of this, examples suggest them- 
 selves on every side, but none is more striking than the one 
 devised by Dupuytren for the cure of artificial anus, the most 
 disgusting and loathsome malady to which human nature is 
 subject, and one deemed altogether incurable, until that excel- 
 lent surgeon, by a combination of profound pathological and 
 physiological knowledge, succeeded in planning and executing 
 an operation, that was alone sufficient to immortalize his 
 name. 
 
 The study of morbid anatomy, however, is attended with no 
 ordinary difficulties, and, when imperfectly understood, is liable 
 to lead to erroneous results, for it requires much candour, much 
 patience, and that experience which can be only acquired by 
 long continued practice, to enable us to judge concerning 
 diseased appearances. The power of accurately discriminating 
 in the dead body the traces of disease, cannot be suddenly 
 acquired, and so numerous are the various errors to which 
 superficial observers are liable, that much injury has thus 
 resulted to medical science, diseased appearances being in some 
 cases overlooked, and in others recorded where they did not 
 exist. Those who are aware how often the congestion which 
 frequently takes place immediately before or after death, in the 
 pulmonary tissue, and in the mucous membranes of the lungs 
 and alimentary canal, alters the physical properties of these 
 parts, so as almost exactly to simulate the vestiges of inflamma- 
 tion, will understand how it happens that in investigations con- 
 nected wdth the real or supposed diseases of these parts, facts 
 have been marshalled against facts, and observations arranged 
 against observations, until the path which promised simplicity 
 and order, terminated in perplexity and confusion. Hence the 
 doctrines of Broussais received so many corroborations, and 
 appeared to rest upon numerous series of undoubted and well 
 authenticated facts. 
 
 The morbid anatomist must of all things beware of seeing too
 
 48 CLINICAL MEDICINE. 
 
 much. He must avoid imposing on himself hy everywhere 
 seeing exactly what he expected to see, and above all things let 
 him not always force himself to see something ; for many 
 diseases proceed to a fatal termination without having produced 
 any evident morbid alteration. 
 
 When I come to treat of the pathology of the brain and 
 nervous system, I shall have occasion to advert to errors which 
 late authors have committed from too great an anxiety, on the 
 one hand, to reduce to a certain and definite system the morbid 
 appearances of the brain and spinal marrow, as connected with 
 their diseases, and, on the other, to find, in every case where the 
 cerebral or nervous functions had been diseased, lesions of struc- 
 ture to account for the symptoms. Tbus, to cite one of numerous 
 instances, I shall have occasion to prove that epilepsy and mania 
 often commence suddenly and violently, without the existence 
 of any organic alteration ; and, indeed, that organic lesions are 
 not necessarily connected with these formidable diseases, is 
 sufliciently proved by the occasionally sudden iiianner in which 
 they cease. Thus, a gentleman of great literary reputation was 
 many years a patient of mine before his death, which happened 
 in 1831, at the age of seventy. From the age of twenty-five to 
 fifty-five he suffered from violent and frequently recurring fits of 
 epilepsy ; after having continued for thirty years, the disease 
 ceased suddenly, without any assignable cause, and during the 
 last fifteen years of his life he had not a single fit. I shall 
 have occasion to show you how fine-drawn and how ill-founded 
 are the observations of those, who profess to account for every 
 nervous disturbance during life by cerebral lesions ; who pro- 
 fess to distinguish accurately, during life, inflammation and 
 irritation of the arachnoid or dura mater, from irritation or 
 inflammation of the brain itself ; who maintain that one series 
 of symptoms is produced by inflammation of the cortical, and 
 another by inflammation of the medullary substance ; who have 
 strainer] their eyes to discover, and their veracity to impose upon 
 us, proofs that inflammatory or other diseased states of certain 
 portions of the brain invariably caused similar afi"ections of 
 certain mental functions. These errors of some, even of the 
 most eminent French pathologists, it will be my duty to notice 
 from time to time ; but I am sorry to say that much more 
 unpardonable errors and misstatements have found their way
 
 THE STUDY OF MORBID ANATOMY. 49 
 
 into En^lisli and Irish publications on the pathology of the 
 brain, and which I shall be compelled to speak of hereafter. 
 
 Having made the preceding observations on the dangers which 
 arise from an ill-directed application of the studies of physiolog^y 
 and morbid anatomy to the practice of medicine and surgery, I 
 feel myself imperatively called on to present the other side of 
 the question to your view, in exposing the still more dangerous 
 doctrine advocated by those who depreciate the value of pathology 
 and morbid anatomy, as only instructive after the death of the 
 patient — and even then as not unfrequently calculated rather 
 to mislead than to advance the interests of practical medicine.* 
 
 It must be conceded that he who is only a'physiologist cannot 
 hope to cure disease, and that the mere morbid anatomist will 
 be often misled by post-mortem appearances — if he have not 
 attentively watched the progress of symptoms, and the effects of 
 medicines during life ; for, unless this be done, he will, as I 
 have already said, often mistake secondary for primary lesions, 
 will confound effects with their causes, and will refer to certain 
 alterations of structure that which had originated in a functional 
 disorder — a morbid state of parts very different from that which 
 is observed after death. But when, to an accurate knowledge of 
 physiology and morbid anatomy is joined an extensive observa- 
 tion of the progress of symptoms and the effects of therapeutical 
 agents, how much more certain and satisfactory will be our 
 practical decisions, and how much more likely our efforts to be 
 attended with success, than if we merely studied disease at the 
 bedside of the patient. In the latter case indeed we might 
 become expert nosologists, be accurately acquainted with certain 
 groups of symptoms, and even not unfrequently adopt the proper 
 method of treatment. These sj^mptoms, considered together, 
 we would call by a certain name, and hand down to posterity 
 this new acquisition of medical knowledge, perhaps clothed in 
 the garb of a dead language, and invested with the false dignity 
 of a learned tongue. But what have we really thus effected for 
 posterity? — Our followers read our definitions of disease with an 
 acquiescing admiration, and, sure of the efficacy of the remedies 
 we have recommended^ they go forth with an overweening con- 
 
 * The dangers above enumerated may be almost all avoided by institutions such as 
 the Dublin Pathological Society, founded in 1838, and by means of which morbid 
 specimens are exposed to an examination most likely to disclose their real nature. 
 VOL. I. 4
 
 50 CLINICAL MEDICINE. 
 
 fidence in quest of the group of symptoms we have described, 
 and when they have met with them they look upon their task as 
 already half accomplished, and promise a successful termination 
 of the disease. 
 
 " Tell me the name of the disease," was the motto of the 
 nosologist, " and I will tell you the remedy ; " but, gentlemen, I 
 will engage to tell you the names of a hundred diseases, without 
 your being able to name the proper method of treatment. I tell 
 you a man has dropsy, his limbs are anasarcous, water is ac- 
 cumulated in the peritoneal cavity, his urine is scanty, and his 
 thirst increased. Will you, from this very excellent nosological 
 definition, venture to prescribe for this case of dropsy ? For the 
 sake of the suffering patient and your own conscience, prescribe 
 not on such data. And yet I regret to be obliged to say, that 
 such a method of proceeding is by no means rare, nay, it is even 
 a matter of daily occurrence. But this case of dropsy wdll not 
 yield. Some other boasted specific hydragogue or diuretic is had 
 recourse to ; still the patient grows worse and worse, and finally 
 dies, but his friends are not discontented with the medical 
 attendant, who excuses himself by asserting that he has success- 
 ively resorted to every remedy which has been recommended in 
 dropsy; and in truth if you look over the list of medicines 
 exhibited in rapid succession, you will probably find that his 
 excuse is not unsupported by facts. But, gentlemen, these 
 cases in which everything has been tried are exactly those in 
 which nothing has been tried, in which medicine has followed 
 medicine, and each symptom of disease has indiscriminately 
 been the object of attack, until death approaches with accelerated 
 steps, and charitably closes a scene distressing to humanity, and 
 disgraceful to the cause — I was going to say — of science ; but 
 who will venture to give so ennobling a name to this pseudo- 
 practical knowledge, this worse than absolute ignorance ? 
 
 Gentlemen, I am not combating phantoms ; I do not, Quixote- 
 like, contend with imaginary giants ; no, gentlemen, what I 
 have described exists, the picture I have drawn has many an 
 original. But let us have done with this subject ; let us turn 
 to the gratifying considerations of the progress which practical 
 medicine is making under its parent sciences, — physiology and 
 morbid anatomy. 
 
 The reason of man is now more fully employed than at any
 
 THE STUDY OF MORBID ANATOMY. 51 
 
 former period ; a vast store of mental power, a vast mass of mind 
 is everywhere at work ; what formerly was vainly attempted by 
 the labour of a few, is now easily accomplished by the exertions 
 of the many. The empire of reason, extending from the old to 
 the new world, from Europe to our Antipodes, has encircled the 
 earth : the sun never sets upon her dominions, — individuals 
 must rest, but the collective intelligence of the species never 
 sleeps ; at the moment one nation, wearied by the toils of day, 
 welcomes the shades of night, and lies down to seek repose, 
 another arises to hail the light of morning, and, refreshed, speeds 
 the noble work of science ! 
 
 All inquirers commence, as it were, at the same point, as 
 the labours of their predecessors are equally at the disposal of 
 all, and consequently it is not surprising we should often find 
 them arriving together at the same end ; thence the number of 
 simultaneous discoveries of the same fact now so common. It 
 is not unusual to find the publications of France, Germany, 
 Italy, and England announcing the same discovery, and each 
 zealously claiming for their respective countrymen an honour 
 which belongs equally to all. I am sorry to say that, with some 
 splendid exceptions, this interesting and innocent controversy 
 has been carried on by other countries, while Ireland has put in 
 no claim for a share of the literary honours awarded to the 
 eftbrts of industry or genius. But, gentlemen, this state of 
 inaction, this state of mental torpor, is daily ceasing, and the 
 time has passed away when we could not point out among our 
 brethren any who had advanced the boundaries of the medical 
 sciences, and thus promoted the interests of humanity. 
 
 Now we can enumerate many whose names form a catalogue 
 the subject of congratulation for the present, of happy augury 
 for the future ; for cold must be the breast of him who will not 
 hail with joy every symptom of our country's literary regeneration, 
 — dead the feelings which are not elated at the boon conferred 
 on our species by every advance made by those who devote them- 
 selves to the grand, the noble pursuit of relieving the suflering, 
 of healing the diseased. But time bids me stop : I shall, 
 therefore, conclude by observing that the attention lately devoted 
 to the distinctions between real and pseudo-morbid aj^pearances, 
 the diligent cultivation of morbid anatomy by men not the 
 slaves of preconceived opinions, the abandonment of all systems
 
 52 CLINICAL MEDICINE. 
 
 whose baseless fabric rests on the phantoms of vital physiology, 
 the importance now justly attached to medical statistics, to the 
 study of endemic and epidemic maladies, to the operation of 
 morbid poisons : these, and various other circumstances, give 
 us reason to hope that the progress of the human mind in 
 investigating the means of preventing and curing diseases will 
 not be less rapid than it has been in the other departments of 
 knowledge. And thus it will be proved that if man has passions 
 which impel him to the destruction of man, if he be the only 
 animal who, despising his natural weapons for attack or defence, 
 has devised new means of destruction, — he is also the only 
 animal who has the desire or the power to relieve the suffer- 
 ings of his fellow-creatures ; the only animal in whom the 
 co-existence of reason and benevolence attests a moral as well 
 as an intellectual superiority.
 
 53 
 
 LECTURE IV. 
 
 THE PULSE. 
 
 The posture of the body has a very considerable influence on the 
 frequency of the pulse, even in healthy persons, and this influence 
 being still more marked in disease, it has been long a matter of 
 common observation, that the pulse is more frequent in the erect 
 than in the horizontal posture. This subject, not having been 
 investigated with the accuracy it merits, I have made it the 
 object of numerous experiments, the results of which appear in 
 some respects novel, and not devoid of practical utility. In 
 healthy persons the pulse in the erect posture is more frequent 
 than in the horizontal, by from six to fifteen beats in the minute. 
 If the pulse is but sixty, the difference is generally not more 
 than six or eight, and this difterence increases with the frequency 
 of the pulse at the time of the experiment ; thus if it has been 
 raised to 90 or 100 by moderate exercise, it is not unusual to 
 find the difierence twenty or thirty. 
 
 As the muscular exertion necessary to keep the body in the 
 erect posture might be considered as the cause of this greater 
 frequency, it became necessary to contrive means of placing the 
 body in any desired posture, without the necessity of muscular 
 exertion on the part of the subject of the experiment ; this was 
 eff"ected, and it was found that when the posture was changed by 
 means of such a contrivance, the difference between the frequency 
 in the horizontal and the erect posture was not less than when 
 muscular exertion was used. 
 
 I now anticipated, that if the body was placed with the head 
 down and the feet up, a still further retardation of the pulse 
 would be produced ; it was, indeed, natural to conclude, from the 
 preceding experiments, that posture alone was the cause of the 
 retardation observed in the body when placed horizontally, and, 
 consequently, that this effect would be augmented on still more 
 depressing the head, and that themaximum of retardation would 
 occur in the inverted position.
 
 51 CLINICAL MEDICINE. 
 
 I was inclined still more to this opinion, from considering 
 that in the inverted position the return of blood from the brain 
 being opposed by the force of gravity, that organ would neces- 
 sarily become the seat of sanguineous congestion, to a degree 
 capable of producing cerebral compression and consequent retar- 
 dation of the pulse ; for I cannot subscribe to the opinion of Dr. 
 Abercrombie and others, who maintain that the quantity of 
 blood circulating within the cranium never varies in quantity* ; 
 here, however, as it not unfrequently happens, preconceived 
 ideas were not found to accord with experiment, and no further 
 retardation of the pulse was thus efiected, neither, on the other 
 hand, was it accelerated bej'ond the number observed in the 
 horizontal position. This fact I verified by experiments made 
 in the presence of Dr. Jacob, Dr. Apjohn, and Mr. Harris. It 
 appears very singular, that a posture so unnatural as the in- 
 verted should produce no effect on the frequency of the pulse, as 
 compared with the horizontal, while a change from the latter to 
 the erect, both natural postures, is attended with so great an 
 acceleration. In the inverted posture, although the frequency 
 of the pulse is not altered, its strength is diminished, and often 
 very considerably ; it is not unusual, too, for it to become irre- 
 gular, a fact that may be explained by the greater weight of the 
 blood pressing back on the aortic valves, and thus necessarily 
 opposing an unusual impediment to its egress from the left ven- 
 tricle. The pulse is also evidently stronger in the horizontal 
 than in the erect posture, consequently its maximum of strcngtli 
 and minimum of /requeue i/ are attained together. This may, I 
 conceive, account more satisfactorily than has been hitherto 
 done, for the relief obtained by placing patients in the horizontal 
 posture, in order to avoid syncope, as, for instance, that produced 
 by venesection. In all other diseasesf in which I have investi- 
 
 * Dr. Burrowes of London has recently tested by experiment the truth of 
 Abercrombie's assertion, and he has satisfactorily proved that the quantity of the 
 blood circulating within the brain does vary under different circumstances, and is 
 especially influenced by the position of the body. I must refer to his excellent book 
 on the '■ Cerebral Circulation," published in 1846, for an account of the experiments 
 lie performed, and their results. 
 
 f Owing to the kindness of Mr. Sohan, I had an opportunity of examining the pulse 
 of a lady, aged 50, of strong constitution, in whom, i^ince her childliood, the frequency 
 of the pulse has never exceeded .'58 in a minute. It is the same in all postures, and its 
 frequency is not aitertd by the accesyion of febrile or inflammalory ajftctions. There is 
 no suspicion of any disease of the heart.
 
 THE PL'LSE. 55 
 
 gated this subject, I have found a difference between the fre- 
 quency of the pulse in the erect, sitting, and horizontal postures ; 
 hut in six cases of hypertrophy icith dilatation of the heart, no such 
 difference was "perceptible, altJioKf/Ji all these patients, at the time 
 of my making the experiment , were in a debilitated state, which.it 
 will just now appear, is that in which the changes indticed by 
 position arc the most remarkable. In four of these cases the 
 existence of hypertrophy with dilatation has been ascertained by 
 post-mortem examination, and of the other two, a man and a 
 woman, at present in the Meath Hospital, there can be no doubt 
 of the state of the heart in one of them, while in the other the 
 existence of hypertrophy is more than probable. For the sake 
 of accuracy I shall give the precise results of the experiments I 
 made before you on these six patients ; where two numbers 
 follow each other, they denote successive quarters of a minute, 
 that being first which immediately followed the change of 
 posture. 
 
 Doyle, ^^onda1/, Pulse in Horizontal position, 72 
 
 Sitting, 72 
 
 Standing 80 
 
 Tuesday. • Horizontal, 72 
 
 Sitting, 80, 72 
 
 Standing, 80, 72 
 
 Wedtiesdcnj, Horizontal, 72 
 
 Sitting, 72 
 
 Standing, 72 , 
 
 MaLONE, Pulse in Horizontal position, CO 
 
 Sitting, 7fi, 60 
 
 Standing, 7G, CO 
 
 In both of these cases, although the pulse during the first 
 quarter of a minute after the change of posture rose in frequency, 
 yet in the next it fell to the previous standard ; indeed, it may 
 be remarked that the greatest frequency, «7w'/'c muscular exertion 
 lias been used to assume the sitting or erect posture, is observ- 
 able in the first ten seconds which follow that exertion, both in 
 health, and still more remarkably in disease ; and consequently 
 the first quarter, or even half of a minute, should be rejected 
 where we wish to ascertain the permanent alteration thus pro- 
 duced. 
 
 In two other cases, Gorman and Be illy, in whom the hyper- 
 trophy and dilatation had attained to a great size, even this 
 acceleration during the first few seconds was scarcely perceptible,
 
 56 CLINICAL MEDICINE. 
 
 and the pulse almost at once resumed its former standard. The 
 same observation applies to the two patients at present (5th 
 July) in the hospital : in the man the pulse is 76, both when he 
 is lying or sitting ; in the woman, in whom certainly extreme 
 hypertrophy with dilatation exists, the pulse is constantly above 
 100, and the same in both postures. They have been both long 
 ill, and are much debilitated by the effects of the disease, and of 
 the remedies employed to mitigate its violence. 
 
 In these cases of diseased heart I have already remarked the 
 hypertrophy and dilatation were very great, and in five of them 
 certainly, and in the sixth probably, the left ventricle was 
 involved in the disease ; and I am inclined to think that this 
 permanence of the pulse in all positions of the body will be only 
 found to exist in such cases, and not in those where the hyper- 
 trophy and dilatation are less considerable, and consequently the 
 diagnosis more obscure. This circumstance may, it is true, 
 detract from the value of the observations so far as regards diag- 
 nosis, but certainly does not diminish its physiological interest. 
 I may observe, too, that should future observations prove that 
 hypertrophy of the heart is not always attended by this 
 permanency of the pulse, and I believe it is not, yet its occur- 
 rence in so many cases of that affection is nevertheless an 
 interesting fact. In pursuing this inquiry, it will be necessary 
 to compare the effects of posture in hypertrophy with and 
 "without disease of the valves of the heart and aorta. It would 
 be premature to inquire into the cause of this phenomenon, but 
 it immediately suggests itself to the mind, that it depends on 
 the increased strength and energy of the left ventricle when in 
 a state of hypertrophy, and which, in a great measure, place its 
 contractions, as it were, beyond the influence of these causes 
 which, in other diseases, attended with debility, and even in 
 many persons in health, enable a change of posture to produce 
 so remarkable an alteration in the frequency of the pulse. I 
 shall now give the results of a great number of observations, made 
 both in hospital and in private practice, upon this effect of 
 change of posture on the frequency of pulse in other diseases. 
 
 1st. That the greatest difterence occurs in patients labouring 
 under fever, or in a debilitated state in consequence of fever or 
 any other cause. It may amount to 30, 40, or even 50, between 
 the horizontal and erect postures.
 
 THE PULSE. 57 
 
 2clly. That this difference decreases after the first quarter of 
 an hour in most cases, but always remains considerable as long 
 as the same position is observed. 
 
 3dly. That in persons not much debilitated the difference is 
 much less than that stated above, and often does not amount to 
 more than 10. 
 
 4thly. That when the patient lies down, the pulse rapidly falls 
 to its former standard. 
 
 5thly. That in some the increase in frequency is greater be- 
 tween the horizontal and sitting posture than between the latter 
 and the erect ; while in others the contrary takes place, so that 
 generally the frequency in the sitting posture may be taken as a 
 
 VIC<(II. 
 
 ()thly. In persons convalescent from fever or acute diseases, I 
 find it is extremely useful to the physician to ascertain the com- 
 parative frequency of the pulse in the horizontal and in the erect 
 position. The greater the difterence, the greater is the debility 
 of the patient, and consequently the more guarded must his 
 medical attendant he in allowing him to sit up for any lenyth 
 of time, particularly if the pulse on his lying down does not 
 resume its usual degree of frequency. 
 
 In the case of a young man named St. Leger, who was lately 
 a patient at Sir Patrick Dun's Hospital, the variation of the pulse 
 in different positions of the body was very remarkable. He was 
 just recovering from fever, and exhibited a state of the pulse 
 which is not unfrequently observed under similar circumstances. 
 During his convalescence the pulse went on declining in fre- 
 (juency, until it sank to thirty-six in the minute. "When I made 
 him sit up in bed, his pulse began to rise rapidly, and, in the 
 space of a minute, was at sixty-four. When he stood up, it 
 became much quicker, hut grew so weak and indistinct that it 
 could not he felt at the wrist. On applying a stethoscope over the 
 region of the heart, I found that its pulsations amounted to 112 
 in the minute. Here is a very remarkable difference of pulse 
 depending entirely on change of position. With respect to the 
 number of respirations in this young man, I found that when 
 lying down they were only fourteen, but when he stood up they 
 were thirt}'. This is a very curious fact, and one which I have 
 not before observed. 
 
 In this case, the pulse was very little more than in the propor-
 
 58 CLINICAL MEDICINE. 
 
 tion of two and a half to one, as compared with respiration, 
 whereas it ought to he as four to one. We had another case at 
 the same time in the hospital, in which the pulse was 84, and 
 the respiration 42 in a minute ; and a third case in which the 
 pulse was 120, while the respiration was only 12. I have 
 myself seen one case in which the pulse was 60, and the respira- 
 tion 50. 
 
 This variation in the relations which the pulse and respiration 
 hear to each other, is principally observed in fever and pulmonary 
 disease. I am at present attending a lady in fever, whose pulse 
 was 120, and respiration 26, until within the last twenty-four 
 hours, since which respiration has increased to 40, hut the pulse 
 has sunk to 86. Now, is this lady's state improved ? Would 
 you prefer having her in her present or past condition ? For 
 my part, I will say that in such a case I would rather have the 
 pulse than the respiration accelerated. A quickening of the 
 breathing in fever, without any particular lesion of the thoracic 
 viscera, is always a proof that the muscular powers of organic 
 life have been injured ; that the diaphragm and respiratory 
 muscles are impeded in their functions ; and that the case is of 
 a dangerous character. 
 
 I do not know, gentlemen, any point on which accurate obser- 
 vations are more wanting than on the proportion between the 
 pulse and respiration in various states of the system, and in 
 various diseases. Facts upon this subject might be easily 
 collected, and would probably lead to curious and instructive 
 results. This would form an excellent subject for a monograph, 
 and might be investigated by any student who possesses atlen- 
 tion and perseverance, and has extensive opportunities for obser- 
 vation. Having touched upon the change in the frequency of 
 the pulse produced by alteration of position, I may here remark 
 that subsequent observations have confirmed the validity of the 
 diagnostic mark which I was the first to draw from this circum- 
 stance, in distinguishing functional from organic disease of the 
 heart. The general proposition may now be considered as estab- 
 lished, that in a debilitated person, when a sudden change of 
 position makes little or no difference in the frequency of the pulse, 
 we may conclude that the heart, or at least its left ventricle, is 
 increased in size and strength. 
 
 A dicrotous pulse is a prognostic sign of great value in
 
 THE PULSE. 59 
 
 many diseases. The following conclusions of mucli practical 
 importance are, T think, especially deserving your careful atten- 
 tion : — 
 
 In fever, a dicrotous pulse, which is at the same time hard, is 
 (I vcvji had symptom, if it last more than twenty-four hours : 
 when succeeded by epistaxis, and when it disappears after 
 moderate epistaxis, it is not bad ; it may in the same fever thus 
 appear and disappear several times, but each time it becomes 
 more serious. When, in fever, a hard dicrotous pulse lasts for 
 many days without any tendency to hemorrhage, the case, in nine 
 out of ten, ends fatally. 
 
 In hemoptysis, epistaxis, and internal inflammations, a very 
 hard dicrotous pulse sometimes occurs, which resists all treat- 
 ment, and portends a fatal issue ; no matter how much the other 
 symptoms may improve, so long as the pulse continues of this 
 character, the patient is in imminent danger. 
 
 To return, however, to what I was before speaking of— the 
 eftects of posture on the pulse — authors who have written con- 
 cerning the effects of digitalis on the organs of circulation, speak 
 of the difterence between the pulse, as observed in different posi- 
 tions, as an inexplicable anomaly, and seem quite ignorant that 
 a similar phenomenon occurs in a less degree in health, and in 
 an equal degree in many diseases. The fact appears to be, that 
 digitdlis, besides a great and debilitating influence on the whole 
 constitution, and particularly the nervous system, possesses a 
 jycidiar power of diminishing the frequency of the pulse; but it 
 is no anomaly that, in persons under its influence, debilitated 
 and nervous as they always are, when it is exhibited in doses 
 sufficient to retard the pulse, there should be a great difference 
 between the frequency of the pulse as examined in the horizontal, 
 the sitting, and the erect postures. 
 
 I need scarcely add, that I cannot advance even a plausible 
 conjecture concerning the reason why a change of position should 
 so afifect the frequency of the pulse. It is singular enough, how- 
 ever, that Humboldt should have observed something similar in 
 the hearts of frogs, cut out of the body, the great vessels being 
 tied. In one of these experiments the heart being placed on u 
 piece of glass horizontally, after twelve minutes its pulsations 
 had sunk to twelve in a minute. It was now suspended perpen- 
 dicularly, and after two minutes the number of pulsations rose to
 
 60 
 
 CLINICAL MEDICINE. 
 
 twenty.* Baer, in his work, Uber Entivicklung gcschicJite dcr 
 TMere, &c., has made the curious observation, that in hatching 
 eggs artificially, the chick in ovo soon dies if the egg he so placed 
 as to rest on either end. This circumstance, which he does not 
 attempt to explain, suggests an obvious and beautiful explanation 
 of the reason why eggs are not round but oval, as the latter 
 shape effectually prevents them from assuming a position in the 
 nest which would be fatal to the enclosed foetus. Some ova, as 
 for instance those of certain reptiles, are round ; but I know of 
 no bird whose eggs are not more or less oval. It would be 
 interesting to investigate the cause of this phenomenon, as also 
 to examine into the reasons of the remarkable difference which 
 exists between the effects of position on the human foetus i?i utero, 
 and on the human adult. In the former the inverted or semi- 
 inverted position of the body is the natural position ; in the latter 
 it is insupportable for any length of time. 
 
 Annals of Medicine, vol. iv. 239.
 
 61 
 
 LECTURE V. 
 
 THE GENERAL LAWS OF INFLAMMATION. MARSHALL HALl's 
 
 \TEWS. THE CIRCULATION OF THE BLOOD. — INFLUENCE OF 
 
 THE CAPILLARIES. 
 
 Gentlemen, — The general laws which govern inflammatory 
 action, and the relation which the vascular system bears to that 
 process, constitute a most important subject, which has engaged 
 the attention of the ablest pathologists and practitioners in this 
 country for the last half century. Since the date of the great 
 John Hunter's celebrated Avork, which gave the first impulse to 
 this investigation, many British and Continental writers have 
 applied their talents to the illustration of the changes the vas- 
 cular system undergoes during the progress of inflammation. 
 Thomson, Hastings, W. Philip, James, Burns, and Marshall 
 Hall have performed numerous and interesting experiments, 
 which throw light on its phenomena ; and we have gained much 
 by the assiduity and research they have displayed, in endeavour- 
 ing to illustrate a matter of such acknowledged difficulty. Still, 
 these authors appear to have adopted some erroneous views, and 
 to have misunderstood or overlooked some points of peculiar 
 importance. I shall first direct your attention to the opinions 
 of Dr. Marshall Hall, as explained in his lectures published in 
 the Lancet. Dr. Hall, possessing extensive acquirements and 
 high professional reputation, has cultivated the sciences of 
 physiology and pathology with distinguished zeal, and made 
 numerous experiments and microscopical observations, tending 
 to illustrate the subject of inflammation ; his opinions are, 
 therefore, entitled to serious consideration. 
 
 Speaking of the inflammatory process. Dr. Hall observes — 
 " I conclude that each cause of inflammation first induces such 
 a physical effect upon the internal surface of the capillaries, as 
 leads to the adherence of the globules of blood to it, and to 
 their ultimate stagnation. This stagnation augments as the 
 inflammation increases, and becomes more diff"used, and seems
 
 62 CLINICAL MEDICINE. 
 
 to constitute the essential character of the disease." Here you 
 perceive that he believes the tirst step to be the adherence of the 
 globules of the blood to the internal surface of the capillaries ; 
 the consequence of which is, that the calibre of these vessels 
 is considerably diminished, so that they become obstructed, 
 and cause a stagnation of the blood, which Dr. Hall looks 
 upon as the essential character of inflammation. 
 
 Further on he says — " I have never been able to detect any 
 action in the capillaries themselves. It is, probably, by the 
 partial obstruction to the circulation in the capillaries, that the 
 minute arteries become enlarged." Now observe, according to 
 this mode of explanation, the circulation being obstructed in the 
 capillaries, in consequence of the adherence of the globules of 
 blood to their sides, the arteries which supply them are pro- 
 pelling blood into obstructed vessels, and consequently become 
 enlarged or dilated — and why ? Dr. Hall says, " according to 
 the well-known law, that muscular organs augment, with obstacles 
 to their functions." Here I may, in the first place, observe, that 
 Dr. Hall is not warranted in looking upon the minute arteries 
 as muscular organs ; but, waiving this point, how can the law 
 alluded to explain the supposed increase in the capacity of the 
 minute arteries '? It might, indeed, explain the increase of 
 thickness in their parietes ; but is it not plain, that this very 
 addition to the thickness of the arterial walls, so far from 
 increasing, must diminish their calibre ? 
 
 Again, he observes — " It is probably by the fact of stagnation 
 that inflammation differs from blushing, eruptions, &c." Here, 
 you perceive, he introduces the qualifying terrn, " probably." 
 He continues — " It is generally asserted, that there is a series 
 of vessels which only circulate the serum of the blood, and 
 exclude the globules. This I believe to be mere hypothesis. 
 Vessels which only admit of single globules will aj)pear 
 colourless. In inflammation, the minute arteries which only 
 admit single globules at a time enlarge, and admit a greater 
 number, and then the red colour becomes visible." He goes on 
 then to say — "This enlargement of the blood-vessels is not 
 confined to the minute arteries, for the larger vessels in the 
 immediate vicinity of the inflamed part also become enlarged. 
 * * * * This is owing to the obstruction of the true capil- 
 laries." And he illustrates this by instancing the application of
 
 THE GENER.U. LA^YS OF IXFLAilMATION. G3 
 
 ji ligature to an arterial trunk, the consequence of which is, 
 that the collateral arteries of the part hecome increased in size, 
 in consequence of the ohstruction. We shall see afterwards, 
 how little this admits of heing proved. He says — " It is not 
 known how fur this enlarged state of the arteries extends from 
 the seat of the inflammation ; but, in the case of an inflamed 
 finger, the pulse at the wrist of the corresponding arm beats 
 }nore strongly than it does on the opposite one." 
 
 Such are Dr. Marshall Hall's views of the causes of inflamma- 
 tion, and the part which the capillaries and minute arterial 
 vessels play in that interesting process. You perceive, by the 
 brief outline I have given, that he attributes all the phenomena 
 to adherence of the blood-globules to the sides of the capillaries, 
 the consequent obstruction of these vessels, and the enlargement 
 of the minute arteries to which that obstruction gives rise. In 
 this view of the case the vessels are regarded as passive, and are 
 distended on purely mechanical principles ; in fact, their en- 
 largement is a mere dilatation. 
 
 Notwithstanding the respect I entertain for the learning, 
 ability, and industry of Dr. Marshall Hall, I must say that I 
 look upon his views as purely hypothetical, and am convinced 
 that he has arrived at unsound conclusions with respect to the 
 nature of inflammation. I shall not, however, take up your 
 time by going over his positions seriatim, and showing their 
 untenable character ; but shall proceed at once to lay before you 
 the opinions to which observation and reflection have led me, 
 and which have been taught for many years in my lectures on 
 the Institutes of Medicine. I shall not, like Dr. Marshall 
 Hall, attempt to explain the nature of inflammation, or deter- 
 mine its proximate cause, but shall content myself with en- 
 deavouring to arrange its phenomena, and point out their order, 
 and the share which the capillaries have in the inflammatory 
 process. Before entering on this subject, it may be necessary to 
 premise a few observations on the circulation in general. 
 
 The human body is composed of various parts, diflering in 
 their ultimate structure, chemical composition, and vital func- 
 tions. There is a very remarkable difl"erence between muscle 
 and areolar tissue, and between the latter and nervous tissue. 
 If we examine these parts more closely, we find them difl"ering 
 not onlv in their structural arrangements, but also in the
 
 64 CLINICAL MEDICINE. 
 
 ingredients or materials of which they are composed. In muscle 
 we find a large quantity of fibrin or colouring matter ; in carti- 
 lage, fibrous membrane, and tendinous substance, we find more 
 or less of the fibrous structure of muscle, but we do not meet 
 with fibrin, and tiiere is not the slightest trace of colouring 
 matter. The same blood furnishes materials for the growth and 
 nutrition of all, and conveys the nutrient particles to red and 
 white tissues alike ; but the white parts require not red blood, 
 and consequently receive none. Blood is a compound fluid, 
 which contains, as it were, the raw material of all the tissues in 
 a fluid state ; it is, in fact, flesh in a state of fluidity, and 
 destined to combine with and support the solid portions of the 
 frame. It is conveyed by the arteries all over the body, supply- 
 ing each tissue with its appropriate materials, and contributing 
 to its growth, sustentation, and repair, in the amplest, and yet 
 in the most economical manner. It does not enter the tissue of 
 every organ in that state which has been termed arterial, and 
 in which it appears as a fluid of a bright red colour. This is an 
 error of which nature is never guilty. It would be absurd if all 
 parts of the blood were carried to all the diff"erent tissues indis- 
 criminately ; and it would, moreover, be a great waste of vital 
 and mechanical power. The chief bulk of the blood is made up 
 of a transparent fluid or lymph, holding in solution various salts, 
 besides albumen and fibrin. The red globules are immersed, 
 but not dissolved, in this fluid ; and it appears from the observa- 
 tions of Mayer, that in the minute vessels the red globules 
 occupy the central j)art, surrounded by the transparent fluid. 
 The colouring globules are necessary for the nutrition of mus- 
 cular, mucous, and some other tissues ; and are carried by the 
 minute vessels wherever they are required. Every part of the 
 blood is required in a muscle ; fibrin and colouring matter for 
 its essential fibre ; albumen, fatty matter, etc., for its areolar 
 tissue and adipose membrane. The white tissues, as I have 
 already observed, receive no red blood, because they require 
 none — this is quite certain. Serous membrane, for instance, 
 contains neither fibrin nor colouring matter : at what point of 
 the circulation does the separation of the albumen take place ? 
 Is it an act of nutritive secretion which separates it from the 
 whole mass of arterial blood, or ai-e only the serous portions of 
 the blood carried to the white tissues ? " Serous vessels," says
 
 THE GENERAL LAWS OF INFLAMMATION. G5 
 
 Miiller, ** that is, blood-vessels which are too minute to allow 
 the passage of the red particles, and which are traversed, there- 
 fore, merely by the lymph of the blood, may possibly exist, but 
 they have not been demonstrated." 
 
 It seems to me, however, that it is by no means necessary for 
 blood-vessels to be too minute to allow the passage of red globules, 
 in order to make these vessels the vehicles of lymph alone. 
 The entrance of the globules into them will be determined by 
 other circumstances than their size. Already, as the blood 
 approaches the capillary system, the microscope detects a ten- 
 dency to a separation between its lymph and colouring globules ; 
 and no doubt their complete separation is effected by vital 
 agencies, independent of mere calibre. Hence we may explain 
 the fact, that no red blood seems to circulate in serous mem- 
 branes during health ; but the moment inflammation sets in, 
 the natural play of vital energies is deranged, and the red 
 globules, finding their way into unwonted channels, vessels 
 innumerable, before filled with a transparent lymph, and there- 
 fore not visible, start suddenly into view, in consequence of 
 their now containing an opaque and coloured fluid. 
 
 According to Hall, MuUer, and other physiologists, all minute 
 vessels contain red particles, which, however, are believed to 
 exert no influence on their colour, so long as these particles are 
 only admitted singly, and not several at a time. But when 
 inflammation comes on, according to Hall these vessels are 
 enlarged in consequence of obstruction, and then, admitting a 
 greater proportion of red globules, become visible. Now, 
 gentlemen, observe how suddenly, when the conjunctiva con- 
 nected with the sclerotic is irritated, numerous vessels appear 
 filled with red blood. Here is no time for the adhesion of 
 globules to the. internal surfaces of the vessels — no time for the 
 gi-adual enlargement of vessels previously too small for the 
 admission of the red globules ; no, the vessels existed there, but 
 they contained no red globules ; they admitted none, because 
 their admission would have proved unnecessary or injurious. I 
 do not deny the sudden enlargement of minute vessels ; on the 
 contrary, I believe in it most firmly, and am persuaded that the 
 minute and capillary arterial branches which, in health, admit 
 only lymph, may suddenly expand and increase iu size. I do 
 not, for reasons hereafter to be detailed, coEsider this expansion 
 VOL. I. 5
 
 6Q CLINICAL MEDICINE. 
 
 as passive ; and I believe that the red globules made little or no 
 part of the fluid previously circulating iu these vessels. Indeed, 
 it seems rather illogical to argue that, because red globules 
 might be present without imparting a perceptible red colour to 
 this fluid, that, therefore, they are present. When the contents 
 of a vessel are to the eye colourless, the onus prohandi lies with 
 him who asserts the presence of red colouring matter ; and, 
 until that is proved, in each particular case, the contained fluid 
 must be regarded as colourless. 
 
 As to the idea that lymph vessels could not exist unless their 
 diameter was smaller than that of the red globules, it is too 
 mechanical to deserve serious attention. The entrance of 
 animal matters into, and their propulsion along vessels, depend 
 most assuredly on other conditions than mere size of particles. 
 Indeed, Miiller expressly says — " In the most minute capillaries 
 which are not red, nor even yellow, but quite transparent, there 
 is merely a single line of red particles, separated by unequal in- 
 tervals, and from time to time no red j)articles are seen in these 
 colourless vessels ; but I have seen no canals through which red 
 particles did not occasionally pass, and which, therefore, 
 deserved the name of vasa serosa, and Wedemeyer, who says he 
 has seen such vasa serosa himself, confesses that some of the 
 red bodies traversed them from time to time." Here, then, we 
 have my argument confirmed by observation, and the fact proved, 
 that the entrance and jMssage of theredpariiclcs docs not depend 
 on the mere size of the vessels. 
 
 If we take an accurate view of the general circulation, we shall 
 find, then, that there is a great circulation of red fluid containing 
 the raw material of all the tissues ; which fluid, in its integral 
 state, is destined chiefly for the muscles of voluntary and 
 involuntary motion, into every part of which red vessels pene- 
 trate, and from which red blood returns. In fact, red blood 
 forms, as it were, a separate circulation, sweeping by the white 
 tissues, to which it merely detaches its uncoloured lymph, while 
 the red blood enters the capillaries of the red tissues. When 
 the minute arteries arrive at the parts where red blood is no 
 longer necessary, they send off smaller vessels which contain 
 only white blood, mixed with comparatively few, if any, red 
 globules, while the branches which carry red blood proceed to 
 join the corresponding veins.
 
 THE GENERAL LAWS OF INFLAMMATION. 67 
 
 I dissent from the common notion that the circulation of the 
 blood goes on very rapidly. It has been computed that the 
 heart expels from two to four ounces at each stroke of the left 
 ventricle ; and if we compute the quantity of blood in the body 
 to be from twenty to thirty pounds, we shall be led to con-elude 
 that the whole mass of the blood passes through the heart in a 
 very short space of time. This, however, is only taking a partial 
 view of the matter. It is true that there is a rapid central 
 current of red blood which accomplishes its circle through the 
 body in a very short time ; but a large proportion of the juices 
 of the body circulates very slowly through the tissues it supplies, 
 being detained in the capillary system for a considerable period 
 before it is returned to the general mass of the circulation. If 
 you compare the relative circulations of different classes of 
 animals, you will find that they differ considerably in the com- 
 position of their blood, as well as the rate at which it travels 
 through the system. Some animals have only white blood and 
 a capillary circulation — without any distinct arteries or veins. 
 Others possess vessels corresponding to arteries and veins — but 
 still no distinct organ like the heart. Finally, we arrive at a 
 higher class, which has not only distinct arteries and veins, but 
 also a heart. In each of these classes the circulation differs not 
 only in the properties of the circulated fluid, but also in the 
 velocity with which it travels. It is much slower, much more 
 sluggish in the lower than in the upper classes of animals. In 
 the same way, blood does not circulate so rapidly in tissues of a 
 low degree of organization (as bone, cellular and fibrous mem- 
 brane), as in the red parts of the body. It is, therefore, not 
 unreasonable to suppose that bone lives at one rate, fibre at 
 another, muscle at another, and nervous matter differently from 
 all. These views are of importance when brought to bear on the 
 subject of inflammation, and tend to explain the slow progress it 
 makes in certain tissues. 
 
 You must have perceived that, from the very beginning, I 
 have rejected the idea that the blood is propelled through the 
 system by the vis a tcrgo alone. If that were the case, the 
 current, though diminishing in velocity as it receded from the 
 heart, would be equable in vessels of the same size throughout 
 the whole system. But, in my opinion, the current of circula- 
 tion has many different rates, which depend not on the vis a
 
 68 CLINICAL MEDICINE. 
 
 tergo alone, or the distance from the heart and size of the vessels,* 
 hut on the vital energy of the vessels themselves. Hear what 
 Miiller says on this subject : " Wedemeyer's description of the 
 course of the blood in the anastomosing capillaries agrees per- 
 fectly with what I have observed. Sometimes, he says, the red 
 particles flow rapidly from one current into another, as if by 
 attraction. In other cases, the current which they join is very 
 rapid, hut they are arrested, as it ivere, in the collateral current, 
 and only from time to time find means of entering. Sometimes 
 a red particle is even thrown back out of the rapid current into a 
 weaker stream, and is again repelled. I have also remarked 
 that the same anastomosing branch between two currents some- 
 times receives the blood in one direction, and sometimes in the 
 other, and that variations of pressure and position and motions 
 of the animal are always the causes of these changes." 
 
 Such is Miiller' s testimony concerning the circulation of the 
 capillaries, and it bears me out in the assertion, that a very 
 great portion of blood (using that word in its most comprehen- 
 sive sense, and me&mng thereh j nutritive fluid), is comparatively 
 stagnant in the capillary system ; but I must confess that I felt 
 much astonished at Miiller's assertion, that " all these variations 
 in the capillary currents are, just as in currents of water on 
 irrigated land, merely the results of mechanical causes." 
 
 Having made these preliminary observations, we are now 
 better prepared to speak of the forces by means of which the 
 circulation of blood is accomplished. Most authors, and with 
 them Miiller, have stated that the motion of the blood in the 
 capillaries is wholly dependent on the heart's action. Now 
 these vessels are mere simple membranous tubes, and there is 
 no doubt that their membranous parietes must exert a strong 
 power of endosmosis and exosmosis, as shown by Dr. Rogers in 
 the American Journal of Medical Science. This power must 
 necessarily have a great influence on the motions of the blood 
 contained in the capillaries, causing a mutual interchange of 
 contents between vessels in contact with each other, and between 
 the vessels and surrounding parenchj^ma of the organs. Again, 
 it has been proved by Dr. Draper, in the same journal, that in 
 
 * The blood's velocity in its progress from the heart is diminished chiefly by two 
 physical causes, viz., increase of friction, and the increasing capacity (considered as a 
 whole) of the vessels which couta'n it.
 
 THE GENERAL LAWS OF INFLAMMATION. 69 
 
 capillary tubes and organic pores a motion of the contents must 
 result when the contained fluid possesses certain physical pro- 
 perties, from its mere contact with the internal surface of vessels 
 so minute. 
 
 Here, then, are two sources of motive power quite independent 
 of the heart's action, and which must necessarily influence, in a 
 most important manner, the capillary circulation : but this is 
 not all, for there resides in the small vessels connected with 
 the capillaries, whether minute arteries or minute veins, a 
 vital sensihilitij which enables them, by suddenly or gradually 
 changing their calibre, to increase or diminish the quantity of 
 fluid in any particular organ or tissue. 
 
 Facts in abundance may be brought forward in proof of this 
 assertion. When a fatty or fleshy tumour arises on any part of 
 the body, we have new vessels, as it were, created ; and there is 
 no reason to attribute their formation to anything like a dilating 
 vis a tergo. But the formation of the vascular system in the 
 foetus affords the strongest proofs. Here the smaller and more 
 minute parts are formed first, the development commencing with 
 the capillaries and extending to the minute arteries and veins,, 
 and then to the larger trunks ; until, at last, the heart is super- 
 added, at first of an elementary, afterwards of a complicated 
 structure. 
 
 The best account of the development of the vascular system in 
 the foetus is contained in Von Baer's work, published in 1837, 
 in Konigsberg.* He says (Part II. p. 126), that there is no 
 doubt that the blood is formed before the vessels. The forma- 
 tion of blood goes on in every part of the body, and, when 
 formed, it is put in motion by the agency of some unknown 
 cause which impels it in the proper direction, until it at length 
 reaches the central formation of blood, around which is developed 
 a tubular canal, afterwards to be further modified and changed 
 into the heart. In truth the first motions of the blood are 
 towards the heart, and consequently the first vessels formed are 
 the veins ; a fact in itself sufficient to disprove the hypothesis 
 that this motive power which presides over the circulation resides 
 exclusively in the ventricles of the heart. What do we find 
 occurring in the case of pseudo-membranes resulting from 
 pleuritic inflammation ? Exactly what takes place in the 
 
 * Uber En1wicklnv() Ceschichte der Tkiere, itc.
 
 70 CLINICAL MEDICINE. 
 
 development of the foetus. A large quantity of lymph is effused, 
 which at first has no vascular connexion whatever with the 
 parietes of the chest. After some time, however, the effused 
 lymph becomes organized, and vessels begin to form in its sub- 
 stance ; these extend gradually, and join the vessels of the 
 tissue with which the lymph lies in contact. Of this formation 
 of vessels of effused lymph there can be no doubt ; I have often 
 examined it with admiration, and it is likewise attested by 
 Andral. When a mass of lymph, effused into the pleural cavity, 
 is about to organize itself, and become vascular, a vast number 
 of red points make their appearance throughout the mass, and 
 are connected with very minute streaks having a vascular dis- 
 tribution. In this lymph, then, red blood is manufactured, as 
 in the fostal body at an earlier period of development, and vessels 
 are formed ; and sanguineous circulation no doubt exists. 
 
 These facts, I say, bear strongly on the question before us, 
 proving beyond a doubt that the vital properties of living matter 
 are capable of forming vessels, and of rapidly increasing their 
 size when formed. To account for the sudden increase in the 
 size of vessels belonging to an inflamed part, we must look to 
 this fact, and not rely solely on increased vis a tergo aided by 
 obstruction. 
 
 Now the whole of Dr. Marshall Hall's explanation depends on 
 these two causes — vis a tergo and obstruction. But I say that 
 vessels may be formed, multiplied, and enlarged independently 
 of these causes, and in consequence of an altered vital action of 
 the parts in which the process occurs. Let me refer to the case 
 of the impregnated uterus. In the unimpregnated state, the 
 womb is a small organ, with vessels and nerves so small as 
 scarcely to admit of being satisfactorily traced. What takes place 
 after conception ? It has now new and important functions to 
 perform, and it becomes proportionally increased in magnitude 
 and vital activity ; its arteries and veins become elongated and 
 enlarged ; its walls become thickened, and its nerves increased 
 in size. And yet we are told that this increase in the size of its 
 vessels depends on obstruction. Where does the obstruction 
 exist ? What proof have we that there is any increased vis a 
 tergo ? Will any of these principles account for the augmented 
 size of its nerves ? Tiedemann has proved beyond contradiction 
 that the nervous matter of the womb is augmented to a very
 
 THE GEXEKAL LAWS OF INFLAMMATION. 7l 
 
 remarkable degree during the impregnated state, and that 
 minute nervous filaments, scarcely discoverable with the aid of a 
 microscope, enlarge into bands visible to the naked eye. The 
 same thing occurs with respect to the minute arteries and veins ; 
 from being but barely perceptible, they become large tortuous 
 vessels, carrying an abundant supply of blood, and performing 
 their functions with extraordinary activity. I do not pretend to 
 ofier any explanation of these facts ; I merely place them before 
 you, and show you the analogy which exists between the vascular 
 and nervous development. 
 
 The vessels increase in size and capacity, so do the nerves ; 
 and the augmented size and capacity of both depend on the 
 same unknown cause. The nerves are developed in the same 
 order as the vessels, and, like the latter, they increase from the 
 circumference to the centre. Nay, I am persuaded that, did our 
 means of investigating the nerves possess the same advantages 
 as those we enjoy in the examination of the vessels, we should 
 find that, in inflamed parts, the nervous matter increases, in 
 many cases, as rapidly and to as considerable an extent as the 
 vascular. 
 
 So far, gentlemen, I have endeavoured to lay before you proofs 
 of the independence of the capillary circulation, a fact which I 
 have long since brought forward in my public lectures, and of 
 which I have written somewhat in detail, in my views of Dr. 
 Joerg's work on Atelektasis of New-born Infants. These views, 
 I am happy to state, have been further confirmed by Dr. Houston, 
 in his essays published in the tenth and twenty-fourth volumes 
 of the Dnhlln Journal. In these essays, which I recommend to 
 the attentive perusal of every student. Dr. Houston gives an 
 account of an extraordinary case of twins born of a healthy 
 young woman, between the seventh and eighth month of her 
 pregnancy. One of the children was, to all outward appearance, 
 perfect in every particular, and of the full growth of its age ; the 
 other, a female, and the subject of Dr. Houston's communication, 
 was a monster, of somewhat smaller size than its companion. 
 Both were alive at the time of delivery, but died almost im- 
 mediately after. There was a separate cord, and a separate set 
 of membranes, for each foetus. The abnormal one had neither 
 brain, heart, lungs, nor liver ; the kidneys were of enormous size, 
 nearly filling the abdomen, and extending to the apex of the
 
 72 CLINICAL MEDICINE. 
 
 cavity formed by the ribs. The umbilical vein, after quitting the 
 cord, descended between the abdominal muscles and peritoneum 
 as far as Poupart's ligament, and there opened into the external 
 iliac vein, which became enlarged in size at this point. From 
 this vein all the veins of the body were derived ; large branches 
 passed to the pelvis, thighs, and kidneys, and smaller ones to the 
 intercostal spaces, and the tumour which constituted the head. 
 These veins were devoid of valves, and terminated in the capil- 
 laries. From the latter, the arteries began by fine roots, and 
 gradually coalescing, united into a sort of aorta on the forepart of 
 the spine, which descending, divided into the iliac and hypogastric 
 arteries in the usual way. No communication existed between 
 the arteries and veins, except at their capillary terminations. 
 
 Such is the history of this very remarkable case, as given by 
 Dr. Houston. I have not time at present to enter into his 
 arguments ; but I think he has satisfactorily proved, that in 
 this instance the circulation was carried on without the aid of 
 the heart of the other twin (as supposed by Sir Astley Cooper), 
 or of the heart of the mother, and that it depended solely ou 
 the vital energy of the capillary and other vessels. 
 
 Another case of a monster without a heart, is related in the 
 American Journal of Medical Science, for February, 1838, by 
 Dr. Jackson, of Boston. This was likewise a twin ; and there 
 can be but little doubt that its circulation was quite independent 
 of any assistance derived from the heart of its fellow. 
 
 I have already spoken of the dilatation of the arteries and 
 veins of inflamed parts, as being produced by something very 
 different from mere distention ; and that it is not of a passive 
 but an active nature. That the larger vessels actively dilate, can 
 scarcely be doubted by any one who has observed the state of the 
 temporal arteries in phrenitis or apoplexy ; that the veins have a 
 similar power may bo observed on plunging the hands or feet into 
 a hot medium, whether moist or dry. Blisters applied to the 
 skin produce for the time increased size of the cutaneous veins ; 
 and sores on the leg may, when considerable and of long duration, 
 give rise to a varicose state of the veins. When a grain of sand 
 falls into the eye, how sudden is the redness — how numerous the 
 vessels which now appear gorged with blood ! This change takes 
 place in a few seconds, and, in my opinion, can be most satis- 
 factorily accounted for, by supposing that the capillaries and
 
 THE GENERAL LAWS OF INFLAMJIATION. 73 
 
 smaller vessels enjoy a wide range of size, if I may use the 
 expression, and are capable of enlarging or diminishing tlieir 
 calibre, according to the exigencies of the case and the state of the 
 circulation. That the large arteries and veins do so, is acknow- 
 ledged by all, and is proved by arterial trunks contracting on 
 their contents so as to maintain their proper tension, no matter 
 how much blood is drawn from an animal. The larger veins are 
 capable of a like contraction and expansion : can similar pro- 
 perties be denied to the smaller arteries, possessing, as they do, 
 an elastic coat proportionally thicker ? The vascular phenomena 
 attending a blush ought to have taught physiologists how rapidly, 
 how instantaneously, blood may be drawn to a particular part, 
 and may again desert it ; and that, under circumstances where 
 the i-'is a tergo could not determine a flow of blood to the part in 
 question, more than to any other in the body. Do we need 
 microscopic examinations on the capillaries of recently killed 
 animals to instruct us, when such phenomena offer themselves, 
 as it were, for the very purpose of illustration? When the child 
 breathes for the first time, the air admitted into the lungs gives 
 new energy to their capillaries, and at once the great current of 
 blood flows through the pulmonary arteries, deserting the ductus 
 arteriosus. In a seven months' child the latter passage is still 
 very large ; and yet, when the child breathes, its being open 
 eff'ects very little, if anything, towards diminishing the flow of 
 blood into the pulmonary arteries. 
 
 Here, again, we observe how arteries grow independently of 
 mere pressure from within ; for the j)ulmonary arteries and pul- 
 monary veins are enlarging themselves long, long before they are 
 called on to be channels for a quantity of blood at all proportioned 
 to their calibres. John Hunter observed the enlargement of the 
 arteries of an inflamed part, and his observations, and those of 
 others, have brought to light a periodical and remarkable increase 
 in the size of the vessels destined to promote the growth of the 
 stag's horns. Are we, in this case, to explain that enlargement 
 by obstruction, or by the vis a tergo ? It is impossible to do so ; 
 and we must, then, look to the vessels of the part itself for a 
 solution of the question. In such instances, as in the case of 
 the pregnant uterus, these vessels are endowed with this power 
 of growth and enlargement, quite independently of the general 
 vascular system, or the action of its centre — the heart.
 
 74 CLINICAL MEDICINE. 
 
 I am the more anxious to impress on you this view of the sub- 
 ject, as the hypothesis of obstruction has been adopted by many 
 iate writers, as explanatory of the local changes of circulation 
 attending inflammation. Thus Dr. Williams, in his admirable 
 lectures pubKshed in the Medical Gazette (No. 528), says, "We 
 cannot, in the present state of pathological knowledge, doubt that 
 the circulation through the inflamed vessels is, to a certain degree, 
 obstructed ; whilst, either as a consequence of this, or from some 
 co-operating influence, the vessels leading to the part become 
 dilated, and being thus more open than others to the pulse-wave 
 of the heart, they become the seat of that throbbing hard pulse 
 that has been mistaken for increased action of the vessels 
 themselves." 
 
 Now, gentlemen, you observe here that Dr. Williams expresses 
 himself doubtfully about the dilatation of the vessels being caused 
 by obstruction, and he even speaks of some co-operating influence. 
 We shall, therefore, content ourselves with having recited his 
 opinion on this subject. I must observe, however, that the 
 dilatation of the vessels, however caused, can on no principle 
 account for their becoming the seat of throbbing, and a hard 
 pulse : their being more open than others to the pulse- wave from 
 the heart could, at the utmost, only place them in the situation 
 of other arteries naturally of the size they have now attained to ; 
 but we do not find that such arteries throb, or have a hard pulse. 
 Arteries do not throb, or become the seat of a hard pulse, in 
 proportion to their size. That is not the fact ; and, consequently, 
 Dr. Williams's explanation cannot be admitted. 
 
 Dr. Wcatherhead, who has arrived at very nearly the same view 
 of the subject with myself, says, " The first effect of an excitant, or 
 irritant, applied to any part of the body, is to attract the blood to 
 the seat of irritation, and to quicken its current in the capillaries." 
 So far we perfectly agree. Here Dr. Weatherhead estimates the 
 vital energy of the vessels of the part at its true value, and does 
 not call in the aid of an increased vis a tcrgo to account for an 
 augmented determination of blood to any particular locality ; but 
 to what follows I cannot accede :— " If these efiects be kept up 
 beyond a certain period, or carried beyond a certain degree, the 
 excitation continues to attract as much blood as before, while the 
 power of the capillaries to forward it diminishes, by the exhaus- 
 tion ensuing from their prolonged over-action." There seems
 
 THE GENERAL LAWS OF INFLAJnLVTION. 75 
 
 but a weak analog}' in support of the assertion, that increased 
 vascular action must necessarily produce vascular exhaustion. 
 
 It may be objected to my view, that dilatation of an active 
 nature cannot bo conceded to the capillaries, whose coats are 
 quite thin and membranous ; but when the objects are so minute, 
 it is quite impossible to determine the physical or vital powers of 
 tissues ; and we should recollect that what is deficient in degree 
 may, in the case of capillaries, be made up by their number, 
 which is immense in every part of the body. Still, so far as 
 our observations do go, they seem to establish the property in 
 question.* 
 
 Miiller, whose opinion on all physiological questions is of the 
 greatest weight, has adopted on this subject an hypothesis which 
 appears to mo to be quite untenable. It is observable that the 
 first of the following paragraphs, which I quote from his work, 
 proves, that when writing it, he felt conscious that the remarkable 
 phenomena of vital tnrgesccnce are totally irreconcilable with 
 the theory, which denies any permanent circulating power but 
 that of the heart, and which asserts that "the motion of the 
 blood in the capillaries is wholly dependent on the heart's action ! " 
 Let us hear what he says concerning vital turgescence of the 
 blood vessels : — "Although it be denied that the circulation is 
 in any way aided by an attraction between the blood and the 
 capillaries, yet the existence of such an attraction or afiinity may 
 be admitted in the instance of the ' turgescence, turgor vitalis, 
 or orgasm,' observed to take place in certain parts of the body, 
 which are the seat of increased vital action, independently of the 
 action of the heart. This condition of turgescence is very evident 
 in plants : thus to the fruit-bud, which contains the impregnated 
 ovum, there is, as Burdach remarks, an afflux of sap : ubi 
 stimulus, ibi affluxus. 
 
 " The mutual vital action, or affinity between tlie blood and the 
 tissues of the body, which is an essential part of the process of 
 nutrition^ is, under many circumstances, greatly increased ; and 
 gives rise to an accumulation of blood in the dilated vessels of the 
 organ. It is seen, for example, in the genitals, during the state 
 
 * It is only this very year that physiologists have for the first time admitted that 
 the middle coat of arteries, besides elastic tissue, is provided with muscular fibre. The 
 discovery of this fact is due to the investigations of Henle, and has been confirmed by 
 the electro-magnetic experiments of Ed. and E. H. Weber. — Supplement to Miiller's 
 Physiology, by B;ily and Kirkes. 1848, p. 2.
 
 76 CLINICAL MEDICINE. 
 
 of sexual desire, in the uterus during pregnancy, in the stomach 
 during digestion, and in the processes of the cranial bones on 
 which the stag's antlers afterwards rest, at the time of the 
 repi'oduction of these parts. The local accumulation of blood, 
 with the dilatation of old, and the formation of new vessels, is, 
 however, seen most frequently in the embryo, in which new 
 organs are developed in succession by a process of this kind : 
 while, on the other hand, other organs, such as the branchiae of 
 the salamander and frog, and the tail of the latter animal, become 
 atrophied, and perish as soon as the vital af&nity which existed 
 between the blood and their tissues ceases to be exerted. 
 
 " The phenomena of turgescence have been supposed to depend' 
 on an increased action or contraction in the arteries. But arteries: 
 present no periodic contractions of a muscular nature ; and a 
 persistent contraction of the arteries, unless it were progressive 
 or vermicular, or aided by valves arranged in a determinate 
 direction, would be quite inadequate to produce a state of 
 turgescence in any part. 
 
 " To explain the state of orgasm of the uterus during pregnancy, 
 and of the bony processes which bear the antlers of the stag, we 
 must presuppose the existence of an increased affinity between 
 the blood and the tissue of the organ. This condition may be 
 excited very suddenly, in the instantaneous injection of the cheeks 
 with blood in the act of blushing, and of the whole head under 
 the influence of violent passions, in both of which instances the 
 local phenomena are evidently induced by nervous influence. 
 The active congestion of certain organs — of the brain, for example 
 — while they are in a state of excitement, is a similar pheno- 
 menon. 
 
 " If the organ which is susceptible of the increased affinity 
 between the blood and the tissue is, at the same time, capable of 
 considerable distention, tumefaction and erection take place."* 
 
 It will, I believe, be readily acknowledged that Miiller's 
 explanation is, after all, a mere hypothesis. Is this affinity 
 between the blood and the tissues of the body chemical ? or is it 
 a mutual vital action ? If the latter, then the vessels, they being 
 the ouhi tissues in contact irith the blood, are active, contrary to 
 liis previous hypothesis. As to the chemical explanation of a 
 blush, it surely docs not merit examination. 
 
 * Miillers Physiology. Translated by W. Baly, M.D, 2nd ed., vol. i. p. 238.
 
 THE GENERAL LAWS OF INFLAMMATION. 77 
 
 The facts referred to by Miiller in the above passage all tend 
 to corroborate the view I have adopted, and show that local 
 changes of nutrition, vascularity, and circulation may be quite 
 independent of the heart's action. 
 
 We must next turn our attention to the increase in size of 
 some of the larger arteries. 
 
 " Apply a ligature," says Dr. Hall, " to the principal artery of 
 a limb ; the circulation is then carried on by the collateral 
 branches, which become enlarged for this very purpose, and in 
 consequence of the obstruction." Now let us study the pheno- 
 mena a little more accurately, and we shall soon see how erroneous 
 is this explanation. 
 
 In the first place, what are the physical results produced by 
 tying one of the large arteries of a limb ? The vis a tcrgo, or 
 propelling power of the heart, continues just as before ; the 
 quantity of fluid or blood within the whole system of arterial 
 tubes is unchanged, while the forces to be overcome by the 
 circulating power remain also the same. In fact, all the general 
 physical conditions are unaltered after the ligature has been 
 applied, except that a portion of the blood can no longer enter the 
 tied artery. 
 
 Let us now investigate what effects this non-entrance of a 
 certain portion of the blood into its accustomed channel is likely 
 to produce on the rest of the arterial system. When the principal 
 artery of a limb is tied, the blood circulating in the remaining 
 arteries of the body and the other arteries of that limb is pressed 
 more strongly against the arterial parietes. But as the distend- 
 ing force resulting from this increased j)ressure is not confined 
 to any particular artery of the body, but affects all, more or less, 
 it is obvious that a power so extensively distributed and subdivided 
 can exert but little distending influence on any individual artery, 
 or, in other words, can tend but little to dilate any of the arterial 
 tubes. Now it is obvious, from the laws of hydrostatics, that 
 this increased pressure will be more exerted, in 'proportion, on 
 the main collateral arteries of the limb than on the smaller ; it 
 will, in truth, be scarcely sensible in the latter, and yet these 
 are the very arteries which enlarge first after the operation for 
 aneurism. The increase in the size of the arteries commences, 
 not where it ought to commence, if it depended merely on dila- 
 tation from increased pressure, viz., in the larger arteries and in
 
 78 CLINICAL MEDICINE. 
 
 the collateral branches close to the ligature, but it commences in 
 the smaller and more distant arterial ramifications. In addition 
 to the fact that a proportionally less pressure is thrown on the 
 smaller arteries, we must recollect that the latter have parietes 
 much thicker in proportion to their calibre than the larger , 
 branches. This is another material objection to Dr. Hall's 
 explanation of their increase in size. 
 
 What are the phenomena observed after applying a ligature to 
 an artery of large size, where a sufficient collateral circulation 
 may be supplied ? First, the sudden diminution of circulation 
 in the parts below the ligature gives rise to coldness and paleness 
 of the limb ; but in a few hours the circulation gradually returns, 
 the thermometrical temperature of the limb rises, and the activity 
 of the capillary system is greater than in the natural condition 
 of the limb. This excitement continues for some time, and then 
 diminishes to the ordinary standard of health. In eight, twelve, 
 or twenty-four hours, after the application of a ligature to the 
 main artery of a limb, we find the skin of the parts below the 
 ligature pale and cool, but in a few hours afterwards its tem- 
 perature rises, and it exhibits an evidently increased arterial 
 action. Now it is difficult to conceive that the main collateral 
 branches have been dilated in so short a space of time. 
 
 The mode in which the phenomena witnessed in this instance 
 are best explained, seems to me to be the following. When a 
 large portion of the blood destined for the supply of a limb is cut 
 off, all the tissues of a part so deprived receive a shock : the 
 muscles, nerves, capillary vessels — in fact, the vital functions of 
 the whole — are more or less affected. After some time, however, 
 the vital depression is followed by reaction, and this commences 
 in the smaller arteries and capillary system, its commencement 
 being marked by uneasy sensations, increase of temperature, 
 and arterial throbbing. The initiative of the restoration of 
 the circulation belongs to the extreme vessels, which take on 
 an increased action, and this is gradually extended to larger 
 arteries. These gradually augment in power, become enlarged 
 and distended, and at length the circulation of the affected limb 
 is restored to a state of efficacy, equal, if not identical with its 
 pristine condition. Now, you are told that the increased activity 
 of the capillary vessels in this instance is referred to the vis a 
 tergo operating through the anastomosing branches. This is a
 
 THE GENERAL LAWS OF INFLAMMATION. 79 
 
 l;ilse assumption. In the first place, the influence of the heart's 
 action, when the blood passes through small anastomosing 
 branches, and by circuitous courses, must be less powerful 
 than before the operation, when the main channels remained 
 pervious. The vis a tergo is therefore lessened, and yet the 
 capillary distention is greater than before the operation, or in 
 the sound limb. 
 
 In the next place, this argument is of more force, when it is 
 considered that the enlargement commences in the smaller, and 
 gradually extends to the larger vessels ; and also, that in some 
 cases the branches from the main artery, through Avhich the 
 blood must pass, do not become perceptibly enlarged. Thus 
 Mr. Hodgson, in his work on diseases of arteries, says, — " The 
 dilatation takes place principally in minute ramifications. The 
 trunks, and the mouths of the vessels going off above the place 
 of obstruction in the main artery, in several preparations, did not 
 appear larger than in their natural state, and in a few instances 
 only a slight dilatation was perceptible." From these facts it is 
 obvious that the vessels least under the influence of the heart are 
 the most dilated. But the most decisive proof is the return of 
 the capillaries and minute arteries to their ordinary size, at the 
 time when, the larger branches being dilated, the vis a tergo 
 should be more operative. Hence it would appear that the 
 power of distention resides in the arteries themselves, the irrita- 
 tion commencing in the capillaries, and being sympathetically 
 propagated to the larger vessels. This is further confirmed by 
 the fact, that, if an inflamed part, or a vascular tumour, be sup- 
 plied by several arteries, and one of them be divided, the others 
 will enlarge. 
 
 It is scarcely necessary for me to direct your attention here to 
 the phenomena which occur in the erectile tissues, as the corpora 
 cavernosa, &c. It cannot surely be maintained that the sudden 
 increase in the afllux of blood to these parts is owing to any 
 vis a tergo, or momentary augmentation of the propelling power 
 of the heart. No ; tissues of this kind enjoy the power of 
 attracting to themselves an increased quantity of blood, in virtue 
 of the vital power resident in them, and not from any peculiar 
 exertion of extraneous forces. In fact, the capillary vessels 
 enjoy the property of actively dilating, and drawing the blood 
 into them, and this appears to be one of the principal causes of
 
 80 CLINICAL MEDICINE. 
 
 the circulation. Of this there is abundant proof. It has been 
 observed in vivisections, that after the heart has ceased to act, 
 the capillary vessels remain distended, and appear to carry on 
 their functions as long as any blood is supplied to them from the 
 arteries. It has been also remarked, that the larger arterial 
 branches become first empty, then the smaller, and finally the 
 capillaries. Dr. Philip states, that he has observed the circula- 
 tion of the mesentery to continue for several minutes after the 
 heart had been excised. This is the true explanation of the 
 fact, that the arteries are so frequently found quite empty after 
 death. 
 
 One of the strongest proofs we have of the power which the 
 capillaries possess of drawing blood to themselves, is derived 
 from the phenomena observed in vascular tumours. If scratched, 
 or slightly wounded, these tumours frequently bleed to an 
 alarming extent ; while the division of the arteries which lead 
 to them, and the removal of the whole mass, is attended with a 
 comparatively small loss of blood. This is further exemplified 
 in the familiar operation of opening the temporal artery. If the 
 artery be only partially divided, and its connexion with the capil- 
 laries still to a certain degree maintained, it bleeds copiously ; 
 but if it be cut across, and the connexion wholly destroyed, it 
 ceases to bleed altogether. Professor Smith, of Philadelphia,* 
 amputated a leg below the knee, for dry gangrene of the foot and 
 ankle. The great arteries were found wholly altered in their 
 structure, being, as it were, converted into tubes of bone. 
 Although pressure was completely removed from the femoral 
 artery, and no means whatever were used to suppress the 
 hemorrhage, the quantity of blood lost did not amount to half 
 a table-spoonful. At the same time the action of the heart was 
 vigorous, and the pulse at the wrist of the ordinary strength 
 and fulness. Now in this case some blood must have been 
 passing through the tibial arteries before the operation, for 
 there was some circulation in the leg down as far as the ankle, 
 and the collateral arteries, or anastomosing branches, were not 
 enlarged. 
 
 * This fact is mentioned in a monograph wliich I received from Ameiica many years 
 ago. Unluckily I have mislaid it, and cannot call to mind the author's name. He 
 advocated views similar to those I have here attempted to establish, and to him I am 
 indebted for the argument derived from the placental circulation.
 
 THE GENERAL LAWS OF INFLAMMATION. 81 
 
 If we refer to the phenomena of wounds which engage 
 arteries, we shall find, as I have already stated, when 
 alluding to the operation of opening the temporal artery, 
 that the wounded artery of an injured limb bleeds much 
 more than the same artery of an amputated one. Hence it 
 is that branches which would pour out a large quantity of 
 blood, if merely wounded, sometimes do not require a ligature 
 at all, although their divided orifices open on the surface of 
 a stump. Another instance in which the attracting power 
 of the capillaries may be seen, is in cases where portions of 
 an amputated finger have again united, of which we have 
 several examples. In this case the fluids eff"used by the upper 
 cut surface are absorbed and circulated by the vessels of the 
 amputated tip. 
 
 But one of the most remarkable proofs of the position I have 
 laid down is derived from the circulation of the blood in the 
 placenta. In this instance the impetus which the blood possesses 
 in the umbilical arteries has been attributed to the vis a tergo 
 derived from the heart of the fffitus. But after the detachment 
 of the placenta, after the birth of the foetus, the pulsation in the 
 cord ceases ; first at the placenta, and then at the umbilicus of the 
 infant. After this period a section of the cord is not followed 
 by anything like the amount of hemorrhage which might be 
 expected from the division of vessels of such diameter, and in 
 many instances there is no loss of blood whatever. Now why 
 does the flow of blood cease in the umbilical arteries ? The 
 vis a tergo is as powerful after birth as before, and operates on 
 blood in tubes free from obstruction. It cannot be attributed to 
 cold, for the circulation continues in every part of the infant ; 
 nor to exhaustion, for the fcetus loses no blood, and its circu- 
 lation is now independent of the mother. Neither is it owing 
 to the action of the lungs, which are said to divert the blood 
 from the placenta, for although a greater portion of blood is 
 carried to the lungs, after than before birth, yet this would not 
 account for the total cessation of the circulation in vessels so 
 large as the umbilical arteries. The explanation, therefore, com- 
 monly given is not capable of being proved. From the facts 
 which I have brought forward, it would appear that the organic 
 vital actions of the placenta depend upon its own life, and that 
 when this body is detached from the uterus, it of course dies, 
 VOL. I. 6
 
 82 CLINICAL MEDICINE. 
 
 and the functions of its capillary system cease. The suction- 
 power of the small vessels then continues no longer to assist 
 the vis a tergo in carrying blood through the umbilical arteries, 
 and the circulation declines, first at the placenta, and finally 
 in the umbilical arteries, at their junction with the abdomen of 
 the foetus.
 
 83 
 
 LECTUKE VI. 
 
 INFLAMMATION. THE CAPILLARY CIRCULATION. 
 
 Gentlemen, — I have now laid before you at some length the 
 argaments derived from experiments and pathology in favour of 
 the capillaries having a direct influence on the circulation. 
 Those which may be borrowed from comparative anatomy are 
 still stronger. If we look to the vegetable kingdom, we shall 
 find that the force with which the sap — the blood of plants — 
 circulates in their vessels is very great. Hales and Dutrochet 
 have proved this by direct experiment. If a vine be cut down 
 in spring to the distance of three feet from the ground, it 
 throws out sap with such a force as to raise twenty- one feet 
 of water. In other experiments this power was found capable 
 of raising thirty-two and a half inches of mercury, or thirty-five 
 feet five inches and three-quarters of water ; and thirty-eight 
 inches of mercury, or forty-three feet three inches and one-third 
 of water. To effect this prodigious circulation, as it takes place 
 in plants, the force must be very great, for we know that it 
 is capable of raising from the ground a large quantity of water, 
 combined with nutritious principles, to the top of the loftiest 
 palm or forest tree — in fact to an altitude of one hundred and 
 fifty feet. 
 
 Now in what organs does this power reside ? There is no- 
 central organ in plants, nothing like a heart — nothing like laro-e 
 arterial tubes. How, then, is the ascent of the nutritious fluid 
 accomplished '? Let us study the phenomena for a moment, and 
 we shall find sufiicient evidence to satisfy ourselves that the 
 fluid circulating in each part of the tree is brought to it chiefl,y 
 hji the action of the vessel of the part itself. I do not mean to 
 deny the great power which the spongioles of the roots, acting 
 as capillary systems, exert in driving the fluids they absorb 
 through the tubular vessels of trees ; this power is no doubt 
 aided by the buds and leaves, whose capillaries, when acted on 
 by a proper temperature, discharge their vital functions with
 
 84 CLINICAL MEDICINE. 
 
 activit}', and are capable of drawing tlie sap to tlie extremities 
 of the branches. Thus in the case of a vine observed by 
 Richerand, one branch of which had crept into a smith's shop, 
 this branch remained in leaf, or rather threw out fresh leaves in 
 winter, while all the other branches continued quite bare. Again, 
 cut off a branch of a living plant and place it in water, how 
 actively does it absorb the water, and endeavour to prolong its 
 existence. In winter this attraction of the ultimate ramifica- 
 tions of plants ceases, but returns again with the genial 
 warmth of spring, when the buds begin to expand. 
 
 Phenomena analogous to these are also observed in many 
 animals. There are numerous tribes of animals possessing an 
 active circulation, which have no heart whatever. Thus the 
 Medusae and Echinodermata, which must enjoy an active circu- 
 lation, as is proved by their rapid growth, have no heart. In 
 the Holothurio tubulosa, Cuvier has traced vessels going to the 
 organs of respiration (pulmonary arteries), and vessels coming 
 from the same (pulmonary veins), as also a system of arterial 
 and venous tubes destined to carry on the general circulation, 
 but no heart. There are numberless examples of this arrange- 
 ment to be found in the animal kingdom. In fact, a great deal 
 of the motion observed in the fluids of the human body is effected 
 by other means besides the heart, and these means are the 
 powers possessed by the capillary vessels and membranous 
 tissues of the body, which, by virtue of an unknown law, aid 
 materially in the circulation. 
 
 You perceive, then, gentlemen, that my views are quite op- 
 posed to those who assert, that in inflammation the enlargement 
 of the capillaries is passive. Dr. Hastings and Dr. Philip allow 
 that the capillaries dilate during inflammation, but they attri- 
 bute this effect to debility. This, however, is a mere assump- 
 tion. The phrases, passive and debilitated, put one in mind of 
 another hackneyed expression founded alike on fallacy, namely, 
 indolent ulcers. Now there is nothing more active than what is 
 termed an indolent ulcer. It manufactures more secretion, uses 
 more blood, and produces more pain than any equivalent por- 
 tion of the same tissue throughout the body, and j^et it is termed 
 indolent ! It is so with regard to the capillaries. It is said 
 that in inflammation the capillary vessels are obstructed, and 
 their force weakened. What is the real fact ? Take an instance
 
 INFLAMMATION. 85 
 
 of conjunctivitis. What do you observe here ? The affected 
 membrane is swollen, its nervous sensibility exalted, its ther- 
 mometrical temperature increased, its secretion augmented. 
 Are any of these symptoms of debility ? I think they can 
 hardly be looked upon as such. The increase of pain, heat, 
 and fluid secretions, the augmentation in size, all the phenomena, 
 in fact, are opposed to the theory of debility. There is no 
 passive dilatation or weakness ; the capillaries enlarge and 
 dilate from increased, and not from diminished action ; red 
 blood finds its way into vessels which before received only 
 white ; and unusual secretions occur in the aff"ected parts. The 
 capillaries have the initiative ; with them commences the enlarge- 
 ment, ichich afterwards extends to the smaller arteries, and from 
 these to the larger branches. 
 
 Under ordinary circumstances, the capillary circulation con- 
 tinues some time after the heart has ceased to beat, for the 
 capillaries belong to that class of tissues which possess an 
 inferior degree of vitality ; and it has been shown by Bichat that 
 such tissues survive those of a higher degree of organisation. 
 Hence, the capillaries continue to act for some time after the 
 heart has ceased to beat ; and as it is a law that the capillaries 
 of the lungs will not transmit uon-arterialized blood, the 
 systemic veins become gradually distended, while the systemic 
 arteries are emptied, so that, after deaths we seldom find any 
 blood in the latter. 
 
 A very curious case, published by Dr. Houston, supports very 
 strongly the views which I have now put forward. In this case 
 the circulation had ceased in one of the lower extremities. The 
 foot, and afterwards the leg, were attacked with dry gangi-ene, 
 of which the patient died. No obstruction was found in the 
 vessels after death, and the ordinary injection passed readily 
 into all the arterial ramifications. The arteries were all per- 
 vious, and apparently natural in their texture. Now, if the 
 circulation of the limb had depended on the arteries alone, it 
 would not have ceased so completely. 
 
 Some time ago I attended, with Mr. Cusack, a patient from 
 the North of Ireland, a young lady of rather delicate constitu- 
 tion, who was attacked at a certain hour every day, in a very 
 singular way. The circulation in one of her legs seemed almost 
 to cease, and the limb became remarkably pale and cold. This
 
 86 CLINICAL MEDICINE. 
 
 state of the limb would last for ten or twelve hours, and then an 
 alteration took place ; the leg became hot and painful, and its 
 temperature became so disagreeable to the patient that she was 
 obliged to keep the leg outside the bed clothes, and have it con- 
 stantly wetted with cold water and vinegar. During all this 
 time the action of the heart was natural, and the circulation of 
 the rest of the body unaltered. Here we have a certain portion 
 of a limb at one period of the day quite cold and pale, and at 
 another extremely hot and painful. How can this be said to 
 depend on any vis a tergo ? The true explanation of the matter 
 is, that it depends on a periodic affection of the nerves, capillaries, 
 and smaller arteries of the part. 
 
 Before I conclude this interesting subject, I think it well to 
 lay before you the views of some celebrated physiologists, which 
 coincide with my own, and are strongly corroborative of the 
 doctrines which I have for many years advocated. I shall first 
 quote the opinions of Dr. Carpenter, the most modern and one 
 of the most distinguished of our British physiologists, from the 
 third edition of his Treatise on Physiology (p. 568) : their 
 importance is sufficient apology for quoting them in this place. 
 
 " We now come to the last head of the inquiry into the 
 powers which convey the blood through the capillary system 
 — that, namely, which concerns the agencies existing in the 
 capillaries themselves. Many discussions on this subject may 
 be found in physiological writings, and it has so immediate a 
 bearing on one of the most important questions in pathology 
 — the nature of inflammation — that it deserves the fullest atten- 
 tion. The chief question in debate is the degree in which the 
 capillary circulation is influenced by any other agency than the 
 contractile power of the heart and arterial system ; some physio- 
 logists maintaining that this alone is sufficient to account for all 
 the phenomena of the capillary circulation ; and others asserting 
 that it is necessary to admit some supplementary force, which 
 may be exerted either to assist, retard, or regulate the flow of 
 blood from the arteries into the veins. We shall first consider 
 what evidence there is of the existence of any such force ; and, 
 when led to an affirmative conclusion, we shall examine into its 
 nature. No physiological fact is more clearly proved than the 
 existence, in the lower classes of animals, as well as in plants, 
 of some power independent of a vis a tergo, by which the circu-
 
 INFLAMMATION. 87 
 
 latiug fluid is caused to move through their vessels. This 
 power seems to originate in themselves, and to be closely con- 
 nected with the state of the nutritive and secreting processes, 
 since anything which stimulates these to increased energy 
 accelerates the circulation, A\hilst any check to them occasions a 
 corresponding stagnation. It may he convenient to designate 
 this motor force by the name of capillary power, it being clearly 
 understood, however, that no mechanical propulsion is thence 
 implied. On ascending the animal scale, we find the power 
 which, in the lower organisms, is diffused through the whole 
 system, gradually concentrated in a single part, a new force, 
 that of the heart, being brought into operation, and the circula- 
 tion placed, in a greater or less degree, under its control. Still 
 there is evidence that the movement of the blood through the 
 capillaries is not entirely due to this, since it may continue 
 after the cessation of the heart's action, may itself cease in par- 
 ticular organs when the heart is still acting vigorously, and is 
 constantly being affected in amount and rapidity by causes 
 originating in the part itself, and in no way affecting the heart. 
 The chief proofs of these statements will now be adverted to. 
 
 " When the flow of blood through the capillaries of a trans- 
 parent part, such as the web of a frog's foot, is observed with the 
 microscope, it appears at first to take place with great evenness 
 and regularity. But on watching the movement for some time, 
 various changes may be observed, which cannot be attributed 
 to the heart's influence, and which show that a certain regulating 
 or distributive power exists in the walls of the capillaries, or in 
 the tissues which they traverse. Some of these changes, in- 
 volving variations in the size of the capillary tubes, have been 
 already referred to ; others, however, are manifested in great and 
 sudden alterations in the velocity of the current, which cause a 
 marked difterence in the rates of the movement of the blood 
 through the several parts of the area under observation. Some- 
 times this variation extends even to the entire reversion, for a 
 time, of the direction of the movement, in certain of the trans- 
 verse or communicating branches, the flow always taking place, 
 of course, from the stronger towards the weaker current. Not 
 unfrequently an entire stagnation of the current in some par- 
 ticular tube precedes this reversion of its direction. Irregularities 
 of this kind, however, are never frequent when the heart's action
 
 88 CLINICAL MEDICINE. 
 
 is partially interrupted ; as it usually is by the pressure to which 
 the animal must be subjected in order to allow microscopic 
 observations to be made on its circulation. Under such cir- 
 cumstances, the varieties in the capillary circulation, induced by 
 causes purely local, become very conspicuous, for when the whole 
 current has nearly staf^nated, and a fresh impulse from the heart 
 renews it, the movement is not by any means uniform (as it 
 might have been expected to be), through the whole plexus sup- 
 plied by one arterial trunk, but is much greater in some of the 
 tubes than it is in others ; the variations being in no degree 
 connected with their size, and being very different at short 
 intervals. 
 
 " The movement of the blood in the capillaries of cold-blooded 
 animals, after complete excision of the heart, has been repeatedly 
 witnessed. In warm-blooded animals this cannot be satisfactorily 
 established by experiment, since the shock occasioned by so 
 severe an operation much sooner destroys the general vitality of 
 the system ; but it may be proved in other ways to take place. 
 After most kinds of natural death, the arterial system is found, 
 subsequently to the lapse of a few hours, almost or completely 
 emptied of blood ; this is partly, no doubt, the effect of the tonic 
 contraction of the tubes themselves : but the emj)tying is com- 
 monly more complete than could be thus accounted for, and must 
 therefore be partly due to the continuance of the capillary cir 
 culation. Moreover, when death has taken place suddenly, from 
 some cause (as, for instance, a violent electric shock) that 
 destroys the vitality of the whole system at once, the arterial 
 tubes are found to contain their due proportion of blood. 
 Further, it has been ascertained that a real process of secretion 
 not unfrequently continues after general or somatic death ; urine 
 has been poured out by the ureters, sweat exuded from the sldn, 
 and other peculiar secretions formed by their glands ; and these 
 changes could not have taken place unless the capillary circula- 
 tion were still continuing. In the early embryonic condition of 
 the highest animals, the movement of the blood seems to be un- 
 questionably due to some diffused power, independent of any 
 central impulsion : for it may be seen to commence in the 
 vascular area, before the development of the heart ; the first 
 movement is towards, instead of from the centre, and even for 
 some time after the circulation is fairly established, the walls of
 
 INFLAMMATION. 89 
 
 the heart consist merely of cells loosely attached together, and 
 can hardly be supposed to have any great contractile power. 
 
 " The last of these facts may be said not to have any direct 
 bearing on the question, whether the capillary power has any 
 existence in the adult condition ; but the phenomena occasionally 
 presented by the foetus at a later stage appear decisive. Cases 
 are of no very frequent occurrence in which the heart is absent 
 during the whole embryonic life, and yet the greater part of the 
 organs are well developed. In most or all of these cases, however, 
 a perfect twin foetus exists, in which the placenta is in some 
 degree united with that of the imperfect one ; and it has been 
 customary to attribute the circulation in the latter to the influence 
 of the heart of the former, propagated through the placental 
 vessels. This supposition has not been disproved (however im- 
 probable it may seem) until recently, when a case of this kind 
 occurred, which was submitted to the most careful examination 
 by an accomplished anatomist." 
 
 As the case alluded to, viz., that by Dr. Houston, is given in 
 the preceding lecture, I shall not again introduce it, but pass on 
 to the conclusions which Dr. Carpenter deduces from it. " It is 
 evident," he says, " that a single case of this kind, if unequi- 
 vocally demonstrated, furnishes all the proof that can be needed 
 of the existence, even in the highest animals, of a capillary 
 power, which, though usually subordinate to the heart's action, is 
 sufficiently strong to maintain the circulation itself, when the 
 power of the central organ is diminished. In this, as in many 
 other cases, we may observe a remarkable power in the living 
 system to adapt itself to exigencies. In the acardiac fcetus, the 
 capillary power supplies the place of the heart up to the period 
 of birth, after which, of course, the circulation ceases for want of 
 due aeration of the blood. It has occasionally been noticed that 
 a gradual degeneration in the structure of the heart has taken 
 place during life, to such an extent that scarcely any muscular 
 tissue could at last be detected in it, without any such interrup- 
 tion to the circulation as might have been anticipated, if it 
 furnished the sole impelling force. 
 
 "It is equally capable of proof, on the other hand, that an in- 
 fluence generated in the capillaries may afl'ord a complete check 
 to the circulation of a part, even when the heart's action is un- 
 impaired, and no mechanical impediment exists to the transmis-
 
 90 CLINICAL MEDICINE. 
 
 sion of blood. Thus cases of spontaneous gangrene of the lower 
 extremities are of no unfrequent occurrence, in which the death 
 of the solid tissues is clearly connected with a local decline of 
 the circulation, and in which it has been shown by examination 
 of the limb after its removal, that both the larger tubes and the 
 capillaries were completely pervious : so that the cessation to the 
 flow of blood could not be attributed to any impediment, except 
 that arising from the cessation of some power which exists in the 
 capillaries, and is necessary for the maintenance of the current 
 through them. 
 
 " The influence of prolonged application of cold to a part, may 
 be quoted in support of the same general proposition ; for, although 
 the calibre of the vessels may be diminished by this agent, yet 
 their contraction is not sufficient to account for the complete 
 cessation of the flow of blood through them, which is well-known 
 to terminate in the loss of their vitality. The most remarkable 
 evidence on this point, however, is derived from the phenomena 
 of asphyxia, which will be more fully explained in the succeeding 
 chapter. At present, it may be stated as a fact which has 
 now been very satisfactorily ascertained, that if admission of air 
 into the lungs be prevented, the circulation through them will 
 be brought to a stand, as soon as the air which they contain has 
 been, to a great degree, deprived of its oxygen, or rather has 
 become loaded with carbonic acid ; and this stagnation will, of 
 course, be communicated to all the rest of the system. Yet, if it 
 have not continued sufficiently long to cause the loss of vitality 
 in the nervous centres, the movement may be renewed by the 
 admission of air into the lungs. Now, although it has been 
 asserted that the stagnation is due to a mechanical impediment, 
 resulting from a contracted state of the lungs in such cases, this 
 has been clearly proved not to be the fact, by causing animals to 
 breathe a gas destitute of oxygen, so as to produce asphyxia in a 
 different manner ; the same stagnation results as in the other 
 case. 
 
 " If the phenomena which have been here brought together be 
 considered as establishing the existence, in all classes of beings 
 possessing a circulating apparatus, of a capillary power which 
 aflbrds a necessary condition for the movement of the nutritious 
 fluid through those parts in which it comes into more immediate 
 relation with the solids, the question still remains open as to its
 
 INFLAMMATION. 91 
 
 nature. That the capiHaries? possess a contractile power, far 
 higher in degree than that of the Lirge arteries, and more easily 
 excited than that of the smaller, appears scarcely to admit of 
 doubt ; though to what it is due, may be reasonably questioned. 
 It has been recently asserted by Schwann, that they possess the 
 same kind of fibrous tissue in their walls as do the large vessels ; 
 and this cannot be regarded as improbable. It is not possible, 
 however, that their contractility could have any influence in 
 aiding the continuous motion of blood through them, unless it 
 were exercised in a very different manner from that of which 
 observation affords us evidence ; for when we are microscopically 
 examining the capillary circulation of any part, it is at once seen 
 that the vessels present no obvious movement, and that the 
 stream now rendered continuous by the elasticity of the arteries, 
 passes through them as through unelastic tubes. The only 
 method in which the contractility of the capillaries could produce 
 a regular influence on the current of blood would be an alter- 
 native contraction and dilatation, or a peristaltic movement ; and 
 of neither of these can the least traces be discerned. Hence we 
 should altogether dismiss from our minds the idea of any 
 mechanical assistance afforded by the action of the capillaries to 
 the movement of the blood. That the contractile coat of the 
 capillaries has for its office to regulate the calibre of the vessels, 
 can scarcely be doubted ; but any general permanent contraction 
 would only occasion an obstacle to the circulation, — as is shown 
 by the effects of stimulating injections, which, if thrown into the 
 vessels before their vitality has been lost, will not j)ass through 
 the capillaries. It would appear, therefore, to be through their 
 action on this coat that local stimuli occasion a contraction of 
 the capillaries ; their effect, however, is different from what might 
 have been anticipated ; for, instead of the capillary circulation 
 being retarded, it is accelerated, at least until an abnormal 
 condition results from their continued operation. Here again is 
 another evidence that something different from mechanical power 
 must be the agent that operates in all the foregoing cases. 
 
 " It appears from the preceding facts that the conditions under 
 which the power in question uniformly operates, may be thus 
 simply and definitely expressed : — Whilst the injection of blood 
 into the capillary vessels of every part of the system is due to the 
 action of the heart, its rate of passage through those vessels is
 
 92 CLINICAL MEDICINE. 
 
 greatly modified by the degree of activity in the processes to 
 which it should normally be subservient in them. The current 
 being rendered more rapid by an increase in their activity, and 
 being stagnated by their depression or total cessation. Thus 
 it seems that ' the capillaries possess a distributive power over 
 the blood, regulating the local circulation independently of the 
 central organ, in obedience to the necessities of each part.' If 
 this be true, it is evident that the dilatation or contraction of the 
 capillaries will only have a secondary influence on the movement 
 of the blood through them. The former condition is usually an 
 indication of diminished vital energy ; and when it is observed, 
 it is almost invariably accompanied by a retardation or partial 
 stagnation of the current ; on the other hand, the application of 
 a moderate stimulus, which excites the contractility, accelerates 
 for a time the motion of the blood, by rendering more energetic 
 that reaction between the fluids and the surrounding tissues, 
 which is the condition that really has the most influence over the 
 current." 
 
 In the Edinhurfih Medical and Surgical Journal for July, 
 1842, you will find an admirable paper by Dr. Holland, of 
 Sheffield, on " The Forces by which the Blood is Circulated in 
 Capillary Vessels." 
 
 The author goes through all the arguments that have been 
 advanced to prove that the circulation through these vessels is 
 entirely due to the force of the heart, and he show^s most satis- 
 factorily how very irreconcilable such doctrines are with facts of 
 every-day occurrence. At the end of the paper he mentions an 
 experiment, which I believe to be unobjectionable, and, if possible, 
 even more conclusive than Dr. Houston's monster; it proves 
 beyond doubt that the circulation through the capillaries is 
 entirely owing to a vital property of these vessels, and independent 
 of the influence derived from a vis a tcrgo. We shall allow Dr. 
 Holland to speak for himself: — "The umbilical vein conveys 
 arterial blood from the placenta to the foetus, the umbilical 
 arteries convey venous blood from the foetus to this organ. The 
 origin and termination of these two classes of vessels in the 
 placenta are involved in much obscurity. No direct connexion 
 is traced between them. Whatever opinions may be held 
 respecting the functions of this organ, or its relation to the 
 uterus, it will scarcely be doubted that the vein terminates in
 
 INFLAMMATION. 93 
 
 capillaries, and that the arteries originate in the same kind of 
 vessels. It is not our intention to examine the phenomena of 
 foetal circulation, but to allude only to one striking peculiarity, 
 viz., the circulation of blood in the umbilical vein. This fluid is 
 transmitted from the placenta to the foetus without the aid of any 
 propulsive organ. The capillaries are, indeed, the only sources 
 of motive power shown to exist, and hence the placenta, separated 
 from the uterus, appeared capable of determining the influence 
 of capillaries, and the efficiency of it in urging the blood through 
 the long capacious vein. To institute the experiment a placenta 
 was procured, twenty minutes after separation from the uterus, 
 and placed, with the exception of the cord, in a bladder, which 
 was immersed in water at the temperature of 100° Fahrenheit. 
 The free extremity of the cord, at the same moment, was elevated 
 to an angle of 30°, resting on the edge of a glass, and at the 
 distance of a foot from the placenta. At the commencement 
 of the experiment no blood escaped from the vein, but in two 
 minutes from the immersion it began to flow, and continued for 
 about twenty minutes, and at this time it was found that the 
 glass had received above one ounce. Here, then," continues Dr. 
 Holland, " is an experiment, much less exceptionable in its 
 character than any with which we are acquainted, demonstrating 
 the power of the capillaries to carry on the circulation, not only 
 in their own complicated network of vessels, but in larger 
 vessels, and which ultimately terminate in a capacious vein ; and 
 the difficulty to the motion of the blood was intentionally 
 increased by the elevation of the whole cord above the level of 
 the placenta. Had this organ been immersed without the 
 bladder, the absorption or imbibition of the water would have 
 invalidated the experiment. The water is employed as an 
 external stimulant for the purpose of maintaining, what may be 
 conceived to be the natural temperature of the placenta. 
 
 " The flow of blood in this experiment, in our opinion, arises 
 entirely from the influence of the capillaries. The stimulus of 
 the water causes the blood to excite them to contraction, and the 
 escape of it is not opposed by any impediment. We cannot 
 imagine that the experiment produces any important modification 
 in the conditions of the blood. The water is not absorbed, nor 
 is the temperature of it elevated above the heat of the body. 
 The consideration of the circulation in this case is not compli-
 
 94 CLINICAL MEDICINE. 
 
 cated by circumstances acting a tergo, or in advance of the 
 blood ; nor by the agency of respiration, or the struggles of an 
 animal in torture or placed in a constrained position." 
 
 In Adelou's PJu/siologie cle VHomme, vol. iii. p. 321, you 
 will find the following remarks strongly corroborative of my view 
 of the capillary circulation : — 
 
 " In microscopical observations on living animals," he says, 
 "we have seen the blood in the small vessels not only circulat- 
 ing from arteries towards veins through the capillary systems, 
 with such phenomena that its progress could not be ascribed to 
 the action of the heart, but often stopping, as if hesitating on 
 the direction which it was to follow, and even retrograding with 
 astonishing rapidity, and for a long time. On irritating a 
 white part, the blood is observed all at once to flow into the 
 capillary system of this part, and this system appears to exert a 
 sort of suction or absorbing power on this fluid." 
 
 Such, gentlemen, are some of the arguments in favour of the 
 supposition that the capillary vessels exercise a remtirkable 
 influence over the circulation. There are other proofs which I 
 shall not touch on at present, as the more immediate business 
 of the hospital prevents me from deviating any further from the 
 path of strict clinical investigation. You may ask, perhaps, 
 why I have entered on this subject at all, or why I have dwelt so 
 long on matters which appear to possess only a mere theoretical 
 interest. Because I am persuaded that much error exists with 
 respect to the nature of the forces employed in carrying on the 
 circulation, and because I think it of the most vital importance 
 that you should be in possession of correct principles to guide 
 you in the numerous emergencies attendant on the treatment of 
 disease. The human body, in its development from a lower to 
 a higher degree of organisation, loses none of its character, it 
 ascends, retaining in its more perfect development all that is 
 possessed in an inferior state. In the first stage of its develop- 
 ment it possessed a diffused nervous and vascular system. It 
 then acquired small nervous strings and capillary vessels, and 
 finally larger arteries, larger nerves, nervous centres, and a heart. 
 In the same way its circulation commenced, beginning in the 
 smaller vessels and extending to the larger, aided by the vis a 
 tergo, but independent of it in a remarkable degree. From this 
 view of the subject it follows that, in many cases of disease, we
 
 INFLAMMATION. 95 
 
 are to look to the forces which regulate the circulation of the part 
 afl'ected, and not to any vis a tergo, or propelling power of the 
 heart. The physician and surgeon must study the life of each 
 part in attempting to estimate its morbid conditions. It was a 
 want of proper knowledge on this subject which led to so many 
 errors in practice. Among these I may mention the treatment 
 of Egyptian ophthalmia, in wdiich it was thought necessary to 
 drain the patient of blood for the purpose of subduing a mere 
 local inflammation. In truth, the treatment of local inflamma- 
 tion, whether afi'ecting external organs, as phlegmon, carbuncle, 
 erysipelas, or internal parts, as pleurisy, peritonitis, &c., can 
 never be properly understood, until the old doctrine which (by 
 teaching that the vis a tergo was everything in inflammation) 
 led to a too general use of venesection, has been laid aside and 
 sounder opinions adopted.
 
 96 
 
 LECTURE VII. 
 
 FEVER IN IRELAND. — EPIDEMIC OF 1847. 
 
 Before entering on the treatment of Typhus Fever, I wish to 
 make a few preliminary observations upon its nature and peculiar 
 characters. In the first place, typhus fever is endemic in this 
 country; at no period, from the earliest records down to the 
 present, has it been entirely absent — a fact of which you can 
 easily satisfy yourselves by consulting our old authors, and by 
 referring to the annual reports of the fever hospitals, established 
 through different parts of Ireland. Fever, as I have said, is 
 always endemic in Ireland, but occasionally for one year or one 
 season, or a succession of years or seasons, it becomes much 
 more than usually rife, and then it is said to be epidemic. In 
 my report of the fever which devastated the west of Ireland in 
 1822, I advanced the opinion that such epidemics are consequent 
 on great dearth of provisions, and their unwholesome quality. 
 These are, no doubt, aggravating circumstances, but that they 
 are not the sole or even the chief causes of typhus epidemics, is 
 evident from what I have since frequently witnessed, viz., the 
 occurrence of fever epidemics during years of plenty, of which 
 1826 was a remarkable example. 
 
 The epidemic fever of the last year (1847) might, to a super- 
 ficial observer, appear an argument in favour of the former view, 
 and both immediately previous to and after its commencement, 
 this doctrine of the connexion between dearth of provisions and 
 fever has been strongly advocated by some ; but, as I shall show 
 a little further on, this, like most epidemic visitations, may be 
 traced to other and more immediate causes. 
 
 That fever, in Ireland at least, depends on some general 
 atmospheric change which affects the whole island simultane-
 
 FEVER IN IRELAND — EPIDEMIC OF 1847. 97 
 
 onsl)', independent of situation, aspect, height above the level 
 of the sea, diyness or moisture of the soil, or any other circum- 
 stance connected with mere locality, is proved by the fact, that 
 when typhus begins to increase notably in the Dublin hospitals, 
 we may always rest assured that a nearly simultaneous increase 
 of fever will be observed in Cork, Galway, Limerick, and Belfast, 
 as I have on more than one occasion ascertained by writing to 
 the physicians of fever hospitals in these cities. 
 
 For a considerable period there was a great tendency among 
 physicians to refer the origin of typhus, and almost every variety 
 of fever, to malaria, or unwholesome emanations from the soil, 
 produced by the decomposition of vegetable matter. In Ireland 
 facts do not bear out this hypothesis ; for, as already stated, 
 when an epidemic of fever has become established, it breaks out 
 simultaneously in situations the most different, and in some 
 where no such emanations can be supposed to exist. Thus, I 
 have seen a whole family affected in the telegraph, situated at 
 the summit of Killiney, a mountain formed of bare granite, and 
 indeed the granite and mountain districts beyond Rathfarnham, 
 Tallaght, and Killikee, supply the Meath Hospital with its 
 worst cases of typhus. The malarious origin of fever in general, 
 has, I may remark, become much less probable since the pub- 
 lication of the official documents connected with the sickness and 
 mortality of the British troops in the Colonies, and from which, 
 as Major Tulloch reports, it clearly appears that fevers of the 
 most malignant character frequently arise in places presenting, 
 to all appearance, a combination of circumstances most favour- 
 able to the exclusion of malarious influence, while fever is never 
 endemic in other stations, where all the reputed sources of 
 malaria exist together. 
 
 There can be no doubt that in Ireland, as in other countries, 
 the effects of cultivation and drainage on the health of the in- 
 habitants are very remarkable, and I myself have witnessed 
 several exemplifications of the improvement of the public health 
 thus effected. Formerly ague was of rather common occurrence 
 in some marshy districts in the immediate vicinity of Dublin, 
 and consequently when I was a pupil, cases of intermittent 
 fever were constantly to be met with in the hospitals ; now 
 the low grounds have been drained, and thus the production 
 of ague has been entirely arrested. It may be cited as a proof 
 
 VOL. I. 7
 
 98 CLINICAL MEDICINE. 
 
 of the former frequency of ague in Dublin, that when sulphate 
 of quina had been discovered in France, we in Ireland were 
 among the first British physicians who verified its anti-aguish 
 powers ; and Dr. Barker and I, each of us, published tables of 
 many cases of ague cured in hospital by that remedy. If I 
 am not mistaken, the first dose of sulphate of quina ever 
 administered in Ireland was by myself, at the Drumcondra 
 Fever Hospital. 
 
 It is now generally admitted that drainage greatly improves 
 the health of the public ; and this opinion has lately received 
 additional support from the investigations of Mr. Chadwick, 
 relative to the sanatory condition of the labouring population, 
 from whose work the following passage is extracted : — 
 
 *' In considering the circumstances external to the residence 
 which affect the sanatory condition of the population, the impor- 
 tance of a general land drainage is developed, by the inquiries 
 as to the causes of the prevalent diseases, to be of a magnitude 
 of which no conception had been formed at the commence- 
 ment of the investigation : its importance is manifested by the 
 severe consequences of its neglect in every part of the country, 
 as well as by its advantages in the increasing salubrity and 
 productiveness wherever the drainage has been skilful and 
 efiectual. The following instance is presented in a report 
 from Mr. John Marshall, jun., the clerk to the union in the 
 Isle of Ely :— 
 
 " It has been shown that the Isle of Ely was at one period in 
 a desolate state, being frequently inundated by the upland waters, 
 and destitute of adequate means of drainage : the lower parts 
 became a wilderness of stagnant pools, the exhalations from 
 which loaded the air with pestiferous vapours and fogs. Nov,', 
 by the improvements which have from time to time been made, 
 and particularly within the last fifty years, an alteration has 
 taken place which may appear to be the effect of magic. By the 
 labour, industry, and spirit of the inhabitants, a forlorn waste 
 has been converted into pleasant and fertile pastures, and they 
 themselves have been rewarded by bounteous harvests. Drain- 
 age, embankments, engines, and enclosures have given stability 
 to the soil (which in its nature is as rich as the Delta of Egypt), 
 as well as salubrity to the air. These very considerable im- 
 provements, though carried on at a great expense, have at last
 
 FEVER IX IRELAND — EPIDEMIC OF 1847. 99 
 
 turned to a double account, both in reclaiming much ground 
 and improving the rest, and in contributing to the healthiness 
 of the inhabitants. Works of modern refinement have given a 
 totally different face and character to this once neglected spot ; 
 much has been performed — much yet remains to be accom- 
 plished by the rising generation. The demand for labour pro- 
 duced by drainage is incalculable ; but when it is stated that 
 where sedge and rushes existed but a few years since we uo^v 
 have fields of waving oats and even wheat, it must be evident 
 that it is very great. 
 
 " On reference to a very perfect account of the baptisms, 
 marriages, and burials, in Wisbeach, from 1558 to 1826, I find 
 that in the decennial periods of which 1801, 1811, and 1821 
 were the middle years, the baptisms and burials were as 
 under : — 
 
 Population 
 Baptisms. Burials. in 1801. 
 
 1796 to 1805 1,627 1,535 4,710 
 
 1806 to 1815 1,654 1,313 5,209 
 
 1816 to 1825 2,165 1,390 6,515 
 
 " In the first of the three periods the mortality was 1 in 31 ; 
 in the second, 1 in 40 ; in the third, 1 in 47 ; the latter being 
 less than the exact mean mortality of the kingdom for the last 
 two years. (See Eegistrar-General's Second Report, p. 4, folio 
 edition.) These figures clearly show that the mortality has 
 wonderfully diminished in the last half century, and who can 
 doubt but that the increased salubrity of the fens produced by 
 drainage is a chief cause of the improvement ? " 
 
 Evidence of a similar nature is given with reference to various 
 parts of England. 
 
 In the reports given from the parish ministers in the statistical 
 accounts of Scotland, the efi'ects of drainage upon the general 
 health of the population are strongly marked in almost every 
 county, expressed in notes made from an examination of the 
 returns. Sutherland — Parish of Rogart : " Healthy, and a good 
 deal of draining." Far : " Subject to no particular disease ; a 
 deal of draining." Ross and Cromarty — Alness : " Dry and 
 healthy ; climate improved by drainage." It is to be under- 
 stood, that drainage appears to .form the essential part of agri- 
 cultural improvement which is connected with the improvement 
 of health. Thus, the notes from another parish in the same
 
 100 CLINICAL MEDICINE. 
 
 county, Kilmuir, Wester, and Suddy, state it as "healthy; 
 great improvement; scarcely an acre in its original state." 
 Eosmarkie: "Healthy; agriculture much improved." Elgin — 
 New Spynie : "Healthy; much waste reclaimed, much drain- 
 ing." Alves : " Dry and healthy, well cultivated ; wood 
 sometimes used for drains." Banff — Deckford : " Healthy, and 
 people long lived ; much draining." Kincardine — Fordoun : 
 '' So much draining that now no swamps ; formerly agues 
 common, now quite unknown." Angus — Carmylie : "Health 
 improved from draining." Kinross — Kinross : " Agues preva- 
 lent sixty years ago in consequence of marshes, now never met 
 with." Oswell : " Ague prevailed formerly, but not since the 
 laud was drained." Perth — Methven : " The north much im- 
 proved by draining." Eedgorton : " Healthy ; no prevailing 
 disease ; ague was frequent formerly, but not since the land has 
 been drained and planted." Moneydie : "Healthy; an immense 
 improvement by draining." Abernyte : " Since the land was 
 drained, scrofula rare and ague unknown." Monzie : " Healthy ; 
 a good deal of land reclaimed." Auchterarder : " Much drain- 
 ing, and waste land reclaimed ; climate good." Muckhart : 
 " Great improvement in agriculture ; ague formerly prevalent, 
 not so now." Muthill : " Healthy ; much draining, and culti- 
 vation extended." And similar statements are made from the 
 rural districts in all parts of the country. 
 
 Ague is the most remarkable disease engendered by a marshy 
 state of the country, and consequently the disappearance of ague 
 forms the most easily noted and most striking change in the 
 health of the inhabitants produced by drainage ; hence ague is 
 so often mentioned in the above extract. There is no doubt, 
 however, that drainage not merely removes ague, but is beneficial 
 to the public health, in removing various other maladies and 
 derangements of the health which are observable among the 
 inhabitants of marshy districts; and the remark made with 
 respect to Ahcnnjtc, ''since the land was drained, scrofula rare,'' 
 was, no doubt, founded on accurate observation. 
 
 Numerous other statements, corroborative of the preceding, 
 might be easily brought forward, but though ready to allow the 
 general improvement in the health of the public resulting from 
 drainage, improved habits of cleanhness and increased comforts, 
 yet I cannot admit that in Ireland we are to expect any notable
 
 FEVER IN IRELAND — EPIDEMIC OF 1847. 101 
 
 diminution of continued fever from the operation of these causes. 
 In making this statement, you are aware that I am opposing the 
 usually prevalent opinion. The grounds for my dissent have 
 been partly explained to you already, for, according to my obser- 
 vation, the increase or diminution of fever in Ireland arises from 
 some unknown general atmospheric, or, if you will, climatic 
 influences, quite independent of locality ; and, consequently, the 
 most improved and thoroughly drained towns and country 
 districts are quite as liable to epidemics of typhus as are the 
 most neglected and marshy parts of our island. The causes 
 which occasion these epidemics are, on the other hand, in no 
 way connected with the notable variations in the seasons, for with 
 us the ravages of typhus are observed sometimes in dry, some- 
 times in rainy seasons ; and its epidemics appear quite uninflu- 
 enced either by the cold of winter or the heat of summer. Other 
 complaints are obviously dependent on the physical characters of 
 the seasons, and I have made the curious observation, that when- 
 ever the weather in Dublin becomes dry and steady, the public 
 becomes unhealthy. This singular fact admits, perhaps, of 
 explanation ; for so habituated is the Irish constitution to rapid 
 changes of temperature, wind, and rain, that it is placed, as it 
 were, in an unaccustomed, and therefore unnatural position, 
 when the weather is dry and steady. 
 
 Be this as it may, the fact is undoubted, that fever is neither 
 so prevalent nor so fatal in any of the western kingdoms of 
 Europe as in Ireland. This opinion has been long entertained 
 by physicians, and its truth is fully confirmed by the following 
 extract from Surgeon Wilde's valuable report uj)on the table of 
 deaths published in the Report of the Commissioners of the 
 Irish census in 1841. 
 
 " The total deaths from fever in Ireland during the ten years 
 included between June, 1831, and June, 1841, afi"orded by the 
 census returns, amount to 112,072 — in the proportion of 100 
 males to 86'14 females, being one death in every 10'59 of the 
 mortality from all causes, and one in 3*4 of the deaths of the 
 total epidemic class of diseases. 
 
 " The provincial summaries afibrd the following proportions 
 of the mortality from fever, compared with the total deaths, in 
 the difi'erent districts, and the hospitals and institutions, &c. : —
 
 102 
 
 CLINICAL MEDICINE. 
 
 PHOVIXCES. 
 
 RURAL DISTRICT. CIVIC DISTRICT. 
 
 HOSPITALS, &C. 
 
 TOTAL. 
 
 Epidemic. 
 
 General. 
 
 Epidemic, 
 
 General. 
 
 Epidemic. 
 
 General. 
 
 Epidemic. 
 
 General. 
 
 TKIXSTER 
 
 MUXSTKK 
 
 LTLSTKB 
 
 COXNAUGHT .. 
 
 1 in 3-2.5 
 
 — 3-48 
 
 — 3-39 
 
 — 3-27 
 
 1 in 13-02 
 
 — 11-22 
 
 — 11-59 
 
 — 9-54 
 
 1 in 7-23 
 
 — 6-71 
 
 — 4-.')3 
 
 — 6-97 
 
 1 in 19-55 
 
 — 17-55 
 
 — 1-2-03 
 
 — 15-64 
 
 1 in 1*09 
 
 — 1-24 
 
 — 11 
 
 — 1-2 
 
 1 in 2-52 
 
 — 2-2 
 
 — 2-27 
 
 — 3- 13 
 
 1 in 3-21 
 
 — 3-.i9 
 
 — 3-32 
 
 — 3-46 
 
 1 in in-85 
 
 — 10-68 
 
 — 10-81 
 
 — 9-79 
 
 J)UBLINCITY.. 
 COUKCITT .. 
 
 lilSLFAST 
 
 UALWAY 
 
 IRELAND 
 
 — 
 
 - 
 
 1 in 8-24 
 
 — 6-77 
 
 — 4-ni 
 
 — 7-27 
 
 1 in 21 -3C 
 
 — 16-75 
 
 — 111-55 
 
 — 15-98 
 
 1 in 1-1 
 
 — 2ii2 
 
 — 1-06 
 
 — 1-06 
 
 1 in 2-69 
 
 — 1-93 
 
 — 1-38 
 
 1 in 301 
 
 — 4-49 
 
 — 2-5 
 
 — 4-91 
 
 lin 7-68 
 
 — 10-51 
 
 — 6-14 
 
 — 10-45 
 
 1 in 3-36 
 
 I in J 1-28 
 
 1 in 6-41 
 
 linie-78 
 
 1 in 1-14 
 
 1 in 2-4 
 
 1 in 3-4 
 
 1 in 10-59 
 
 From this document it follows that the mortality from fever 
 in Ireland amounts to a fraction less than one-tenth of the whole 
 mortality, whereas in London the fever deaths do not amount 
 to more than one-fiftieth of the total deaths. This difference 
 becomes more striking from considering that deaths in Dublin 
 from fever are actually nearly double the deaths from the same 
 cause in London. The last census made the population of 
 London amount to one million nine hundred thousand, whilst 
 that of Dublin is two hundred and thirty-three thousand. 
 
 The admirable papers of Dr. Cowan have thrown much light 
 upon the comparative frequency of fever in different parts of 
 Britain, and his tables prove that Glasgow is more unfavourably 
 situated, as regards fever, even than Dublin ; for in 1835, 1836, 
 1837, the deaths from fever alone were 412, 841, 2,180, being, in 
 the relation to the mortality from all diseases, one in 15*6, 10, and 
 4*7 annually ; but as the year 1837 was remarkable for a fearful 
 epidemic, this mortality is over the average, for Dr. Cowan in 
 another place shows, that while in Glasgow, with a population of 
 200,000, the annual average of fever, deduced from seven years, 
 ending with 1836, has been 1,842 cases; in Manchester, with a 
 population of 228,000, it has been for the same period only 497 ; 
 in Leeds, with a population of 123,000, only 274 ; and in New- 
 castle, with a population of 58,000, so little as 39. These 
 numbers bring out, in striking contrast with Ireland, the immu- 
 nity from fever enjoyed by large English towns, and corroborate 
 the remark already made, that the eastern and central parts of 
 Britain, enjoying a climate more different from that of Ireland, 
 so likewise are much freer from fever than the western parts of 
 liritain, whose climate approximates more to the Irish.
 
 FEVER IN IRELAND — EPIDEMIC OF 1847- 103 
 
 It is curious that in those towns in England which have 
 greater intercourse with Ireland, as Liverpool, Manchester, 
 Bristol, typhus predominates more than in others not similarly 
 circumstanced. It was on this account that Dr. Lombard * con- 
 cluded that maculated typhus fever was imported into England 
 and Scotland hy Irish labourers, who go over in such numbers 
 every year to reap the harvest. But from the statistical reports 
 of Dr. Cowan and others, it appears that, as regards Scotland, 
 this explanation is anything but satisfactory, and it seems more 
 probable that the west of England, Scotland, and Ireland, in 
 which the climate is almost the same, possess the same com- 
 binations of circumstances which produce typhus. Nothing, 
 indeed, can be more remarkable than the facility wdth which a 
 simple cold (which in England would be perfectly devoid of 
 danger) runs into maculated fever in Ireland, and that, too, 
 under circumstances quite free from even the suspicion of 
 contagion — in truth, except when fever is epidemic, catching 
 cold is its most usual cause. 
 
 Much has been said and written about epidemics among cattle 
 being simultaneous with human epidemics, and we have the 
 testimonies of Homer and Herodotus in support of the popular 
 belief. I am quite sure that various diseases, such as ague, 
 remittent and bilious fever, &c., &c., may be brought on by 
 miasmata, which, emanating from the earth, may likewise pro- 
 duce epidemics among cattle. Mr. Chadwick's w^ork contains 
 the following striking statement : — 
 
 " In the course of inquiries as to what have been the effects of 
 land drainage upon health, one frequent piece of information 
 received has been that the rural population had not observed 
 the effects on their own health, but they had marked the effects 
 of drainage on the health and improvement of the stock. Thus 
 the less frequent losses of stock from epidemics are beginning to 
 be perceived as accompanying the benefits of drainage in addition 
 to those of increased vegetable production." 
 
 Dr. Edward Harrison, in a paper in which he points out the 
 connexion between the rot in sheep and other animals, and 
 some important disorders in the human constitution, observes : — 
 
 " The connexion between humidity and the rot is universally 
 admitted by experienced graziers ; and it is a matter of observa- 
 
 * Dublin Medical Journal, vol. x.
 
 104 CLINICAL MEDICINE. 
 
 tion, that since the brooks and rivulets in the county of Lincoln 
 have been better managed, and the system of laying ground dry, 
 by open ditches and under draining, has been more judiciously 
 practised, the rot is become far less prevalent. Sir John Pringle 
 informs us, that persons have maintained themselves in good 
 health, during sickly seasons, by inhabiting the upper stories of 
 their houses ; and I have reason to believe that, merely by con- 
 fining sheep on high grounds through the night, they have 
 escaped the rot. 
 
 " The late Mr. Bakewell was of opinion that, after May-day, 
 he could communicate the rot at pleasure, by flooding, and 
 afterwards stocking his closes, while they were drenched and 
 saturated with moisture." 
 
 The sanatory effects of road-cleansing — to which house-drainage 
 and road-drainage are auxiliary, is, it appears, not confined to 
 the streets in towns and the roads in villages, but extends over 
 the roads at a distance from habitations on which there is 
 traffic. Dr. Harrison — whose testimony has been cited on the 
 subject of the analogy of the diseases of animals to those which 
 affect the human constitution — in treating of the prevention of 
 fever or the rot among sheep, warns the shepherd that, although 
 he may provide drained pasture and avoid " rotting-places " in 
 the fields, all his care will be frustrated if he do not avoid, with 
 equal care, leading the sheep over wet and miry roads with 
 stagnant ditches — which are as pernicious as the places in the 
 fields designated as " rotting-places." He is solicitous to 
 impress the fact, that the rot, i.e., the typhus fever, has been 
 contracted in ten minutes, that sheep can at " any time be 
 tainted in a quarter of an hour, while the land retains its 
 moisture and the weather is hot and sultry." He gives the 
 following instance, amongst others, of the danger of traversing 
 badly drained roads. " A gentleman removed ninety sheep 
 from a considerable distance to his own residence. On coming 
 near to a bridge which is thrown over the Barling's river, one of 
 the drove fell into a ditch and fractured its leg. The shepherd 
 immediately took it in his arms to a neighbouring house, and 
 set the limb. During this time, which did not occupy more 
 than one hour, the remainder were left to graze in the ditches 
 and lane. The flock were then driven home, and a month after- 
 wards the other sheep joined its companions. The shepherd
 
 FEVER IN IRELAND — EriDEMIC OF 1847. 105 
 
 soon discovered that all had contracted the rot except the lame 
 sheep ; and as they were never separated on any other occasion, 
 it is reasonable to conclude that the disorder was acquired by 
 feeding in the road and ditch bottoms." The precautions 
 applicable to the sheep and cattle will be deemed equally 
 applicable to the labouring population who traverse such roads. 
 
 With reference to this question I may remark, that although 
 I have carefully watched the progress of fever in Ireland for 
 more than a quarter of a century, I have not been able distinctly 
 to connect its epidemics with any epizootic disease, — true it is, 
 that occasionally typhus fever is prevalent at a time that some 
 fatal epidemic affects horned cattle, pigs, and sheep, and from 
 such an occurrence, an incautious reasoner might be led to 
 assume a natural connexion between the two epidemics as both 
 proceeding from the one cause. A more protracted series of 
 observations will, however, dispel this illusion, for he will then 
 see that the connexion is only accidental. Of this the years 
 1841 and 1842 afforded a remarkable example ; for during both 
 the cattle of Ireland were decimated by a most malignant 
 epizootic, while during the same period I never recollect a greater 
 immunity from typhus : in fact, the wards of the Meath Hospital 
 were often destitute of a single specimen of that disease. 
 
 Before leaving this part of the subject, I will, as I promised 
 in the commencement of this lecture, proceed now to take a 
 short review of the fever epidemic of last year (1847), more 
 especially of the causes by which it was produced ; and conclude 
 with a summary of my opinions. 
 
 Having made some inquiries into the prevalence of fever in 
 Ireland in 1837 — 38, which I published at length in the 14th 
 volume of the Dublin Journal of Medical Science, I was led to 
 the conclusion, that the chief causes of the epidemic diffusion of 
 fever in Ireland must be of a very general and not of a local 
 nature, for we find the most exact agreement between results 
 observed in cities far asunder, and widely differing in aspect and 
 position. It must have been an influence coextensive with the 
 island, and acting everywhere with a nearly equal degree of 
 intensity, which brought about this coincidence, and made fever 
 attain its maximum and minimum at the very same time in 
 various places. It is well to keep in mind that the establishment 
 of the existence of this epidemic influence (which in Ireland,
 
 106 CLINICAL MEDICINE. 
 
 even wlien at its mimmum, is but too productive), does not 
 preclude us from admitting that many other causes of minor 
 importance may in Ireland give rise to typhus ; among these we 
 may reckon catching cold, fatigue, mental emotions, and con- 
 tagion. And the result of last year's epidemic fully bears out 
 this conclusion. 
 
 A vast amount of mischief was produced by the attempt made 
 to connect fever epidemics with a deficiency of food; and the 
 great diffusion, the rapid spread, and the unusual mortality 
 which characterised the fever of 1847, must be to a great extent 
 ascribed to the prominence which from the very first was given 
 to famine, as an exciting cause of typhus fever in Ireland. The 
 text put forth so authoritatively, " if there be no famine, there 
 will be no fever," prevented proper attention from being paid 
 to the real causes which produce and promote the spread of 
 epidemic diseases ; and the means adopted to supply a deficiency 
 of food were, as I shall now show, singularly productive of those 
 causes. 
 
 Want of a sufficiency, or food of an unwholesome or improper 
 character, predisposes the human frame to disease by its debili- 
 tating effects on the system, and thus individuals become more 
 suscejitible to the contagious influence of epidemics when they 
 exist ; but I cannot admit that either cause is sufficient to 
 generate an epidemic. Overcrowding, deficient ventilation, 
 and tilth, are causes which in themselves give rise to epidemic 
 diseases ; and when to these are added the debilitating effects 
 of famine, we have a combination of circumstances extraordin- 
 arily calculated to promote the diffusion of a contagious disease 
 previously in existence, and, as I have already said, typhus fever 
 is always endemic in Ireland. 
 
 Owing to the failure of the potato-crop and other concomitant 
 circumstances, there was great want of food in this country in 
 1845 and 1846. In the former year there was no remarkable 
 increase in the number of cases of typhus fever which are at 
 all times to be met with in Ireland, and active measures were 
 taken to provide the people with employment and a sufficiency 
 of food. The measures adopted had the effect of congregating 
 tegether large masses in the open air in a cold Avet season, and 
 of ovcrcrowdiog the poor-houses and hospitals throughout the 
 whole country to a most frightful extent.
 
 FEVER IN IRELAND — EPIDEMIC OF 1847. 107 
 
 " Famine, also," to quote the words of Dr. Lalor in his 
 graphic description of this epidemic as it prevailed at Kilkenny, 
 " drove crowds of half- famished people into our large and more 
 wealthy towns and cities, where the means of procuring food 
 were more abundant, and the wretched and overcrowded 
 lodging-houses, in which this class of persons found shelter, 
 became the foci of contagion, and of the worst forms of fever. 
 The foulness of the atmosphere was augmented by the accumu- 
 lation of filth and heaps of manure and human ordure in our 
 lanes and alleys, to an enormous and most pernicious extent ; 
 partly owing to the prevalence of bowel complaints ; partly to 
 the dearness and dearth of food, which absorbed all the time 
 and means of our people in providing for present subsistence ; 
 and partly to the inability or unwillingness of the farmers to 
 expend money in purchasing this manure for the cultivation of a 
 crop so precarious as potatoes. It was in the neighbourhood of 
 such lanes and alleys too that fever prevailed chiefly and most 
 fatally amongst the wealthier classes."* 
 
 The congregating or crowding together of people, either in 
 the open air or in buildings, has been at all times productive 
 of disease. Thus in the year 1812, in the province of Gujerat, 
 West Hindostan, the people crowded into the towns in conse- 
 quence of the great destitution which prevailed, when an 
 epidemic broke out amongst them which nearly decimated the 
 people ; but the epidemic was of small-pox, and not fever. But 
 never, perhaps, in the history of the world was such a fearful 
 commentary on the effects of the entassement of individuals 
 witnessed as in Ireland, during the year 1847. The newspapers 
 and periodicals of the day teemed with illustrations of the fact, 
 that the Irish epidemic of 1847 had its origin in the congre gating 
 together large masses of people at puhlic works and at depots for 
 the distribution of food, and in the overcrowding the ivorkhouses. 
 I shall now proceed to bring before you some of these illus- 
 trations. 
 
 Let me first refer you to the report of the Poor Law Commis- 
 sioners published in May, 1847. It contains some fearfully 
 interesting particulars respecting the progress of disease and 
 mortality in Ireland. It appears, on reference to the report, 
 that while the total number of deaths which occurred in the 
 
 * Dublin Quarterly Journal of Medical Science, vol. T. p. 30.
 
 108 CLINICAL MEDICINE. 
 
 union workhouses in Ireland, for the week ending the 4th April, 
 1846, amounted to 159, the total number who died in the week 
 ending the 3rd April, 1847, amounted to 2,706. A more fearful 
 fact still is the large increase of sickness, and the large propor- 
 tion of fever. The number of inmates had a little more than 
 doubled, the numbers being on the 4th of April, 1846 — 50,861 ; 
 and on the 3rd April, 1847 — 106,888 ; but the numbers in the 
 hospitals increased from 8,121 to 28,239, while the numbers in 
 the fever hospitals increased from 864 to the fearful number of 
 8,931. The most alarming fact disclosed by these returns is the 
 rate of mortality which existed, and its rapid increase from the 
 previous November. In April, 1846, the weekly rate of mortality 
 was 3 in every 1,000 inmates. In November it showed a 
 decided tendency to rise. During the four weeks of December 
 it ran up from 7'4 to 8"6, then to 10'3, and then to 11. In 
 January, 1847, it was 12*2 the first week, 13*3 the last. In 
 February it was 17 the first week, 19"5 the last. In March it 
 ranged from 22 to 20, and in April it rose to 25 — twenty-five 
 out of every thousand died in the last week for which there is 
 a return. 
 
 In one of the local papers published about this time I find 
 the following observations : — 
 
 " Fever has been slowly and steadily increasing in Cork for 
 some months, and any man who calmly peruses the medical 
 report on the state of the Cork workhouse, in February last, 
 will feel surprised, not that fever has spread with such fearful 
 rapidity in Cork, but that the tempestuous sweep which 
 now appals its afi"righted citizens was so long stayed. In the 
 workhouse the inmates were put three, and four, and five in a 
 bed, and in the convalescent ward of the hospital there were 
 forty-five beds for one hundred and twenty persons ! What 
 result could be expected from such a state of things save that 
 which followed '? " 
 
 In other workhouses also we find the same efi"ects to have 
 occurred wherever they were overcrowded. It was so in Dublin, 
 in Fermanagh, in Galvvay, in Limerick, in Waterford, &c. The 
 Kilmallock workhouse, built for 800 inmates, contained on the 
 27th of February nearly 1,500 within its precincts. The conse- 
 quence was that fever and dysentery became fearfully prevalent, 
 and the inmates, struck with terror, began to leave the house,
 
 FE^^R IN IRELAND — EPIDEMIC OF 1847. 109 
 
 when the Poor Law Commissioners' sealed order against further 
 admissions was received. That the overcrowding was the cause 
 of the disease in this hast instance there can be no doubt, for 
 when the inmates were reduced to 1,000, in the month of April, 
 the number of sick rapidly diminished. 
 
 The following extract which I read from a letter received in 
 May, 1847, from Dr. Dillon, surgeon to the Co. Mayo Infirmary, 
 and one of the poor-law guardians, is strong testimony on this 
 subject: — "The Poor Law Commissioners have given sad proof 
 of their ignorance of medical police, and total incompetency to 
 direct or be connected with the sanatory state of the country 
 — wherever their houses were in full operation, there existed 
 disease, and only there. We would not open our doors and con- 
 gregate poverty and filth, when we had not funds to meet its 
 expense ; w-e w^ere dismissed, and held up to odium ; but, thank 
 God, w^e have spared human life by our decision, and have kept 
 this locality more free from disease than any other union in the 
 kingdom where the poor-law was in full operation ; at the same 
 time we fed our poor by private subscriptions, and lost fewer 
 from want of food than any other place." 
 
 It is not my intention to enter into a detailed historic account 
 of this epidemic. I am chiefly anxious to bring forward the 
 additional proofs which it affords of the causes by which the 
 epidemic outbreaks of typhus fever are produced in this country, 
 and of the contagious character of the disease. No town in 
 Ireland suftered more from this epidemic than Cork, and in no 
 town were these causes more rife. I have now shown you to 
 what an extent the workhouse of that city was overcrowded ; and 
 as a consequence the number of victims to fever and pestilence 
 was frightful. From the 22nd of December, 1846, to the 24th 
 of April, 1847 — four months — 2,130 persons died in the build- 
 ings comprising the union workhouse. The great increase set 
 in about that time, and continued to the middle of March, when 
 the curative measures of the board began to take efi'ect, and a 
 gradual though somewhat fluctuating decline soon took place. 
 The following are the deaths for each week and month from 
 December 27th : —2nd January, 59 ; 9th, 59 ; 16th, 60 ; 23rd, 
 60 ; 30th, 91 ; total for January, 329. 6th February, 128 ; 
 13th, 164; 20th, 146; 27th, 168 ; total for February, 606. 
 6th March, 143 ; 13th, 183 ; 20th, 171 ; 27th, 175 ; total for
 
 110 CLINICAL MEDICINE. 
 
 March, 672. 3rd April, 159 ; 10th, 128 ; 17th, 132 ; 24th, 104 ; 
 total to the 24th April, 523 ; making in all, as ahove stated, the 
 almost incredible number of 2,130. In the month of May 359 
 died, and in June a little more than 200. From this date, when 
 the numbers in the workhouse were much reduced, and other 
 sanatory precautions taken, the number of sick and the pro- 
 portionate mortality rapidly diminished. 
 
 Numberless are the instances in which fever has been the 
 issue of crowding patients too closely. An eminent surgeon, the 
 late Mr. Pearson, when attached to the Lock Hospital, London, 
 uniformly observed that fever prevailed in the establishment 
 when more than a certain number of patients were placed in any 
 of the wards. Kepeated observations of this kind induced him 
 afterwards to limit the number of beds in each ward, and the 
 consequence was a complete absence of fever from the place. 
 
 But there were other causes also in operation in Cork, which 
 promoted the spread of disease there. The following extract, 
 which I read from a Cork newspaper of the day, presents us with 
 a view, you might suppose, of a plague-stricken town in the 
 middle ages, and not of the second city in Ireland, affected with 
 fever in the middle of the 19th century : — " The incursion of 
 rustic paupers into the city still continues unabated, the only 
 change being that it is less observable, as they wait on the out- 
 skirts of the town till dark, when they may be seen coming in 
 droves, the bed-clothes strapped to the shoulders of the father, 
 while the children carry pots, pans, jugs, old sacks, and other 
 articles. On an average, about three hundred of these miser- 
 able creatures come into the city daily, who are walking masses 
 of filth, vermin, and sickness. They squat on straw in the 
 principal streets, and teem in the lanes and alleys, fruitful 
 sources of contagion and disease ; and if the officers of health 
 are not active and expeditious in cleansing and whitewashing, it 
 is to be feared that pestilence will commit frightful ravages in 
 those densely peopled and ill-ventilated parts of the town. The 
 deaths in the city, including the workhouse, jails, and other in- 
 stitutions, as well as the desultory mortality in the streets from 
 fever and starvation, average at present about 500 weekly. 
 Although the Cat Fort Hospital was opened on Monday, with 
 accommodation for 200 patients, it is quite insufficient for the 
 numerous fever cases seeking relief, many of the patients lying
 
 FEM2R IN IRELAND — EPIDEMIC OF 1847. Ill 
 
 on straw in the street leading to the hospital. Another hospital 
 capable of receiving 120 patients is about to be opened in the 
 same neighbourhood. Whole families are now to be seen in the 
 public thoroughfares, some stretched on straw in the sun, others 
 lying under blankets, all disgusting-looking objects, and living 
 on the charity of the passengers. Several batches of them were 
 to be seen on Camden Quay during the week. Although exhibit- 
 ing every appearance of outward wretchedness, many of them 
 are impostors, as they have sums of money on their persons, and 
 on being referred to the food depots for relief, they indignantly 
 refuse it. The mistaken charity of the public keeps those 
 people within the precincts of the city, on which they have no 
 claim whatever ; and they should be sent to their own homes, as 
 relief committees and soup depots are now generally established 
 throughout the country. On Wednesday a countrywoman 
 deserted her child, which was a pitiful object, half naked, and 
 full of small-pox, and left it in the middle of Patrick Street as a 
 legacy to the citizens." 
 
 I cannot forbear reading for you here some judicious observa- 
 tions, which bear strongly on the subject I have been discussing, 
 from the Westminster Review for April, 1847 : — 
 
 " It is most lamentable to see that in the eagerness of impulse 
 to apply the principle of relief, there has been, and continues to 
 be, a total disregard of the mode. Pestilence has followed in the 
 footsteps of benevolence, and yet death itself has awakened no 
 suspicion of error in the aid we have given to its fearful devasta- 
 tions. We are told of a mortality in Irish workhouses at the 
 rate of 70,000 per annum ; but can it be pretended, with even 
 the appearance of plausibility, that this mortality is the result of 
 destitution ? Are not the inmates of workhouses at least fed 
 and warmed and clothed '? Is there a member of the Health of 
 Towns Association who could not tell the Government that this 
 heavy rate of mortality can only be the consequence of over- 
 crowding and defective ventilation ? And is such overcrowding 
 and defective ventilation to continue under a new poor-law, in 
 the name of charity, and not to be denounced as the agency of 
 slaughter ? Let us note here a fact stated in the reports of Mr. 
 Twisleton, that as late as the 17th of October, 29 only of the work- 
 houses in Ireland, out of 130, were full, or nearly full ; and that 
 in the remaining 101, there was still accommodation for 34,000
 
 112 CLINICAL MEDICINE. 
 
 inmates more than had heen received. It was not till the 
 Government expenditure upon public works had created a 
 o-io-antic army of 500,000 men to swallow up all the resources 
 of the country, that the continued rise in the price of provisions, 
 and the desertion of families by the able-bodied, drove the feebler 
 portion of the whole population to the workhouses as a last refuge. 
 A last refuge indeed ! — there to sicken and die. . . . And let us 
 note again the corresponding manner in which out-of-door pesti- 
 lence followed out-of-door relief, injudiciously administered. A 
 noble lord, reading in the papers frightful tales of deaths by 
 ' starvation,' of which he is at first incredulous, rushes from 
 Oxford to Skibbereen, to learn the real facts by personal obser- 
 vation. He is taken to a cabin containing thirty inmates, all 
 dead or dying. He sees the death-cart, and dead bodies thrown 
 into it by callous assistants with indecent haste. He does not 
 inquire whether plague in a hovel could, by possibility, have 
 arisen from other causes than want. He does not see in Skib- 
 bereen a town of the better class, well situate, comparatively 
 prosperous, but become a great centre for relief works — a focus 
 for English charity — and therefore suddenly overwhelmed by an 
 influx of pauperism from the surrounding districts, swarming 
 into every kennel for nightly shelter. He heeds nothing of the 
 evidence of sanatory reports — not even of the old and familiar 
 history of the Black-hole of Calcutta. He reflects not that to 
 extend the system may be to deepen the abyss of misery it has 
 opened. He demands no modification of eleemosynary aid, but 
 only more of that which has been afforded ; and, struck with 
 horror at that which he has witnessed, he hastens back to 
 England — to augment the horrors." 
 
 Another mistake also made was the sudden change from a 
 deficient and unwholesome diet to a full supply of nutritious food, 
 which the paupers were subjected to on their admission into the 
 workhouses. Any general change from habitual and hereditary 
 diet, even to better, proves unwholesome, and renders the human 
 frame more susceptible to disease. In Cork, during the epidemic, 
 they were obliged to form an encampment for the troops, as the 
 recruits, who joined half-famished, suffered much, and fell into 
 bad health from the change of diet. From a somewhat similar 
 cause, some years ago, one of the finest regiments in Sweden, 
 consisting of Dalecarlians, lost nearly half its men. Having
 
 FEVER IN IRELAND — EPIDEMIC OF 1847. 113 
 
 been ordered to the capital from their own district, the sudden 
 change of diet from their accustomed black bread and peas to the 
 better and more nutritious food of Stockholm so completely 
 undermined their health, that, to save the few who escaped 
 disease, their usual food was restored to them. 
 
 The observations I have already made are all proofs, too, of 
 the contagious character of this fever ; but its rapid spread to 
 Liverpool and Glasgow — the two cities in Great Britain in most 
 immediate communication with Ireland — and its subsequent 
 progress to British America and New York, by means of the 
 emigrant ships, can leave no doubt on this subject. 
 
 In the beginning of May, 1847, Lord Brougham presented a 
 petition from Liverpool to the House of Lords, stating that 
 103,000 Irish paupers were accumulated in that town within the 
 last six months ; and soon after we find that the Irish typhus 
 fever broke out there in all its virulence, causing very great 
 mortality. Thus, according to the report of the Registrar- 
 General of Mortality in England, for the quarter ending 
 June oOth, 1847, we find that in Liverpool, in the district of 
 St. Martin, the deaths were 661, being 200 more than in the 
 corresponding quarter of the previous year — typhus and diarrhoea 
 being the prevailing diseases ; in Great Stewart Street district, 
 the deaths were 1,080, a very great increase of mortality, "owing 
 to the Irish fever which, raged amongst the poor." In Dale Street 
 district, " deaths 809, an increase over the previous quarter of 
 230, entirely owing to increase of fever amongst the lower order 
 of Irish — 280 were from fever, and 40 from small-pox." In 
 St. Thomas district, " the deaths (598) are very considerably 
 above the average this quarter, in consequence of the very alarm- 
 ing increase of fever." In Mount Pleasant district, "deaths 
 1,007, exceed the former quarter by 499, owing entirely to the 
 great influx of Irish paupers into Liverpool." In Islington 
 district the deaths were 466, an increase of 193 over the corre- 
 sponding quarter of 1846; and in St. George's district "the 
 number of deaths (188) exceeds that of any preceding quarter, 
 and shows an increase over the corresponding quarter of 1846, of 
 88." And in the return for the quarter ending the 30th of 
 September, 1847, the Registrar-General makes the following 
 observations on the state of this great city: — "In itself one of 
 the unhealthiest towns of the kingdom, Liverpool has for a year 
 VOL. I. 8
 
 114 CLINICAL MEDICINE. 
 
 been the hospital and cemetery of Ireland. The deaths registered 
 in the four quarters of 1846 were 1,934, 2,098, 2,946, and 2,735; 
 in the three quarters of 1847, ending in September last, 8,068, 
 4,809, and 5,669 ! [to this I may add the return, since published, 
 for the last quarter of 1847, 3,725, making the total mortality for 
 that year 17,271]. The population of Liverpool was 228,054 at 
 the last census. It is impossible to represent more correctly than 
 is done by the short notes of the registrars, the piteous spectacle 
 which this great town presented — with the floating lazarettos on 
 the Mersey — the workhouses crowded with destitute paupers — 
 the three large sheds, which will hold 300 persons, nearly full of 
 patients at the present time, and the fever getting more prevalent 
 among the upper classes." 
 
 From Liverpool the typhus fever rapidly spread throughout all 
 the large towns in England, and it was chiefly in the overcrowded 
 towns of the manufacturing districts, Manchester, Leeds, Bir- 
 mingham, Sheffield, &c., and in London, that it prevailed most 
 extensively and the mortality was greatest. 
 
 To Glasgow it was imported directly from Ireland, and there, 
 too, the mortality was very great, the proportion of deaths far- 
 exceeding the cholera year. The mortality tables for that city 
 for the year ending December 81st, 1847, show that the number- 
 of deaths was 18,886, an increase over 1846 of 7,250 deaths ! — 
 the great mortality arising, it is stated, from the frightful 
 immigration of poor Irish, from whom fever spread throughout 
 the community. 
 
 The number of emigrants who left this country, in the year 
 1847, for America is calculated to have been more than double 
 that of the previous year, and, as a necessary consequence, the 
 ships were all not only crowded but packed with passengers. 
 There was scarcely a single ship in which typhus fever did not 
 break out on the passage, and the mortality, as we might expect,, 
 was still greater than on land. From authentic documents now 
 before me, it would appear that the number of Irish who 
 emigrated to British North America, in 1847, was at the lowest 
 computation 74,539 ; of these 5/293 are reported to have died on 
 the passage ; 8,568 were admitted into the quarantine hospital 
 at Grosse Island, of whom 8,452 are said to have died — an 
 average of 40 per cent. ; and of those who were taken into the 
 marine and emigrant hospital at Quebec, or who had procured
 
 FEVER IN IRELAND — EPIDEMIC OF 1847. 115 
 
 lodgings in that city up to the 9th of October, there died 1,041 — 
 an aggregate of 9,786 deaths up to the period of the survivors 
 leaving for Montreal, an average of over 12 per cent. From the 
 account which we have had of the losses of individual ships, I am 
 ([uite sure that this statement is anything but over-drawn. The 
 ■" Ceylon," with 257 steerage passengers, had 30 deaths and 115 
 m fever on her arrival. The " Loosthauk," with 349 steerage 
 jnissengers, had 117 deaths, and only 20 escaped fever. Three 
 vessels taken together lost 275 passengers. The return of the 
 lu'alth-officers at New York shows an aggregate of 957 deaths at 
 soa on board of vessels coming from European ports, and 
 likewise that three-fourths of the number admitted into the 
 (juarantine hospital (most of them Irish) have been taken from 
 Jji'itish vessels. 
 
 Convincing proofs these facts of the causes of Irish typhus 
 fever, and of its contagious character ! In fine, I may state that 
 from an attentive consideration of the last and of previous 
 epidemics of fever in Ireland, I have arrived at the following 
 conclusions. 1st. That epidemics of fever may occur in Ireland 
 without any scarcity of food, — as proved by the history of many 
 of our past epidemics. For information on this subject I would 
 refer especially to the commentary of Mr. Wilde on the Govern- 
 ment census of 1841, and published in the Commissioners' report. 
 2ud. That a scarcity may coincide with an epidemic. 3rd. As 
 an epidemic of fever occurs at short intervals, and famine is un- 
 fortunately not less frequent, it consequently follows that an 
 epidemic tendency to fever must frequently coincide with a 
 visitation of famine. 4th. In 1847, as no epidemic had occurred 
 for several years, the chances of coincidence were greater still. 
 5th. The contagious character of the typhus fever of Ireland was 
 further proven by the late epidemic. Barristers and solicitors re- 
 turning from circuit brought the fever to town with them. I had 
 at one time five from Galway under my own care in Dublin ; and 
 Mr. Rynd informed me that in the convict depot all the cases of 
 fever came from the country. 6th. The fact of fever not often 
 spreading in families in this city when brought from the country, 
 proves that the causes which acted in the country were such as I 
 have assigned — entassement, bad ventilation, filth, &c. 
 
 While this sheet is going through the press, we have had
 
 116 CLINICAL MEDICINE. 
 
 another practical proof of the operation of the causes I have in 
 this lecture mentioned as productive of typhus fever in Ireland. 
 The gaol of Galway was crowded with prisoners in the beginning 
 of this year (1848), forced indeed to receive nearly double the 
 number it could contain with due attention to the health of its 
 inmates. As a consequence, fever broke out amongst those con- 
 fined there, and is now spreading among the inhabitants of the 
 town. This fact needs no comment !
 
 117 
 
 LECTURE VIII. 
 
 GENERAL OBSERVATIONS ON FEVER. CLASSIFICATION. — 
 
 CONTAGION. 
 
 I HAVE already stated that when a person gets a feverish cold in 
 Ireland, it is more apt to pass into continued fever than it is in 
 England : this is especially the case when fever prevails as an 
 epidemic, in which case the transition into fever takes place on 
 account of one or other of the following causes. First — the 
 patient had been exposed to contagion, whose effects might never 
 have become perceptible, had not his constitution been assailed 
 by the feverish cold. Secondly — in many cases there has been 
 uo previous exposure to contagion, and yet a feverish cold will 
 finally determine the breaking out of fever, no doubt under the 
 action of the prevailing epidemic influence. Thirdly — indi- 
 viduals who are debilitated by excesses, night-watching, and 
 bodily fatigue are of all others the most liable to slide from 
 feverish cold into fever : if, in addition to these causes, mental 
 anxiety, or intellectual labour have been harassing the individual, 
 the fever generally assumes a most dangerous form, being attended 
 with want of sleep, raving, and often violent delirium early in the 
 disease. 
 
 The well-known fact that individuals have sickened on the 
 spot on smelling the effluvia from a patient's person or evacua- 
 tions has led to the supposition that the contagion of fever 
 influences the system through the nerves ; and in support of this 
 opinion many refer to prussic acid, which, they say, kills by its 
 action on the nerves, and before it has been absorbed. 
 
 Another class of inquirers asserts that the blood is the seat of 
 the first morbid change, and with equal confidence refers to the 
 action of vegetable poisons, which they assert never produce any 
 effect on the system until they enter the circulation.* In the 
 present state of our knowledge it is quite impossible to determine 
 
 * Blake's Experiments, Edinhurgh Med. and Surg. Journal, vol. liii. p. 49, And 
 Muller's Elements of Physiologij, by Baly, 2nd edition, vol. i. p. 262. 
 
 I
 
 118 CLINICAL MEDICINE. 
 
 in what manner the poison acts, and, happily, it is equally unim- 
 portant. This much is certain, that changes in the nature of the 
 secretions, as in the sweat, sputa, mucus of the tongue, feces 
 and urine, take place simultaneously with changes in the blood, 
 and they are all the result of some common unknown cause. 
 Of course once the blood is changed, the secretions become more 
 rapidly altered, and when the secretions are changed, the blood is 
 more quickly deteriorated ; but the knowledge we thus obtain 
 leads to no satisfactory explanation or practical result. 
 
 Lately the investigations of chemists respecting the com- 
 position of the blood in fever and other diseases, have excited 
 hopes that we are on the eve of discovering some more 
 secure basis for our practice, founded on the analysis of 
 that fluid. I must confess that, however I applaud these 
 efforts of science, I entertain no hopes that they will be 
 followed by the expected beneficial consequences : for, except 
 the good effected in diabetes mellitus, by diminishing the 
 quantity of starch in the bread such patients eat ; and 
 the advantage derived from medicines and articles of diet, in 
 certain derangements of the urinary functions, such as in the 
 phosphatic and lithic diatheses ; — except in these instances, 1 
 know of no improvement in practice for which we are indebted to 
 chemistry : and even here the result was obtained not by an 
 examination of living, but of secreted fluids ; and, in truth, it is 
 vain to look for remedies founded on chemical principles, when 
 these principles cannot even approximate to aff"ording us an ex- 
 planation of the mode of action of our best established medicines. 
 When chemistry reveals why tartar emetic vomits, jalap purges, 
 or opium causes sleep — when chemistry detects palpable changes 
 in the blood produced by these remedies, then we may begin to 
 hope that this science can conduct us still further, and may even, 
 by disclosing the morbid changes which the blood undergoes in 
 disease, become useful to us in searching for remedies capable of 
 counteracting and even preventing these changes. 
 
 The diff"erent theories of fever, as they have been called, have 
 much and often injuriously aff'ected practice. The speculations 
 of Brown, Cullen, Clutterbuck, Broussais, Rasori, Armstrong, 
 and our Indian physicians, have successively introduced the 
 stimulant, diaphoretic, general antiphlogistic, leeching, tartar 
 emetic, mercurial plans ; each of which has in its turn been
 
 GENEEAL OBSEEVATIONS ON FEVER. 119 
 
 pushed to a most deleterious excess. For my own part, I have 
 long abandoned every hope of being able to frame any satisfactory 
 theory of fever, and therefore confine myself altogether to a dili- 
 gent study of its symptoms, watching how they are grouped, and 
 in what order they follow each other, and observing closely the 
 eftects of treatment on their progress ; and in my choice of 
 remedies I am guided either by experience, or an analogy derived 
 from the action of medicines, in other diseases which present 
 the greatest similarity to the complications that occur in fever. 
 
 Fever in this island exhibits a great variety of character, and 
 even during the same epidemic remarkable differences are 
 observable, as appears from the subjoined summary, taken from 
 Cheyne and Barker's valuable account of the epidemic fever of 
 1817 and 1818, vol. i. p. 425 :— 
 
 " Delirium ferox was observed in Limerick, and another 
 symptom indicating a determination of blood to the head, 
 namely, hemorrhage from the nose, which, in some instances, 
 took place to a very considerable extent. 
 
 "As to the organs chiefly affected in the progress of the 
 disease, some variety seemed to exist. In most instances the 
 brain has been reported as the organ which suflered chiefly. In 
 some places, as at Ennis, the lungs were not at all affected 
 during the early periods of this epidemic fever ; but in other 
 places the lungs next to the brain principally suffered ; this was 
 observed in Listowel. The same remark was made at Tralee, 
 and Dr. Bishop observed at Kinsale that the lungs were frequently 
 affected in children. At Ennis it was noticed as a peculiarity in 
 the fever, that profuse perspiration occurred in its earlier stages 
 without any relief to the patient ; and it was remarked at Water- 
 ford, as stated in the report at page 251, that copious perspira- 
 tion often aff"orded no relief. Yellowness of the skin and tunica' 
 adnata of the eyes was frequently noticed at Cork. The head 
 and biliary system were more than usually affected. 
 
 " As the disease advanced, it was observed in most or all parts 
 of the province, that eruptions of different kinds, either closely 
 allied to or varieties of those termed petechial, very generally 
 accompanied it. In some instances the eruption was papular, or 
 a motley appearance of the skin, or a rash somewhat resembling 
 the measles showed itself. At Cork, Dr. M. Barry remarked 
 that, in the species of fever which he termed synochus, petechiae
 
 120 CLINICAL MEDICINE. 
 
 seldom occurred earlier than the fourth or fifth day ; but his 
 observation, if it does not express it directly, at least implies 
 that their occurrence was frequent. They ivere generally of a 
 bright red colour, sometimes small, at other times large. He 
 did not consider them dangerous, nor find it necessaiy to abstain 
 from those measures of depletion which were useful when high 
 excitement prevailed. In a communication from Clonmel, Dr. 
 Fitzgerald states that petechise occurred in four cases out of 
 five. At Fermoy, petechias appeared very generally among the 
 poor. At Kinsale, a red rash, we believe of the kind above 
 mentioned as resembling that of the measles, was common, and 
 petechia3 were more inclined to be red than brown in that neigh- 
 bourhood. At Listowel, petechiae were so common that Dr. 
 O'Connel did not see six cases of fever unattended by a petechial 
 eruption, Avhich often appeared early in the disease. The fre- 
 quency of petechia was noticed also at Waterford, as well as 
 of the eruption resembling measles already mentioned. The 
 frequency of an eruption resembling measles was noticed at 
 Bandon by Dr. Clarke and Dr. Jenkins. At Clonmel petechiae 
 were common even amongst children, in whose cases this erup- 
 tion was not indicative of peculiar danger, but, on the contrary, 
 often attended a mild disease. It was observed in the neigh- 
 bourhood of Tramore, and we believe the same to have happened 
 in every part of Ireland, that one member of a family had 
 petechijB and aggravated symptoms of typhus, whilst the relatives 
 in the same room had fever in the mildest form. In many 
 instances, particularly in the more advanced stages of the 
 epidemic, the lungs were observed to suffer, as at Fermoy, 
 Listowel, and Mallow, according to the authorities already 
 quoted ; but both at Cork and at Ennis, places very remote from 
 each other in this province, the lungs, at least at the com- 
 mencement of its epidemic progress, were but rarely affected in 
 this fever. 
 
 "As the epidemic advanced, gastric symptoms were observed, 
 and mention has been already made of the frequency at this time 
 of dysentery, which, in many parts of Munster, kept pace with 
 fever. Dr. Grogan, of Limerick, remarked that pains resembling 
 those of rheumatism were common ; and he also noticed a symp- 
 tom, which there is reason to believe was not unfrequent in 
 most parts of Ireland, namely, that the tongue, which in most
 
 GENERAL OBSERVATIONS ON FE\^R. 121 
 
 febrile diseases is white or altered in colour and other appear- 
 ances, in many cases exhibited no morbid change, and remained 
 moist and clean during a great part of the disease. From the 
 same authority we learn that increased heat of the surface, which 
 is generally considered peculiarly characteristic of fever, was, in 
 many instances at Limerick, altogether wanting ; this absence 
 of the usual febrile heat is observed in the worst kinds of fever." 
 
 Farther on, the report states that "Dr. Milner Barry of Cork, 
 in his account of the fever in that city, relates that the disease 
 presented itself under different forms, which he arranges under 
 the following heads — 1. Synochus ; 2. S. Cephalica ; 3. S. 
 Pulmonica; 4. S. Hepatica ; 5. S. Gastrica ; 6. S. Enterica ; 7. 
 Typhus Gravior ; 8. Typhus Mitior ; 9. Febricula. From the 
 arrangement which Dr. Barry here adopts, it is evident that a 
 determination to particular organs was at Cork, as at other 
 places, of frequent occurrence." 
 
 For more than twenty years I have in my lectures advocated 
 the' doctrine, that morbid anatomy had not served to reveal the 
 cause of fever, which I looked upon to be an essential disease, 
 or, to use the words of Fordyce, " Fever is a disease which 
 " affects the ivhole system ; it affects the head, trunk, and extremi- 
 " ties ; it affects the circulation, absorption, and the nervous system; 
 " it affects the body, and it affects the mind ; it is therefore a 
 " disease of the tvhole system, in the fullest sense of the term. It 
 " does not, hoivever, affect the various parts of the system uni- 
 " formly and equally, but, on the contrary, sometimes one part is 
 " more affected than another." " This excellent view of fever 
 seems to be borne out completely by modern pathology, and 
 particularly the last part, where he says that in cases of fever 
 one part is more affected than another. We have, for instance, 
 cerebral fevers, nervous, bilious, gastric, and catarrhal fevers, by 
 which it is to be observed, we do not mean to imply that there is 
 nothing more than simple disease of the brain, or nerves, or 
 liver, or bowels, or respiratory system, but that in each of these 
 fevers disease predominates in some particular part. So that 
 when we speak of these fevers we speak of such a fever as Fordyce 
 has described, in which one part of the body is affected more 
 than the rest."* 
 
 I am happy to find that the views I have so long entertained 
 
 * stokes' Practice of Physic, American Edition, page 409.
 
 122 CLINICAL MEDICINE, 
 
 in opposition to the great majority of writers both in Britain 
 and on the Continent are now generally acknowledged to be 
 correct, as will appear by the following passage taken from the 
 able essay on continued fever by Dr. Christison in the Library 
 of Medicine. 
 
 "Anatomical characters of continued fever. — The pathological 
 anatomy of continued fever remained, till lately, in a very crude 
 and unsatisfactory condition. But no other topic has attracted 
 so much attention during the last five and twenty years, or has 
 been investigated with more success, so far as the accumulation 
 of facts goes. Whether the result has been hitherto beneficial in 
 reference either to pathological doctrine or medical practice, is a 
 question which admits of some doubt. A very great variety of 
 morbid appearances has been indicated as occurring in fever. Of 
 these many are plainly incidental, because they do not by any 
 means present themselves regularly. Others, however, have been 
 held to be invariable ; and consequently authors have sought for 
 the nature and essence of fever, in the local morbid action which 
 gives rise to such appearances. On taking into account the 
 general result of the observations of all pathologists of credit, 
 it seems impossible to avoid the conclusions, that no morbid 
 appearance is invariable except congestion of internal organs ; 
 that every other pathological fact which has been observed is not 
 constant, and is therefore the effect of a secondary disease ; and 
 that, in all the observations hitherto made on the pathological 
 anatomy of fever, we must be content with discovering its 
 consequences, not its causes. The information which has been 
 amassed is important in a practical point of view, as turning the 
 attention of practitioners to the necessity of studying and treat- 
 ing those secondary affections, which in various circumstances 
 are the occasion of suffering, danger, or death. But it does not 
 seem to throw much light on the real essence of fever ; and by 
 being rashly assumed to furnish that light, it has led to grave 
 theoretical and practical errors." * 
 
 In fact, gentlemen, the knowledge we possess of the pathology 
 of typhus fever is of a negative character. Pathology teaches us 
 what typhus is not, rather than what it is ; it shows us that it is 
 neither cerebritis, meningitis, pneumonia, pleurisy, gastritis, or 
 enteritis, for it may exist without any of these, and they may 
 
 * Library of Medicine, vol. i. p. 105.
 
 GENERAL OBSERVATIONS ON FEVER. 123 
 
 exist without typhus fever ; hut it also shows that one or other 
 of these lesions frequently arises in the course of that fever, and 
 these require special attention. 
 
 It is difficult to classify the different varieties of fever that 
 are observed in this city. The following are the most re- 
 markable of the distinct varieties that have come under my 
 notice : — 
 
 1st, Simple continued fever, without macuhie, or any notable 
 determination to particular organs. '2nd, Continued fever, with- 
 out maculae, with determination to some organ. 3rd, Continued 
 fever, with macule. 4th, Continued fever, accompanied from 
 the very beginning by gastric derangement and epigastric tender- 
 ness. 5th, The last mentioned species, but in a more intense 
 form, having black vomit and yellowness of the skin superadded. 
 6th, Continued fever, with petechias. 
 
 I have observed each of these varieties of fever constituting 
 epidemics, which lasted for longer or shorter periods ; but with 
 us the dominant type of epidemics is the maculated form. This 
 species, too, confers more immunity upon the sufferers than any 
 other variety of fever, and in this respect, as well as in its well- 
 marked eruption, it approaches in character to the exanthemata ; 
 like the exanthemata, too, this species of fever seems to be the 
 most contagious. 
 
 Concerning contagion, the physicians of Ireland and Scotland 
 are nearly agreed in attributing that quality to fever. The fever 
 wards of the Meath Hospital are by no means crowded, and are 
 both well ventilated and cleanly, while the building itself is 
 placed in the most salubrious part of the vicinity of Dublin, being 
 built upon the site of Dean Swift's garden ; and yet it almost 
 invariably happens that when a patient, labouring under any 
 other acute, or any chronic disease, is admitted into a fever ward, 
 he gets fever in the course of a fortnight, or even sooner. This 
 happens the more surely if the patient is placed in the immediate 
 vicinity of a maculated case. Among the pupils who attend the 
 hospital, the greater number are sooner or later attacked by 
 fever, and the same is true of the porters, laundry-maids, and 
 nurses. 
 
 Moreover, in the recent epidemic with which this country was 
 afflicted, the contagious character of the fever was, as I have 
 already shown, peculiarly manifested; and especially by the
 
 124 CLINICAL MEDICINE. 
 
 great mortality which it caused among the members of the 
 medical profession,* 
 
 I have great pleasure in recommending Dr. Christison's obser- 
 vations on this subject, and shall here quote briefly some of the 
 arguments advanced by him in support of the contagious nature 
 of the disease. In the first place, he says that in districts thinly 
 inhabited fever is generally very rare, whereas in large towns, 
 where numbers of people are living in a crowded state, typhus 
 fever is never absent. When it becomes epidemic in a large 
 town, it never bursts forth with impetuosity, like the diseases of 
 undoubted miasmatic origin, but extends gradually, and always 
 the more slowly the larger the city, so that many months may 
 elapse before it reaches its full height. It then begins to decline, 
 retires as gradually as it commenced, and finally resumes its 
 natural condition, afi"ecting only a few indi-sdduals here and there, 
 and at distant intervals. 
 
 At the commencement of an epidemic, fever is found to spread 
 at first, not by scattered unconnected cases occurring at a distance 
 from one another, but by slow degrees around one or more 
 invaded localities as foci ; first creeping from one individual to 
 another of a family, then from family to family — according to 
 their proximity, relationship, or general intercourse — and at 
 length to the surrounding population promiscuously. 
 
 But a further argument of very great weight may be drawn, 
 even from the very violations of this general rule. For some- 
 times the disease is seen suddenly to arise, and gradually to 
 spread in parts of a town where it had not previously existed ; 
 and this in concurrence with the arrival of the disease by im- 
 portation from a previously invaded locality. 
 
 " Another argument, more powerful perhaps than any other, 
 and upon which alone the doctrine of the communicahility (Dr. 
 Christison used this word in preference to contagion or infection) 
 of fever might be rested, is, that in circumscribed localities, 
 inhabited by crowded bodies of men, fever is observed invariably 
 to spread among the healthy, when it is introduced to a great 
 extent from without, but never materially at any other time. 
 This is a general mode of expressing the history of such institu- 
 
 * For much most valuable information on this head I would refer to Drs. Cusack 
 and Stokes' laborious and trustworthy essay in the fifth volume of the Dublin Quarterly 
 Journal of Medical Science, new series.
 
 GENERAL OBSERVATIONS ON FEVER. 125 
 
 tions as infirmaries and fever hospitals. During the last twenty 
 years the Infirmary of Edinburgh has been made the receptacle 
 of a large proportion of fever cases in three epidemics, which 
 have lasted between three and four years ; and there have been 
 two intervals varying from three to five years in duration. 
 During the intervals, when fever cases from without were few, 
 fevers originating within the hospital were extremely rare among 
 any classes of individuals attached to its service. But, during 
 the prevalence of the several epidemics, fever abounded in every 
 department of its service : physicians, clinical clerks, general 
 servants, nurses, washerwomen, apothecary's assistants, all 
 suffered more or less, and some to an excessive degree. The 
 same facts were observed even more remarkably in an institution 
 which was, during the same interval, occasionally occupied as a 
 fever hospital. In three epidemics it was made use of for this 
 purpose ; and at various periods during the last twenty-five 
 years it has also been occupied, when fever did not prevail 
 epidemically in the city, by crowded bodies of men ; first by 
 soldiers as a barrack, then as a retreat for some hundreds of 
 people who were turned out of their houses in winter by an 
 extensive fire, next as a quarantine house during the prevalence 
 of cholera ; and for some years past, during the worst epidemic 
 of fever which has yet prevailed in the city, it has been occupied 
 by about 300 of the very lowest of the community, namely, as a 
 house of refuge for vagrants and other destitute persons. Now, 
 on each occasion, when it was occupied as a fever hospital, the 
 people on service in the institution suffered to an extraordinary 
 degree, scarcely a single individual escaping an attack who 
 remained a moderate length of time in it. But on other 
 occasions fever was either absolutely unknown, or the cases 
 were rare and distant, and easily referable to the particular 
 manner of life of the individuals composing the population of 
 the establishment. It is also worthy of notice, in reference 
 to both chains of facts here mentioned, that neither around 
 the infirmary, nor around the late fever hospital, did fever 
 ever prevail to any material extent during any of its epidemic 
 visitations."* 
 
 It is unnecessary to allude to the many instances of fever 
 occurring amongst nurses, porters, and clinical clerks in different 
 
 * Library of Medicine, vol. i. p. 156.
 
 126 CLINICAL MEDICINE. 
 
 fever hospitals, facts which strongly bear out the view that 
 typhus fever is eminently contagious. 
 
 Another interesting point connected with the contagion of 
 fever has lately been inquired into, viz., to determine the par- 
 ticular period of the disease when this character is most re- 
 markable. 
 
 Dr. Perry, of Glasgow, was the first, I believe, who advanced 
 the opinion, that the stage of convalescence was the most in- 
 fectious in typhus fever. He considers typhus fever as a true 
 exanthema. He says, " I have for some years entertained the 
 opinion, founded upon an extensive series of observations, that 
 contagious typhus is an exanthematous disease, and is subject to 
 all the laws of the other exanthemata ; that, as a general rule, it 
 is only taken once in a lifetime, and that a second attack of 
 typhus does not occur more frequently than a second attack of 
 small-pox, and, judging from my own experience, less frequently 
 than a second attack of measles or scarlet fever. 
 
 ** From numerous observations and experiments, I am satisfied 
 that it is not contagious before the ninth, day, perhaps not till a 
 later period of the disease. Among many circumstances which 
 establish this opinion, I may mention one experiment which I 
 made upon a pretty extensive scale. The fever wards of the 
 Glasgow Royal Infirmary are each capable of containing twenty 
 patients. The beds are arranged in two opposite rows, and are 
 pretty near each other. While the patients are in the acute 
 wards, they are not allowed the use of their clothes, though they 
 may be able to sit up ; they are, therefore, almost constantly 
 confined to bed, excepting when rising to stool ; and there is about 
 one close-stool to every three patients. Into the fever-house are 
 admitted cases of measles, scarlet fever, and small-pox ; and 
 patients are very frequently sent in labouring under bronchitis, 
 pneumonia, erysipelas, and other local inflammatory affections. 
 I found by experience, that when the latter class of patients 
 were sent to the convalescent ward, where they necessarily mixed 
 with the others, almost all those who had not a previous attack 
 of typhus fever were either seized with it before leaving the 
 house, or returned soon after their dismissal labouring under it ; 
 the period intervening between the time of their being sent 
 to the convalescent ward and the attack never being less than 
 eight days. Although means were taken to keep those recovering
 
 GENEKAL OBSERVATIONS ON FE\'ER. 127 
 
 from small-pox, scarlatina, &c., in a separate room from those 
 convalescent from typhus, the rooms being adjoining the non- 
 intercourse was incomplete, and the result was, that these 
 diseases occasionally spread among the typhus convalescents, 
 and the convalescents from small-pox and scarlatina caught 
 typhus. In consequence of these observations, I adopted the 
 practice of not sending, as formerly, to the convalescent wards, 
 those patients affected with inflammatory diseases, unless I 
 ascertained that they were secured against the disease by having 
 had a previous attack of typhus ; but kept them in the acute 
 fever wards till they were so far recovered as to go to their own 
 homes, and the result was (and the practice was continued for 
 several months), that not one of those detained in the acute 
 wards caught the disease while there, or returned with it after- 
 wards. From the above and other observations, I have adopted 
 the opinion that typhus, like measles, small-pox, &c., is chiefly 
 spread during the period of convalescence. In the paper already 
 noticed, I have mentioned the desquamation of the cuticle which 
 usually takes place when a patient is convalescent from typhus. 
 Do the fine scales thrown off in this state contain the poison 
 which, by adhering to the clothes and hair of the patient, 
 are carried about with him, and, being rubbed off, are, while 
 floating in the atmosphere, applied to the mucous surface, or 
 inhaled by a susceptible recipient, in whom it produces, after 
 a certain time, the specific disease ? "* 
 
 I must here acknowledge, although frequent mention has 
 been made in this lecture of petechial fevers, particularly in the 
 passage cited from Cheyne and Barker's work respecting the 
 fever of 1817 and 1818, and although, in compliance with the 
 generally received opinions, I have set down this fever as a 
 distinct species, that I myself have never seen petechial fever 
 epidemic in Ireland. I was clinical clerk at Sir Patrick Dun's 
 Hospital during the great epidemic of 1816 and 1817. The 
 eruption consisted of maculae, somewhat resembling measles, 
 frequently dark and livid in bad cases ; but, except in a very 
 few instances indeed, there were no true petechioe. In 1822 I 
 had the charge of a large district in the town of Galway, when 
 fever was committing great ravages ; then, too, the eruption was 
 maculated. I cannot account for so many witnesses testifying 
 
 * Dublin Medical Journal, vol. x. p. 385.
 
 128 CLINICAL MEDICINE. 
 
 the contrary to this statement, except by supposing them to 
 have been misled by appearances ; for it must be confessed that, 
 although true 2>ctechi(S are rare, true Jiea-hites are common in 
 Ireland. Most observers, too, seem to have been very in- 
 accurate in their phraseology, as is evident from the above 
 quotation from Cheyne's work. Dr. Barry plainly uses the 
 word petechics very loosely — " They were generally of a hrigld 
 red colour, sometimes small, at other times largeJ" Surely this 
 is quite descriptive of maculae, but totally inapplicable to 
 petechiae ; and the same may be said of the other observers, 
 most of whom, I verily believe, overlooked the true eruption, 
 and noted down flea-bites as petechiae ! Connected with the 
 question first raised by Dr. Perry, whether maculated typhus 
 should be considered as an exanthema, the fact is deserving of 
 notice, that children exhibit the eruption much less frequently 
 than adults, although they are quite as liable to the fever when 
 it is epidemic. This fact is the more remarkable, because in 
 measles, scarlatina, &c. — the true exanthemata — the eruption is 
 more constant in children than in adults.
 
 129 
 
 LECTURE IX. 
 
 THE GENERAL TREATMENT OF FEVER. 
 
 I SHALL to-day proceed to speak of the general treatment of 
 fever ; and in the first place I may observe that we are now at a 
 point of time possessing no common interest for the reflection of 
 medical observers.* It is nearly two years since my attention 
 was first arrested by the appearance of maculated fever, of which 
 the first examples were observed in some hospital patients from 
 the neighbourhood of Kingstown. This form of fever has lasted 
 ever since, prevailing universally, as if it had banished all other 
 forms of fever, and being almost the only type noticed in our 
 wards. Within the last four days, however, a change appears 
 to have taken place. Scarcely any cases of maculated fever 
 have been admitted within the last fortnight, and the majority 
 of fever patients at present under treatment are free from 
 cutaneous eruption so frequently observed during the last two 
 years. The cases which we have recently admitted present no 
 spots or maculae, and have been termed, perhaps improperly, 
 simple typhoid fever. And here permit me to observe, that it 
 would be very wrong to conclude, from this circumstance, that 
 our recent cases are of a more favourable description than those 
 which preceded them ; the disease, it is true, appears to have 
 lost a character which is always looked upon as bad and un- 
 favourable, but it may be just as dangerous a modification of 
 fever as the eruptive typhus. During the predominance of the 
 latter form, all cases without maculte were in general simple and 
 free from danger ; but it is probable that this is not the case at 
 present. There are two cases of this non-maculated typhus in 
 the female ward, which are of an extremely doubtful character, 
 and in which it would be difficult to predict the result. Indeed, 
 were I to make any prognosis, I should say that the chances, if 
 not against them, are at least very fairly balanced. 
 
 Now, gentlemen, as it appears we have come to a change, and 
 
 * The beginning of this lecture was delivered during the sesaion 1836 — 7. 
 VOL. I. 9
 
 130 CLINICAL MEDICINE. 
 
 that we may have to treat a new modification of fever, it behoves 
 us to be extremely vigilant. I invite you to watch and study, 
 with the closest attention, the cases of fever which come before 
 you. Let us, in the first place, endeavour to ascertain whether 
 we have seen the close of one epidemic, and are now at the com- 
 mencement of another. The number of cases of simple typhoid 
 fever has, you perceive, increased in a very remarkable manner, 
 and the number of cases of eruptive typhus has become remark- 
 ably scarce. But there is another and a more important reason 
 why we should study these cases with all due diligence and 
 attention. They may be the first examples of a new epidemic, 
 and every new epidemic, as it has its peculiar characters, so has 
 it its peculiar treatment. We cannot follow the same track 
 which we have pursued for the last two years — we cannot apply 
 our remedies with the confidence of experience — we must now 
 strike into a new path, and for some time our practice must 
 be tentative and experimental. It was only after a good deal of 
 experimental observation that we were able to arrive at a plan of 
 treatment adapted to meet the exigencies of the maculated form 
 of fever : and it is very probable that this new fever may prove 
 at first extremely difficult to manage ; and it may be some time 
 before the diminished rate of mortality shall show that we have 
 at length discovered its true character, and the remedies best 
 calculated to arrest its progress. 
 
 Let me now direct your attention to some practical points 
 connected with the treatment of the maculated fever wbich has 
 prevailed for the last two years, and which has spread to a very 
 considerable extent in this city and its environs, attacking alike 
 the upper, middle, and lower classes of society. It is not my 
 intention to enter into a detailed history of the origin and 
 progress of this fever, its varieties, symptoms, and pathological 
 phenomena ; my purpose is to furnish you with a brief but com- 
 prehensive outline of its treatment, and of the remedies which 
 have been found most successful in its removal, as well as the 
 most appropriate time and mode for their application. 
 
 Having made these general observations, I may observe, in 
 addition, that in the whole range of human maladies there is no 
 disease of such surpassing interest and importance as fever ; and 
 I cannot dwell too much on the necessity of your applying most 
 attentively to the study of its pathology and treatment. If you
 
 THE GENERAL TREATMENT OF FEiTUR. 131 
 
 compare the mortality from fever with that resulting from any 
 other disease in this country, you will be struck with the over- 
 whelming fatality of this affection, and will readily admit the 
 inestimable value of a thorough knowledge of its nature and 
 treatment. Recollect, too, that fever is a disease which numbers 
 among its victims persons chiefly in the prime of life, and during 
 the most active and useful stage of existence, — fathers and 
 mothers, persons who are the ornament or the stay and support 
 of their families, the intellectual, the industrious, the efficient, 
 those whose lives are most valuable to their friends, — and to 
 society. This gives an additional intei'est to the study of fever, 
 and should stimulate you to endeavour to arrive at a correct 
 knowledge of its nature and treatment. 
 
 And here let me observe, that there is nothing more untrue 
 than the assertion, that the treatment of fever is a matter of 
 indifference. It has been the custom to look upon every 
 plan of treating fever as idle and absurd, and until very lately 
 there were many persons in this country who believed that 
 patients recovered, not from having had the advantage of treat- 
 ment, but from goodness of constitution or some favourable 
 accident ; and it was usual with such persons to appeal to the 
 experience of Dr. Rutty, who in recording the history of the 
 epidemics of his own time (1741), observes, "the poor, aban- 
 doned to the use of whey and God's good providence, recovered, 
 while those who had generous cordials and great plenty of 
 sack perished." And, indeed, I must admit that the treatment 
 of some of the cases of fever which I witnessed when a student, 
 would seem to justify the quaint and sarcastic observation of Dr. 
 Piutty. At that period, whether it was from bad treatment or from 
 what has been termed the nimia diligentia medici, it is a fact 
 that the maximum of mortality was among the rich, and that 
 those who were most attended to died most speedily. In the 
 epidemics of 1816, 1817, 1818, and 1819, it was found by 
 accurate computation, that the rate of mortality was much 
 higher among the rich than among the poor.* This was a 
 startling fact, and a thousand diff'erent explanations of it were 
 given at the time ; but I am inclined to think that the true 
 
 * " The rich are less frequently affected with epidemic fevers than the poor, but 
 more fretjuently die of them. Good fare keeps oft' diseases, but increases their 
 mortality when they take place.'' — Fletcher's Pathology, p. 27.
 
 132 CLINICAL MEDICINE. 
 
 explanation was, that the poor did not get so much medicine, 
 and that in them the vis medicatrix had more fairplay.* I 
 could appeal to the practice of those times in proof of this 
 opinion, and as we go along I shall have an opportunity of 
 alluding to this part of the subject again, and contrasting the 
 practice of the present day with that which was generally 
 followed thirty years ago. If you look to Dr. Cheyne and Dr. 
 Barker's Synopsis of the plan of treatment employed by the 
 physicians of those days, you will be prepared, from a mere 
 inspection of it, to admit that it was at least as hard to escape 
 the physician as the disease. Since that period our practice has 
 greatly improved, and things are much changed ; the preponder- 
 ance of fatal cases is now to be found among the poor ; and the 
 mortality among the rich, or those who have proper medical 
 advice from the commencement, is not one-third of that which is 
 found among the indigent, who are generally neglected at the 
 commencement of the disease. I am therefore fully prepared 
 to deny that, in the present state of medical knowledge, our 
 practice is a matter of indifference ; on the contrary there is no 
 disease in which diligent attention and skilful treatment are 
 more frequently successful than in fever, nor is there any affec- 
 tion of equal importance in which our therapeutic means are 
 more efl&cient and valuable. 
 
 Now, when called on to treat a case of fever, there are several 
 things which require your attention. In the first place, you 
 should examine the state of the family arrangements. This is 
 a matter which men are apt to overlook or treat as a matter of 
 indifference, but in my mind it is of no ordinary importance, and 
 should be always attended to. You should never, if possible, 
 undertake the treatment of a case of fever where the friends or 
 relations of the patient supply the place of a regular fever nurse. 
 The mistaken tenderness of relatives, and their want of due 
 firmness, presence of mind, and experience, will frequently 
 counteract your exertions and mar your best efforts. Affection 
 
 * " On the whole, the mildest and simplest treatment seems to be the most generally 
 successful, and the result of a certain Lady Bountiful's practice forms its best com- 
 mentary. She begins with an antimonial emetic ; the patient is washed every morning 
 with soap and water, gets every second day half an ounce of sulphate of magnesia, on 
 the seventh day a blister to the neck, and if necessary some diluted wine, this seldom 
 and sparingly; of 120 in fever treated after this mechanical plan, not one died." — 
 Cheyne and Barker's Report, p. 444.
 
 THE GENERAL TREATMENT OF FEVER. 133 
 
 and sorrow cloud the judgment, and lience it is that very few 
 medical men ever undertake the treatment of dangerous illness 
 in the members of their own families. The sympathy which a 
 nurse should have for her patient should be grounded on a 
 general anxiety to serve, and a strict sense of duty, as well as a 
 laudable desire of increasing her own reputation ; it is, in fact, a 
 sympathy analogous to that which should actuate a physician. 
 Again, it will not do to have a nurse who has been usually 
 employed in other diseases ; your assistant must be a regular 
 fever nurse, and the man who undertakes the treatment of a 
 long and dangerous case of fever without such an assistant will 
 often have cause to regret it. I could mention to you many 
 cases illustrative of the truth of this assertion. I could tell you 
 that, where 1 have permitted the continuance of the services of 
 one of the family, or of a common nurse, I have been almost 
 invariably annoyed and disappointed. I now make it a general 
 rule to refuse attending any dangerous and protracted case of fever 
 without a properly qualified nurse. 
 
 There are many nurses who are extremely attentive, but 
 inexpert and injudicious, and their ill-judged attentions are 
 frequentl}^ prejudicial to the patient. A fever nurse has a vast 
 deal in her power ; if an enema is to be administered, the patient 
 will be much less disturbed and annoyed than if it were given 
 by an unskilful person. The mere handling of a patient — the 
 moving of him from one bed to another — the simple act of 
 giving him medicine or drink — the changing of his sheets and 
 linen — the dressing of his blisters — and a thousand other offices, 
 can be performed with advantage only by an experienced nurse. 
 Always bear in mind that it is of the utmost importance to 
 economize the patient's strength in fever. The very act of 
 lifting him up, or moving him from one side to another, tends to 
 produce exhaustion. In the advanced stages of fever, the services 
 of a properly qualified nurse are inestimable. Then there is the 
 moral management of the patient, and this is an ofiice which no 
 one can undertake unless qualified by experience, and a correct 
 knowledge of the habits of persons labouring under such forms 
 of disease. Every one admits the value of moral superintendence 
 in the treatment of the insane. Now there are very few patients 
 who are not in a state analogous to insanity, for a longer or 
 shorter period, during a course of typhus fever. There is a
 
 134 CLINICAL MEDICINE. 
 
 necessity for moral management in fever as well as in insanity, 
 and this is understood only by an experienced nurse. Friends or 
 relatives are seldom found capable of discharging this office. If 
 they chance to discover, from the physician's remarks or ques- 
 tions, the weak points of the patient's case, they generally con- 
 trive to let him know them in some way or other. If the patient 
 is restless, for instance, the ill-judged anxiety of his friends will 
 most certainly prevent him from sleeping. They steal softly to 
 his bed, di-aw the curtains, move the candle so as to make the 
 light fall on his eyes, and wake him perhaps at the moment he is 
 settling down to rest. If he happen to take an opiate, and that 
 they are aware of the nature of his medicine, they inform him of 
 it, and his anxiety for sleep, conjoined with their inquiries, 
 prevents its due operation. Hence, when you prescribe an 
 opiate, you should not in any case say anything about it ; and 
 it should not be administered in such a way as to lead the patient 
 or his friends to expect decided benefit from it. It is only where 
 I have to deal with prudent persons, that I break through my 
 rule of concealing both the nature of the medicine and the results 
 which I expect from its operation. One of the best ways of 
 giving an opiate is to administer it in the form of an enema. 
 The patient's attention is then turned away from the considera- 
 tion of loss of rest — he supposes that the enema is to act on his 
 bowels, and in expecting a motion he drops asleep. You will 
 often, too, succeed in producing sleep in this way, where you 
 would fail in bringing it on by an opiate administered by the 
 mouth. Another recommendation attached to this mode of 
 exhibiting opiates is, that it can be employed in cases of deli- 
 rium, where the patient obstinately refuses to swallow any kind 
 of medicine. Let me give you here another caution. Do not let 
 the patient know the situation or extent of his danger, however 
 you may feel bound to act in reference to these matters towards 
 his relatives or friends. If you apprehend mischief in the 
 brain, do not commence by examining the head, or putting 
 your questions in such a manner as to lead him to suspect 
 the scat and nature of the affection. The same remark may 
 be applied to the examination of the thorax and abdomen. 
 
 In the next place, when treating a case of bad typhus, do not 
 think that it will be sufficient to see your patient once a day. 
 But you will say, perhaps, that our hospital patients here do
 
 THE GENERAL TREATMENT OF FEMCR. 135 
 
 VC17 well, and yet they are visited only once in the twenty-four 
 hours. True — but then we have experienced nurses to look after 
 them at all hours ; we have the valuable surveillance of our 
 apothecary, ]\Ir. Parr ; we have the attendance of the resident 
 pupils, and of the gentlemen who take charge of the cases. You 
 see, then, that they do not depend on a solitary visit. How often 
 has Mr. Parr, or the resident pupil, found it necessary to change 
 the treatment adopted at the morning visit ? How often have the 
 remedies of which we had only given a hint in the morning, been 
 actively and energetically employed before the close of the day ; 
 and how often have lives been saved by the valuable attentions 
 to which I have just alluded ? No one should attend a case of 
 fever without having proper medical assistants. My practice, in 
 general, is to visit my fever patients two or three times a day ; 
 and, when I have a bad or a dangerous case to manage, I always 
 have a competent medical assistant to stay by the patient and 
 watch every change of his malady. 
 
 I do not know how they manage this matter elsewhere, but in 
 this city we have so many zealous, intelligent students, so many 
 young medical friends, and so many well-educated apothecaries, 
 that we are never at a loss for an assistant. This fact is, I think, 
 a sufficient answer to the objections put forward by Dr. Johnson, 
 in the Medico-Chirurgical Bevieiv. He says that tartar emetic 
 is a two-edged sword — an agent powerful alike for good or evil, 
 and in the administration of which no ordinary circumspection 
 is demanded. All this I am willing to admit ; there is no 
 remedy capable of producing more mischief when abused, but, 
 when properly watched, it is, I am confident, the means of saving 
 many valuable lives. He says, also, that Dr. Graves cannot give 
 that share of attention to his patients which the employment of 
 such a remedy demands. He is quite mistaken on this point. 
 I am never- at a loss for some skilful person to remain with the 
 patient, watch the operation of each dose, and modify or change 
 it according to circumstances. The want of proper assistants 
 may be elsewhere an objection to the administration of tartar 
 emetic, but this objection does not hold good with respect to 
 Dublin. 
 
 One or two more observations of a general nature. Some 
 persons have such a terror of foul air in cases of fever, that you 
 will find all the windows in the house thrown open, not even
 
 136 CLINICAL MEDICINE. 
 
 excepting those of the patient's bed-chamber, and wherever you 
 turn you are sure to meet with a current of air. Now, this is an 
 unnecessary practice, likely to entail disease on the family, and 
 local inflammation on the patient. The bed -room of a patient 
 labouring under fever should be well aired, but without what is 
 termed thorough air ; and it should, if possible, be a quiet back 
 room, away from the street. In the next place, it should be 
 sufficiently large to hold two bedsteads conveniently ; and you 
 should order the attendants to have two w^ell-aired beds in readi- 
 ness, from one of which the patient should be changed to the 
 other every twelve or twenty-four hours. You can scarcely have 
 an idea of the comfort this affords to a person in fever. The 
 room can be kept properly ventilated by a fire, and the tempera- 
 ture can be regulated by a thermometer. Some persons are in 
 the habit of constantly sprinkling the room with vinegar — others 
 with the chlorides. I do not know that it is necessary, and I 
 think that the use of chlorine is doubtful, if not improper, and 
 may prove injurious to the patient. 
 
 Having made these few general observations on the steps to be 
 taken by those who enter on the treatment of typhus, I shall now 
 proceed to speak of diet and medicines. In a disease like fever, 
 which lasts frequently for fourteen, twenty-one, or more days, the 
 consideration of diet and nutriment is a matter of importance, 
 and I am persuaded that this is a point on which much error 
 has prevailed. I am convinced that the starving system has, in 
 many instances, been carried to a dangerous excess, and that 
 many persons have fallen victims to prolonged abstinence in 
 fever. This was one of the errors which sprung from the 
 doctrines of tbose who maintained that fever depended on general 
 or topical inflammation. They supposed that fever arose from 
 inflammation, and immediately concluded that, to treat it 
 successfully, it was necessary to reduce the systera by depletion 
 and low diet, and to keep it at this point during the whole course 
 of the disease. Hence the strict regimen — the diete ahsolue — of 
 the disciples of the physiological school, and of those who looked 
 on inflammation as the essence of fever. The more the 
 symptoms appeared indicative of inflammatory action, the more 
 rigorous was the abstinence enforced. If a patient's face was 
 flushed, or his eyes diffused, no matter what the stage of the 
 fever was, they said, *' Here is inflammation of the brain, and
 
 THE GENEKAL TREATMENT OF FEVER. 137 
 
 nonrisliment will exasperate it." If lie had red or dry tongue, 
 and abdominal tenderness, they immediately inferred the existence 
 of gastro-enteritis, and all kinds of food, even the lightest, were 
 strictly forbidden. That this proceeds from false notions on the 
 nature of fever is beyond doubt, and I pointed out this fact 
 many years ago, long before the appearance of Piorry's work. Let 
 us, in the first place, examine the results of protracted abstinence 
 in the healthy state of the system. Take a healthy person and 
 deprive him of food, and what is the consequence ? First, hunger, 
 which after some time goes away, and then returns again. 
 After two or three days the sensation assumes a morbid 
 character, and instead of being a simple feeling of want and a 
 desire for food, it becomes a disordered craving, attended with 
 dragging pain in the stomach, burning thirst, and, some time 
 afterwards, epigastric tenderness, fever, and delirium. Here we 
 have the supervention of gastric disease, and inflammation of 
 the brain as the results of protracted starvation. 
 
 Now, these are in themselves very singular facts, and well 
 deserving of being held in memory. Read the accounts of those 
 who perished from starvation after the wreck of the "Medusa " and 
 the " Alceste," and you will be struck with the horrible conse- 
 quences of protracted hunger. You will find that most of the 
 unhappy sufferers were raging maniacs, and exhibited symptoms 
 of violent cerebral irritation. Now, in a patient labouring under 
 the efi"ects of fever and protracted abstinence — whose sensibilities 
 are blunted, and whose functions are deranged — it is not at all 
 improbable that such a person, perhaps also suffering from 
 delirium or stupor, will not call for food, though requiring 
 it ; and that if you do not press it on him, and give it as 
 medicine, symptoms^ like those which arise from starvation in 
 the healthy subject may supervene, and you may have gastro- 
 enteric inflammation, or cerebral disease, as the consequence of 
 protracted abstinence. You may, perhaps, think that it is 
 unnecessary to give food, as the patient appears to have no 
 appetite and does not care for it. You might as well think of 
 allowing the urine to accumulate in the bladder, because the 
 patient feels no desire to pass it. You are called on to interfere, 
 where the sensibility is impaired, and the natural appetite is 
 dormant ; and you are not to permit your patient to encounter the 
 horrible consequences of inanition, because he does not ask for
 
 138 CLINICAL MEDICINE. 
 
 nutriment. I never do so. After the third or fourth day of fever, 
 I always prescribe mild nourishment, and this is steadily and 
 perseveringly continued through the M^hole course of the disease. 
 
 Again, let us see how close a resemblance the symptoms 
 generated by long-continued denial or want of food bear to those 
 which are observed in the worst forms of typhus. Pain of the 
 stomach, epigastric tenderness, thirst, vomiting, determination 
 of blood to the brain, suffusion to the eyes, headache, sleepless- 
 ness, and, finally, furious delirium, are the symptoms of pro- 
 tracted abstinence ; and to these we may add, tendency to 
 putrefaction of the animal tissues, chiefly shown by the 
 spontaneous occurrence of gangrene of the lungs. It has been 
 shown by M. Guislain, physician to the hospital for the insane 
 at Gand, that in many instances gangrene of the lungs has 
 occurred in insane patients who have obstinately refused to take 
 food. Out of thirteen patients who died of inanition, nine had 
 gangrene of the lungs. You perceive, then, that starvation may 
 give rise to symptoms of gastric disease, to symptoms of cerebral 
 derangement, and to mortification of the pulmonary tissue. It is 
 not, therefore, wrong to suppose that when a system of rigorous 
 abstinence has been observed in fever, and when food has been 
 too long withheld, because, forsooth, the patient does not call 
 for it, and because his natural sensibilities are blunted and 
 impaired — it is not, I say, unreasonable to infer that gastric, 
 cerebral, and even pulmonary symptoms may supervene, analogous 
 to those which result from actual starvation.* 
 
 An attentive consideration of the foregoing arguments has led 
 me, in the treatment of long fevers, to adopt the advice of a 
 country physician of great shrewdness, who advised me never to 
 let my patients die of starvation. If I have more success than 
 others in the treatment of fevers, I think it is owing in a great 
 
 * Huxham gives tlie history of a gentleman who obstinately starved himself to 
 death, and would not for many days, either by force or persuasion, swallow any kind 
 of food, or a drop of li(juor. He soon grew feverish, flashed in his face, and very hot 
 in his head ; his pulse was small but very quick, in four or five days his breath became 
 exceedingly offensive, his lips dry, black, and parched, his teeth and mouth foul, black, 
 and bloody, his urine vastly highly-coloured, and stinking as much as if it had been 
 kept a month ; at length he trembled continually, could not stand, much less walk, 
 raved and dozed alternately, fell into couvulsive agonies frtqueutly, in which he some- 
 times sweated pretty much about the head and breast, though his extremities were 
 ((uite cold, pale and shrivelled ; the sweat was of a very dark yellow colour, and of a 
 most nauseous stench.
 
 THE GENERAL TREATBIENT OF FEVER. 139 
 
 degree to the adoption of this advice. I must, however, observe 
 that great discrimination is required in the choice of food. 
 Although you will not let your patient starve, do not fall into 
 the opposite extreme : you must take care not to overload the 
 stomach. When this is done, gastro-enteric irritation, tympanitis, 
 inflammation, and exasperated febrile action are the consequences. 
 I have witnessed many instances of the danger of repletion in 
 febrile diseases. A case of this kind occurred some time ago in 
 this hospital, in a boy who was recovering from peritonitis. In 
 another case, in private practice, an incautious indulgence in the 
 use of animal food was followed by a fatal result. A young lady 
 ate some beefsteak, contrary to my orders, at an early period of 
 convalescence from fever, relapsed almost immediately, and died 
 of enteritis in thirty-six hours. 
 
 Food must be given with great care and judgment, particularly 
 in the beginning of fever. For the first three or four days, 
 particularly if the patient be young and robust, water, weak 
 barley-water, and whey will be sufficient. After this it may be 
 well to begin with some mild nutriment. What I generally give 
 is some well-boiled gruel, made of groats and flavoured with 
 sugar, and if there be no tendency to diarrhoea, a small quantity 
 of lemon juice. The ordinary oatmeal gruel does not answer 
 sufficiently well for this purpose, for it is apt to produce 
 griping and diarrhoea — symptoms which are extremely disagree- 
 able in the commencement of fever, and which often lead to 
 others of a more troublesome and formidable character. I 
 am also much in the habit of ordering a little thin panado, 
 morning and evening, during the latter part of the first, and 
 the beginning of the middle stage of fever. A small slice of 
 bread is slightly toasted, and boiling water poured on a table- 
 spoonful of the crumbs, in sufficient quantity to make a thin 
 panado, of which the patient takes a tablespoonful two or three 
 times a day. It may be flavoured with a very small quantity of 
 lemon juice and sugar, if there be no tendency to diarrhoea ; but 
 where this exists, or where you are administering mercurials, I 
 think you should be cautious in the use of acids. Although 
 medical men of the present day do not object to giving acids 
 during the use of mercurials, I think the practice is not entirely 
 devoid of danger, and I think our predecessors were right in 
 withholdinij them under such circumstances.
 
 140 CLINICAL MEDICINE. 
 
 You will begin, then, on the third, fourth, or fifth day, accord- 
 ing to circumstances, with a little gruel ; and after two or three 
 days, you may add a little panado, giving, as I have already 
 observed, a sjioonful of either every third hour. As the fever 
 advances you may add some mild animal jelly or broth ; and one 
 of the best kinds of nutriment in the middle and latter stages of 
 fever is chicken broth. I do not speak here of chicken water ; 
 but I mean good and well made chicken broth. Give this, but 
 give it in small quantities, and with great caution at first. 
 Watch the effects of the few first spoonfuls ; it may act injuri- 
 ously, and you should give it up, at least for some time, if it 
 produces any bad eifects. If it brings on heaviness, sickness of 
 stomach, flushing of the face, excitement of pulse, and increased 
 feverishness, give it up, and return for some time to the gruel 
 and panado. You can try it again in a day or two ; for although 
 your patient does not bear it to-da}^, he may to-morrow or the 
 day after ; and it is a most fortunate circumstance when it agrees 
 with him, for, as I have already observed, it is the best kind of 
 nutriment you can give in the middle and latter stages of fever. 
 Recollecting the tendency to diarrhoea and intestinal irritation 
 in fever, you will be extremely cautious in allowing your patients 
 the use of fruits. Indulging patients in the use of grapes and 
 oranges is a very popular, but, in my mind, a very hazardous 
 and improper custom. I have on many occasions seen persons 
 injured by fruits of this description. Stewed and roasted apples 
 are still more dangerous ; they are apt to produce tormina, 
 flatulence, diarrhoea, and intestinal inflammation. All acid or 
 raw fruits have a tendency to produce irritation of the stomach 
 and bowels, and should be avoided altogether, or very sparingly 
 used. 
 
 In this hospital we seldom prescribe effervescing draughts, and 
 never give them in the ad libitum quantity which some persons 
 recommend. Thirst can be sufficiently assuaged by the use of 
 whey, or common water acidulated with currant jelly or raspberry 
 vinegar, given in small portions, and at certain intervals. Some- 
 times you will succeed eff'ectually in controlling feverish thirst 
 by the use of a very light infusion of cascarilla, acidulated with 
 a small quantity of muriatic acid. I have seen this employed 
 with success by Mr. Kirby, and I have often prescribed it myself 
 with the best effects. Very often a small quantity of some light
 
 THE GENERAL TREATMENT OF FE\'ER. 141 
 
 bitter, slightly acidulated, will appease the morbid thirst of fever 
 more effectually, and for a much longer period, than large 
 draughts of water, or any of the fluids usually employed for the 
 same purpose. You should always bear in mind, that thirst in 
 fever does not exclusively depend on a dry or parched state of 
 the mouth or fauces, but lies much deeper in the system, and 
 has its origin in some peculiar derangements of the nerves, most 
 probably of those belonging to the ganglionic system. In going 
 through a fever ward, you meet with numerous illustrations of 
 the truth of this position ; one man, with a moist tongue and 
 fauces, labours under insatiable thirst, while you will observe 
 another with parched tongue and throat, and yet without any 
 desire whatever for fluids, or any choice as to their temperature. 
 "We had two examples of this in the fever ward during the past 
 week. One patient with a moist tongue was incessantly calling 
 for drink, while another man, who had his tongue almost 
 perfectly dry, exhibited a very remarkable indifference to fluids. 
 
 One general observation as to the administration of food and 
 nutriment in fever. All kinds of food and nutriment should be 
 given by day, and the patient should, if possible, be restricted to 
 the use of fluids by night. The natural habit is to take food by 
 day and not by night, and in sickness as well as in health we 
 should observe the diurnal revolution of the economy. 
 
 When you give nutriment, then, be careful in observing the 
 usual periods of meals. The space of time to which I limit the 
 giving of chicken broth, jelly, arrowroot, and other mild articles 
 of diet, is from eight o'clock in the morning to eight in the 
 evening. Always make it a rule that your patient shall take 
 nutriment within the space of those twelve hours during which 
 he is accustomed to take his meals when in health, and allow 
 him nothing but mild diluent fluids during the night. I am 
 persuaded that I have seen much benefit derived from following 
 this simple plan. 
 
 With respect to drinks, the mildest, of course, should be 
 preferred : on this point most persons are generally agreed, and 
 it will be unnecessary for me to detain you with any particular 
 observations. There is one error, however, which is vei*y fre- 
 quently committed in the use of drinks in fever ; patients are 
 generally allowed to drink too much. It may be urged that they 
 have a strong desire for fluids ; but they should not be gratified
 
 142 CLINICAL MEDICINE. 
 
 in everything they wish for. They labour under a constant state 
 of nervous irritation and restlessness, and will beg of you to do 
 twenty different things to relieve their immediate feelings ; but 
 it would be just as improper to give them large quantities of 
 drink every time they desire to call for it, as to indulge them in 
 any momentary whim which may be the offspring of their disor- 
 dered and changeable fancy. The continued swilling of even the 
 most innocent fluids will bring on heaviness of stomach, nausea, 
 pain, and flatulence, and predisposes to congestion and intestinal 
 irritation. From the mere ingestion of a large quantity of the 
 simplest fluid, you will frequently see well-marked symptoms of 
 gastric irritation arise during the course of fever. This is not a 
 picture drawn from imagination ; I have witnessed it on many 
 occasions during the course of my practice. It is extremely 
 painful, indeed, to be obliged to refuse drink to a patient labour- 
 ing under intense thirst ; but you should never allow them to 
 take a large quantity of fluid at a time ; you should impress 
 upon them the danger attendant on such a practice, and tell 
 them that a spoonful or two, swallowed slowly, allays thirst more 
 efi"ectually than drinking a pint at a time. The sensation of 
 thirst, as you all know, is almost entirely confined to the fauces 
 and upper part of the pharynx, and it is as much relieved by a 
 small quantity, swallowed slowly and gradually, as it is by a large 
 quantity gulped down at once. 
 
 Besides the simple fluids, there are other drinks required in 
 fever. Beer, ale, porter, wine, tea, and coffee are also frequently 
 used in the treatment of fever, and are of the utmost value when 
 employed on appropriate occasions ; they are adjuvants of the 
 highest importance in the dietetic management of fever, and it 
 will require some time to explain the rules by which you should 
 be guided in their administration. I shall therefore speak of 
 them according to the indications with which they are given ; 
 and first of tea and coffee. 
 
 You are aware that we give sedatives and narcotics to tran- 
 quillize, to produce a species of exhaustion of the mental 
 faculties, and to bring on sleep ; and I do not see any reason 
 why we should not also administer expergefacients, or remedies 
 calculated to maintain intellectual activity, and keep the patient 
 awake. Among the remedies most frequently employed for the 
 latter purpose arc tea and coffee. You have lately seen an
 
 THE GENERAL TREATMENT OF FEVER. 143 
 
 infusion of green tea useful in a case of narcotism wbicli occurred 
 in the fever ward. A man in the latter stage of fever, and 
 labouring under great nervous excitement and total loss of sleep, 
 was ordered an opiate enema, after we bad tried various otber 
 means witbout success. During tbe course of the evening be 
 got twelve drops of black drop, witb two ounces of mucilage of 
 starcb, in tbe form of enema, and soon after fell into a sound 
 sleep. Wben we came next morning and inquired after liim, 
 everytbing was reported to bave gone on well ; tbe opiate enema 
 bad answered tbe purpose completely, and tbe man was still sleep- 
 ing deeply. We found, bowever, on a more accurate examination, 
 tbat be was in a kind of letbargic state and could scarcely be 
 roused. Wben addressed in a loud tone of voice, be raised bim- 
 self beavily and slowly, balf opened bis eyes, gave a brief answer 
 to our questions, and tben, leaning back on bis pillow, dropped 
 asleep. Observe bere tbe danger connected witb this state. 
 He was in an advanced stage of fever, bad been restless and 
 sleepless, and bad suddenly passed to an opposite state. Tbe 
 rapidity witb wbicb coma bad supervened on sleeplessness, and 
 tbe danger of fatal congestion of tbe brain coming on, gave me 
 considerable alarm. Tbere was no use, bowever, in tbinking of 
 wbat bad been done ; tbe man's state called for prompt and 
 decided measures, and we proceeded at once to attack tbe 
 symptoms of our own creation. One of tbe gentlemen went 
 down and got some green tea, of wbicb be made a strong 
 infusion, and administered a strong dose of it to tbe patient. 
 Tbis bad tbe desired effect ; tbe symptoms of coma gradually 
 disappeared, and wben I came to see bim in tbe afternoon, be 
 was quite out of danger. Green tea was first introduced bere 
 as an expergefacient in tbe treatment of coma by Dr. Edward 
 Percival, sou of Dr. Percival of Mancbester ; and some years 
 ago be read a paper at a meeting of tbe College of Physicians, 
 in wbicb be brought forward several cases of coma and stupor, 
 in which green tea had produced the most favourable effects. 
 On tbe Continent they generally use strong coffee for the same 
 purpose. Whether these beverages produce this effect by their 
 influence on the circulation, or on the nervous system, I am 
 not prepared to say ; but there cannot be a doubt of their efficacy 
 and value in many cases of tbis description ; and I am frequently 
 in tbe habit of usins both witb this intention.
 
 144 CLINICAL MEDICINE. 
 
 While on the subject of expergefacients, I shall beg leave to 
 read for you a very curious case from the 13th number of the 
 Boston Medical and Surgical Journal, in which an experge- 
 facient of a less agreeable character was employed to rouse a 
 patient from the lethargic stupor brought on by a large dose of 
 laudanum. There are some transatlantic peculiarities of ex- 
 pression in the details of this case, but I have no doubt of its 
 being correct. It is entitled " a case of successful treatment by 
 flagellation, where a large dose of laudanum had been taken." 
 And the author. Dr. Joseph Barrett, of Middleton, Connecticut, 
 proceeds as follows : — 
 
 " Tincture of opium is not unfrequently resorted to for de- 
 structive pui-poses. It is also, unfortunately, and too frequently, 
 taken by mistake, and proves fatal before efficient means can be 
 adopted to counteract its deleterious effects on the system. I 
 am induced, therefore, to offer a short statement of a case of 
 poisoning with laudanum that fell under my care several years 
 since, for the following reasons : first, the success that attended 
 the mode pursued ; and, secondly, not having met with any such 
 means recorded, to my knowledge,* either in works on medicine, 
 or in treatises on poisons." 
 
 Observe, it is not I that am speakiug here, but Dr. Barrett, of 
 Middleton, Connecticut. 
 
 " In the year 1822, February 23rd, I was called on to see 
 Mr. Wright Harris (this was in the State of New York), who 
 had intentionally taken a large dose of laudanum for the pur- 
 pose of destroying himself. He had committed this act during 
 his absence from home, under circumstances which it is not im- 
 portant to relate. Much time (about three hours) was therefore 
 lost before any effectual measures could be adopted for his relief. 
 His case, as I found him, appeared to be altogether hopeless. 
 Before my arrival, emetics and various drinks had been tried, 
 besides frictions, and constant though ineffectual attempts had 
 been made to irritate the oesophagus by feathers. All these means 
 had failed, and the patient was in such a profound sopor, that 
 apparently nothing but warmth remained to indicate that life 
 had not already become extinct. The quantity of laudanum 
 taken was ascertained to be one ounce and a half. The case 
 
 * This practice, though not generally adopted, has been recommended by several 
 authors in Europe.
 
 THE GENERAL TREATMENT OF FEVER. 145 
 
 appearing so desperate, justified me in the course of treatment 
 which I was, under existing circumstances, then obliged to 
 adopt. 
 
 " Internal remedies having entirely failed, there was no chance 
 left but for high external excitements. I therefore determined 
 to use vigorous measures. I commenced with flagellations, using 
 long, pliant, fresh twigs to the palms of the hands and soles of 
 the feet. These were briskly applied, and in a short time gave 
 indications of uneasiness and pain. This treatment was unre- 
 mittingly pursued till the man spoke, and complained of being 
 pained by the whipping, when this severe appliance was 
 relaxed ; but on so doing, he instantly sunk into a profound 
 stupor, from which he was again only roused by the severity of 
 the whipping. It required the aid of a number of men to take 
 turns in the flagellation, as well as to support and walk him 
 about, for a cessation of the use of the rods was followed by 
 instantaneous stupor. After about six or eight hours under 
 this course, the stupor was lessened, and the severity of the 
 flagellation mitigated; but, as the case required constant high 
 excitement it was still repeated at intervals, till eventually the 
 exercise of walking was sufficient to keep him awake. This was 
 in about twelve hours from the commencing with the flagella- 
 tion. He afterwards experienced but little inconvenience from 
 his hands and feet, and was perfectly restored in a few days to 
 his usual health. I would here state that the first proposal 
 made by me to adopt flagellation, as the only hope, was objected 
 to by persons present, fi'om its carrying with it the semblance 
 of unkindness towards what was regarded by them as a corpse ; 
 and it was not till the application of the rods by myself in the 
 first instance, that I obtained the aid of those present ; but as 
 soon as the patient began to move, and at last spoke, they took 
 hold with alacrity, and, by dividing themselves into relief 
 parties, they very cheerfully, and rather amusingly, kept up the 
 castigation so long as the state of the patient required it at their 
 hands. He by no means seemed to relish this harsh proceeding, 
 and in return gave his attendants several severe blows. If, 
 while lifting his arm to give a blow, the flagellation was then 
 entirely suspended, the arm would instantly sink powerless ; to 
 such a degree had the eff"ects of the narcotic drug prevailed over 
 the nervous system, that nothing but the torture of the rods could 
 VOL. I. 10
 
 146 CLINICAL MEDICINE. 
 
 rouse him. On his recovery it was said that the man's wife was 
 highly satisfied with the remedial com-se, which she believed to 
 have a good effect upon his subsequent conduct." 
 
 I have already alluded to the abuse of soda or seltzer water 
 and effervescing draughts in fevers. It is very much the custom, 
 both in hospital and private practice, to look upon the latter as 
 a remedy which may be administered at the pleasure of the 
 patient or the discretion of the nurse. They are certainly to 
 many persons a most grateful means of cooling thirst ; but the 
 cautious physician will never allow his patient to indulge too 
 much, for he knows that their frequent use distends the stomach, 
 and produces a tendency to tympanitis and bowel complaint. 
 I am also of opinion that the exhibition of large quantities of 
 free carbonic acid is a very doubtful, if not a dangerous practice 
 in fever, and may increase that tendency to narcotism and func- 
 tional derangement of the nervous and respiratory systems 
 which is observed in every case of genuine typhus. In addition 
 to this, the evolution of a large quantity of fixed air in the 
 stomach frequently causes a very disagreeable sense of distention 
 and suffocation, and acts injuriously on the mucous membrane.
 
 147 
 
 LECTUKE X. 
 
 THE GENERAL TREATMENT OF FEVER. TYMPANITIS. — HICCUP. — 
 
 HEMORRHAGE FROM THE BOWELS. 
 
 Before I proceed to speak further of the diet and remedies to 
 be employed in the treatment of typhus fever, allow me to make 
 a few observations. There is a patient at present in the fever 
 ward, whose case shows the necessity of strict attention and in- 
 cessant watchfulness on the part of those who have the manage- 
 ment of bad cases of fever. A man who has been labouring 
 under delirium, with symptoms of cerebral excitement and con- 
 gestion, was ordered the tartar emetic solution, with the view of 
 reducing the increased vascular action ; but on inquiry this 
 morning, we find that he has taken no medicine, and that his 
 symptoms have been allowed to go on unchecked for twenty- 
 four hours. He refused to take his medicine, and the nurse 
 very improperly neglected to report the circumstances of the 
 case, in order that proper steps might be taken to remedy so 
 dangerous an omission. Thus a whole day has been lost at a 
 most critical and important period of fever. There can be no 
 excuse for such negligence as this, for it could be easily 
 remedied. Patients in this state have always more or less 
 thirst, and a spoonful of the tartar emetic solution could be 
 mixed with whey or cold water, and administered in this way 
 without his knowledge, or, if he refused to drink any fluid, it 
 might be given in the form of enema. There is no excuse, 
 therefore, for such negligence ; and when you recollect the 
 state that such patients are in — their nervous excitement, in- 
 cessant raving, agitation, struggling, and sleeplessness — you 
 will be able to appreciate the dangerous and even fatal conse- 
 quences that may arise from culpable neglect of this kind. 
 
 At our last meeting I spoke of the use of food and drink, and 
 laid before you my views of the most appropriate articles of 
 diet in the various stages of fever. I told you that I attributed
 
 148 CLINICAL MEDICINE. 
 
 much importance to the use of a proper regimen, and that I 
 looked upon the observance of this principle as a main cause of 
 success in the treatment of typhus. I think it is chiefly owing 
 to our care in this respect that so few of our patients have 
 tympanitis. Now and then we have cases of fever with 
 tympanitis and diarrhoea, but in the majority of instances, 
 these are persons who have been under treatment before ad- 
 mission, and who have been too much purged. The use of 
 drastic purgatives in the early and middle stages of typhus is 
 one of the most fertile sources of subsequent evil, and there are 
 few evils of greater magnitude than tympanitis with diarrhoea, 
 and gastro-enteric inflammation, particularly in the latter stage 
 of fever. Now, if you inquire into the history of the cases 
 in which these symptoms are most distinctly marked, you 
 will find that in at least two-thirds, powerful cathartics 
 have been employed not once, but repeatedly, in the com- 
 mencement of the disease. Almost all cases in which 
 calomel and colocynth, or aloes, followed by black draught, have 
 been liberally used in the commencement, become tympanitic, 
 and frequently at a very early period.* The same mischief, but 
 
 * The views of Dr. Stokes quite agree with mine : — 
 
 "A common practice has prevailed in these countries, and, indeed, still exists to a 
 very great extent, of making the patient take a purgative medicine every day ; and 
 this, I regret to say, is too often done, even in cases where the surface of the small 
 intestine presents extensive patches of ulceration. Now. I will ask you, can anything 
 be so barbarous as this, or can it be exceeded in folly or mischief by the grossest acts 
 of quackery ? Here we have an organ in a state of high irritation, and exhibithig a 
 remarkable excitement of its circulation ; and yet we proceed to apply stimulants to 
 that organ, and to increase the existing irritation. Would it not be absurd in a case 
 of inflammation of the knee or elbow-joint to direct a patient to use constant exercise 
 and motion ? Would it not be a very strange practice to apply irritants to a raw and 
 excoriated surface? Yet something equally absurd, and equally mischievous, is done 
 by those who employ violent purgatives in a case of inflammation of the digestive 
 tube in fever. This has been the great blot in the history of British practice. 
 Calomel, and black bottle, and even jalap, and aloes, and scammony, have been pre- 
 scribed for patients labouring under severe and extensive dothinenteritis. Morbid 
 stools are discharged, and the more morbid they are, the more calomel and purgatives 
 does the physician give to change their character, and bring them back to the standard 
 of health. I want words to express the horrible consequences. Too often have I 
 seen fever patients brought into the hospital with diarrhoea, hypercatharsis, and 
 inflammation of the mucous membrane, from the use of purgatives administered 
 before their admission. Practitioners will not open their ej-es. They give purgatives 
 day after day, a very easy i)ractice, and one for which there are plenty of precedents ; 
 bat it is fraught with the most violent consequences. I will freely admit that the 
 flisciples of the school of Broussais have gone too far in decrying the use of laxatives 
 altogether ; but if they have lost hundreds by this error, British practitioners have 
 /cilled thousands by an opposite plan of treatment. In cases of fever, where there is
 
 THE GENERAL TREATMENT OF FEVER. 149 
 
 in a less degree, is apt to occur where a system of strict ab- 
 stinence has been enforced and continued undeviatingly for a 
 considerable length of time. Want of food, even in the healthy 
 state of the system, is apt to produce flatulence, weakness, and 
 distention of the stomach ; and in many instances gives rise to 
 very serious forms of gastro-intestinal irritation. The cliete absolue 
 is very apt to produce the same efi"ect in fever. Even the abuse 
 of drinks of the simplest and most innocent description is apt to 
 produce flatulence, distention, and a tendency to tympanitis. 
 Hence the value of the rule which I laid down in my last lecture, 
 viz., to allow the patient only small portions at a time, and to 
 order him to swallow them slowly. The abuse of the ordinary 
 drinks, as common water, whey, barley-water, soda and seltzer 
 waters, and effervescing draughts, is a frequent source of tympa- 
 nitic swelling in fever. 
 
 Having commenced the subject of tympanitis in fever, I cannot 
 do better than proceed now to describe its causes and the mode 
 of treating it which I have found most effective. 
 
 The mucous membrane of the alimentary canal secretes air 
 in great abundance during health. The immediate uses of the 
 secretion have not been enough studied, nor have I now sufficient 
 time to dwell on this subject ; it may be remarked, however, 
 that the presence of air in the bowels must be of great import- 
 ance, both physically and chemically assisting digestion, which 
 essentially consists in the gradual softening and final solution 
 of the solid food, and the absorption of the dissolved portions. 
 Physically the air must facilitate the motions of the alimentary 
 bolus, keeping the bowel in a suitable state of distention, and 
 being ready immediately to occupy the place of the solid or fluid 
 contents as they are moved about or absorbed ; chemically, it is 
 well known that certain gases, such as carbonic acid — a gas 
 
 no decided symptom of gastro-enteric disease, there can be no objection to the use of 
 laxatives, if required, but they should always be of the mildest description. You 
 will gain nothing by violent purging in fever, mild laxatives alone can be employed; 
 and where there is any sign of intestinal irritation present, even these should be used 
 w-ith caution. There is one way of opening the bowels, which you may always have 
 recourse to with advantage in fever, viz., the use of enemata. There is not the 
 slightest doubt that occasionally accumulations of fecal matter will take place, and 
 tend to keep up irritation ; but they should alwaj-s be removed with the least risk of 
 producing bad consequences. To purge in fever when intestinal irritation is present 
 is a practice opposed alike to theorj- and experience, and I have already stated that 
 its results are most horrible.'' — Dr. Stokes' Lectwen, American edition, p. 500.
 
 150 CLINICAL MEDICINE. 
 
 always very abundant in the intestine — possess a remarkable 
 power of rendering various solids more readily soluble in water, 
 particularly when these gases are subjected to the effects of 
 pressure in close vessels along with the solvent fluid, a state of 
 things which exists also in the intestines. Another chemically 
 powerful gas secreted by the mucous membrane of the bowels is 
 sulphuretted hydrogen. In the upper portion of the canal com- 
 mon air is most abundant ; in the lower the two other gases 
 become predominant — a distribution not fortuitous, but no doubt 
 destined to fulfil important purposes. It appears, indeed, that 
 those portions of the alimentary canal which secrete fluid acids 
 (the muriatic and acetic) do not secrete acid gases, while the 
 remaining portions secrete these gases in great abundance, so 
 that one may be considered as supplemental to the other. 
 
 I am not aware that physiologists have as yet considered this 
 subject in the point of view here brought forward,* although it 
 evidently illustrates many things connected with practice. Thus 
 I have frequently remarked, and I would call attention to the 
 fact, that in persons labouring under dyspepsia, and in whom the 
 derangement appears to be limited to the stomach, the sup- 
 plementary digestion in the small intestines appears to be 
 carried on with great activity. Such persons suffer much imme- 
 diately after having taken food ; they experience an oppressive 
 sense of weight about the stomach, with flatulence and distention ; 
 in fact, they feel exceedingly uncomfortable until the food passes 
 into the duodenum, where the digestive power is in full vigour 
 and activity. As soon as this occurs, the sense of weight and 
 distention rapidly disappears, and they are no longer troubled 
 with flatulence. I have further noticed that such persons do not 
 lose flesh or strength, and an inspection of their alvine discharges 
 has shown that every particle of nutritious principle has been 
 absorbed, and found its way into the system. This I have fre- 
 quently observed. Persons will apply for advice who have been 
 for a long time labouring under symptoms of derangement of the 
 stomach ; yet they are by no means emaciated, and are quite 
 capable of discharging the duties of situations which require 
 great mental and bodily activity. This shows that, if the process 
 of digestion does not go on well in the stomach, it must some- 
 
 * This view of the uses of air in the alimentary canal, first published by me in 1836, 
 has been completely verified by the subsequent researches of Liebig.
 
 THE GENERAL TREATMENT OF FEVER. 151 
 
 where else. If, in such a case, the stomach is weak and unable 
 to perform its functions, the remaining part of the digestive tube 
 is strong, and pours out the fluids necessary for completing the 
 process with great energy. 
 
 Again, we meet with many persons who never complain of 
 acidity, pain, flatulence, or sense of distention and weight in the 
 stomach, and yet they are frequently annoyed with unpleasant 
 abdominal sensations ; they have costive or irregular bowels, 
 diarrhoea, tormina, tympanitis, fetid, unhealthy evacuations, and 
 scanty, high coloured urine. They feel uncomfortable, not 
 immediately after a meal, but in three or four hours ; they lose 
 flesh and strength, and have a pale, sallow, unhealthy look. 
 Here the dyspepsia is intestinal ; the stomach works well, and 
 performs its functions with vigour, but when the alimentary 
 mass enters the small intestines, it produces a great deal of dis- 
 comfort, because the supj)lementary digestion is deranged, and 
 its performance attended with much labour and difficulty. 
 
 In some cases both these forms of dyspepsia are combined, 
 and these are, of course, the worst ; but they exist quite distinct 
 from each other, and a patient, with his stomach in a perfectly 
 normal and healthy state, may labour under dyspepsia from 
 derangement of the digestive functions of the small intestines ; 
 or, with the latter in a healthy state, he may have indigestion 
 from simple gastric derangement. We have, indeed, reason to 
 conclude, that when organic or functional disease so impairs the 
 energies of the stomach that it assists but little in the per- 
 formance of digestion, the intestinal digestion becomes more 
 intense ; it is only thus that we can account for the absence of 
 emaciation in certain cases, such as that of Napoleon Buonaparte, 
 where, nevertheless, the stomach was so extensively disorganized 
 as totally to prevent its taking any part in the process of 
 digestion. 
 
 The preceding remarks, though not directly connected with, 
 are nevertheless illustrative of the subject under consideration — 
 it being evident that the secretion of air natural to the mucous 
 membrane of the intestines during health, may readily be 
 augmented in disease, so as to give rise to intestinal tympanitis. 
 This happens in all cases where inflammation or congestion 
 attacks this tissue — an occurrence particularly frequent in fever. 
 When tympanitis takes place in the commencement of fever, it
 
 152 CLINICAL MEDICINE. 
 
 invariably proceeds from inflammation, and is usually preceded 
 by tenderness and other unequivocal symptoms of inflammatory 
 action witliin the abdominal cavity. The remedy for this com- 
 plication consists in local blood-letting freely applied together 
 with small doses of Dover's powder, and considerable doses of 
 hydrargyrum cum creta : all active aperients should be avoided, 
 but emollient lavements are often useful. 
 
 When tympanitis occurs during the middle or latter stages of 
 protracted fever, it is sometimes inflammator}', but more fre- 
 quently depends on a state of venous congestion ; occupying a 
 considerable extent of the mucous membrane of the small 
 intestines, which subsequently becomes gorged with blood, and 
 livid, and secretes, among other morbid matters, a large quantity 
 of gases. This tympanitis is often preceded by bowel complaint, 
 unaccompanied by abdominal tenderness or pain, in the first 
 instance — a state of things which may last for one or several 
 days before inflation of the intestines commences. When this 
 occurs, then, if it proceeds rapidly, the belly becomes painful 
 and somewhat tender on account of the sudden distention ; and 
 a superficial observer is thus apt to attribute the tympanitis to 
 active inflammation. 
 
 Now, as this state of things takes place at a period of great 
 debility, when the powers of life are already much exhausted, 
 and when even the application of a few leeches may be followed 
 by alarming weakness, it is evident that this tympanitis must be 
 treated in a manner diff"erent from that above spoken of. In 
 general, it will be right to commence with the exhibition of ten 
 or fifteen grains of magnesia, with the same quantity of rhubarb, 
 given in some carminative vehicle, such as spearmint or fennel 
 water; after this has operated, the belly should be well stuped, 
 and rubbed with a stimulating terebinthinate liniment. It 
 often happens that, after the operation of the rhubarb, the 
 diarrhoea, and with it the tympanitis, begins sensibly to 
 diminish, and then a little care soon removes these symptoms 
 altogether. Sometimes, however, no such improvement follows ; 
 and the belly continues to swell, while the bowel complaint is 
 unchecked. This is a dangerous crisis, and requires the utmost 
 judgment in its treatment. 
 
 It is of great consequence to remark, that when the bowel 
 complaint, has preceded intestinal tympanitis in fever, and when,
 
 THE GENERAL TREATMENT OF FEVER. 153 
 
 notwithstanding the continuance of the bowel complaint, the 
 tympanitis has gone on increasing, oil of tm-pentine will seldom 
 be of the least use, whether exhibited by the mouth or in an 
 enema. We must, therefore, under these circumstances, look 
 for some remedy difierent from those usually recommended, and 
 such remedy we possess in the acetate of lead. 
 
 Pathologists are agreed that venous congestion and active 
 inflammation of the mucous membrane of the intestinal canal 
 may often be associated together ; and, in fact, although these 
 two states are different, and require difierent remedies, yet they 
 so nearly approach each other as to require medicines taken 
 from the class of antiphlogistics ; the one requires, however, a 
 very difi'erent antiphlogistic from the other, just as chronic 
 dysentery must be combated by remedies difi'erent from those 
 suited to acute bowel complaints. Oil of turpentine is admirably 
 suited to the cure of congestive tympanitis in fever, where no 
 bowel complaint, or a very slight one, has preceded or accom- 
 panied it. But is oil of turpentine an antiphlogistic remedy ? 
 I answer, does it not cure certain cases of iritis, of sciatica, and 
 of epilepsy ? When, however, a bowel complaint forms the chief 
 feature in a patient's state, and is associated with tympanitis, 
 then the acetate of lead must be our sheet anchor. 
 
 I was first led to use this medicine in considerable doses, in 
 the latter stages of protracted fever, on the recommendation of 
 Dr. Bardsley, for the purpose of preventing that state of the 
 bowels which so insidiously leads to ulceration of Peyer's glands. 
 Dr. Bardsley certainly deserves much credit for the introduction 
 of this remedy, with which I became familiar in consequence of 
 using it largely in Asiatic cholera — a disease in which the serous 
 discharges are almost invariably preceded, and, when the patient 
 recovers, invariably followed, by a coinous secretion of air into the 
 bowels. This.it was that led me to observe the anti-tympanitic 
 properties of the sugar of lead ; for I have found it to be a 
 remedy, not merely for the secretion of serous fluid into the 
 intestines, hut for the secretion of air in that disease. Afterwards, 
 analogy led me to apply it to the cure of tympanitis combined 
 with diarrhoea, in the middle or latter stages of fever ; and I 
 have had much reason to congratulate myself upon this new^ 
 application of the remedy, for it has been very successful in my 
 hands. It may be well to observe that sugar of lead, besides its
 
 154 
 
 CLINICAL MEDICINE. 
 
 astringent, seems to possess antiphlogistic properties; otherwise 
 we could scarcely account for its good effects in active hemorrhage, 
 and in violent action of the heart, for which latter, when given 
 in large doses, it is much celebrated in France. 
 
 In the above sketch of the treatment of tympanitis, my chief 
 object being to jioint out the circumstances in Avhich acetate of 
 lead or turpentine may be used, I have omitted mentioning 
 many other remedies and methods of treatment, as being 
 sufficiently known to practitioners in general ; among these 
 probably none is more effectual than leeching the anus in inflam- 
 matory cases, and, in all, mercurial dressing applied over a very 
 large vesicated surface on the abdomen. 
 
 Oil of turpentine is useful not only in the tympanitis of fever, 
 but also in the delirium which attends the low stage of that 
 disease. You will meet cases of fever, where depletion and 
 blistering have been carried to their full extent, and yet your 
 patient's head remains afiected ; his eye is clear, intelligent, 
 and free from suffusion, but he raves at intervals, gropes with 
 his hands, picks the bed-clothes, and grinds his teeth. Here 
 we have not only an affection of the brain, but we observe, in the 
 last-mentioned symptoms, one of the signs of intestinal irrita- 
 tion. In such cases, the vital energies are much depressed ; 
 you cannot use leeches or blisters or other depletory measures ; 
 it would be a great mistake to employ them. What are you to 
 do ? Prescribe opium in moderate doses and at certain intervals, 
 as, for instance, from five to eight drops of black drop every sixth 
 hour ; give your patient a little wine, and have recourse to the 
 oil of turpentine. Here the value of this remedy is very great 
 indeed, for it not only opens the bowels (a point of considerable 
 importance in such affections), but also removes tympanitis, and 
 exercises a powerful influence in controlling and quieting the 
 nervous system. I have seen persons lives saved by a few doses 
 of the oil of turpentine, and have watched its tranquillizing 
 effect on the nerves with pleasure and surprise. The following is 
 the prescription which I use : — 
 
 R. Olei Terebintliini, f5i. 
 Olei Ricini, f5iss. 
 Aquae, £51. Misce, Hat haustus, sexta qudque bora sumendus. 
 
 Under certain circumstances, turpentine is likewise useful in
 
 THE GENERAL TREATMENT OF FEVER. iOO 
 
 intestinal hemorrhage occurring in fever. A person in fever gets 
 increased frequency of pulse, heat of skin, dry tongue, and about 
 the twelfth day his head becomes engaged, his countenance 
 flushed, eyes suffused, and a tendency to sensorial derangement. 
 His bowels at the same time are affected, and tympanitis appears. 
 Matters then grow worse, he begins to pass blood, and, on visit- 
 ing him, his alarmed relatives show you quantities of thin 
 grumous blood which he has discharged from his bowels. Now, 
 what course are you to pursue in this case ? Stop all medicines 
 whatsoever, and let your patient alone. Watch the progress of 
 this discharge, and you will find that it disappears gradually, 
 and, when this occurrence takes place, never do anything. As 
 in fever a patient may get epistaxis, and it may usher in a 
 favourable crisis, so, in like manner, he may have a critical dis- 
 charge of blood from the bowels. In either case, you are not to 
 interfere with the wise provisions of nature, or to give anything 
 which may produce irritation, or cause a cessation of this salutary 
 process. You recollect a case of this kind in the hospital, which 
 the students requested me to stop, and that I refused to do so, 
 because I thought the hemorrhage critical. But it may happen 
 that this sanguineous flux may go on so far as to threaten great 
 danger. This is certainly an occasional result, for I have seen 
 epistaxis terminate fatally. Here you must interfere to avoid 
 a greater evil ; and it is at this critical period that the internal 
 exhibition of oil of turpentine combined with opium may be 
 ventured on ; but while the bleeding continues moderate, and 
 exhibits no threatening indications, and is accompanied by a 
 corresponding diminution of fever, you should leave the matter 
 entirely to nature. You perhaps have seen a patient here, who 
 on the fourteenth day of fever got this discharge of grumous 
 blood, and may remember that we gave nothing but a little of 
 the saturated, solution of carbonate of ammonia. Now, if we 
 had given this patient an opiate, we should have repressed a 
 sanatory effusion, or, if we had given him a purgative, we 
 might have precipitated it into a fatal hemorrhage. 
 
 I shall next proceed to make a few observations upon hiccup. 
 
 When hiccup occurs in typhus fever, it is generally owing to 
 a congested state of the mucous membrane, accompanied by 
 flatulent distention of the stomach and bowels. A remarkable 
 case of this sort occurred to Dr. Ireland and myself, in which a
 
 156 CLINICAL MEDICINE. 
 
 corpulent man, labouring under maculated typhus, hiccupped, 
 during several days, more than eighteen hours out of the twenty- 
 four, as was ascertained by notes kept by his sister, who carefully 
 watched him. 
 
 In such cases, the remedies adapted for tympanitis in typhus 
 fever are most appropriate, and therefore much variety of treat- 
 ment is required. Thus, when hiccup occurs early in the 
 disease, along with much thirst, parched tongue, and tender 
 epigastrium, the treatment ought to consist of leeches to that 
 part, iced water in small quantities, diete absolue, and bland 
 aperient injections. But, when it comes on late in the disease, 
 we must have recourse to stimulating liniments applied to the 
 spine, blisters to the epigastrium, and, if the bowels are at the 
 same time confined and distended, oil of turpentine inter- 
 nally or by lavement, while the strength is supported by wine 
 and proper nutriment. Here the oil of turpentine is best given 
 in doses of two or three drachms, combined with castor oil ; but, 
 on the other hand, when diarrhoea is present, together with 
 tympanitis, we must have recourse to acetate of lead, as before 
 recommended, to various stimulants in small and repeated doses, 
 such as turpentine, aether, &c., combined with opium. In fever, 
 hiccup occasionally occurs without any obvious derangement of 
 the alimentary canal being present, and without our being able 
 to detect any cause of th'is symptom. Our treatment under such 
 circumstances must be empirical, and relief will be frequently 
 obtained by the exhibition of some substance which has an 
 obvious action on the nervous system : but, as I have said, our 
 treatment must be empirical — in one patient we may find success 
 attend the exhibition of an alkali, in another of an acid. The 
 same observation applies to swallowing of ice, or water as hot 
 as it can be drank, to the various narcotics and stimulants, to 
 musk, camphor, &c. 
 
 Let me again call your attention to another circumstance con- 
 nected with the state of the digestive organs in fever, which I 
 incidentally mentioned a few moments since, namely, hemorrhage 
 from the bowels. I have seen four patients in whom the occur- 
 rence of hemorrhage from the bowels induced death — in all the 
 fever had a marked gastric character, and the passing of blood was 
 at first unattended by tenesmus, pain in the abdomen, or any 
 swelling of the bowels or tenderness denoting local ailment in
 
 THE GENERAL TKEATMENT OF FEVER. 157 
 
 tlie intestina,! canal. The bleeding continued many days, the 
 stools being mostly copious, and consisting either altogether of 
 black grumous clots mixed with fluid blood, or else of blood 
 mixed intimately with fecal matter. Sometimes not more than 
 one or two evacuations took place daily, and the debility not 
 being proportioned to the quantity of blood lost, it is more than 
 probable that in such cases the bleeding continued into the 
 bowels in much greater quantity than the blood was evacuated. 
 
 In all these cases the hemorrhagic, dicrotous pulse (see page 
 59) preceded the discharge of blood. 
 
 It has been satisfactorily proved by modern investigations, that 
 the dark-coloured matter similar in appearance to coffee-grounds, 
 which is discharged from the bowels in this disease and yellow 
 fever, consists of the coagulum of blood broken down and dark- 
 ened in tint by the acids of the intestinal canal. I had lately an 
 opportunity of observing a fact strikingly corroborative of this 
 explanation. A young gentleman labouring under very severe 
 fever, with violent headache, was attended by Sir Philip 
 Crampton and I. On the seventh day of his illness, two 
 leeches were applied to the internal surface of his nostrils, and 
 produced a very copious flow of blood, large quantities of which 
 were swallowed by the patient during his sleep. In thirty-six 
 hours after the bleeding had ceased, the nurse-tender became 
 very much alarmed on observing the blackness of the alvine 
 discharges. She told the family it was a very dangerous 
 symptom, and I was sent for in great haste. I need scarcely 
 add that, on seeing the evacuation of so large a quantity of 
 matter resembling cofi'ee-grounds, the true explanation of the 
 occurrence immediately suggested itself, and enabled me to 
 dispel the alarm of my patient's parents. 
 
 When blood is swallowed by a person in health, whose diges- 
 tive organs are vigorous, it never forms anything like coffee- 
 grounds in the large intestines, but is thoroughly digested 
 and absorbed in the superior portion of the alimentary canal.
 
 158 
 
 LECTURE XL 
 
 THE GENERAL TREATMENT OF FEVER. — EMETICS. — PURGATIVES. — 
 
 BLEEDING. 
 
 Having spoken at some length respecting epidemics, one only 
 fact occm-s to me in addition to those already detailed. It by 
 no means follows, when fever has a decidedly malignant type, 
 that other acute diseases which prevail at the same time should 
 exhibit a similar tendency ; thus measles and scarlatina are 
 often epidemic simultaneously with fever, and yet each of the 
 three may present a different type. In the year 1842 we wit- 
 nessed a very widely disseminated epidemic of scarlatina, whose 
 character was most malignant and fatal, and yet fever during 
 that period was unusually mild in its form, while measles were 
 rife and of a purely inflammatory character. Here, then, was a 
 year during which fever, without becoming inflammatory, ceased 
 to be typhus, scarlatina assumed a typhoid character, and 
 measles prevailed, but of a purely inflammatory type ! This 
 statement, for the accuracy of which I can vouch, teaches how 
 difficult it is to explain the causes which give to epidemics their 
 peculiar complexion ; indeed, for several years scarlatina had 
 been extremely malignant, and during the same period measles 
 very benign ; so that we must not too hastily adopt the hypo- 
 thesis that some general cause exists capable of simultaneously 
 modifying diseases of different species— an hypothesis which 
 has found many advocates, among the rest Dr. Watson, who 
 says, " Sydenham found that measles of an unusually bad kind 
 prevailed in London in the years 1670 and 1674 ; the very same 
 years in which small-pox was also remarkably malignant and 
 fatal. This illustrates what I have stated before, viz., that the 
 typhoid tendencies of these and other febrile disorders depend 
 less upon any peculiar virulence in their exciting causes, than 
 upon some change previously effected in the human body by the 
 silent and gradual influence of certain predisposing causes." * 
 
 * Lectures on the Practice of Physic, vol. ii. \-. 750, 1st ed.
 
 THE GENERAL TREATMENT OF FEVER. 159 
 
 I have already observed, that it is not my intention to give a 
 systematic account of the practice to be adopted in the treatment 
 of typhus, I have designedly passed over many important 
 points, being unwilling to trouble you with any observations on 
 practical matters in which my opinions coincide with the latest 
 and best authorities. T shall therefore touch very briefly on the 
 subject of emetics in fever, as the rules by which the administra- 
 tion of these remedies are regulated have been laid down with 
 precision by many modern writers. 
 
 I am not in the habit of using emetics in fever, except when 
 called in at the very commencement of the disease. Here 
 emetics are of great value, and will often succeed in stoppino- 
 the fever. There is no way in which you would be more likely 
 to cut short an attack of fever than by the administration of 
 an emetic, if you chance to see the patient when the fever is 
 just beginning. I speak here without any subterfuge, and 
 without grounding my opinions on the results of doubtful 
 or merely suspicious cases. I speak not of cases of bad feverish 
 cold, in which the symptoms, at the commencement, bear a very 
 strong analogy to those which usher in typhus ; I speak of cases 
 where the patient gets rigors, followed by the usual symptoms of 
 feverish excitement, after exposure to contagion, and is seen on 
 the evening of seizure. 
 
 If I were called to visit a patient who had been attacked with 
 shivering, headache, quickness of pulse, increased temperature of 
 skin, and lassitude, during the prevalence of an epidemic, or 
 after exposure to contagion, and happened to see him a few hours 
 after the attack, I should certainly bleed him, and administer an 
 emetic : and I think he would have a very good chance of 
 escaping the disease. I think the exhibition of emetics an 
 excellent practice in the commencement of fever, but I must 
 observe that the period for their exhibition is very brief. After 
 the lapse of twenty-four or thirty-six hours from the occurrence 
 of the rigor, they will not succeed in cutting short the fever. A 
 few hours make a vast difference in the chances, and after the 
 lapse of twenty-four hours there is, generally speaking, very little 
 hope of extinguishing the disease. At the termination of that 
 period, it has in most cases seized hold of the constitution too 
 lirmly to be shaken off by an emetic, even though aided by 
 bleeding ; but for the first few hours after seizure, the plan I
 
 160 CLINICAL MEDICINE. 
 
 have mentioned affords you a reasonable hope of being able to 
 put a stop to the mischief at once. Army surgeons, and practi- 
 tioners who have opportunities of treating incipient disease, are 
 well aware of the truth of these observations. I have myself 
 witnessed many cases in private practice, of medical men and 
 students who had been attacked with symptoms of fever after 
 exposure to contagion, and who escaped by taking an emetic and 
 being bled in proper time. 
 
 Let me here read for you a few observations on the use of 
 emetics at the commencement of fever, which appear to me to be 
 very judicious : — 
 
 " When the opportunity offers of administering remedies in 
 the first days of fever, an emetic may often be given with advan- 
 tage, especially where the tji^e of the fever is mild. An emetic 
 clears the stomach of offending matters or sordes, which may be 
 either undigested aliment, bile, thickened and vitiated mucus, or 
 its own thin acid or acrid secretions. Besides which, an emetic 
 has the additional advantage of determining the blood to the 
 surface, and in this way relieving the oppressed state of internal 
 organs. A powerful emetic may sometimes give the system a 
 shock, sufficient to alter the course of the symptoms, and even to 
 cut the fever short. This practice, however, is not without its 
 dangers. In some cases it determines morbid action to the 
 stomach, and renders that organ irritable during the whole 
 course of the fever. At other times an emetic brings on local 
 inflammation in some important viscus, on the same principle 
 that it forces out sweat. As a general rule, we are not justified 
 in giving an emetic, unless we have reason to think that the 
 stomach is foul, that is, loaded with acrid matters, whether 
 formed within the body, or received into it from without." — 
 Gregorys Practice of Medicine, page 121. Sixth Edition. 
 
 *' The arrest of fever may he also successfiilly attempted during 
 the stage of invasion, or up to the commencement of vascular 
 reaction or excitement ; but when once this period has super- 
 vened, the fever will run a regular course, although it will often 
 be much shortened by treatment. Fevers, I believe, caused by 
 infection, are very rarely arrested after reaction is established. 
 The means just advised for the formative stage may likewise be 
 tried in that of invasion ; but much discrimination is requisite 
 in the choice of means. Camphor, ammonia, and warm diapho-
 
 THE GENERAL TREATMENT OF FEVER. IGl 
 
 retics and diluents, sometimes with opium when the head is not 
 ailected, the warm hath, the vapour or heated air bath, and 
 frictions subsequently, are the most generally appropriate. In 
 robust persons, and where terrestrial emanations have been the 
 chief cause, a w\arm emetic and active stomachic purgatives may 
 also be exhibited ; but they should more rarely be ventured upon 
 in other circumstances, for the reasons just assigned. When 
 there is tenderness at the epigastrium, with other signs of gastric 
 irritation and depression of nervous power, instead of an emetic 
 or cathartic, a large sinapism, or a warm turpentine epithem 
 should be placed upon this region, and over a great -part of the 
 abdomen ; or, in other cases, upon the inside of the thighs ; but 
 neither of these ought to be resorted to if reaction have super- 
 vened, nor continued after it has come on." — Cojjeland's Medical 
 Dictionary, vol. i. page 921. 
 
 Except at the commencement, then, I am not an advocate for 
 the use of emetics in fever. If they fail in checking the disease, 
 they are apt to be followed by considerable debility of the 
 stomach and general system— states which it would be better to 
 avoid, where the patient has to run through the course of a long 
 and exhausting disease. If called to a case of fever in which you 
 cannot give an emetic, there are two or three other remedial 
 agents you may employ to moderate the feverish excitement, and 
 render the disease milder and more manageable during its pro- 
 gress. One of these is James's powder, with which you may 
 combine blue pill or hydrargyrum cum creta, if necessary, giving 
 two or three grains of each every third or fourth hour, according 
 to circumstances. Another remedy, which many are in the 
 habit of using, particularly where the fever is accompanied with 
 symptoms of inflammatory excitement, is a weak solution of 
 tartar emetic. Two grains of tartar emetic may be dissolved in 
 a pint of barley-water, and of this mixture a table-spoonful may 
 be taken every second hour. These are good and useful remedies 
 in the first stages of fever ; they moderate the feverish excite- 
 ment, act gently on the bowels, and produce more or less 
 diaphoresis. 
 
 It most commonly happens that the jjhysician is not called to 
 
 see a case of fever until forty-eight hours, or perhaps three or 
 
 four days have elapsed, from the period of seizure. In this 
 
 climate feverish colds are extremely frequent ; and as their 
 
 VOL. I. 11
 
 162 CLINICAL MEDICINE. 
 
 symptoms bear considerable resemblance to those of incipient 
 fever, and very few are capable of making a distinction between 
 them for some time, a person attacked with fever usually regards 
 it, at the first onset, as the result of cold, and expects to be able 
 to alleviate or remove it in a few days by bathing his feet and 
 taking a warm drink at night, with, perhaps, some opening 
 medicine on the following morning. The usual period, however, 
 at which the feverish cold had been accustomed to decline, passes 
 over without the expected amendment, the patient feels himself 
 weaker and worse, the conviction is brought home to him that 
 his disease is something more than an ordinary cold, and he 
 sends for a physician about the third or fourth day. Now at this 
 period, I believe, you must be content to let the fever run its 
 course ; for it has taken root too deep to be expelled by a coiij) de 
 main, and yet many persons seem to think they can still succeed 
 by what they term bold and decided treatment. The mode 
 which they generally adopt is, first, to administer an emetic, and 
 then to have recourse to copious and continued purgation. This 
 leads me to say a few words on the use of purgatives in fever. 
 
 The abuse of purgatives, particularly in the first stage of 
 fever, continues, I am sorry to state, even to the present day, 
 a blot on the character of practical medicine. Large doses of 
 calomel and vegetable purgatives, in the form of pill or bolus, 
 followed by draughts composed of infusion of senna, Epsom 
 salts, and electuary of scammony, form the chief part of the treat- 
 ment in fever with too many practitioners. I know well that 
 this is a mode of proceeding too commonly employed, and I 
 have frequently heard those who adopt it, when questioned as to 
 the remedies they have used, declare, with much self-satisfaction, 
 'that the patient's bowels have been well cleared out. This, I 
 believe, is a very common mode of treating fever in the incipient 
 stage ; and though there can be no objection to the administra- 
 tion of a purgative, as a cautionary measure, particularly where 
 an accumulation of fecal matter in the bowels is suspected, I 
 must confess that my experience does not authorize me to say 
 that fever can be either checked or mitigated by continued 
 purgation. 
 
 If active purgation does not check fever in the commencement, 
 what benefit then can be expected from it ? People will tell you 
 that full purging must act beneficially in two ways : by unload-
 
 THE GENEKAL TREATMENT OF FEVER. 163 
 
 ing the bowels, and by evacuating the general system. With 
 regard to evacuating the bowels, I think it can be done well and 
 sufficiently by the use of mild aperients. It is seldom necessary 
 to give active purgatives, and we never have occasion to continue 
 their employment from day to day. The bowels, I repeat, can 
 be sufficiently unloaded by the exhibition of mild aperients and 
 enemata, and even these will seldom be required more than once 
 or twice in the commencement, and occasionally during the 
 course of the disease. The second question (in reference to the 
 use of purgatives as general evacuants) is, whether it is prudent 
 or safe to act antiphlogistically on the system through the 
 medium of the intestinal canal, during the first stage of fever '? 
 My opinion is, that it is not. I grant that the administration of 
 active purgatives is followed by a copious evacuation of the fluid 
 secretions of the intestinal canal, and that in this way you 
 deplete the system to a very considerable extent. Admitting all 
 this, and, moreover, that depletion is required, still I am of 
 opinion that this is not the best way of effecting it, and shall 
 always give a preference to the action of other remedies. I 
 prefer the action of James's powder, or tartar emetic, or nitrate 
 of potash, or leeches, or, in fact, any remedy which will act with 
 less risk of subsequent mischief. 
 
 I have observed that the abuse of active purgatives in the com- 
 mencement of fever — nay, even the exhibition of cathartics two 
 or three times in the beginning of fever, in persons with irritable 
 bowels, is very apt to induce excitement of the gastro-intestinal 
 mucous surface, giving rise to early and profuse diarrhoea, 
 tympanitis of a bad and unmanageable character, and not unfre- 
 queutly to disease of the mucous coat of the digestive canal. 
 Great tenderness of the belly, meteorism, and exhausting 
 diarrhoea, are the general consequences of early and continued 
 purgation. In private practice I can generally tell, by examining 
 the patient's belly, whether he has been actively purged in the 
 commencement of the disease or not. I invite you to study the 
 cases that come before you in hospital, with reference to this 
 point ; I think you will find in most instances, that the patients 
 who have escaped active purgation before admission will get 
 through the disease with little or no tympanitis. The physician 
 who merely employs mild aperients and enemata — who does not 
 use active purgatives from day to day, as is too often done — will
 
 164 CLINICAL MEDICINE. 
 
 not have his plans of treatment embarrassed by the occurrence of 
 dangerous tympanitis, or obstinate and debihtating diarrhoea ; 
 nor will he have the melancholy prospect before him of having 
 an inflammatory affection of the gastro-intestinal mucous mem- 
 brane to treat, at a period when neither the condition nor the 
 constitution of the patient will bear anything like antiphlogistic 
 measures. 
 
 As to purging in general, the idea of curing fever by it is quite 
 absurd. In fever all the secretions are affected, and it wouldl 
 be idle to think of altering and improving all by acting on the' 
 bowels. Take the skin, for example. Consider what a depar- 
 ture there is from the normal state ; observe the quantities oft 
 moisture which exude from it without any apparent cause, or its- 
 equally inexplicable dryness. Its odour, its feel, its nervous andl 
 vascular conditions, are all more or less altered. Take the lungs,, 
 in the next place. There is generally some change in the smell ofl 
 the patient's breath ; there is some change also in the quantity ofl 
 the pulmonary exhalation ; there is an alteration in the rate andl 
 mode of respiration ; and I have ascertained, by experiment, that: 
 a person in fever does not consume as much oxygen, or give out: 
 as much carbon, as he would in a state of health. Observe the; 
 functions of the brain, or those of the liver or kidneys, and see. 
 how much they have departed from the normal state. Every 
 secretion, every function, is more or less deranged, and willl 
 remain so as long as the fever lasts. You have no right to think; 
 that you will be able to restore the healthy state of the stomach andl 
 bowels any more than that of any other organ. The secretions^ 
 of the lungs, liver, pancreas, kidney, stomach, and skin are alll 
 deranged, or more or less suppressed, and will not be restored to) 
 a healthy state until a crisis comes on, or the disease begins tO) 
 decline. 
 
 As long as the belly is soft and fallen, and where the bowels* 
 have been sufficiently opened in the commencement of the' 
 disease, I do not feel the least anxiety if the patient remains 
 without having a stool for two or three days. I have, on some' 
 occasions in private practice, been induced to consent to the 
 exhibition of a purgative where I did not think it required ; and 
 have seldom done so without regretting it afterwards. The 
 patient has been going on well, the belly soft and fallen, no 
 tenderness present, and no distinct evidence of fecal accumulation.
 
 THE GENERAL TREATMENT OF FEVER. 165 
 
 All this I have pointed out to the practitioners in attendance 
 with me, but to no purpose. They would generally observe in 
 reply, " Oh ! this may be all true ; but you see the patient has 
 had no stool for the last thirty-six hours, and it would be quite 
 wrong to let him go on in this way any longer." Indeed, 
 you will frequently meet with cases in which you should exercise 
 much caution in the administration even of enemata. An illus- 
 tration of this remark occurred to me lately in practice. In a case 
 of fever in which the patient's friends were importunate as to the 
 necessity of opening the bowels, the ordinary purgative injection 
 was prescribed. It proved too active, and produced much irri- 
 tation of the bowels, giving rise to an increased secretion of 
 gas into the intestines, and a considerable degree of temporary 
 tympanitis. 
 
 You will be guided, therefore, in the administration of purga- 
 tives, not by the rule of those who are dissatisfied with less than 
 two or three motions in the day, but by the circumstances and 
 exigencies of the case ; and you will be cautious in giving purga- 
 tives, except where you have good reasons to conclude that there is 
 an accumulation of feces. In this way you w'ill avoid tympanitis, 
 diarrhoea, and inflammatory aifectlons of the bowels ; symptoms 
 which always give great annoyance to a practitioner, and tend 
 greatly to embarrass his practice in the treatment of all fevers of 
 a typhoid character. 
 
 So far concerning the administration of purgatives as a cure 
 for fever, or as a means of diminishing its violence. You 
 perceive that I think their employment more than questionable, 
 and in this particular am consequently at issue with Hamilton, 
 and a great number of writers. There are, however, circumstances 
 which may arise during the course of typhus, and may require 
 a free use of purgative medicines ; we are then forced to have 
 recourse to purgatives, not in the hope of curing the fever itself, 
 but for the purpose of removing or alleviating certain superadded 
 symptoms. 
 
 It may be well to mention some of the chief of these symptoms. 
 One of the most common is determination of blood to the head, 
 producing delirium, headache, &c. In many examples of this 
 nature, occurring at an early period of typhus, purgatives of a 
 very active nature are amongst our most efficacious remedies. Na}', 
 even in the advanced stages of fever, delirium and determination
 
 166 CLINICAL MEDICINE. 
 
 to the head are seldom relieved by tartar emetic, unless it pro- 
 duces very copious, yellow, watery stools. Many patients become 
 uneasy and restless at night in the latter periods of fever, in con- 
 sequence of insufficient evacuations from the bowels ; whenever, 
 therefore, restlessness or sleeplessness supervene unexpectedly, 
 and that the bowels are confined, the occurrence of these 
 symptoms calls for aperients, even though the belly be not very 
 full and tumid. Preternatural fulness of the belly and tympanitis 
 often demand purgatives at any period of the disease. 
 
 In some cases, when a troublesome diarrhoea has yielded to 
 astringents, a very obstinate and long-continued state of consti- 
 pation comes on, apparently connected with impaired muscular 
 power of the intestinal tube. At first the confinement of the 
 bowels produces no uneasiness on the part of the medical atten- 
 dant, inasmuch as it is unattended by any fulness or tension of 
 the abdomen, and the patient may, in other respects, aj)pear to 
 be doing well. After some days, however, it is judged prudent 
 to excite alvine evacuations, which is attempted cautiously, for 
 the practitioner bears in mind the violence of the previous 
 diarrhoea. He therefore chooses mild purgatives at first, and 
 next day, finding them ineff"ectual, he ventures on the exhibition 
 of more active medicines, and orders a frequent repetition of 
 injections. Even these steps fail, and constipation continues for 
 several days after the efforts to remove it have been commenced. 
 This is a juncture full of difficulty. In such cases, much caution 
 must be used in employing active cathartics, and great care 
 should be taken to remove any hardened feces which may be 
 present in the rectum or sigmoid flexure of the colon. This 
 must be done partly by the finger, or by means of an appropriate 
 scoop, as, for instance, a marrow spoon, and by injections of soap 
 and water. When no such mechanical obstructions exist, to 
 account for the failure of the cathartics, we must proceed 
 cautiously, and not rashly accumulate medicines of this de- 
 scription in the stomach and bowels of the patient. 
 
 Very active purgatives, though they fail to stimulate the para- 
 lysed bowels so as to evacuate their contents, may yet irritate 
 their intestinal mucous membrane, and cause destructive inflam- 
 mation. For this reason, Avhere moderate doses of colocynth, 
 gamboge, jalap, scammony, rhubarb, &c., have failed, they must 
 not be repeated ; neither, except in desperate cases, ought we to
 
 THK GENERAL TREATMENT OF FEVER. 1G7 
 
 administer croton oil internally. The neutral salts, senna, 
 magnesia, and, above all, castor oil, given combined with oil of 
 turpentine, or uncombiued and very frequently repeated, must 
 be our chief internal medicines. In some cases, the compound 
 decoction of aloes, with small doses of sulphate of magnesia, will 
 succeed in exciting the paralysed bowels to action, where other 
 and more powerful purgatives have failed. Injections should be 
 perseveringly repeated, and varied both in quality and quantity ; 
 and they should be always thrown as far as possible into the 
 bowel, by means of a flexible tube and Read's syringe. When 
 they are retained, and excite swelling of the belly, as too 
 frequently happens in these cases, we must desist from their 
 use. 
 
 This obstinate state of constipation may be supposed to 
 depend on a degree of paralysis of the bowels ; for usually in 
 such cases an evident paralysis aflects the bladder, causing 
 retention, or its sphincters, giving rise to an involuntary 
 dribbling of urine. 
 
 On the subject of bleeding in fever I have but very few remarks 
 to offer. In the first place, with respect to the power which 
 venesection possesses of checking fever, it may be observed, that 
 there can be no doubt that it has frequently been found capable 
 of effecting this purpose, particularly where it has been properly 
 employed, and in conjunction with other means. I speak here 
 with reference to cases in which bleeding has been used under 
 favourable circumstances, and very soon after seizure — as in 
 students, medical practitioners, hospital attendants, soldiers, 
 and seamen. In such persons, and others where circumstances 
 have been equally favourable, there is no doubt that venesection 
 has frequently succeeded in cutting short fever ; and if called to 
 a case of typhus within the first ten or twelve hours after seizure, 
 I should have no hesitation in having recourse at once to vene- 
 section, followed by an emetic ; and my own experience convinces 
 me that I should afibrd my patient a very good chance of escap- 
 ing the disease. I have on several occasions succeeded in 
 arresting the progress of fever by these means ; and the records 
 of naval and military practice furnish many proofs in corrobora- 
 tion of my statements. I have also the authority of Dr. Cheyne 
 (whose experience on every point connected with fever was 
 immense) in favour of the efficacy of bleeding in commencing
 
 168 CLINICAL MEDICINE. 
 
 fever, as a mode of treatment which has frequently proved suc- 
 cessful in his hands. But it is only in the very commencement, 
 and during the stage of rigor, that you can hope to derive any 
 advantage from venesection in cutting short an attack of fever. 
 I do not mean to say that you have in typhus, as in inter- 
 mittent fever, distinct rigors, lasting each for half an hour, or 
 even longer. By the stage of rigor in typhus I mean to desig- 
 nate the period of formation, during which the patient complains 
 of recurrent chills, although his skin feels hot to the touch when 
 examined by another person. This stage lasts generally from 
 twelve to twenty-four, and in a few cases to thirty- six hours ; 
 and it is only during this stage that you have a chance of 
 extinguishing the fever at once, by the abstraction of blood from 
 the system. 
 
 You may also have recourse to venesection within the first day 
 or two, for the purpose, not of arresting fever at once, but of 
 lowering inordinate vascular action in persons of a robust habit, 
 and where the fever sets in with violent headache, great heat of 
 skin, and a firm bounding pulse. We do not, however, at 
 present meet with many such cases, nor are we often called in 
 at a period when venesection might be advantageously practised. 
 The physician seldom sees a case of fever until the third or 
 fourth day, and then it is too late to think of general depletion 
 by the lancet. This explains why venesection is so seldom 
 employed in typhus in our hospitals. 
 
 Moreover, in entering on the treatment of any case of fever, you 
 should bear in mind the nature of the prevailing epidemic, and 
 be careful how you proceed with respect to bleeding ; and if you 
 take away blood, do not go so far as you w^ould if treating a case 
 of fever under different circumstances, and of a genuine inflam- 
 matory character. I know that many persons have asserted that 
 you can bleed in all cases of fever, no matter what the state of 
 debility may be ; because this, they say, is only apparent, and 
 depends upon congestion and oppression of vascular action. I 
 do not know how far this doctrine may be applicable to former 
 epidemics, but, in the recent epidemics of fever we have had, it 
 certainly does not hold good ; and no man in his senses would 
 think of adopting it as a guide for his practice. I have seen 
 some of the most intense, dangerous, and protracted cases of 
 fever, commence without any appreciable increase of vascular
 
 THE GENERAL TREATMENT OF FEVER. 169 
 
 action, with a soft slow pulse, a cool skin, no appearance of 
 congestion of any internal organ, in fact without any symptom 
 which would, even in the youngest and most robust habits, call 
 I'or the use of the lancet. 
 
 Increased vascular action, and this, you should always bear in 
 mind, is not in itself a proof of an inflammatory diathesis in 
 fever, but rather one of a set of symptoms produced by the same 
 morbid cause. The heat of skin and rapidity of pulse are, just 
 like the debility, products of the same morbid cause, and not the 
 results of inflammation. You should also recollect that in fever, 
 as well as in other diseases in which the nervous system is greatly 
 deranged, the pulse is not unfrequently a very deceptive guide. 
 In many cases of fever, where the patient happens to be of an 
 irritable habit, the pulse exhibits a degree of thrill and apparent 
 hardness, which might lead an inexperienced or inobservant 
 practitioner into serious errors. I do not mean to say that an 
 inexperienced finger will not be able to distinguish a pulse of 
 this kind from one of genuine hardness, but I know that many 
 persons have been misled by it, and I warn you against the danger. 
 
 Again, never use the lancet when there is any, even the 
 slightest appearance of maculfe, no matter how intense the 
 headache, heat of skin, or signs of general vascular action may 
 be. I have seen some cases in which the lancet was used 
 during the presence of maculae, and I have seen its employment 
 followed by the most lamentable consequences. You should, 
 therefore, never omit to examine the skin, for circumstances 
 might occur which would authorise a moderate use of the lancet, 
 provided there was no sign of maculae present. Formerly, persons 
 were very much in the habit of employing arteriometry when the 
 headache and delirium were violent, regardless of the period or 
 stage of fever ; and nothing was more common than to see a 
 physician ordering the temporal artery to be opened on the 
 eighth, ninth, or even tenth day. This was very much the 
 practice during the time when the doctrine of tjq^hus being the 
 result of inflammation of the brain prevailed in this country 
 and England, and a very unsuccessful practice it was. You 
 perceive we seldom have recourse to arteriotomy here ; it may 
 be occasionally necessary, and when it is, we employ it ; but 
 as a general practice it does not appear entitled to any merit, 
 nor can we give it our recommendation.
 
 170 CLINICAL MEDICINE. 
 
 The examples which you have seen in hospital show you that 
 local inflammation arises, generally speaking, at a period when 
 general bleeding is no longer admissible. I shall speak hereafter 
 of the mode in which leeches are to be applied to the head, with 
 the view of relieving headache and cerebral congestion ; it is not 
 necessary that I should say anything respecting their application 
 to the epigastrium, or abdomen, for the relief of gastro-intestinal 
 symptoms in the beginning of fever, as there is very little chance 
 of your doing any mischief, even by the free use of leeches, at 
 this period : it only remains for me to make a few remarks on 
 the use of leeches and cupping-glasses, in the more advanced 
 stages of the disease. 
 
 Well ; your patient, suppose about the ninth or tenth day, 
 gets pain in the side, cough, and increased frequency of respira- 
 tion, and, on examination, you find sufficient evidence of the 
 existence of pneumonia. Or he complains of abdominal symptoms, 
 and you have strong reason to think that hepatitis or enteritis is 
 present. Here you will have recourse to leeches or cupping, 
 according to the circumstances of the case. An attack of 
 pneumonia, coming on in fever, frequently acts as a stimulus to 
 the economy ; the collapse of fever disappears more or less, and 
 the pulse becomes more firm and resisting. This is a fortunate 
 occurrence, for under such circumstances the patient is better 
 able to bear depletion, and you may proceed at once to apply 
 cupping-glasses or leeches to his chest, regulating the quantity 
 of blood you abstract not only with reference to his present 
 symptoms, but also to his future condition. But it sometimes 
 happens that pneumonia occurs at a later period of the disease, 
 and when you cannot use cupping-glasses, or even leeches, to 
 any great extent. In such cases (and the same remark will 
 apply to enteritis, or any other inflammation occurring in the 
 advanced stage of fever), you should leech with great caution. 
 Begin with four or six at a time, and when they drop off, cover 
 the leech bites with a cupping-glass. In this way you will know 
 pretty nearly the exact quantity of blood which the patient has 
 lost, and you can arrest it with less difficulty afterwards. You 
 can then have recourse to calomel and opium, or tartar emetic, 
 according to circumstances. Leech as far as you can, and then 
 have recourse to immediate blistering, and such other means as 
 the exigencies of the case may demand.
 
 THE GENERAL TREATMENT OF FEVER. 171 
 
 You may leech, then, freely, and without any particular caution, 
 in the commencement of fever, whether it be for cerebral or for 
 thoracic or abdominal symptoms ; but, as the fever advances, 
 you must exercise more discrimination and care, both as to the 
 number of leeches you apply, and the time you allow them to 
 bleed. In applying leeches to the head, I would advise you not 
 to put them on both temples or behind both ears at once, as 
 this is awkward, and prevents the patient from lying on either 
 side. You may also, in cases of cerebral irritation, apply them 
 to the nostrils or septum narium ; in this way you will be able 
 to get away a large quantity of blood by means of very few 
 leeches, for one or two at a time will be sufficient. In leeching 
 the chest and abdomen, in particular, I advise you never to have 
 recourse to fomentations with the view of getting more blood 
 from the leech-bites. Fomentations are too often a source of 
 fresh mischief in cases of this kind, leading to exposure of the 
 patient to cold, and to the annoyance of having his linen and 
 bedding kept wet for hours together. Always give directions to 
 have cupping-glasses or hot dry flannel cloths applied as soon 
 as the leeches drop off, and you will have less difficulty in 
 arresting its flow afterwards, a point of some importance in 
 cases where the loss of even a trifling quantity of blood is often 
 of great moment, and likely to have a very powerful efiect on the 
 state of the patient.
 
 172 
 
 LECTURE XIT. 
 
 TEE USE AND EMPLOYMENT OF BLISTERS IN FEVER. 
 
 Blisters are employed in a variety of diseases, but are followed 
 by very different physiological effects, and capable of serving 
 very different purposes, according to their mode of application. 
 In fever they are generally employed either as stimulants, or as 
 evacuants and derivatives. As stimulants, they may be used 
 with the intention of rousing the depressed energies of the 
 system in general, by their action on the nervous and circu- 
 lating systems, or of stimulating the torpid functions of some 
 particular part or organ. With this object in view they are 
 applied as flying blisters — that is to say, for a space of time not 
 exceeding two or three hours, and solely with the intention of 
 producing a stimulant effect. You have seen some cases of 
 fever in our wards, in which the powers of life were greatly 
 depressed, the exti-emities cool, the action of the heart feeble, 
 the pulse weak, respiration short and imperfectly performed, and 
 a tendency to faintness and sinking ; and you have observed 
 that in such cases we derived great benefit from the application 
 of flying blisters over the region of the heart, the epigastrium, 
 chest, and inside of the legs and thighs. We applied our 
 blisters in these situations, left them on for three or four hours, 
 and then removed them ; and you have seen them, when em- 
 ployed in this way, succeed in rousing the vital energies, the 
 depressed action of the heart and capillary system, and the 
 flagging state of the respiratory action, as shown by the increased 
 strength of the pulse, the more general diffusion of heat, and the 
 renewed play of the various functions. 
 
 In such cases, where the stimulant effect alone is required, it 
 would be wrong to leave the blisters on longer than two or three 
 hours ; it will be quite sufficient if they prove merely rubefacient, 
 or, at most, vesicate so slightly as to give to the blistered sur- 
 face the appearance of a miliary eruption. Here you have all
 
 THE USE AND EMPLOYMENT OF BLISTERS IN FEVER. 173 
 
 the stimulant eftects of blistering, but not followed by their 
 debilitating consequences. Yon are aware that blisters applied 
 in the ordinary way have a twofold effect ; they first rouse, and 
 then depress ; acting primarily as stimulants, and secondarily 
 as evacuants. They first act as stimulants, producing pain, 
 heat, and redness of the part ; after a few hours these symptoms 
 diminish, and are followed by an effusion of serum — in fact, a 
 quantity of white blood is abstracted from the cutaneous capil- 
 laries, and in this way an evacuation is produced, calculated to 
 diminish any accidental congestion in neighbouring parts. The 
 capillaries, by means of their increased action, draw a quantity 
 of white blood to the part ; and, in saying this, I think I am 
 only using a perfectly physiological expression, for the quantity 
 of circulating fluid in any part of the body must depend on the 
 vital action of the capillary vessels of that part. It is to the 
 peculiar state of the capillary vessels, as I have proved in a 
 previous lecture, that the quantity of blood in any part is to be 
 referred, and not to the force or frequency of the heart's action. 
 It is by means of changes produced in them that the phenomena 
 of active congestion and inflammation are produced ; the capil- 
 laries of the afi'ected part enlarge, increase in number, and 
 multiply ; and those which were invisible become visible. These 
 phenomena have been falsely attributed by Hastings and others 
 to debility and impaired action of the capillaries. 
 
 Blisters, then, produce first increased action of a part, and 
 afterwards act as evacuants. They also stimulate the system 
 generally ; but if left on until full vesication is produced, they 
 act as evacuants and depletives, and lower the general tone of 
 the economy. I have frequently observed this succession of 
 events in chronic cases, in which it was found necessary to blister 
 repeatedly during the course of the disease. The patients gene- 
 rally told me that they felt better and lighter on the day on which 
 the blister was applied, but on the next day they usually felt 
 weaker and more depressed ; and this state sometimes lasted 
 more than a single day. You may, therefore, apply blisters as 
 excitants and stimulants ; yet there are many persons who seem 
 to forget this distinction. If, in a case of inflammation occurring 
 in a low state of the system, you propose to apply a certain 
 number of leeches over the inflamed organ, they say, no ; but 
 they have no hesitation in applying a large blister, leaving it on
 
 174 CLINICAL MEDICINE. 
 
 until it produces full vesication, and thus abstracting a consider- 
 able portion of white blood from the system. 
 
 You will not expect me to lay down any general rules for the 
 use and application of blisters in fevers ; you will find all these 
 matters sufficiently explained in your books and manuals. I am 
 not giving anything like a regular outline of the treatment of 
 fever ; in fact, I pass jyer saltum from one point to another, 
 without any attention to order or method. You can read 
 methodical treatises, and then compare them with such de- 
 tached observations as I shall make. And here allow me to 
 make some cursory remarks on that peculiar state of the brain 
 which we most commonly observe in the middle stage of typhus, 
 and in which blisters form one of our most efficient, and in some 
 instances our only mode of relief. In many of the cases of 
 typhus which come under our observation in hospital, we fre- 
 quently meet with a train of symptoms strongly calculated to 
 perplex and puzzle, and which should seldom exist in fever 
 regularly treated ; these are chiefly cases which are admitted in 
 the middle or latter stage of the disease, and at a period when 
 the patient's state of intellect is such as to preclude the hope 
 of obtaining any satisfactory information from a personal 
 examination. 
 
 A man in the lowest class of life, and at a distance from 
 medical aid, is attacked with fever ; for the first eight or teti 
 days he is either improperly treated or altogether neglected, and 
 in this state symptoms arise and superinduce others, causing the 
 most unfavourable complications, and rendering the cure difficult, 
 if not impossible. Now, of all the symptoms which occur in 
 cases of fever, where the state of the principal organs has been 
 neglected, there are none more formidable or more fatal than 
 the cerebral ; nor is there any local affection in fever, in which 
 the value of prevention is so unequivocal and decided. What I 
 wish to impress upon you is, that you should always anticipate 
 the cerebral symptoms in fever. Never allow the cerebral symp- 
 toms to explode — watch the first scintillse of cerebral excitement 
 — repress the commencing mischief, and do not permit your 
 patient to be overtaken by formidable inflammation of the brain. 
 
 Every writer will tell you that when the patient's face is 
 flushed, his eyes suffused, and when he complains of headache 
 and intolerance of light, you should leech and blister his head,
 
 THE USE AND EMPLOYMENT OF BLISTERS IN FEVER. 175 
 
 give him purgatives, tartar emetic, James's powder, and the 
 medicines calculated to bring down cerebral excitement : but a 
 careful and observant practitioner will anticipate all these symp- 
 toms, although there is as yet no particular flushing of the face, 
 headache, or suffusion of the eyes ; and though the patient is 
 still quite rational, he will recognise threatening disease of the 
 brain, and take proper steps to prevent its increase. Watch the 
 functions of the brain attentively, and they will inform you, in 
 almost every case, of the ajjproach of cerebral symptoms. 
 
 You will find in patients who are about to have cerebral 
 symptoms, a degree of restless anxiety, and a higher degree of 
 energy than accords with their condition ; and they either do 
 not sleep at all, or their sleep is broken by startings and inco- 
 herent expressions. When you speak to a person in this state 
 he answers in a perfectly rational manner ; he will tell you that 
 he has little or no headache ; and were you to be led away by a 
 hasty review of his symptoms, you would be very likely to over- 
 look the state of the brain. If you inquire closely, you will find 
 that he scarcely ever sleeps, or even dozes — that he is irritable, 
 excitable, frequently incoherent, and muttering to himself. 
 Under such circumstances, although there is no remarkable heat 
 of scalp, suflusion of the eye, or headache, I am frequently led 
 to suspect the supervention of cerebral symptoms, particularly 
 about the ninth or tenth day of the fever (for it is generally about 
 this period that cerebral symptoms begin to manifest themselves) ; 
 and whenever I observe these premonitory indications, I never 
 hesitate in taking proper measures to anticipate the evil. I 
 immediately order the hair to be shaved off, and blister the whole 
 scalp. Thus, at the period when disease of the brain would most 
 probably have set in, I have the whole external surface of the 
 head pouring out serum, or even suppurating; and when by 
 this treatment I have opposed a barrier to the further progress 
 of the disease, the exhibition of a little tartar emetic will soon 
 remove every trace of it. In laying down this plan of treatment, 
 I have supposed that the patient has been properly treated from 
 the beginning, and that the earlier symptoms of inflammatory 
 excitement have been combated by bleeding, leeching, and other 
 appropriate depletory measures. 
 
 There is, on the other hand, an opposite state of the patient, 
 which in like manner informs me that danger to the brain is at
 
 176 CLINICAL MEDICINE. 
 
 hand. In this case, the patient is almost continually sleeping. 
 When you enter his chamber in the morning, and ask how he 
 does, his attendant generally tells you that he has passed the 
 night most favourably, and that he has slept without almost ever 
 waking since your visit on the preceding afternoon. If he 
 awakens to take drink, he quickly drops asleep again, and when 
 you rouse him he looks rather heavy ; there is some slight 
 suffusion of the tunica adnata, and some appreciable congestion 
 about the external parts of the face and head. Persons in this 
 state, though apparently doing well, and even where they have 
 been properly treated in the beginning, about the ninth or tenth 
 day begin to rave, and exhibit undoubted proofs of congestion 
 and excitement of the brain. 
 
 Now, in all cases of this description, be on your guard, and do 
 not allow symptoms of dangerous import to steal on you. Here 
 you will derive great benefit from the use of blisters. I was 
 lately called to a very remarkable case of this kind, at some dis- 
 tance from Dublin. The patient slept almost constantly, and 
 complained of no headache or heat of scalp. From an attentive 
 examination of the case, however, I was led to predict the 
 approach of cerebral symptoms. Observe, this was a case of 
 spotted fever ; and in this form of fever you can predict the 
 occurrence of such symptoms with a greater degree of confidence. 
 The patient's pulse was 96, his tongue presenting nothing 
 worthy of remark, his behaviour and speech rational, and his 
 sleep almost constant. Kecollecting, however, the period of the 
 fever, and observing carefully the condition of the cerebral func- 
 tions, I had his head shaved and blistered. Notwithstanding 
 this precaution, his cerebral symptoms had proceeded so far that 
 he subsequently got a slight attack of paralysis of the face and 
 tongue, accompanied by a fixed state of the pupils, which would 
 neither contract nor dilate. After having blistered his head 
 extensively, I gave him the tartar emetic solution, to the amount 
 of one-eighth of a grain every second hour. The measures were 
 completely successful in removing the cerebral symptoms, and I 
 have no doubt that the active precautions which had been taken 
 were the means of saving his life. 
 
 There is one symptom connected with cerebral excitement in 
 fever which is well worthy of your notice, as its existence is often 
 sufficient of itself to give timely intimation of the approach of
 
 THE USE AND EMPLOYMENT OF BLISTERS IN FEVER. 177 
 
 irritation or infiaramatiou of the braiu. This is the state of the 
 respiratory function. In fever, the breathing will often announce 
 the approach of cerebral symptoms for days before their actual 
 occurrence. When, in cases of typhus, you find the patient's 
 breathing permanently irregular, and interrupted by frequent 
 sighing — when it goes on for one or two minutes at one rate, and 
 then for a quarter or half a minute at another rate, j'ou may rely 
 upon it that sooner or later an affection of the brain will make 
 its appearance. You will frequently observe the same kind of 
 breathing preceding attacks of apoplexy and paralysis, and 
 indeed it was the occurrence of this symptom, in these and other 
 cases in which the functions of the brain were deranged, that first 
 drew my attention to this Idud of breathing. The first time it 
 engaged my attention was in a remarkable case of an apoplectic 
 nature, which I sat up a whole night to watch. On recollection 
 I found that I had frequently observed an analogous state of the 
 respiratory function in fever on several occasions, although its 
 connexion with excitement of the brain had not struck me 
 before. I speak here of irregularity of breathing, independent of 
 any pectoral affection. But when the patient breathes in a per- 
 manently irregular manner, at one time at a certain rate, and at 
 another at a diftereut rate, — when his respiration is suspicious 
 and heaving, without any disease of the chest or great debility, 
 — you will have some grounds to suspect the existence of cerebral 
 derangement. I am in the habit of calling this kind of breathing 
 cerebral respiration, because my experience has told me that it 
 is almost invariably connected with oppression and congestion of 
 the brain. 
 
 To recapitulate : — When you find a patient in fever lying 
 constantly awake, or when, on the contrary, you find him con- 
 tinually slumbering,— v/heu there is a certain quickness of 
 manner and irritability,— and when the cerebral respiration has 
 been noticed for some time, without any concurrent debility or 
 pulmonary disease, — under such circumstances, you may, in 
 cases of maculated typhus, predict the approach of cerebral 
 symptoms ; and the period about which they generally manifest 
 themselves is the eighth, ninth, or tenth day. Now, in cases 
 of this description, — if you have previously used leeches and 
 antiphlogistics to a sufficient extent, — your best plan will be to 
 shave and blister the whole scalp. 
 
 VOL. I. 12
 
 178 CLINICAL MEDICINE. 
 
 Dr. Little of Belfast, and Mr. Kirby of this city, have fallen 
 into the same train of ideas, and employ blisters at a very early 
 period of the disease, with the view of combating cerebral excite- 
 ment. In a recent instance, in private practice, I think I saved 
 the life of a young gentleman in Harcourt Street, by extensive 
 blistering of the scalp on the fourth day of fever. We were not 
 accustomed to blister at this early period of fever. Formerly it 
 was the practice to bleed and apply leeches for several days to- 
 gether, and never to have recourse to blistering until towards the 
 latter stage of the disease. In common inflammation, or in 
 arachnitis, we do not blister until we have carried depletion by 
 the lancet, leeches, and purgatives, as far as the patient's strength 
 will allow. But this is not the case in fever ; the cerebral con- 
 gestion and irritation, or inflammation, (call it which you will,) 
 which accompanies typhus, differs essentially from ordinary 
 arachnitis or encephalitis, and requires very often a treatment 
 strikingly different. 
 
 One physiological fact connected with sleep may be noticed 
 here. It has been stated by Mr. Mayo, that the pupils are con- 
 tracted during sleep. This is in itself a very curious fact, and I 
 was anxious to verify it. Now we had an excellent opportunity 
 yesterday morning of trying what the state of the pupil was, in 
 two patients who lay soundly sleeping in the fever ward. We 
 came up softly to them as they lay on their, backs, and in a most 
 favourable situation for observation, just opposite one of the 
 windows ; and having opened the eyelids, found that the pupil 
 was actually contracted to the size of a pin-hole. It remained 
 in this state for a while, and then expanded, when they awakened. 
 This is a very curious fact, and appears to be a very beautiful 
 instance of the protective care of nature. To protect the eye 
 while we sleep, nature, as it were, draws the curtain, and thus 
 defends the delicate organ from any accidental dazzling, at a 
 period when consciousness slumbers and is off its guard. 
 
 I have hitherto spoken of blistering in fever chiefly as a power- 
 ful revulsive remedy in the treatment of cerebral congestion ; let 
 us now treat of its employment with other objects in view. In 
 the first place, as has been already explained, blisters may be 
 used as most energetic stimulants in cases where the powers of 
 life flag, and threaten a sudden cessation. Occasionally, in 
 fever, you will find the vital tone reduced to a very low pitch, the
 
 THE USE AND EMPLOYMENT OF BLISTEKS IN FEVER. 179 
 
 heart uncertain in its action, the pulse irregular, the respiration 
 feeble, the skin cool, and the patient so weak that he cannot be 
 lifted up, or even turned in bed, without having a tendency to 
 faint. Here we have to superadd to the ordinary treatment of 
 fever the prompt exhibition of remedies calculated to meet such 
 emergencies, and in addition to internal stimulants we have 
 recourse to powerful stimulation of the cutaneous surface, by 
 what are termed flying blisters. One of the best remedies in such 
 cases is a large blister applied over the region of the heart, to 
 be left on for two or three hours, or until the vascular action of 
 the skin is sufficiently excited. When the patient appears to 
 labour not only under sudden weakness of the heart, but also 
 of the capillary and nervous systems, as shown by coldness of 
 the extremities and sinking of the pulse, it will be necessary to 
 apply flying blisters not only over the region of the heart, but 
 also over various parts of the chest, the epigastrium, and the 
 inside of the legs and thighs. You will find this plan of treat- 
 ment frequently succeed in cases which have a very unpromising 
 aspect. I have now witnessed many instances of this description, 
 in which, from cold, neglect, or debilitating treatment, the 
 patients appeared moribund, with lividity of the extremities, 
 hippocratic face, cold skin, and failing pulse ; and I have seen 
 them saved, as it were miraculously, by the use of carbonate of 
 ammonia, musk, and wine, and the application of warm fomenta- 
 tions to the limbs, followed by a succession of flying blisters. 
 
 Let us take as an illustration the case of Christopher Nolan, 
 which I trust you have all watched with attention. When this 
 man came into the hospital his condition appeared to be com- 
 pletely desperate, he has, however, not only rallied, but is now 
 convalescing rapidly. It is unnecessary for me to enter into a 
 detail of his case, as I trust you have all observed it through its 
 different stages ; I shall only remark, that on his admission he 
 was labouring under fever of the worst character, his body was 
 covered with maculae, he lay constantly on his back, and had low 
 muttering delirium, was unable or unwilling to answer questions, 
 his breathing was oppressed, his pulse rapid, small, and failing, 
 the powers of life awfully prostrated, — in fact, he was in a state 
 of apparently threatening dissolution. 
 
 My first object was to rouse the sinking powers of the system, 
 and with that view I adopted the following treatment. He was
 
 180 CLINICAL MEDICINE. 
 
 put into a comfortable bed, and heat was restored to the surface 
 by diligently rubbing bis trunk and limbs with warm flannel. I 
 next ordered a succession of flying blisters to the neck, chest, and 
 abdomen. I may observe here, that his chest was heaving, there 
 was a general wheezing audible over the whole surface, and he 
 had that peculiar livid expression of countenance and dusky hue 
 of skin, which indicate an imperfect aeration of the blood. With 
 the view of stimulating the oppressed action of the respiratory 
 nei:ves, I had two blisters applied, one on each side of the neck,, 
 above the clavicle ; after remaining on for two hours these were 
 removed, and two more applied over the supra-mammary region, 
 thien over the heart and right side of the chest, and lastly over the 
 epigastrium. In addition to this, he was ordered to have some 
 wine and chicken broth, and a stimulant draught was prescribed, , 
 to be taken regularly every second hour until symptoms of 
 reaction began to appear. 
 
 In employing blisters in this case, my object was to stimulate 
 powerfully and in rapid succession the integuments of the neck,, 
 chest, and abdomen. This practice has in such cases been; 
 attended with very marked results, and in ours proved extremely 
 valuable. Its efficacy seems to depend not on the discharge oft 
 serous fluid, or on any revulsive action of the blisters, but on: 
 the powerful stimulus applied to an extensive cutaneous surface.. 
 
 Blisters applied extensively to the shaven scalp are not only 
 valuable in fever, but also in other diseases, and that under cir-- 
 cumstances in which little benefit could be expected. The same' 
 effects may be produced by rubbing the whole scalp with tartar- 
 emetic ointment ; but, from the pain and inflammation it pro- 
 duces, this proceeding is seldom adopted. I have, however,, 
 occasionally employed it ; and on two recent occasions with the 
 most fortunate results. A friend of mine had lost two childreni 
 from hydrocephalus. About five weeks ago another child, am 
 extremely fine boy, was attacked with symptoms of the same 
 disease. After having laboured for a fortnight under fever, with: 
 great restlessness, vomiting, and diarrhoea, he was observed tO' 
 utter frequently that faint cry which is so characteristic of hydro- 
 cephalus, and to roll his head constantly from side to side. These' 
 symptoms were soon afterwards succeeded by constant motions of 
 the right arm and leg, and subsequently by paralysis of the 
 opposite side. I was consulted before the paralysis occurred,
 
 THE USE AND EMrLOYMENT OF BLISTERS IN FEVER. 181 
 
 and advised the child's father to have the whole of the 
 blistered scalp well rubbed with tartar emetic ointment. The 
 boy recovered completely. I derived also a very striking ad- 
 vantage from the use of the same remedy in a very remarkable 
 epidemic which attacked a family in the neighbourhood of Eath- 
 mines, and which was witnessed throughout its whole course by 
 Dr. Burke and myself. One of the family, a young lady, was 
 attacked with symptoms of fever, accompanied by a pain in the 
 back of the head, and stiffness of the neck. After a few days, 
 symptoms of inflammation of the cerebellum and upper part of 
 the spinal cord became developed. About the seventh day 
 she got strabismus, and soon afterwards was attacked with 
 convulsions : the pupil became permanently dilated, and she 
 was quite blind. I was called to see her at this period, and 
 found her almost in a state of insensibility, with involuntary dis- 
 charge of urine and feces, cold extremities, and irregular pulse. 
 Thinking that nothing could be done for her, I was about to 
 leave the room, when I asked the nurse could she swallow ? She 
 replied she could, and immediately proceeded to offer the young 
 lady some drink, which she swallowed without any difficulty. 
 This at once arrested my attention. I said to myself, if this 
 patient can swallow, she must be still conscious, and while she 
 is so, there is a chance of saving her. I ordered the whole of the 
 scalp, which had been previously blistered, to be rubbed with 
 tartar emetic ointment ; violent inflammation ensued, and she 
 recovered completely. But the curious part of the case is this : 
 — her brother and sister were attacked in exactly the same 
 way, a few days afterwards, although less formidably, and were 
 cured by the same treatment. Shortly afterwards two of the 
 servants got pain in the back of the head and stiffness of neck, 
 followed by signs of an inflammatory affection of the cere- 
 bellum and spinal cord. They were treated in the same way, 
 and recovered. 
 
 What could be the cause of this peculiar fever, manifesting 
 itself in exactly the same way in all the individuals of the family 
 who were attacked ? I endeavoured to arrive at the cause, but 
 could not ; and I merely state the facts, without wishing to 
 attempt anything like an explanation. But the history of this 
 extraordinary form of disease is exactly as I have told you. 
 
 The next use to which we apply blisters is in the treatment
 
 182 CLINICAL MEDICINE. 
 
 of those pulmonary affections which arise during the course of 
 typhus. From what you have seen of the present epidemic, you 
 must be convinced that bronchitis is one of its most frequent 
 compHcations, and that few persons pass through fever without 
 having some affection of the bronchial mucous membrane. You 
 are also aware, that when bronchitis attacks the more minute 
 ramifications of the bronchial tubes, it is very apt to produce 
 congestion and engorgement of the lung. We meet with pneu- 
 monia much less frequently in fever, but it is occasionally 
 observed, and requires the most prompt and decided treatment. 
 In pneumonia, as well as in congestion of the lungs accompanied 
 by inflammation of the smaller bronchial tubes, blisters afford 
 us a most valuable adjunct to the other means which we employ, 
 and admit of being used in cases where no other mode of depletion 
 could be safely borne. 
 
 The affections of the lung in fever are of no small importance, 
 and the stethoscope has not conferred a greater benefit on 
 practical medicine, than by indicating, in diseases of the chest, 
 not merely the existence of disease, but also its locality, extent, 
 and precise nature. It points out to us the portion of the chest 
 in which the bronchial tubes are chiefly engaged, and informs us 
 with certainty when the affection of the smaller tubes has given 
 rise to pulmonary engorgement. The experienced stethoscopist 
 will in such cases be aware of the exact site and nature of the 
 affection, where the mere symptomatic practitioner would be 
 unable to acquire anything more than a loose and undefined 
 notion of pulmonary disease. The latter employs his depleting 
 means at random, and frequently abstracts a large quantity of 
 blood with little benefit to his patient ; the former, aware of 
 the precise situation and extent of the disease, applies his leeches 
 or cupping-glasses immediately over the engorged or inflamed 
 portion of the lung, and relieves his patient at the expense of a 
 comparatively small loss of blood. The same observation will 
 apply with equal force to the use and application of blisters. 
 
 A good and accurate knowledge of the various stethoscopic 
 phenomena is besides of so much more value in the treatment 
 of fever, as at certain seasons of the year almost every case of fever 
 will be complicated with pulmonary derangement ; and it may 
 happen, during the course of an epidemic, that the lungs may 
 be the organs which are chiefly engaged. Although cerebral
 
 THE USE AND EMPLOYMENT OF BLISTEKS IN FEVER. 183 
 
 disease is at present the principal source of danger in fever, it 
 may not be so always. A change may take place in the cha- 
 racter of the epidemic ; the cerebral symptoms which are now of 
 such frequent occurrence may become unfrequent, and we may 
 have the organic aflections chiefly limited to the viscera of the 
 thorax. I have seen many cases of fever in which the principal 
 source of danger was connected with the chest, and where an 
 accurate knowledge of the stethoscope was indispensable to a 
 correct and successful plan of treatment. 
 
 Now, when you have recourse to blisters in treating pulmonary 
 affections, whether these affections be simple or com})licated 
 with typhus, it would be well to recollect that much good may 
 be eftected without leaving the blisters on for a long time, or 
 until they rise fully ; and also that, when risen, it will not be 
 necessary to cut them at once and let out the effused serum. In 
 treating the bronchitis of children, and in the bronchial affections 
 of fever, I have frequently directed the blister to be left un- 
 opened ; and I can state, from experience, that this plan answers 
 very well. The effused serum forms one of the best dressings 
 for the excoriated surface of the skin, and the formation of 
 troublesome sores is avoided. I frequently have recourse to this 
 mode of treating blistered surfaces in children, and persons of 
 irritable habit, in whom the cutis is extremely tender and vas- 
 cular. Such persons, when blistered, will often have profuse 
 discharges, first of serum, and afterwards of sero-purulent 
 matter, from the denuded surface, accompanied by torturing 
 pain, loss of rest, and considerable irritation of the general 
 system. I have seen the discharge continue to flow profusely 
 for five or six days ; in fact to such an extent as to wet several 
 napkins in the course of a day, and expose the patient to the 
 risk of an aggravation of the pulmonary symptoms, in conse- 
 quence of his linen becoming so frequently moistened as to 
 require repeated shifting.* 
 
 In all cases of children and persons of an irritable habit, I 
 would therefore advise you to let the blisters alone, particularly 
 where they have been applied to the fore part of the chest, or 
 
 ♦ In pulmonary diseases, this continued discharge is often very useful, and should 
 he encouraged by dressing the vesicated surface with the French blistering paper, or 
 what I have found equally useful, that prepared by Mr. Bewley of this city ; but in 
 fever the production of such effects from blisters must be avoided, as a surface thus 
 denuded of its cuticle, and inflamed, may be converted into a dangerous sore.
 
 184 CLINICAL MEDICINE. 
 
 any other part not exposed to pressure or friction. As soon as 
 the blister rises, apply over it a piece of lint smeared with sper- 
 maceti ointment, which can be renewed as occasion requires, and 
 leave the rest to nature. I was forcibly struck some time since 
 with the difference of result between this and the ordinary practice, 
 in the case of a young gentleman residing in Camden Street, 
 who had a severe attack of bronchitis towards the termination of 
 fever. A blister had been applied to his chest in the morning, 
 and another in the middle of the day. The first had been opened 
 freely, and dressed in the usual way ; but the other, which had 
 risen about the time I was called in, was left untouched at my 
 request. The one which had been opened caused such a degree 
 of irritation and restlessness, that it was found necessary 
 to give him an opiate every night ; the other gave little or 
 no inconvenience, and healed up much sooner. A still better 
 method is that recently proposed by Dr. Douglas Maclagan of 
 Edinburgh — dressing the blistered surface with cotton. The 
 blister is left on for five or six hours, according to circumstances, 
 a poultice then applied for two hours, and, the raised cuticle 
 having been removed with a pair of scissors, the raw surface is 
 covered with a thick layer of French wadding. It heals com- 
 pletely in about twenty-four hours, but is so little painful after 
 twelve hours that percussion and auscultation may be performed 
 over the part — of course without disturbing the cotton, a matter 
 of much importance in pulmonary affections. 
 
 If I have done nothing better, I think I deserve some merit 
 for being the first to reprobate the practice of keeping on blisters 
 for twelve, eighteen, and twenty-four hours, and for having shown, 
 by numerous experiments, that a much shorter period of time 
 was required to ensure the full effect of these remedies. When 
 I commenced the practice of medicine, blistering was looked 
 upon by most sick persons as one of the severest trials of their 
 patience, and the agony which it caused in some irritable habits 
 was almost insupportable. Blisters were left on for twelve, 
 eighteen, and even twenty-four hours, and, when at length they 
 were removed, the whole epidermis of the blistered part came or 
 was torn away, leaving behind a raw irritable surface, from which 
 large quantities of serum and pus were effused for several days, 
 to the great torture and inconvenience of the patient ; and, not 
 content with this, the practitioners of that time generally dressed
 
 THE USE AND EMPLOYMENT OF BLISTERS IN FEVER. 185 
 
 the excoriated surface with some sharp stimulant ointment, so 
 that the blistered surface most commonly resembled that of a 
 severe burn. 
 
 Ask those who arc our seniors in practice, and they will tell 
 you what blistering was some thirty or forty years ago. They 
 first produced excessive irritation of the skin, by leaving the 
 blisters on too long ; they then irritated the denuded surface with 
 stimulating ointments, and in this way brought on extensive 
 sores of a bad character, which remained long after the disease 
 for which the blisters were applied had disappeared, and which 
 formed, in fact, a new ailment, requiring new medicines and 
 additional attendance. If you look over Mr. Moore's account 
 of the principal remedies employed in the practice of Dublin 
 physicians about the period I allude to, published in the tenth 
 volume of the Dublin Journal of Medical Science, you will find 
 that nothing was more common then than the application of 
 stimulant, and, as they were termed, digestive ointments, to 
 blistered surfaces. I was among the first who assailed this 
 barbarous treatment, and showed that all the good eff"ects of 
 blisters might be secured by leaving them on for a much shorter 
 space of time. I proved by numerous experiments, that in many 
 cases it was not necessary to leave them on more than four or 
 five hours in the adult,* and that they might then be removed 
 and the blistered part dressed with spermaceti ointment. In 
 addition to this, you entirely avoid the irritating effects which 
 blisters are known to produce on the urinary organs. You will 
 very rarely meet with dysuria, or hematuria, where the blister 
 has been left on for the spaces of time I have mentioned. 
 
 Blistering is then to be used with the restrictions I have 
 mentioned, and you will find it a most valuable aid in the 
 treatment of fever and its complications. It may be employed 
 either as a derivative and revulsive, or you may have recourse to 
 flying blisters over the various parts of the body, in certain forms 
 of fever, where there is marked and sudden depression of the 
 powers of life. 
 
 Speaking of depression of the powers of life, reminds me of a 
 curious incident which occurred some time ago in my practice, 
 
 * Of course blisters applied to the fcalp must be excepted. They require at least 
 twelve hours. In old persons generally the skin is much less vascular than during 
 youth and middle age ; and consequently, in the old, blisters require a much longer 
 time to produce the desired effect.
 
 186 CLINICAL MEDICINE. 
 
 and which shows the value of being acquainted with the peculiar 
 habits and idiosyncrasies of families. I attended, with Mr. 
 Kirby, about three years since, a gentleman of middle age and 
 active professional habits, who had been attacked with fever. I 
 was first called to see him on the ninth day of fever, and found 
 him apparently moribund. His pulse was intermittent and 
 irregular, the action of the heart tumultuous, the respiration 
 feeble, and the extremities cool. Mr. Kirby had instantly 
 ordered internal stimulants, and blisters to the region of the 
 heart and epigastrium. The patient rallied, and ultimately 
 recovered. It is to be observed, that the group of formidable 
 symptoms just enumerated had supervened quite out of the usual 
 course, and without any previous warning. They were conse- 
 quently not only alarming but unexpected. About a month 
 afterwards, Mr. Smyly and I were called to see this gentleman's 
 brother, who was living at Dundrum, and who was supposed to 
 have caught fever from his close attention on his brother during 
 his illness and convalescence. What was most remarkable in 
 the case, was that his pulse began to flag and intermit, and he 
 likewise suddenly and unexpectedly got the same symptoms of 
 depression of the vital powers on the very same day and hour as 
 his brother. His symptoms also continued for the same length 
 of time, and yielded, or spontaneously ceased, under the same 
 plan of treatment. In some families you will find a very curious 
 coincidence between the play of the various functions in disease, 
 as well as in health, and you should neglect no opportunity of 
 making yourself acquainted with the family peculiarities and 
 idiosyncrasies of your patients, as knowledge of this description 
 is of the greatest value and importance in the treatment of 
 disease.
 
 187 
 
 LECTUKE XIII. 
 
 WARM FOMENTATIONS TO THE HEAD IN FEVER. — USE OF MERCURY. 
 
 SUBSULTUS TENDINUM. CEREBRAL SYMPTOMS. 
 
 I HAVE already laid before you my views as to the use of 
 general and local bleeding in fever, and pointed out the circum- 
 stances under which they might be employed. In treating of 
 general bleeding, I stated that we used it at the commencement 
 of fever, with a view of checking the disease altogether, or of 
 rendering it milder and less dangerous, by moderating excessive 
 inflammatory action, and controlling cerebral excitement. I have 
 also spoken of the use of leeches and blisters, and it only remains 
 for me to say a few words respecting the application of cold to 
 the head as a means of moderating or removing symptoms of 
 cerebral excitement. 
 
 In Dr. Southwood Smith's Treatise on Fever, you will find 
 many cases and arguments to show that where headache and 
 delirium are present, and where the lancet is inadmissible, if 
 you place the patient in a warm bath, and direct a forcible small 
 stream of very cold water on his head, he soon becomes more 
 calm, experiences great relief of his headache, and is frequently 
 brought back to bed quite free from cerebral symptoms. The 
 burning heat of the skin is quickly replaced by a sensation of 
 coolness, or even cold, the flushing of the face disappears, the 
 delirium vanishes, and a favourable crisis is often produced. 
 Indeed, the effects of this remedy are extremely remarkable, and I 
 have no doubt that many of the cases in which I have employed 
 tartar emetic with such signal advantage would derive equal 
 benefit from this mode of treatment. 
 
 The cold afi"usion, as recommended by Dr. Smith, and practised 
 at the Charite Krankenhaus at Berlin, is most certainly an 
 excellent and energetic remedy, and I regret that we have not 
 apparatus in this hospital for applying it ; but I fear its utility 
 must be, at least for some time, limited to public institutions,
 
 188 CLINICAL MEDICINE. 
 
 and that it cannot be employed to any extent in private practice. 
 There is a good deal of prejudice against applications of the 
 kind in this country. At the time that cold affusions were 
 used in the treatment of scarlatina, much mischief was done 
 by their indiscriminate employment, and this added to the 
 general feeling of dislike towards them. At all events, cold 
 affusion is a remedy which requires an apparatus seldom at the 
 command of the physician in private families, and, indeed, I 
 think that in most cases we may do very well without it. 
 
 You are all aware that, in cases of determination to the head, 
 the common practice is to shave the scalp, and apply cold 
 lotions. In my lectures I have repeatedly pointed out the 
 imperfect and even . hurtful mode in which this remedy is 
 ordinarily applied, and endeavoured to show that it is calculated 
 rather to increase than diminish the heat of the integuments. 
 Cold lotions act as a powerful refrigerant, if constantly repeated, 
 so as to keep the part below the standard temperature of the 
 body. But this is seldom or never done. The nurse applies the 
 lotion, and then, perhaps, drops asleep, or occupies herself with 
 some other business, until at last she is attracted by the vapour 
 arising from the patient's head, and then she renews the applica- 
 tion. I need not say, that in this way all the good effects of 
 cold, as a refrigerant, are entirely lost, and that a degree of 
 reaction is produced which must altogether mar and nullify its 
 application. I have, therefore, given up, except in very few 
 cases, the practice of applying cold lotions, and give a pre- 
 ference to the use of warm fomentations of equal parts of vinegar 
 and hot water, applied to the temples and shaven scalp, and 
 frequently repeated. I am quite sure we employ warm applica- 
 tions for the relief of headache and cerebral symptoms much less 
 frequently than we ought. You are aware that surgeons are in 
 the habit of treating some local inflammations with warm, and 
 others with cold applications, and that the rules laid down for 
 distinguishing the cases in which cold, and those in which warm 
 fomentations should be used, are deficient in precision, and that 
 most commonly the practitioner has to refer to his own individual 
 experience for the guidance and determination of his choice. So 
 it is, also, with respect toUhe use of fomentations to relieve the 
 pain and congestion of internal parts, among which I include 
 determination to the head in fever, accompanied by intense
 
 WARM FOMENTATIONS TO THE HEAD IN FEVER. 189 
 
 lieadache, restlessness, and delirium. In some cases of this 
 description, cold applications will give ease ; in others most 
 relief is obtained by fomenting the head with water as hot as it 
 can be borne. 
 
 The idea of employing hot fomentations in cases of this 
 description was first communicated to me in 1833, by the late 
 Mr. Swift, who became accidentally aware of their value whilst 
 washing his face one day in very warm water, at a moment when 
 labouring under severe headache. The sudden relief obtained 
 by the application of hot water induced him to try it exclusively 
 in the headache of influenza, and with the most satisfactory 
 results. In the influenza which appeared in this country in 
 1833 and 1837, and again recurred in 1847, one of the most 
 remarkable symptoms was intense headache. This was accom- 
 panied by great debility, and was not amenable to the ordinary 
 modes of depletion. Now, in the first of these epidemics, Mr. 
 Swift found that by applying water as hot as it could be borne to 
 the forehead, temples, and back of the head, great and almost 
 instantaneous relief was obtained, and that in this way he was 
 able to keep a most unpleasant symptom in check, while he was 
 taking measures to remove the disease. I have also heard from 
 my friend Dr. Oppenheim, of Hamburg, that he had discovered 
 that this was the best means of afi'ording relief under the same 
 circumstances. Mr. Swift's observations first led me to think 
 of applying hot fomentations to the head in other diseases, and 
 although I cannot give you any particular rules for determining 
 the cases in which you should employ them, I can say that you 
 will generally find warm vinegar and water the best and most 
 ef&cacious application in the ordinary headache of fever. 
 
 I shall next ofi'er you a few observations on the use of mercury 
 in fever ; and, first, are we to have recourse to mercury or not in 
 typhus ? I do not allude here to its use as an aperient ; but, 
 when called to treat a case of fever, are you to proceed at 
 once to bring the patient's system under the influence of 
 mercury ? Are you, in addition to the other measures usually 
 adopted in the treatment of fever, to go on with the administration 
 of mercury until you aff"ect the mouth, and bring on salivation ? 
 This was the practice in my earlier days, and great confidence 
 was placed in it by the majority of practitioners. It has been 
 also very extensively recommended by army and navy surgeons
 
 190 CLINICAL MEDICINE. 
 
 in the treatment of tropical fevers, but I must confess that I 
 am not at all inclined to adopt this practice, and that I have seen 
 abundant reasons why I should neither employ nor recommend 
 it. In the first place, we have observed in our wards that 
 patients with other diseases have frequently caught fever from 
 exposure to infection, at a time when they were fully under the 
 influence of mercury. In the next place, we have observed 
 that persons who were thus attacked with fever while in a 
 state of salivation did not escape better than others, and that 
 in them the disease ran its full course, aggravated rather than 
 diminished in its danger by the pre-existing mercurialization. 
 These facts I have frequently seen verified in hospital and 
 private practice. 
 
 You perceive, then, that mercurialization neither protects a 
 man from the contagion of typhus, nor does it produce a favour- 
 able modification in its type or progress. Again, I have repeat- 
 edly witnessed the daily and continued exhibition of mercury in 
 fever, and I cannot recollect a single case in which it appeared 
 to check the disease, moderate its symptoms, or bring about a 
 favourable crisis. I am aware that, in entering my protest 
 against this practice, I dissent from a very considerable body of 
 my brethren, who, from the beginning to the end of fever, never 
 cease in their attempts to bring the patient's system under 
 the influence of mercury. I am convinced that, in the cases in 
 which recovery is stated to have followed this practice, the post 
 hoc has been mistaken for the propter hoc. Besides, fever is one 
 of those afl'ections in which you will find it extremely difficult, 
 and often impossible, to bring the system fully under the influ- 
 ence of mercury. There are certain states of the system which 
 prevent altogether the full operation of mercury, and bad typhus 
 is one of these states. Where fever has laid deep hold of the 
 constitution, you cannot affect it with mercury. When a patient 
 recovers who has been mercurialized during the course of fever, 
 he does not recover because his system came under the influence 
 of mercury, but he comes under the influence of mercury because 
 he recovers from the fever. Add to this, that mercury is a 
 remedy which requires a peculiar regimen, and that it is very apt 
 to engross the practitioner's attention, and prevent him from the 
 exhibition of remedies which are more directly indicated, and 
 in reality more useful.
 
 WAKM FOMENTATIONS TO THE HEAD IN FEVER. 191 
 
 These considerations, and others, have convinced me that the 
 exhibition of mercury in fever, with the view of touching the 
 gums, is injudicious and unnecessary. There are, however, 
 cases in which you will be compelled to have recourse to mercury, 
 whatever the stage or the type of the fever may be. Whenever 
 inflammation of some internal organ — as, for instance, of the 
 lungs — arises during the progress of fever, you must employ 
 mercury at once ; and cases of pneumonia, which would have 
 proved ftital, have on numberless occasions been treated success- 
 fully by mercurialization. But under ordinary circumstances, 
 and were there no indication similar to that which I have just 
 pointed out, I do not see any advantage to be derived from the 
 use of mercur}'. I am not, therefore, in the habit of employing 
 mercury in fever. Sometimes I use calomel as an aperient, and 
 I frequently prescribe small doses of hydrarg^Tum cum creta, with 
 the view of gently stimulating the liver, and preventing the 
 tendency to congestion of the intestinal canal ; but farther than 
 this I am not in the habit of going ; and I never, except in cases 
 of pneumonia, or inflammation of some internal organ, attempt 
 to bring the patient's system under the influence of mercury 
 during the course of typhus. 
 
 Allow me here to digress a moment from my subject, and make 
 a few observations on the case of the man Cassels, which termi- 
 nated fatally in our wards within the last twenty-four hours. I 
 wish to call your attention to this case more particularly, as I 
 think a diff"erent plan of treatment might have succeeded in 
 saving the man's life. This man was admitted into the fever 
 ward about the seventh or eighth day of his illness. I cannot 
 exactly state how he was treated in the commencement, but I 
 believe he was very badly attended, and that the state of the 
 principal organs was wholly neglected. It will be sufficient to 
 observe, that when he came under our care the chief features of 
 his case were delirium, accompanied by total want of sleep, and 
 a violence of conduct and behaviour calling for the restraint of 
 the strait waistcoat. Now, under circumstances of this nature, 
 the most diligent attention and promptitude are imperatively 
 demanded on the part of the physician, and every step calculated 
 to anticipate danger should be instantly taken. I regret to say 
 that I did not at the time take a correct view of the treatment or 
 precautions necessary to be adopted under such exigencies. I
 
 192 CLINICAL MEDICINE. 
 
 did not expect that the case would terminate fatally in such a 
 short time, and I anticipated henefit from the remedy prescribed. 
 He was ordered to take the tartar emetic solution in full doses ; 
 but, on visiting him next morning, we found that he had obsti- 
 nately refused to take his medicine, and that his symptoms were 
 greatly aggravated. 
 
 In delirium of this kind it is certainly very difficult to manage 
 the patient, and we are frequently obliged to have recourse to 
 force and stratagem to make him take his medicines. I regret 
 extremely that this man's head was not leeched on his admis- 
 sion, as, from the state of his pulse, I think he would have borne 
 it well. Eight leeches might have been applied to his temples, 
 and repeated two or three times the same day, according to the 
 state of his pulse and strength. I think I was wrong in conteut- 
 ing myself with ordering the tartar emetic solution and a blister 
 to his head, and I should have anticipated, from the violence of 
 his behaviour, that it would be very difficult to manage him. 
 
 In cases of this kind, where it is necessary to give tartar 
 emetic (and this is one of the best remedies you can employ in 
 cases of cerebral excitement in fever), you should be always 
 prepared to obviate any omission arising from the obstinacy of 
 the patient ; and when he will not take his medicines voluntarily, 
 you may secure its effects on the system in two different ways. 
 In the first place, it may be secretly mixed with the patient's 
 ordinary drink ; and as such persons are generally thirsty, and 
 seldom refuse drink altogether, an intelligent nurse will readily 
 find means to make the patient take a sufficient quantity of it to 
 secure its full effect on the cerebral circulation. 
 
 Another expedient which you may resort to in similar emer- 
 gencies is to give the tartar emetic in the form of enema. I 
 had recourse to this plan some time since, in a similar case of 
 delirium, and with the best results. After leeching the head I 
 gave the solution of tartarised antimony in enema ; and this 
 can be always done, whether the patient likes it or not, if you 
 take care to prevent his struggles by confining him in a strait 
 waistcoat. The best way of administering it is to dissolve two 
 or three grains of tartar emetic in four or five ounces of mucilage 
 of starch or isinglass, and inject it with the aid of a long flexible 
 tube, so as to make the contents of the syringe pass high up into 
 the bowel. In this way you can secure all the good effects of
 
 WARM FOMENTATIONS TO THE HEAD IN FEVER. 193 
 
 tavtai-ized antimony, in overcoming the congestion of the brain, 
 and procuring sleep. 
 
 In all cases of alarming congestion of the head in fever, I have 
 been long in the habit of using tartar emetic in this way, if the 
 stomach be deranged, and incapable of bearing it safely ; and I 
 can assure you that it is a most fortunate thing to have such a 
 powerful resource in all cases of the kind. I have also not un- 
 frequently given expectorant medicines in the same way, where 
 from the state of the stomach, or the debility of the patient, the 
 ordinary remedies could not be administered by the mouth with 
 sufficient rapidit}', or in sufficient quantity to produce the desired 
 effect. In this manner I have often given the infusion of 
 ipecacuanha — a remedy of very considerable value, and not suffi- 
 ciently appreciated by most modern practitioners. I may also 
 remind you that vomiting, and all the benefits derivable from it, 
 may be likewise thus produced. Of course, the cases in which 
 these expedients are required are comparatively rare, but the 
 practical physician must be always prepared for such exigencies, 
 and be provided with means of meeting them. 
 
 Another of our patients died also within the last few days in 
 the fever ward. He laboured under a very bad form of macu- 
 lated fever, and when admitted was evidently in a hopeless 
 state. I shall not say anything about this case, except to use 
 it as an occasion for making a few observations on a particular 
 state of the cerebro-spinal system, which we not unfrequently 
 observe in cases of maculated typhus, and occasionally in other 
 varieties of fever. Now you observed that this man had not the 
 slightest tendency to sleep ; that he lay with his eyes constantly 
 open, raved incessantly, had subsultus tendinum, floccitatio, and 
 cold extremities, and often attempted to get out of bed. Yet we 
 could not find in him anything like decided evidence of cerebral 
 inflammation.. The tunica adnata was of a clear pearl white, 
 the face pale, and the scalp and integuments of the face cool. 
 You perceive, then, that sleeplessness, delirium, and subsultus 
 tendinum may depend on a state of the nervous system having 
 no connexion with congestion of the brain, or determination of 
 blood to the head. This occurrence has struck me very forcibly 
 in many cases of fever. But I have been most particularly 
 struck with the occurrence of subsultus tendinum in such 
 instances. In the present case we had a patient with sleepless- 
 VOL. I. 13
 
 194 CLINICAL MEDICINE. 
 
 ness and subsultus. But this concurrence of symptoms does 
 not always exist. 
 
 You recollect the case of the hoy in the small fever ward, who 
 laboured under excessive subsultus, and to whom we gave the 
 oil of turpentine in drachm doses with so much benefit. Yet 
 this boy, as you all remember, slept remarkably well. I have 
 frequently pointed out to the class, patients labouring under 
 subsultus tendinum, who slept well, and in v.-hom the tunica 
 adnata was of a pearl white colour, without the slightest suffu- 
 sion. We have subsultus, therefore, occurring in two very 
 opposite states of the nervous system ; we have it accompanied 
 by loss of sleep^ and we have it existing in that condition of the 
 system where the patient slumbers long and heavily, and cannot 
 be easily roused. Hence I am inclined to think that the cause 
 of subsultus resides not so much in the nervous centres as in 
 their extremities. 
 
 I would even go so far as to advance the propo'sition, that if it 
 were possible for the fever to go on, and life to continue after the 
 removal of the brain and spinal cord, I am quite sure that the 
 subsultus would continue. I am almost confident that subsultus 
 tendinum is the result of some derangement of the nervous ex- 
 tremities. I shall show hereafter, when lecturing on the subject 
 of paralysis, that the nervous periphery may become diseased 
 primarily, and without any antecedent affection of the brain or 
 spinal cord. I think it extremely probable that in fever the 
 nervous centres are subject to certain derangements producing 
 coma, sleeplessness, and delirium, but that there are other 
 nervous symptoms which are to be referred rather to a derange- 
 ment of the nervous extremities, and among the latter I would 
 particularly include subsultus tendinum, a symptom which we 
 find co-existing with such opposite conditions of the nervous 
 centres. 
 
 But to return to the case to which I first alluded. Never 
 blister in the early stage of fever, until you have applied leeches 
 in sufficient quantity. In this case, it is true, we could not 
 well ascertain what the period of the fever was ; for the man 
 was brought in, in a state of delirium, and there was nothing 
 known respecting his previous history. You are all aware that 
 a great deal must depend on our knowledge of the period of the 
 fever, and the medicines which have been employed. Had we
 
 WARM FOMENTATIONS TO THE HEAD IN FEVER. 195 
 
 been acquainted with these circumstances, it is probable we 
 would not have fallen into the error we committed. What I 
 wish to impress on you is, that in all cases of maculated typhus, 
 you should be careful in examining the head, and ascertaining 
 whether there are any evidences of cerebral congestion present. 
 If there be headache, strong pulsation of the carotids, suffusion 
 of the eyes, and heat of the face and scalp, along with the other 
 signs of functional lesion of the brain present, you should have 
 recourse to leeching ; beginning cautiously, and continuing their 
 application as long as the patient will bear it with safety. 
 When you have the symptoms already mentioned, and the 
 patient is in the early stage of fever, you may commence by 
 applying one or two leeches to the nostrils, or six or eight to 
 the temples or behind the ears, repeating them two or three 
 times a day, according to the exigency of the case. The best 
 way of using leeches is to apply them in small numbers every 
 six or eight hours, so as to keep up a constant drain from the 
 head. After you have leeched sufficiently you may then have 
 recourse to blisters. In making this change much will depend 
 on the sagacity and skill of the practitioner ; for it requires no 
 ordinary tact to hit on the proper time when you should give up 
 leeching and commence with blisters. 
 
 I shall make no apology for introducing here what I consider 
 to be an important observation, with reference to the pathology 
 and treatment of fever. We had a striking instance of the fact 
 on which I am about to offer some comments, in the case of a 
 little girl who died lately here, in a very remarkable manner. 
 Every fever which commences with vomiting and diarrhoea, 
 whether it be scarlatina, or measles, or t}^3hus, is a fever of a 
 threatening aspect ; and in all such fevers the practitioner should 
 be constantly on the watch, and pay the most unremitting atten- 
 tion to the state of the brain. There is much difference between 
 the vomiting and diarrhoea of gastro-enteritis and this cerebral 
 diarrkcea and vomiting. The latter sets in generally at a very 
 early period of the disease, perhaps on the first or second day, 
 and is seldom accompanied by the red and furred tongue, the 
 bitter taste of the mouth, the burning thirst, and the epigastric 
 tenderness which belong to gastro-enteric inflammation. 
 
 There is also another source of diagnosis, but of a less valu- 
 able kind ; and this is founded on the results of treatment.
 
 196 CLINICAL MEDICINE. 
 
 Gastro-enteric vomiting and diarrhoea are relieved by leeching 
 the belly ; but I need not tell you that this mode of treatment 
 can have no efiect on the vomiting and purging produced by 
 cerebral disease. There is also another means of distinguish- 
 ing : the vomiting and diarrhoea which result from gastro- 
 enteric inflammation are never accompanied by such copious 
 discharges of bile as when they depend on disease of the brain. 
 In diarrhoea from derangement of the brain the quantity of bile 
 passed is very remarkable ; and it is equally curious, that when 
 vomiting follows derangement of the cerebral circulation, in 
 ordinary cases, and without fever, bile is thrown up in very large 
 quantities. This is frequently observed in persons who become 
 sick from swinging or sailing. In such instances a larger 
 quantity of bile is vomited than could occur from mere gastric 
 irritation. Now, in the commencement of cerebral disease, where 
 congestion or inflammation is present, one of the first symptoms 
 is copious vomiting and purging of a bilious character. This is 
 very often the case in scarlatina, and there are few cases in which 
 there is more danger to be apprehended. We had these symp- 
 toms, under veiy unfavourable circumstances, in the little girl to 
 whom I have just alluded. From the imperfect history of the 
 case which we were able to obtain, it appeared that she had been 
 ill of fever for fourteen days before her admission, and had in 
 addition a severe attack of bronchitis and pneumonia. She then 
 got inflammation of the stomach, and finally congestion of the 
 brain, as indicated by the cerebral vomiting and purging. We 
 employed every means in our power to check these symptoms, 
 but without success ; she went on from bad to worse, and she 
 ultimately sank under a combination of affections, which you will 
 frequently observe in many forms of disease as well as fever ; and 
 it is to this point in particular that I wish to direct your attention. 
 You will frequently observe that at a certain period of fever, 
 whether it be inflammatory, nervous, bilious, or typhoid, and 
 very often in other forms of disease, whether depending on a 
 general affection of the system, or connected with inflammation 
 of important organs, when the patient has been going on pretty 
 well for some time, — you will find that about the period when 
 you would naturally expect the fever to go off, and convalescence 
 begin, a new form of fever makes its appearance, and carries off 
 the patient in spite of all your exertions. To this form of
 
 WARM FOMENTATIONS TO THE HEAD IN FEVER. 197 
 
 secondary fever I would give the name of scrofulous, because it 
 resembles in its chief features the intractable form of fever which 
 is frequently observed in persons of an originally scrofulous 
 habit, or who have become so from the abuse of mercury, or 
 other debilitating causes. 
 
 This is a subject which is not well understood, and I am not 
 acquainted with any author who has devoted to it that share of 
 attention to which, from its great importance, it has such decided 
 claims. Its chief characters are that the patient, during its 
 existence, exhibits a strong tendency to inflammatory aifections 
 which bear a close analogy to the scrofulous, both in their 
 intractable character, in the facility with which they pass from 
 one organ to another, and in their frequently unfavourable 
 termination. A patient of this description, while labouring under 
 fever, will frequently exhibit a very remarkable succession of 
 inflammatory aftections. If, during the course of his fever, he 
 gets an attack of gastro-enteritis, you will have great difficulty in 
 managing it ; and no sooner is this overcome than he is seized 
 with bronchitis or pneumonia; and when, by great care and the 
 most skilful treatment, you have overcome this also, he gets 
 scrofulous inflammation of the brain, and dies. 
 
 Now you will frequently meet with patients who, during the 
 course of typhus, will be attacked with this bad form of fever, 
 and get what may be termed scrofulous inflammation of the 
 brain, which carries them off" in five or six days, in spite of all 
 your care. You are aware that persons who are much in the 
 habit of observing diseases of the brain, can generally distinguish 
 between scrofulous inflammation of the brain and its membranes, 
 and that inflammation which occurs in persons of healthy habit. 
 In cases of the latter description, the treatment, if commenced 
 at the first appearance of the disease, is simple and successful. 
 Appropriate bleeding and leeching, with the use of calomel and 
 James's powder, are almost always sufficient to accomplish a 
 cure. When once you have succeeded in touching the gums 
 with mercury, the patient's safety is tolerably certain, and 
 recovery is in general rapid. But in the scrofulous affections 
 of the brain, although 3'ou may have fully mercurialized your 
 patient, you will too often discover that you have merely retarded 
 the progress of the complaint for a brief period; it grows bad 
 again, and carries him off" in spite of all your eff"orts.
 
 198 CLINICAL MEDICINE. 
 
 In the scrofulous hydrocephalus, a much greater time elapses 
 from the appearance of coma and strabismus until death takes 
 place, than in the ordinary forms of meningitis. This fact was 
 well illustrated in the case of the girl to Avhich I have just 
 now referred : she continued to live on for a long time after 
 the ai)pearance of symptoms which you would think ought to 
 terminate fatally in a few hours after they had been developed. 
 There is also a great deal of irregularity in the way the symp- 
 toms come on in cases of scrofulous inflammation of the brain. 
 Sometimes blindness is one of the first symptoms. I recollect 
 having been called, with Dr. Beatty, to see a very fine boy living 
 in Merrion Square, and was very much struck, on entering the 
 drawing-room, to find him walking about, and in apparent good 
 health, but quite blind. Here amaurosis was the first symptom. 
 This was subsequently succeeded by others, and he died in a 
 convulsive fit about a fortnight afterwards. 
 
 We have many excellent observations on the chronic scrofulous 
 fever, but I think that there is no author who has described this 
 acute form with the precision and care which it deserves. It is, 
 however, a very frequent form of fever, and you will see many 
 examples of it among the chronic patients in the medical and 
 surgical wards. You will frequently observe persons who are 
 labouring under acute disease, from accidents or other causes, 
 become feverish and ill again at a time when you expected a 
 remission of their symptoms, or even recovery ; and, without any 
 assignable cause, they will get scrofulous inflammation of some 
 other part or organ, and quickly fall into a state of hopeless and 
 incurable disease.
 
 199 - 
 
 LECTURE XIV. 
 
 HEAD SYMPTOMS IN FEVEE. 
 
 I SPOKE at my last lecture of a man named Cassels, who died 
 in the fever ward with symptoms of cerebral excitement, and 
 stated that I regretted having omitted to leech his head, and 
 prescribe tartar emetic in the form of enema. Since that time 
 we have had an opportunity of examining his body, and the 
 results of the dissection are well worthy your attentive considera- 
 tion. He was a young man of robust habit and apparently good 
 constitution, and laboured under the ordinary form of maculated 
 typhus. Shortly after his admission he was attacked with 
 delirium, which was soon afterwards followed by coma and 
 death. 
 
 Now, suppose you were called to see a patient not labouring 
 under typhus, but exhibiting a similar train of symptoms — that 
 is to say, violent delirium, accompanied by flushing of the face, 
 suffusion of the eyes, headache, and a tendency to get out of 
 bed — in fact, a state of furious excitement requiring the restraint 
 of the strait waistcoat — what idea would you be likely to form of 
 the condition of the brain ? If a patient of this kind had no 
 t}^)hoid symptoms, you would certainly say that he was labouring 
 under meningitis or cerebritis ; and, if the case proved fatal, 
 you would naturally expect to find lesions of the brain fully 
 sufficient to account for all his symptoms. And yoi would in 
 all probability find extensive thickening of the membranes of 
 the brain, with sub-arachnoid eff"usiou, or you would discover 
 softening, increased vascularity, and suppuration of the ence- 
 phalic mass. 
 
 But here a man in fever exhibits all the symptoms of cerebral 
 inflammation ; the cerebral affection runs on to a fatal termina- 
 tion with great rapidity ; he dies comatose. And what do we 
 find on dissection '? Doubtful signs of congestion, and no dis- 
 tinct evidence of inflammation, a slight opacity of the arachnoid
 
 200 CLINICAL MEDICINE. 
 
 at the base of the brain, and about a teaspoonful of clear sub- 
 arachnoid effusion. Now this is a point to which I would 
 earnestly call the attention of every inquiring student. A 
 patient, during the course of typhus, is seized with symptoms 
 which are generally regarded as characteristic of congestion and 
 inflammation of the brain ; he dies, to all appearance, in conse- 
 quence of the intensity and violence of these symptoms, and, on 
 dissection, little or no trace of cerebral disease is found. In the 
 case under consideration, the symptoms present were strongly 
 indicative of congestion, if not of inflammation ; and had the 
 man been free from typhoid symptoms, you would expect to 
 find decided traces of inflammatory mischief. This seems to 
 prove that, in the production of cerebral symptoms in typhus, 
 some cause not to be recognised by the production of cerebral 
 lesions, or in other words something besides mere congestion or 
 inflammation, exists. I have now examined a great number of 
 cases of this description, and the examination has brought home 
 to me a strong conviction, that the delirium of fever depends 
 upon something more than mere inflammation or congestion. 
 
 There is another fact, the study of which is well worthy of 
 attention, as it appears to support very strongly the views I 
 have put forward ; and that is the occurrence of analogous 
 symptoms under opposite conditions of the cerebral circulation. 
 Take, for example, the phenomena of vertigo and headache. 
 Now these symptoms are found in states of the brain which 
 are directly opposite. In incipient congestion of the brain, in 
 that turgescence of the cerebral vessels which precedes apoplectic 
 seizures, one of the most frequent symptoms is vertigo, and the 
 same thing may be affirmed with respect to headache. But we 
 observe the very same symptoms under circumstances totally 
 dissimilar. Frequently, while bleeding a patient for some afiection 
 of the lungs or bowels, or for some accident, we find that after 
 a certain quantity of blood has been lost, the patient becomes 
 pale ; and while the pallor is coming on, he often gets quite 
 giddy, and sometimes complains of headache. Gentlemen who 
 are attending lying-in hospitals are well acquainted with the 
 headache, giddiness, and tinnitus aurium, so constantly com- 
 plained of by females who have suffered from excessive uterine 
 hemorrhage. 
 
 Hence you perceive facts are not wanting to show that opposite
 
 HEAD SYMPTOMS IN FEVER. 201 
 
 states of the cerebral circulation, a superabuudance or deficiency 
 of pressure on the brain, may give rise to similar phenomena. 
 You saw an illustration of this in the case of one of our patients 
 in the fever ward this morning. He was quite free from head- 
 ache as long as he remained in the horizontal posture, but the 
 moment he sat up in bed he complained of headache. Yet this 
 was a man who had not the slightest symptom of determination 
 to the head, and who had been sufficiently depleted during his 
 illness. You will also recollect the fact, that persons who have 
 had a long illness, and remained for many days in the horizontal 
 posture, generally get weakness, giddiness, and sometimes head- 
 ache, when they first attempt to sit up during convalescence. 
 
 This is a point which should be always borne in mind. You 
 are consulted by one person who complains of giddiness, tinnitus 
 aurium, and frequently recurring headache. Y^ou examine the 
 patient carefully, and you find all the symptoms of unequivocal 
 determination to the head. You are applied to by another person 
 labouring under the same symptoms ; but how difl'erent is the state 
 of the brain found to be on a careful examination. One patient 
 is robust, of florid complexion, and with a hard bounding pulse ; 
 the other is a weak chlorotic female, who has been ailing for 
 months, and Avhose pulse is so weak that a slight degree of 
 pressure obliterates the canal of the artery. Yet the tinnitus 
 aurium, giddiness and headache complained of by the latter are 
 just as bad and as troublesome as in the case of the former. 
 
 From a consideration of these points you will perceive that, 
 for the production of cerebral sym])toms in typhus, there must 
 be something more than mere congestion or inflammation of the 
 brain ; but you are not to infer from this that there is no 
 necessity for taking any steps to obviate or remove congestion 
 of the head in fever. On the contrary, I am of opinion that in 
 typhus one of- the principal sources of danger is connected with 
 the head, and that the cerebral symptoms should be always 
 watched with the most unremitting and anxious attention. 
 
 It is this which constitutes the great difference between the 
 mortality in private and hospital practice. In private practice 
 the physician is called at an early period of the disease, and has 
 an opportunity of checking the cerebral symptoms before they 
 rise to a dangerous height ; but hospital patients, in general, 
 are admitted at an advanced stage of fever, and in many instances
 
 202 CLINICAL MEDICINE. 
 
 have been improperly treated, or wholly neglected from the 
 commencement. I am also of opinion that when there is any 
 evidence of determination to the head, the best way of preventing 
 dangerous cerebral symptoms is to deplete the head by the 
 application of a sufficient number of leeches, and then to proceed 
 to the use of blisters. You should direct your attention as much 
 to the head as to the bowels, and one of the best modes of doing 
 this is to apply six or eight leeches behind the ears, and repeat 
 them every six hours until relief is obtained. You should then 
 order the head to be shaved, and kept constantly covered with 
 cloths wet with warm vinegar and water, and at the same time 
 have recourse to the internal use of tartar emetic and nitre, or 
 blue pill with James's powder. Should this plan fail in giving 
 relief, you have a powerful aid in the application of blisters to 
 the scalp, and this must be done extensively, and at once. 
 
 Most of the fatal cases of typhus at present die of cerebral 
 disease ; but in the majority of instances you will find that 
 these were cases in which the head was neglected, and in which 
 the appropriate remedies were used too late. In cases treated 
 from the commencement with judgment, decision, and attention, 
 although the head may be threatened, you will not have one- 
 twentieth of the mortality observed in cases where the early 
 prevention of cerebral symptoms has not been an object of care. 
 One of the worst cases of cerebral disease which I have witnessed 
 for many months, and which would have probably terminated 
 fatally before the seventh day, I saw in consultation with the 
 late Mr. Daly, and yet this case was saved by prompt and 
 decided measures calculated to counteract the cerebral symptoms. 
 
 I have also very recently witnessed another remarkable case of 
 this description at Bray. The patient, a gentleman very full 
 and plethoric, but remarkably temperate, aged thirty-five, was 
 attacked after exposure to cold by intensely violent maculated 
 fever, for which aperients of an active nature were exhibited. 
 I saw him in consultation with Dr. Heffernan on the sixth day. 
 His headache had been relieved by leeching, but his breathing 
 was very quick, and he was almost constantly asleep. Skin very 
 hot ; eyes somewhat suffused ; most copious crop of maculae. 
 We at once blistered the whole scalp ; and on the eighth day 
 blistered it again, and also the nape. On the ninth day the 
 cerebral symptoms, tvhich^ve had been endeavouring to anticipate,
 
 HEAD SYMPTOMS IN FEVER. 203 
 
 came on, but probably our treatment prevented them from being 
 fatal ; for when they appeared, the application of tartar emetic 
 ointment induced a purulent discharge from the whole surface of 
 the twice blistered scalp, in the course of a few hours, and three 
 grains of tartar emetic given in divided doses that day procured 
 a complete cessation of the symptoms, after — mark — after the 
 pupils had been dilated, and one fit of slight paralysis of the 
 mouth and tongue had taken place. 
 
 The result of all my experience in fever is, that the majority 
 of fatal cases are rendered so, in this country at least, by severe 
 cerebral S3'mptoms supervening sooner or later in the disease. 
 Delirium, sleeplessness, stupor, convulsions, extreme subsultus, 
 jactitation, sluggish and dilated, or else extremely contracted, 
 pupils — these are the symptoms we have to fear after the fever 
 has lasted some time ; and, let me repeat it, the chief art of the 
 physician consists not so much in remedying these symptoms as 
 in anticipating them. When he judiciously attempts this, he 
 may not, indeed, always succeed in preventing their supervention, 
 but he will, in many cases, be successful in diminishing their 
 violence, and preventing their usually disastrous effects. 
 
 Permit me next to direct your attention to the case of the 
 patient Murphy, Avho died last week. This case excited a good 
 deal of our attention at the time, and I wish to make some 
 further observations on it while it remains fresh in your minds. 
 
 It was one of those mixed cases of typhus in which, as the 
 fever advances, we observe the usual phenomena of determination 
 to the head, accompanied by a train of symptoms which bear a 
 close analogy to those of delirium tremens. Among the pauper 
 population which we have to treat, you will frequently meet with 
 cases of this description. "We witnessed many examples of it 
 here, but not so man}^ as are to be seen in other hospitals. It 
 is a melancholy but well-known fact, that a great proportion of 
 the diseases which come under our notice, in the acute as well 
 as in the chronic form, are more or less complicated with 
 intemperance.* This you should never forget. In persons of 
 the lower class, who are addicted to the daily use of spirituous 
 liquors, you will find disease assuming a thousand unfavourable 
 
 * Since this lecture was delivered, a great change for the better has been effected 
 by the efforts of the Rev. Mr. Matthew ; the poorer and working classes of Ireland 
 are now for the most part distinguished for temperance.
 
 204 CLINICAL MEDICINE. 
 
 shapes and complications. You will find their fevers intermixed 
 with various symptoms of an anomalous or dangerous character, 
 and their chronic affections embarrassed by organic and visceral 
 disease. You will be repeatedly struck with the strange and 
 protean character which disease assumes under the influence of 
 an habitual intemperance ; and you will often, in the course of 
 your practice, have to endure the annoyance and disappointment 
 of seeing your patient carried off by some new and unexpected 
 malady, after you have succeeded, by infinite toil, ingenuity, and 
 prudence, in removing every trace of his primary afiection. 
 
 The case of Murphy was one of those which have been 
 neglected in the beginning, where the vantage ground has been 
 lost, and the chances of success are diminished almost to 
 nothing. You have observed that all the fatal cases of fever 
 which we have had in hospital were cases admitted at an advanced 
 period of the disease, and in which the head had been neglected. 
 You have also observed how exceedingly difficult it must be to 
 treat cases of this description. The j^atient is admitted at an 
 advanced stage of fever, and at a period when he can give no 
 account of his present or past symptoms, or the mode of treat- 
 ment to which he has been submitted. He comes in with 
 delirium, or coma, and subsultus tendinum ; his symptoms are 
 certainly cerebral, and he exhibits, j)erhaps, a blistered scalj) ; 
 but we can have no means of ascertaining whether he has had 
 headache, heat of scalp, throbbing of the carotid and temporal 
 arteries, or vertigo, — we cannot, in fact, decide with precision as 
 to the exact state of the brain, and our practice must be 
 embarrassed by more or less doubt and obscurity. I have 
 already impressed upon your attention the urgent necessity of 
 watching the head in fever, and I think I cannot too often 
 reiterate the advice which I have given you, to endeavour to 
 check cerebral symptoms before they amount to any degree of 
 absolute danger. The fate of those who have died here will 
 convince you that when cerebral disease has once arrived at its 
 acme, the most energetic measures will often fail in arresting 
 it. It is a matter of vital importance, then, to prevent this 
 lamentable state of things, and, as I have already remarked in 
 this lecture, without waiting until the symptoms of cerebral 
 disease manifest themselves, to anticipate its very origin, and 
 thus be enabled to control with certainty, symptoms which
 
 HEAD SYMPTOMS IN FEVER. 20-5 
 
 assume such a fearful aspect iu cases wlieve cerebral disease has 
 been allowed to go on unregarded. This is the practical lesson 
 which I wish you to draw from the four fatal cases which have 
 occurred in this hospital within the last month. 
 
 There are some points in the case of jNIurphy to which I wish 
 to recall your attention, as I am anxious that you should make 
 them the subject of reflection. For some days before his death 
 he had been delirious and unmanageable, with total loss of sleep, 
 and a contracted state of the pupil. The antiphlogistic and 
 derivative treatment had been employed without eflect ; and 
 seeing that his symptoms were advancing, and his sleeplessness 
 undiminished, I ventured to give him an injection, consisting of 
 two grains of tartar emetic with ten drops of laudanum. I am 
 cautious in the administration of opium in the advanced stage of 
 fever, where there is evidence of determination to the head ; and 
 it was on this account that I ordered it to be combined with 
 tartar emetic, giving also directions that the effect of each dose 
 should be carefully watched. He got three enemata during the 
 course of the night — that is, thirty drops of laudanum altogether. 
 He dozed after the last injection, and appeared more tranquil ; 
 but at our morning visit we found him in a state of coma, with 
 rapid sinking of the powers of life, and death took place in the 
 course of a few hours afterwards. I must confess the issue of the 
 case gave me some degree of uneasiness at the time, as I thought 
 it might have been j)recipitated by the administration of the 
 opium. I could not say but that even this small quantity of 
 opium might have greatly aggravated the cerebral symptoms, and 
 accelerated the fatal event. 
 
 Dissection, however, revealed the true cause of death. On 
 opening the brain, we found extensive arachnoid inflammation, 
 some effusion on the surface of the brain, and an intensely con- 
 gested state of its vessels. The patient, altogether dissipated in 
 his habits, and greatly reduced by fever, had been a young man 
 of rather robust constitution previous to his illness; he had been 
 neglected in the beginning of his fever, which, from the phe- 
 nomena observed after death, must have been characterised by 
 early and decided determination to the brain, producing delirium, 
 watchfulness, coma, and a contracted state of the pupil, which 
 all our antiphlogistic measures were inadequate to remove or 
 control. We did everything in our power : we leeched, blistered,
 
 206 CLINICAL MEDICINE. 
 
 and gave tartar emetic, but without effect ; the case had not 
 come under our care until symptoms of unmanageable cerebral 
 disease had been established. 
 
 This state of delirium, followed by contraction of the pupil and 
 coma, and terminating in death, occurs in two classes of cases : 
 first, in hospital patients of the lower class, who have been neg- 
 lected in the commencement of fever ; and secondly, in persons 
 in the better classes of life, in whom the mind is frequently 
 subjected to over- exertion, and who, when attacked by fever, 
 exhibit a strong tendency to the early development of cerebral 
 symptoms of a bad and unmanageable character. One of the 
 worst symptoms observed in such cases is extreme contraction of 
 the pupil. I have seen the puj)il in some cases contracted to 
 the size of a pin-hole ; and I think I can state, that out of all 
 the cases of this description which I have witnessed, there were 
 but two recoveries. I have seen persons who had exceedingly 
 bad and alarming symptoms of cerebral derangement recover, 
 although accompanied by great dilatation of the pupil ; but I 
 think I have seen but two cases recover in which the pupil was 
 contracted to the small size observed in Murphy. 
 
 With these facts fresh in your minds, allow me to direct your 
 attention to the case of another man, who died lately in the fever 
 ward with cerebral symptoms of an intense character. Now, in 
 this man the very same train of phenomena was present which 
 we observed in Murphy's case. He had, you recollect, typhus of 
 a low character, accompanied by delirium, subsultus, and the 
 ordinary symptoms of determination to the head. I defy any 
 man who compared these two cases together to point out any 
 remarkable difference between them. The delirium, nervous 
 excitement, and watchfulness commenced the same way in both, 
 and ran through the same course ; both had contraction of the 
 pupil, constant muttering and delirium, persistent watchfulness, 
 and subsultus tendinum ; and, in both, the cerebral symptoms 
 terminated in coma and death. I would defy the most accurate 
 symptomatologist to point out any marked distinction between 
 them. Yet how different were the phenomena observed on dis- 
 section ! In the one there was extensive lesion of the membranes 
 of the brain, effusion on its surface, and intense congestion of 
 its vessels ; in the other, there was no appreciable departure 
 from the normal condition. But it is not in typhus alone that
 
 HEAD SYMPTOMS IN FEVER. 207 
 
 we meet with the occurrence of analogous symptoms in cases 
 which exhibit a very different state of the brain after death. We 
 are encountered with the same puzzling contrarieties in many 
 cases of scarlatina. Cases come under our notice in which the 
 patients appear to die entirely from the violence of the cerebral 
 symptoms, and yet, on examination, we find very dissimilar 
 states of the brain. In some, there is palpable and fatal lesion ; 
 in others, there are some dubious marks of congestion, quite 
 insufficient to account for the symptoms ; or the brain is found 
 to be 23erfectly sound and normal. 
 
 It would appear that in scarlatina and fever, the poison of 
 the disease exercises a deleterious influence on the brain, inde- 
 pendently of inflammation, but capable of producing an analogous 
 train of symptoms. Hence it is in many instances extremely 
 difficult to distinguish the cerebral sj^mptoms produced by the 
 poisonous influence of fever on the brain, from those which 
 depend on true inflammation. The one gives rise to delirium 
 and fatal coma as well as the other ; and in the advanced stage 
 of fever, when the manifestations of nervous energy are feeble 
 and imperfect, and when the circulating and respiratoiy organs 
 act with diminished power, the distinction between mere irri- 
 tation and actual inflammation becomes a matter of great 
 difficulty. 
 
 In alluding to the occurrence of analogous symptoms under 
 opposite conditions of the brain, I noticed that headache, tinnitus 
 aurium, and giddiness, have been observed in cases where there 
 was distinct evidence of determination to the head, as well as 
 where there was every reason to believe that the supply of blood 
 to the brain was greatly diminished. You will find a very curious 
 illustration of this fact in the first volume of Guy's Hospital 
 Reports, which contains a very interesting paper from Sir x^Lstley 
 Cooper, on the effects produced by tying the carotid and vertebral 
 arteries. Among other results, it appears that when the supply 
 of arterial blood destined for the brain is diminished, the animal 
 experimented on becomes stupid, is to a certain extent incapable 
 of voluntary motion, and exhibits a very remarkable dilatation 
 of the pupils. This is an extremely curious fact. You are all 
 aware that dilatation of the pupils has been long regarded as one 
 of the most characteristic signs of extravasation and increased 
 pressure on the brain ; and j'et it appears the very same condi-
 
 208 CLINICAL MEDICINE. 
 
 tion of the pupil is observed when you cut off the supply of 
 arterial blood to the brain. We are, I fear, as yet very much in 
 the dark as to the derangement of function which occurs in the 
 brain under opposite states of its vessels ; and I think we have 
 equally imperfect and confused notions of the changes which 
 take place in that organ as the result of fever. 
 
 Dilatation of the pupils is usually regarded as a sign of in- 
 creased pressure on the brain ; and when hydrocephalic symptoms 
 are present, it is generally looked upon as pathognomonic of 
 effusion. Yet from the experiment just alluded to, we find that 
 dilatation of the pupil is also the result of a state of things in 
 which we cannot suppose the existence of anything like increased 
 pressure on the brain. When I speak of increased or diminished 
 pressure on the brain, I am not prepared to maintain that such 
 is actually the case, or that when a man becomes giddy and faints 
 after bleeding, the actual quantity of blood circulating in the 
 brain is diminished, and consequently the amount of pressure ; 
 but when a man gets headache, vertigo, or syncope, from the 
 loss of blood, it must depend upon causes different from those 
 which are connected with congestion of the brain, or extravasa- 
 tion on its surface, or into its substance. What I wish to im- 
 press upon your minds is, that dilatation of the pupils may be 
 connected with very opposite states of the cerebral circulation ; 
 and that in fever it cannot of itself be regarded as a sign of para- 
 mount value in determining the existence of congestion or in- 
 flammation of the brain. 
 
 It may not be amiss to mention briefly on the present occasion, 
 the details of a very remarkable communication, by Surgeon 
 Eussell of the 73rd regiment, formerly a pupil in this hospital. 
 This communication was read by Dr. Wilson, at one of the 
 soirees of the College of Physicians in London, and afterwards 
 published in the Medical Gazette. Mr. Russell observes : — 
 
 " I was led, by the following circumstance, to reflect on the 
 nature of coup cle soldi ; which, as well as I can recollect, is 
 treated of by all authors, and is generally considered to be nothing 
 more or less than true apoplexy, produced by the direct influence 
 of the sun's rays ; that its pathology is the same, and its mode 
 of treatment similar — that is, that all the efforts of the medical 
 attendants should be directed to the head, as the chief, nay, 
 almost the only, seat of the disease ; and here it strikes me a
 
 HEAD SYMPTOMS IN FEVER. 209 
 
 fallacy exists, leading to erroneous principles of practice. In 
 May, 1834, while I was in medical charge of the 68th regiment 
 (a fine corps, composed of men in rohust health), then recently 
 arrived at Madras^ the funeral of a general officer took place ; 
 to which, unfortunately, the men were marched out at an earl}- 
 hour in the afternoon, buttoned up in red coats and military 
 stocks, — at a season, too, when the hot land winds had just set 
 in, rendering the atmosphere dry and suffocating even under 
 shelter of a roof, and when the sun's rays were excessively 
 powerful. The consequence was, that after proceeding two or 
 three miles, several men fell down senseless. As many as eight 
 or nine were brought into hospital that evening, and many more 
 on the following day ; three died — one on the spot, and two 
 within a few hours. The symptoms observed (and they were 
 alike in these three cases) were, first, excessive thirst, and a 
 sense of faintness ; then difficulty of breathing, stertor, coma, 
 lividity of the face, and in one, whom I examined, contraction of 
 the pupil. The remainder of the cases, in which the attack was 
 slighter, and the powers of reaction perhaps greater, or at all 
 events sufficiently great, rallied ; and the attack in them ran 
 on into either an ephemeral or more continued form of fever. 
 The symptoms of these three cases did not more closely 
 resemble each other than did the post-mortem appearances. 
 The brain was, in all, healthy ; no congestion or accumulation 
 of blood was observable ; a very small quantity of serum was 
 effused under the base of one, hut in all three the lungs 
 u'crc conr/ested even to blackness through their entire extent; 
 and so densely loaded were they, that complete obstruction 
 must have taken place. There was also an accumulation 
 of blood in the right side of the heart, and the great vessels 
 approaching it." 
 
 Since our la-st meeting, some cases of fever have occurred in 
 our wards, which have presented too many points of interest to 
 be passed over without any observation. A very curious case 
 occurred here, in a man named Toole, who was admitted on the 
 4th of January. This patient is a robust labouring man, about 
 thirty years of age, and had been ill with fever for ten or eleven 
 days before admission. Of his previous history we could learn 
 nothing ; but wlien he came under our care he appeared very ill, 
 and exhibited great depression of the vital energies, so that we 
 VOL. I. 14
 
 210 CLINICAL MEDICINE. 
 
 found it necessary to encourage reaction by the application of 
 heat to the surface of the body, frictions, warm fomentations, and 
 the internal administration of wine and carbonate of ammonia. 
 On the following night reaction became established ; next day 
 he became irritable and restless, and towards night was seized 
 with delirium. The nurse omitted to report his state to our 
 apothecary Mr. Parr, or the resident pupil ; he was thus left 
 without any treatment until next morning. Now, this is a 
 matter of much regret to me, and I think I cannot do a more 
 essential service to those who are about to enter on the practice 
 of their profession, than to impress, as strongly as I can, the in- 
 dispensable necessity of watching fever patients with the most 
 anxious and unremitting diligence. In a case of bad fever a 
 single visit in the day will never suffice ; two, and even three 
 visits will be required ; and when the patient is in a doubtful or 
 dangerous condition, it will be often necessary to have a properly 
 educated medical person in constant attendance, prepared to meet 
 every emergency, and counteract or modify every unfavourable 
 change. Fever will often run on for several days without any 
 change calculated to arrest our attention, or call for the adoption 
 of any new measures, and yet, in the S2)ace of six hours an 
 alteration may occur, of which the physician should have early 
 and full information. 
 
 Well, this man remained without any treatment for several 
 hours after delirium commenced. On the 6th we ordered his 
 head to be shaved and leeched, and prescribed tartar emetic, in 
 doses of a quarter of a grain, every second hour. Next day we 
 found him as bad as ever. The tartar emetic had failed in 
 diminishing the cerebral symptoms, and his delirium had rather 
 increased. We found also, on inquiry, that he had no sleep for 
 the last three nights. His pulse was weak and rapid, his eyes 
 suffused, his restlessness and delirium such that he required a 
 person to sit by hini constantly, and prevent him from getting 
 out of bed. Under these circumstances, we ordered five drops of 
 black drop to be added to each dose of the tartar emetic mixture, 
 of which he took an ounce every third hour, that is, about a 
 quarter of a grain of tartar emetic. He took four doses of this 
 during the night, and next morning we found that the delirium 
 and sleeplessness continued still unabated, and that the man was 
 sinking fast into a state of stupor and insensibility. He neither
 
 HEAD SYMPTOMS IN FEVER. 211 
 
 answered questions nor put out his tongue when desired ; he had 
 subsultus, and was muttering to himself with great Yoh^hiHty and 
 rapidity of utterance. Indeed, his condition was such tliat I had 
 no hope. Among other symptoms, I should mention that he had 
 contraction of the pupils, a symptom of very unfavourable augury 
 in fever. Having failed with tartar emetic alone, and afterwards 
 with tartar emetic in combination with opium, I had now to seek 
 for some other means of subduing cerebral irritation, and in this 
 emergency had recourse to the use of turpentine — a remedy which 
 I was inclined to adopt in preference to any other, as there was 
 some fulness of the abdomen, and other symptoms indicating the 
 existence of congestion of the intestinal mucous membrane. I 
 therefore ordered two drachms of the oil of turpentine to be made 
 up into a draught with a little oil and mucilage, and administered 
 every second hour. 
 
 I was guided here by a knowledge of the fact, that turpentine 
 exercises a very remarkable influence over many forms of nervous 
 irritation. I can refer for illustration to many affections of the 
 nervous system characterized by excitement, in which turpentine 
 has been emplo3'ed with the most signal benefit. Thus, we 
 frequently find it a most valuable agent in the treatment of 
 chorea, of epilepsy, and of the convulsive fits of children. We 
 have frequently experienced benefit from its use in the treatment 
 of spasmodic affections of the stomach and bowels ; in hysteria, 
 tympanitis, and the subsultus of fever we often derive from it 
 the most rapid and effectual relief. You recollect a case of 
 typhus which was lately under treatment in our wards, and of 
 which one of the most prominent symptoms was general and 
 continued subsultus ; and you have all witnessed how much 
 relief the patient obtained from small doses of oil of turpentine. 
 Hence I was led to conclude that it might be employed with 
 benefit in the. latter stages of fever, where vascular excitement is 
 greatly abated, and where the most prominent symptoms are 
 irritation of the nervous centres, with more or less congestion of 
 the gastro-intestinal mucous membrane. In this case, however, 
 I must confess I used it as a last resource, and did not anticipate 
 the very striking results which followed so unexpectedly. After 
 the second or third dose the patient had two or three fall 
 motions of the bowels, and shortly afterwards fell into a sound 
 and tranquil sleep, from which he awoke rational and refreshed.
 
 212 CLINICAL MEDICINE. 
 
 He is now wonderfully improved in every respect, and I have no 
 doubt tliat his convalescence will go on favourably. 
 
 There is one symptom in this man's case which is worthy of 
 your attention, as connected with the history of fever, although 
 in other respects it does not seem to possess much importance. 
 I allude to the bull£e which have appeared on the calves of his 
 legs, on the inside of the ankles, and on the soles of the feet. 
 This affection seems to belong to that class of eruptive diseases 
 which are occasionally observed during the course of idiopathic 
 fevers, particularly those which have arisen from the introduction 
 of an animal poison into the system. Thus, we sometimes find 
 an eruption of pustules, sometimes of vesicles (as the miliary) ; 
 occasionally we have bullae, and not unfrequently erysipelas. 
 
 We have had another case of spotted or eruptive typhus, in a 
 man named Henry Harpur, which has exhibited in the strongest 
 manner the value of a combination of tartar emetic and opium in 
 diminishing cerebral irritation, and bringing about a favourable 
 change in cases characterized by symptoms of alarming and 
 imminent danger. Those who have witnessed Harpur's case 
 will confess that few cases could present a more unpromising 
 appearance. He had violent delirium, requiring the restraint of 
 the strait waistcoat, a furious aspect, suffusion of the eyes, con- 
 stant raving and muttering, and perfect sleeplessness. His 
 pulse was weak, thready, and rapid ; his tongue and lips parched, 
 fissured, and black ; his breathing quick and irregular ; and his 
 cerebral symptoms of such intensity as to leave little or no 
 ground for hope. In addition, he had continued and general 
 subsultus, and constant irregular motions of the extremities. 
 Now, this man has been rescued from a state of the most 
 imminent danger, and restored to convalescence, by the use of 
 tartar emetic and opium. Those who saw the case two days 
 since, and who have noticed the remarkably improved state of 
 the patient to-day, will agree with me in saying that so favourable 
 a result could scarcely be expected. In this case the tartar 
 emetic and opium were combined with musk and camphor. 
 Where great subsultus tendinum is present, in addition to the 
 usual symptoms of cerebral excitement, I am in the habit of 
 combining musk and camphor with tartar emetic, in the following 
 form : —
 
 HEAD SYMrTOMS IN FEVER. 213 
 
 R'. Mucilagiuis Gummi Arabici, f^ss. 
 Sjrupi Papaveris albi, f^j. 
 Antimonii Tartaiizati, gr. ij. 
 Camphorfc, gr. xv. 
 Mosclii, "►)!]. 
 Aqu.ie, tjivss. Misce. 
 
 The camphor sliould be previously triturated with a few drops 
 of alcohol, and the whole must be rubbed up into the form of an 
 emulsion, of which a table- spoonful is to be taken every second 
 hour, until copious discharges of fluid yellow fecal matter take 
 place — an occurrence always attended by much relief of the 
 cerebral and nervous symptoms, and which marks the period at 
 which we ought to desist from the further use of tartar emetic. 
 In the case which we are now considering, the medicine was 
 administered in draughts, each of which contained half a grain 
 of tartar emetic, ten grains of musk, five grains of camphor, 
 and about ten drops of laudanum. After taking three such 
 draughts, the patient fell into a quiet sleep, which continued 
 for several hours. He awoke quite rational ; and since that 
 period his improvement has been steady and progressive. I 
 have not time to enter any further into the particulars at present, 
 and merely allude to it as one of those instances in which we 
 have succeeded in allaying symptoms of cerebral excitement, 
 where the state of the patient afforded very little grounds for any 
 hope of a favourable termination.
 
 214 
 
 LECTURE XV. 
 
 BED-SOEES IN FEVER. — CONTAGION. — SYMPTOMS OF CONGESTION 
 OR INFLAMMATION OF THE BRAIN IN FEVER. 
 
 A WOMAN has been admitted lately ^Yho had been labouring under 
 fever for a considerable time before she came into the hospital. 
 This poor creature seems to have been in very miserable circum- 
 stances during her illness ; her bedding must have been totally 
 neglected, and no attention paid to cleanliness, for on her 
 admission, though nearly free from fever, she was covered with 
 bed-sores to a frightful extent. Almost every point which had 
 been subjected to pressure had ulcerated, and the ulcers went on 
 undermining the skin, and committing terrible devastation in the 
 areolar substance. Cases like this require great care and un- 
 remitting attention ; it is on the exercise of an active and 
 untiring humanity that the cure will mainly depend. In the 
 first place, you are to recollect that the efforts of the constitution 
 towards the re-establishment of health are impeded by the irrita- 
 tion of the sores ; sleep is prevented, and the patient kept in a 
 state of continued suffering, while a constant drain from the 
 system is kept up by the ulcerative discharge, adding to the 
 amount of existing debility. Hence a pseudo-febrile state arises, 
 characterized by quick pulse, restlessness, and want of sleep, 
 somewhat akin to that which is produced by scrofulous irritation. 
 The appearance, however, of general excitement of the system 
 should never prevent the physician from adopting every mode of 
 strengthening the patient as much as possible. You will not 
 succeed in removing this condition by an antiphlogistic regimen ; 
 the patient requires tonics and narcotics, with a nutritious but 
 not stimulating diet. If you put him on a low regimen, and give 
 anti-febrile medicines, you will do mischief, you will increase the 
 existing debility, and add to the source of febrile excitement. 
 Your practice should be to prescribe a nutritious diet, wine, and 
 the sulphate of quina, and to treat the sores with stimulant 
 applications. The local application which we find most beneficial
 
 BED-SORES IN FEVER. 215 
 
 in such cases, is one composed of two ounces of castor oil and 
 one of balsam of Peru, which is to be applied on pledgets of lint 
 and covered with a poultice of linseed meal two or three times a 
 day. In addition to this, we direct the sores to be washed night 
 and morning with a solution of chloride of soda, in the propor- 
 tion of twenty or thirty drops of the saturated solution to an 
 ounce of water. We also direct the patient to lie occasionally 
 on her face, and enforce the strictest attention to cleanliness on 
 the part of the nurse. Dr. Arnott's hydrostatic bed is an 
 excellent adjuvant in the treatment of this disease. 
 
 Such, then, is an outline of our mode of treatment of bed- 
 sores in fever. We order the patient nourishing, but not heating 
 food; we give wine, regulating its quantity according to its effects 
 on the system, and the liking of the patient ; we prescribe small 
 doses of the sulphate of quina, and administer an opiate at night 
 to allay irritability, and procure sleep. The local treatment 
 consists in the use of stimulant and detergent applications, 
 poultices, attention to cleanliness, and change of position. 
 
 Let me, however, beg your attention for a few moments, while 
 I dwell a little more at length on the subject of bed-sores, a very 
 troublesome occurrence common to most cases of jjrotracted ill- 
 ness, requiring the greatest attention and care on the part of the 
 physician, and in the treatment of which much ignorance is too 
 often displayed by young as well as old practitioners. If the dura- 
 tion of your patient's complaint renders him liable to such affec- 
 tions, how are you to act so as to obviate them ? In the first place, 
 you must pay particular attention to the state of his bed. One 
 of the best modes I am acquainted with of preventing the forma- 
 tion of bed-sores is, to keep your patient perfectly clean, to shift 
 him frequently, and to take particular care to prevent him from 
 lying in the wet. A physician should never trust the arrangements 
 connected with his patient's manner of lying to the discretion of 
 nurses ; he should always look to it himself. You are advised to 
 make your patient change his posture to obviate the eflects of 
 pressure, and to use cushions of various kinds. All these rules 
 are good. You are also told to wash the parts with camphorated 
 spirits of wine when any discolouration appears. This, too, is 
 useful. But, in spite of all this, after fever has continued for 
 some time, and your patient has become debilitated, bed-sores 
 will come on not only in consequence of the effects of pressure, but
 
 216 CLINICAL MEDICINE. 
 
 also from the tendency in the constitution to form those sores. 
 You rememher the case of a man who had a hed-sore under the 
 skin of the sole of the foot, and another under that of the heel, 
 — parts totally exempt from pressure. 
 
 When the first redness, indicating the approach of a bed-sore, 
 has made its appearance, various other means are usually 
 adopted. Some advise the application of pledgets of lint moistened 
 with camphorated spirits, and they endeavour to keep these 
 pledgets in contact with the part, by means of bandages or 
 adhesive plaster. Others use dry lint, or hair-powder, and 
 many are in the habit of immediately covering the affected 
 portion of the skin with adhesive plaster alone. The latter 
 application too often aggravates the mischief, by exciting a rash 
 and itchiness in the surrounding integuments, which become an 
 additional source of inconvenience, and often force the patient to 
 scratch the irritated parts in such a manner as to disturb and 
 remove all the dressings. You must recollect, too, gentlemen, 
 that fever patients are always restless, and frequently delirious, 
 and consequently they are constantly changing their position, 
 and tossing about in the bed, so that it is quite impossible to make 
 use of any contrivance capable of keeping these applications in 
 their place. After they have been fixed on and adjusted with the 
 greatest ease, if you return in a few hours you will find them, 
 if not removed altogether from the part, so wrinkled and 
 crumpled, as to form, by the inequality of their pressure, new 
 sources of irritation. What, then, is to be done ? What means 
 do I recommend to enable us to avoid so serious an evil ? A 
 case of this kind cannot be too vigilantly watched, and it is only 
 by the most anxious attention and care bestowed upon every- 
 thing connected with the cleanliness, dryness, and comfort of 
 your patient, that you can avert the formation of bed-sores in 
 protracted and putrescent fever. 
 
 In private practice, I never treat a fever of this nature without 
 having a second bed in the patient's apartment. After the 
 eleventh or twelfth day, the patient is removed from one bed to 
 another every twenty-four hours ; and when the disease is still 
 further advanced, particularly if the patient wets the bed, the 
 removal may take place every twelve hours. The moment he is 
 changed, all the foul sheets and blankets are removed from the 
 apartment, and, if necessary, a fresh mattrass is provided. Many
 
 BED-SORES IN FEVER, 217 
 
 will contend, that the same object will be gained by carei'iilly 
 shifting the patient from one part of the bed to another, and by 
 a diligent attention to dryness, by means of a constant renewal 
 of sheets and clothes placed under him. These expedients must 
 bo used in both cases, but without the change of bed all our 
 efforts will be too frequently ineffectual. During the progress of 
 long-continued fevers, the relatives and nurses of the sick are 
 apt to become jaded and worn out, at the very time when the 
 greatest vigilance and activity are necessary ; it is then that the 
 physician ought to redouble his vigilance — he ought not to trust 
 too implicitly to what is told him, but inquire into and examine 
 everything himself. 
 
 It is scarcely necessary to observe, that the fresh bed must be 
 well heated with a warming-pan, and that when the patient is 
 weak, his removal must be effected with the greatest care, and 
 he must be carried, as nearly as possible, in an horizontal 
 position, from one bed to the other. When these precautions 
 are observed, it is wonderful what advantage is derived from this 
 plan. Indeed, nothing can be more grateful than this removal 
 from a tossed, foul, and wet bed, to one that is smooth, clean, 
 and in every respect comfortable. How often have I seen this 
 change immediately followed by a sound and refreshing sleep. 
 To be successful practitioners, gentlemen, you must not be 
 merely scientific physicians, but you must understand the more 
 minute duties of the nurse. 
 
 If, notwithstanding these precautions, bed-sores should arise, 
 or if you are called to a case where they have already commenced, 
 there is considerable redness and heat of skin in the affected 
 part ; it looks angry, and is slightly elevated and buffy in the 
 centre ; nay, there may be even slight abrasion of the skin, 
 leaving an unhealthy festering surface. What is to be done ? 
 Wash the parts well, three or four times a day, with a strong 
 solution of nitrate of silver — ten or fifteen grains to the ounce of 
 water ; keep the part perfectly dry in the intervals between its 
 application, and it is wonderful what a speedy amendment will 
 take place. This plan of treatment I first saw successfully 
 employed at the suggestion of Mr. Kirby, in a case of fever, 
 where I thought it perfectly impossible to prevent the formation 
 of extensive, and probably fatal sloughing. You cannot conceive 
 how rapidly the swelling, heat, redness, and puffiness of the part
 
 218 CLINICAL MEDICINE. 
 
 subsided under the use of this remedy ; to me ib was perfecth 
 novel ; but when we reflect upon its utiHty in erysipelas, we are 
 only surprised that it was not before suggested in the treatment 
 of incipient bed-sores. 
 
 With respect to the present epidemic fever,* we have now 
 seen so many instances of its direct communication from one 
 point to another, in our wards, that we are induced to believe it 
 to be contagious. From the great number of applicants labouring 
 under serious and threatening diseases, we are sometimes obliged 
 to put into our fever wards patients affected with local inflamma- 
 tions, accompanied by symptomatic inflammatory fever ; several 
 of these, while recovering. Lave been attacked with symptoms of 
 the present epidemic. A man was admitted last week into the 
 fever ward with violent pneumonia ; the right lung was extensively 
 hepatized, and, in addition to this, the pleura was found to be 
 engorged over a large portion of its surface. The case was one 
 of extreme distress, and the state of the patient apparently 
 hopeless ; however, by appropriate depletion, assisted by mercury, 
 and blisters, convalescence became established, and the pulmonary 
 systems were rapidly subsiding. His system was still under the 
 influence of mercury, his fever had disappeared, his dyspnoea 
 was relieved, his cough and all the other symptoms nearly gone, 
 when he was suddenly attacked with fever, and that of the same 
 character as prevailed among the patients in the same ward. 
 This is, I believe, the sixth or seventh case in which patients 
 labouring under some other form of disease have been seized 
 with symptoms of the present epidemic, while lying in the same 
 ward with fever patients. I have thought it necessary to make 
 this observation, because you will find it asserted in medical 
 works, and by physicians of considerable eminence, that in 
 hospitals fever does not spread from one patient to another, and 
 that where it does appear among many individuals in the same 
 house, its spread is chiefly favoured by want of cleanliness and 
 proper ventilation. This, however, we can state to be the fact, 
 that fever will spread among patients in the same ward, inde- 
 pendent of anything connected with filth or foul air, for we have 
 seen it occur in our wards, which I can assert are kept as clean, 
 and as well ventilated, as any in the kingdom. 
 
 There is one ch-cumstance connected with this case worthy of 
 * Tuis observation applies to the epidemic of 1834.
 
 BED-SORES IN FEVER. 219 
 
 remark, with reference to the supposed anti-febrile properties of 
 mercury. It has been stated that mercury exercises a pro- 
 phyhictic influence over the system, and several persons who 
 have cultivated medicine with success, but particularly some 
 army surgeons of high authority, have asserted that the use of 
 mercury not only cures fever, but also secures against it. I am 
 afraid that in this and other cases mercury has more credit 
 than it deserves. I have seen persons under the influence of 
 mercury take cholera and die of it ; and here we find a man 
 whose mouth is still sore, in whom salivation had not ceased, 
 getting an attack of fever at a time when he had just recovered 
 from another disease. This shows that mercury is not to be 
 looked upon as a prophylactic in cases of fever of a contagious 
 nature. "SVe cannot always cure or prevent fever with mercury ; 
 on the contrary, where fever of a particular kind is present, it 
 prevents the constitution from yielding to its influence. Thus, 
 in a case of hectic fever, brought on by suppuration of the liver, 
 it has been found impossible to bring the system under the 
 influence of mercury. 
 
 There is a case in the female fever ward which requires a 
 passing observation. A young woman, previously in the enjoy- 
 ment of good health, was seized with symptoms of fever after 
 exposure to cold ; she got rigors, followed by headache, hot skin, 
 thirst, nausea, and acceleration of pulse. It is unnecessary for 
 me to detail the symptoms which attended her illness during 
 the past week ; I shall content myself with pointing out the 
 symptoms which particularly attracted my attention to her case 
 on Saturday morning. At that time her fever had increased ; 
 she complained of severe headache and restlessness ; had foul 
 tongue, thirst, and symptoms of gastro-intestinal irritation. 
 Such matters demand no very particular consideration ; what 
 chiefly fixed my attention was the occurrence of slight and 
 transient rigors during my examination : I observed her 
 shuddering three or four times in the space of a few minutes. 
 On questioning her respecting these brief rigors, she informed 
 me that they had occurred with more or less frequency for the 
 last three days. Now, whenever you meet with a sj'mptom of 
 this description in fever, be on your guard ; watch the case with 
 anxious, unremitting attention, and never omit making a careful 
 examination. It is in this "svay that one of the worst complica-
 
 220 CLINICAL MEDICINE. 
 
 tions of fever — treacherous and fatal disease of the brain — veiy 
 often commences. On examining [^this girl, we found that she 
 had not only headache, hut also acute pain referred to the left 
 ear, the external meatus of which was observed to be hot and 
 tender to the touch. In addition to this, we were informed by 
 the nurse that she had been seized vvith a sudden fit of vomiting 
 shortly after we left the ward on the day before. Here Avas an 
 array of threatening symptoms calculated to awaken attention in 
 any, even the most heedless observer. A patient, after exposure 
 to cold, is attacked with symptoms of fever ; she has headache 
 and restlessness ; she then begins to complain of acute pain in 
 the ear, darting inwardly towards the brain ; and, finally, is 
 seized with sudden vomiting. Under these circumstances, it is 
 not difficult to form a diagnosis, and there can be little doubt 
 but that the phenomena here presented were indicative of in- 
 cipient inflammation of the membranes of the brain. It is not 
 easy to say whether in such cases the inflammatory aff'ection of 
 the membranes precedes the external otitis, or whether the 
 inflammation commences in the external ear and spreads in- 
 wards, though I am inclined to adopt the latter supposition, and 
 the circumstance of the fever and earache arising from cold seems 
 to give an additional degree of probability to this view of the 
 question. Be this as it may, there could be no doubt but that 
 this girl was, on Saturday, labouring under incipient inflamma- 
 tion of the membranes of the brain, as denoted by headache, 
 rigors, acute pain in the ear, and vomiting. 
 
 Here let me observe, gentlemen, that in cases of this descrip- 
 tion, I look on the occurrence of external tenderness, not merely 
 as an indication of an internal disease, but also as a favourable 
 symptom. I have remarked that in all cases where this happens, 
 the physician becomes more speedily and sensibly aware of the 
 existence of internal disease, and the remedial means employed 
 act with a more decidedly beneficial effect. I would prefer having 
 to deal with an inflammatory affection of the brain or bowels, 
 accompanied by external tenderness, and would feel much 
 more certain as to the result, than if this symptom were but 
 faintly marked, or totally absent. This observation is founded 
 on experience. 
 
 In treating this case, you have seen that I have ordered relays 
 of leeches to be applied in the vicinity of the aff'ected ear until
 
 BED-SOKES IN FEVER. '22 1 
 
 the earache has ceased. I have long followed this practice of 
 applying a number of leeches in succession for the relief of local 
 inflammation, and I can state with confidence that the result has 
 been, in the majority' of cases, highly satisfactory. Some prefer 
 the application of a great many leeches at once ; but my ex- 
 perience speaks strongly in favour of the practice of applying a 
 small number, repeated at short intervals, until the violence of 
 the local inflammation is subdued. Eelays of six or eight leeches 
 will suffice in the majority of cases of pectoral, cerebral, or ab- 
 dominal inflammation. In some, however, when the attack is 
 violent, fifteen or twenty must be applied at once ; each suc- 
 ceeding relay may consist of a smaller number than that which 
 preceded it. In this manner I have maintained a constant 
 oozing of blood from the integuments over an inflamed organ, 
 for twenty-four, or even thirty-six hours. In addition to this, I 
 determined to bring her system rapidly under the influence of 
 mercur}', and, with this intent, administered calomel to the 
 amount of a scruple in the twenty-four hours. These means 
 have acted favourably, and she feels much better to-day. 
 
 Allow me to make one observation more which this case sug- 
 gests. This young woman, you recollect, had, on her admission, 
 some epigastric tenderness, which we removed by leeching, and 
 she remained free from any symptoms of gastric irritation until 
 last Saturday, when she got a sudden attack of vomiting. Now, 
 in all feverish complaints, ichere, during the course of the dis- 
 ease, the stomach becomes irritable ivithout any obvious caiise, 
 and ivhcre vomiting occurs ivithout any epigastric tenderness, 
 you may expect congestion, or incipient inflammation of the 
 brain or its membranes. If called to a case of scarlatina, where 
 there is severe vomiting, and perhaps diarrhoea, unaccompanied 
 by thirst or epigastric tenderness, what should your practice be ? 
 Are you to direct your attention to the alimentary canal, and 
 endeavour to arrest these symptoms ? No. The vomiting here 
 depends on active congestion of the head, and such cases are 
 very apt to end in coma, convulsions, or death, from disease of 
 the brain. You are all aware, that in cases of injuries of the 
 head, followed by congestion of the brain, vomiting is one of the 
 most prominent symptoms. The same thing occurs in febrile 
 affections, attended with determination to the head. You are 
 not to conclude that a fever is gastric, .because it commences
 
 222 CLINICAL MEDICINE. 
 
 with nausea and vomiting ; this is a serious, and very often a 
 fatal mistake ; yet I am sorry to say it has heen committed by 
 many practitioners, and I have been guilty of it myself. In such 
 cases, you should not waste time in attempting to relieve gastric 
 irritation by cold drinks, and leeches to the epigastrium, or to 
 check diarrhoea by chalk mixture and opiates ; you should 
 direct your attention at once to the seat and origin of the mis- 
 chief, and employ prompt and effectual means to relieve the 
 cerebral congestion. Where the disease sets in with severe 
 vomiting, unaccompanied by distinct evidences of gastric inflam- 
 mation, whether it be common fever, or scarlatina, or measles, 
 or small-pox, I commence the treatment by applying leeches to 
 the head, convinced that in this way I shall be most likely 
 to prevent an approaching dangerous congestion of the brain. 
 I am anxious to impress this observation on your minds, because 
 I am fully sensible of its importance, and feel certain that you 
 will derive much advantage from bearing it in recollection during 
 the course of your future practice. 
 
 There is another subject which I wish to bring before you to- 
 day, namely, the seat of the swellings which, in the latter stages 
 of fever, are usually attributed to inflammation of the parotid 
 and sub-maxillary glands. Every writer on the subject of fever 
 has noticed the occurrence, in the last stage of that disease, 
 of tumors, which not unfrequently suppurate, and which all 
 considered as the consequence of inflammation in the glandular 
 system ; the parotid and sub-maxillary glands being the parts 
 most frequently engaged. Four such cases have lately presented 
 themselves to our observation — two with a favourable, two with 
 a fatal result. The latter afforded us an opportunity of examin- 
 ing the nature and seat of this affection, with a view of determining 
 the correctness of the opinion generally entertained concerning 
 these points. 
 
 According to the best authors, the parotid and sub-maxillary 
 glands, towards the termination of fever, are liable to become 
 painful, tender, and very considerably enlarged ; and the tumour 
 so formed is cither a fatal sjmptom, or else, becoming the seat 
 of a benign suppuration, proves salutary, or even critical. When 
 of the former unfavourable character, they are said sometimes to 
 attain to a considerable size in a very short space^of time, and 
 also to be liable to a disappearance equally rapid.
 
 BED-SORES IN FEVER. 223 
 
 In our first case, the sudden appearance of the tumor was 
 very remarkable, for, in the course of a few hours, two swellings 
 had been formed, in their situation and general appearance 
 resembling mumps of the largest size. They were so extremely 
 tender that the patient screamed on their being touched even 
 in the gentlest manner, yet they were unattended with any 
 cutaneous redness. Without producing any alleviation of the 
 cerebral affection that constituted the predominant symptom of 
 this poor man's fever, these swellings somewhat subsided before 
 his death, which happened on the following day. Much 
 curiosity was excited among the pupils, with regard to the 
 nature of this local affection, and by many it was considered as 
 arising from a sudden inflammation and tumefaction of both 
 parotids — so exactly did the tumors, in extent and situation, 
 resemble the mumps. Their hardness, it is true, was not so 
 great as that usually observed in the latter disease, but this cir- 
 cumstance alone could not be relied on as a distinction. On ex- 
 amination, the parotids were found raised up by the tumors, but 
 were not enlarged or otherwise altered in structure, except that 
 their interstitial areolar tissue was, as it were, bathed in a red- 
 dish serous fluid, evidently the result of a violent inflammation 
 of a peculiar character and short duration. The swellings were 
 owing to the efi'usion of a similar fluid, which abounded most in 
 the subcutaneous areolar membrane, while, in that which per- 
 vades the substance of the muscles, not only in the superficial, 
 but in that more deeply seated, it was observed in lesser quantity. 
 The intermuscular spaces were also occupied by this fluid in con- 
 siderable abundance. 
 
 It may, perhaps, be said that these swellings were essentially 
 different in their nature from the suppurating tumors observed 
 in fever ; but their identity is proved by the case of a young man 
 named Connor, in whom swellings, in all respects precisely 
 similar, arose six days previously to his death. The longer 
 duration of the inflammatory process, of course, produced an 
 alteration of structure somewhat different, but still evidently 
 only an advanced stage of that just described, while it was also 
 as evidently of the class of suppurating tumors. It is worthy of 
 rcmaj-k that, in Connor's case, the tumor on the right side, 
 on the fourth day of its appearance, occupied exactly the same 
 situation that is observed in the mumps, and had likewise the
 
 224 CLINICAL MEDICINE. 
 
 same degree of hardness ; while that on the left side, which was 
 only of two days standing at that period, was situated lower 
 down, and was much less firm. These swellings subsided a 
 good deal a few hours before his death. The areolar tissue, 
 in the parts before enumerated, was not infiltrated merely with 
 bloody serum, as in the other tumors, but this serum was every- 
 where mixed with pus, and the areolar tissue itself had become 
 dense and friable, and was of a reddish, or rather a flesh colour. 
 The parotid and sub-maxillary glands shared in this affection of 
 the areolar tissue, and consequently contributed their proportion 
 to the formation of the tumors ; but they by no means con- 
 stituted the whole of the swellings, or indeed anything like the 
 greater portion of them. 
 
 A few days after Connor had been attacked, a similar swelling 
 arose in a boy, named Byrne, who lay in the bed next to Connor ; 
 but it was confined to one side, and it occupied a position corre- 
 sponding to the parotid, where it was most swollen ; but in its 
 less tumefied parts it extended both further downwards and 
 backwards. This tumor suppurated, and formed an abscess, 
 which was apparently much more superficial than the great mass 
 of the swelling, and unconnected with it ; for when it was 
 opened, and its contents were discharged, the hardness and 
 swelling in the region of the parotid seemed undiminished. The 
 abscess, however, continuing to discharge matter, this swelling 
 gradually declined, and finally disappeared. 
 
 At this very time a woman in the fever wards was attacked 
 with a similar swelling, but which was evidently neither in the 
 situation of the parotid or submaxillary gland : it was confined 
 to the subcutaneous tissue immediately below the ear, and was 
 prevented from suppurating by the application of leeches. 
 
 The facts just stated are, I think, gentlemen, conclusive in 
 proving that the tumors hitherto supposed to arise from inflam- 
 mation of the parotid or submaxillary gland, and which in fever 
 sometimes forbode death, and are sometimes the j)recursors of 
 returning health, are not owing to an affection confined in its 
 action to these glands ; but, on the contrary, the inflammation 
 and its consequent tumefaction are seated in the areolar mem- 
 brane of all the neighbouring parts ; so that the bulk of the 
 tumor is sometimes altogether, and generally for the greatest 
 part, made up independently of disease of these glands. It
 
 BED-SORES IN FEVER. 225 
 
 would be rash to extend this conckision to the mumps — 
 cjnanche parotidca — but I may be permitted to remark 
 that I am far from being satisfied that the seat of the 
 tumors, so called, has not been assumed without sufficient 
 grounds. Indeed this disease so rarely, if ever, proves fatal 
 while the swellings persist, that I do not know of any post- 
 mortem examination of the tumors of mumps on record. Our 
 only guide, therefore, is analogy ; and when we recollect that 
 our swellings agree with mumps, not only in general appearance 
 and situation, but also in the sudden manner in which they 
 arise, and, according to the testimony of authors, in the sudden 
 manner in which they occasionally disappear ; when we recollect, 
 also, that like mumps, they show a decided tendency to be 
 epidemic ; we cannot avoid conceding that the points of resem- 
 blance are strong ; the more so that in both diseases the sudden 
 disappearance of the tumor is always dangerous. The sympa- 
 thetic inflammation of the mammae in females, and of the testes 
 in males, which not very unfrequently follows retrocession of the 
 tumors in cynanche parotidea, may be objected to this analogy, 
 and may be considered as proving the glandular nature of the 
 swelling in mumps. On the other hand, we know of no other 
 glands which are liable to become, in consequence of inflam- 
 mation, so enormously enlarged in the course of a few hours, as 
 the parotids in mumps (if that disease really depends on an 
 affection of these glands alone) ; and, indeed, it may be observed 
 that acute inflammation seems, in all other glands, incapable of 
 causing a degree of swelling at all comparable to that observed 
 in mumps. The swelling, too, in other glands is better defined 
 and more circumscribed, and scarcely liable to the sudden retro- 
 cession observed so frequently in cynanche j^arotidea. It is a 
 singular fact that the salivary secretion is not notably altered in 
 mumps, and yet were this disease dependent on inflammation of 
 the parotids, a suppression, or at least some alteration, in the 
 quantity or quality of that secretion might be expected. Such, 
 gentlemen, are the ideas which have at the moment occurred to 
 me concerning the pathology of these affections — ideas which I 
 have ventured to bring forward merely with a view of exciting 
 further inquiry on the subject. 
 
 VOL. I. 15
 
 226 
 
 LECTUKE XVI. 
 
 TABTAK EMETIC AND OPIUM IN FEVER ATTENDED WITH CEREBRAL 
 
 EXCITEMENT. 
 
 I HAVE several times alluded to the use of tartar emetic in the 
 treatment of the cerebral excitement and determination to the 
 head, which are so frequently witnessed in the advanced stage 
 of typhus fever ; I shall now proceed to mention in detail some 
 of the beneficial effects derived from this plan of treatment, as 
 illustrated by cases which have recently occurred in my own 
 practice, or in that of other members of the profession. 
 
 Did I bring forward this plan of treatment as infallible, or if 
 I boasted that it never failed, then, indeed, you might well 
 doubt my judgment in recommending it to your notice, for 
 infallible remedies never earn the sanction of experience ; but 
 such is not the fact. This treatment we ourselves have seen 
 will not always succeed ; nay, we must acknowledge that it has 
 occasionally disappointed us, even where we seemed justified in 
 calculating upon success. But, gentlemen, we must recollect 
 that every useful remedy is subject to the same charge, and that 
 in the long list of therapeutic agents there does not exist a 
 single medicine which is fairly entitled to the appellation of a 
 true and infallible specific. 
 
 We have failed in several cases with tartar emetic, either alone 
 or combined with opium and other medicines, and patients 
 labouring under typhus have fallen victims to cerebral disease, 
 although we applied the remedy with all due diligence. Yet I 
 think it but fair to observe, that most of the instances in which 
 we failed were cases that had come under our notice at an ad- 
 vanced stage of fever, and where the cerebral symptoms had 
 been wholly overlooked or improperly treated in the commence- 
 ment of the disease. I may observe also, that cases of this 
 description, in which the cerebral symptoms have been permitted, 
 before admission into hospital, to form themselves fully, are
 
 TAKTAR EMETIC AND OPIUM IN FE\'ER. 227 
 
 exceedingly difficult to manage, and terminate fatally at a much 
 earlier period than the ordinary cases of typhus observed in 
 private practice. 
 
 Maculated tj'phus with determination to the head, when 
 improperly treated, terminates not unfrequently about the tenth, 
 eleventh, or twelfth day ; sometimes it is protracted to the 
 thirteenth or fourteenth, but most usually it ends fatally about 
 the eleventh or twelfth. In neglected cases, the cerebral symp- 
 toms frequently assume a fearful violence on the seventh, eighth, 
 or ninth day, and in such instances it must be expected that the 
 best and most appropriate plan of treatment will fail in rescuing 
 the patient from impending dissolution. If, however, we can 
 find out a remedy which, in many cases apparently desperate, 
 succeeds in rescuing the patient from the jaws of death, we must 
 be satisfied. A case of this description has occurred since our 
 last meeting. It has excited the attention of all who witnessed 
 it, as well from the violence of the symptoms, and the apparently 
 hopeless state of the patient, as from the rapidity with which 
 the exhibition of the remedies employed was followed by a 
 striking and decided alteration in the symptoms. Any one who 
 saw him yesterday would scarcely recognise him as the same 
 individual to-day. 
 
 This man, named Fogarty, was admitted about the seventh or 
 eighth day of his fever, according to the account of his friends. 
 Of course in such cases we cannot give implicit credence to those 
 loose statements, for the lower class of persons in this country 
 never calculate the time during which the patient remains out of 
 bed struggling against the disease, a period which, in a people 
 inured to sufi'ering and privation, frequently lasts three, four, or 
 even six days. Well, this man, aged five-and-twenty, and of 
 rather robust constitution, was admitted on the 20th of December, 
 being then about eight or nine days ill. Previously to admission 
 he had taken purgative medicines, had his head shaved, and six 
 leeches applied behind his ears or to his temples, I forget which. 
 Now all these measures, although perhaps insufficient, were 
 extremely proper, and must have produced more or less benefit. 
 When we examined him on the 21st, we found him in a state of 
 high excitement, as manifested by continued mental wandering, 
 incessant talking and raving, and frequent attempts to get out of 
 bed. He had illusions of the senses of sight and hearing, con-
 
 228 CLINICAL MEDICINE. 
 
 sisting of terrific ocular spectra, and alarming sounds, which 
 threw him into a state of intense agitation ; * his eye was red 
 and watchful, and he never slept. Here, then, was a very 
 threatening array of symptoms — perfect insomnia, ocular 
 spectra, illusions of the sense of hearing, a fiery eye, and inces- 
 sant mental wandering. To this was added great derangement 
 of the whole nervous system. His hody was agitated from head 
 to foot by continual tremors, and he had violent and persistent 
 subsultus ; his respiration was interrupted, suspirous, and 
 irregular, amounting at one time to 40 in the minute, after- 
 wards not exceeding 25 ; the acts of inspiration and expi- 
 ration were extremely unequal, and occasionally accompanied 
 by blowing and whistling. In a former lecture I made some 
 observations on this form of respiration, which I termed cerebral, 
 from having first observed it in persons subject to apoplectic 
 attacks, either before or during the paroxysms. It is frequently 
 observed in bad cases of fever, and is a symptom of the greatest 
 importance. He also lay constantly on his back ; his pulse 120, 
 soft, and very weak, so that the canal of the artery could be 
 obliterated by very slight pressure ; his pupils were somewhat 
 dilated ; tongue parched, and brown in the centre, red at the 
 edges and tip ; skin covered with macule ; abdomen soft and 
 full. 
 
 Those who have witnessed the case will acknowledge that the 
 picture I have drawn is not too highly coloured, but, on the con- 
 trary, falls far short of the reality, and no doubt you all expected 
 that if we did not succeed at once in arresting the progress of 
 his symptoms, the case must have proved rapidly fatal. Observe 
 the position in which we were placed. In the commencement of 
 the fever, certain appropriate but inadequate remedies had been 
 employed, and, under a treatment proper but insufficient, the 
 disease had progressed. It was an example of one of the worst 
 forms of fever, characterized by intense cerebral excitement, 
 and accompanied by total want of sleep, persistent delirium, 
 and excessive disturbance of the nervous functions. All these 
 
 * In my last lecture I mentioned that analogous symptoms result from increased or 
 diminished sauguineous pressure on the brain ; the ocular spectra in Fogarty's case 
 evidently depended on determination of blood to the head, but in the case of a lady, 
 the wife of an eminent physician, a continued and varied succession of spectral 
 illusions formed one of the chief symptoms, produced by exhausting hemorrhage after 
 delivery.
 
 TAETAR EMETIC AND OPIUM IN FEVER. '229 
 
 symptoms had come on gradually, and arrived at their acme 
 at a period when the low and dehilitated state of the patient 
 precluded the use of depletive measures to such an extent as to 
 exert any eiFicient control over the most dangerous symptoms. 
 The application of a few leeches would he extremely hazardous, 
 and hlistering would have been wholly useless and nugatory, for 
 before the blister could rise the man would be dead. 
 
 For these reasons, we concluded that the only remedy we 
 could have recourse to with any prospect of success w^as tartar 
 emetic. AYe therefore ordered a draught composed of two 
 drachms of mint water, two of common water, and a quarter of 
 a grain of tartar emetic, to be given every hour, until it produced 
 some decided effect on the constitution. You Avill recollect here 
 that the scale was vibrating between life and death, that it was 
 necessary that our plan of operation should be at once prompt 
 and prudent, decisive and cautious. One of the pupils promised 
 to stay by him the whole day, and watch the effects of the 
 remedy, and I determined to visit and examine him personally 
 in the afternoon. 
 
 In the course of four hours he took four doses of the tartar eme- 
 tic ; the first and second, in fact almost every dose vomited him, 
 but not immediately. He retained each dose for a considerable 
 time, and then threw it up. After the fourth dose, it began to 
 act on his bowels, and then the medicine was suspended for some 
 time, and a small quantity of porter administered. When I saw 
 him at eight o'clock in the evening he had been freely purged, 
 and had discharged a considerable quantity of bilious yellow fluid 
 from his bowels. He had also enjoyed about an hour's sleep ; 
 his respiration was now more uniform and natural ; his raving 
 greatly diminished ; the subsultus and tremors were nearly gone, 
 and the man appeared quite tranquil. I then ordered him a 
 wine-glassfulof porter, with two drops of black drop, to be 
 repeated every second hour for three or four turns successively. 
 I saw that the cerebral symptoms were evidently diminished, 
 and that there was a tendency to returning tranquillity and 
 repose, and I wished to follow up and assist the operations of 
 nature. To-day this man is in a most favourable state. His 
 skin is covered with a most profuse warm perspiration ; he has 
 slept well ; belly soft and natural, respiration slow and regular, 
 and pulse diminished in frequency. He is calm, rational, and
 
 230 CLINICAL MEDICINE. 
 
 composed, and I think I am not too sanguine in anticipating for 
 him a speedy and certain recovery.* 
 
 It is always an unpleasing and ungracious task for any indi- 
 vidual to be obliged to come forward with proofs of the originality 
 of his contributions to science. This task some have endeavoured 
 to impose on me, and have sought to impugn both the origi- 
 nality and utility of my method of using tartar emetic and opium 
 in typhus fever. Their arguments do not require any answer, 
 and may be passed over in silence without any loss to you or 
 prejudice to me, for certainly you could derive little profit from 
 hearing the statements of my opponents, and I but slight credit 
 from their refutation. Suffice it, then, to say that the pre- 
 scriptions filed by the apothecaries of Dublin establish my 
 claims, for you will search in vain among them for one bearing 
 a date prior to the publication of my papers on the use of tartar 
 emetic and opium in the advanced stages of fever, and in 
 which these medicines are prescribed in the way, or anything 
 like the way, recommended and practised by me. Since that 
 date, such prescriptions have daily become more numerous, and 
 I am proud to bear testimony to the general liberality of the 
 profession, for the greater number of my brethren have not 
 merely tried my plan of treatment, but have acknowledged its 
 utility, and have hastened to assure me that, until my pub- 
 lications, they had not seen it practised. But enough of this, 
 let us not employ in general encomiums that time which may be 
 more profitably dedicated to instructive details ; let us therefore 
 again recur to facts. 
 
 I have received from Mr. Burke and Dr. Beauchamp the notes 
 of an extremely interesting case of this description. The case 
 is extremely valuable as having been observed by Mr. Burke 
 from the commencement ; I shall read the whole of it from his 
 letter, as it is well worthy of attention. 
 
 "I was called on the 25th of November to see Mrs. M., a 
 married woman, without family, of a weakly and nervous habit, 
 though generally enjoying good health. She complained of 
 having had chilliness on the preceding day, and now that she 
 was hot, thirsty, had pain in the head and back, and great 
 debility. On examination I found that petechiae covered the 
 chest and abdomen ; the eyes suffused ; face red ; scalp hot ; 
 
 * He recovered rapidly and completely.
 
 TAETAR EMETIC AND OPIUM IN FEVER. 231 
 
 pulse 110, small and hard; tongue covered with a creamy 
 exudation ; no abdominal or chest affection ; secretions and 
 excretions arrested. She was ordered some aperient medicine, 
 and directed to be kept very quiet. 
 
 " !2Gth. — Passed rather an uneasy night, frequent startings ; 
 some raving ; complains of headache, and that the light and 
 noise are distressing ; pulse as before, face more flushed, bowels 
 open. I directed a cooling lotion for the head, and a diaphoretic 
 mixture containing liquor acetatis ammoniae, and nitre. On the 
 27th she complained of the headache being made worse by 
 the noise in the house, from which I determined to have her 
 removed, and I therefore did not put any active treatment into 
 requisition. 
 
 " 30th. — This day she was removed to a quiet airy room. 
 I then had her head shaved, eight leeches applied behind the 
 ears, and a blister to the nape of the neck ; bowels opened by 
 enemata. 
 
 " Up to the 5th of December, which was the tenth day of her 
 illness, she went on tolerably well, occasionally raving at night ; 
 tongue dry and red ; pulse very weak, 110 ; eyes much suffused ; 
 face occasionally flushed, then pale ; scalp hot. At this period 
 Dr. Beauchamp saw her, and from the weakly habit of the 
 patient, and the peculiar tremulous feel of the pulse, he thought 
 it advisable to let her have some weak chicken broth and 
 light negus ; the latter had soon to be discontinued on account 
 of the excitement it produced. 
 
 " On the 14th day she became more delirious and somewhat 
 unmanageable, though previously very gentle ; however, when 
 spoken to she answered tolerably reasonably. Ordered to con- 
 tinue the lotion, enemata, and saline draughts. 
 
 " Dr. Beauchamp and I saw her next day about ten o'clock in 
 the forenoon, being the fifteenth day of her fever. Previous to 
 our going into the room, the nurse gave us a frightful picture of 
 the way she spent the night. She had been perfectly unmanage- 
 able, continually screaming, and imagining she saw frightful 
 apparitions, and had been convulsed during the night. On 
 entering the room, we found her with her hands outstretched and 
 rigid ; a mixture of wildness and terror in her face, her eyes 
 red and protruded, pupils contracted, pulse not to be counted, 
 and scarcely to be felt ; feet cold and stift'. When spoken to
 
 232 CLINICAL MEDICINE. 
 
 she made no answer, but kept her eyes steadily directed towards 
 the foot of the bed. Her aspect was altogether frightful, and 
 Dr. Beauchamp observed that her state appeared to be a com- 
 bination of delirium with hysteria. 
 
 *' The question now was, what were we to do ? We dared not 
 apply leeches, blisters would be doubtful, and the probability 
 was that the patient would sink before they vesicated. There 
 was no indication for cold to the head, for the scalp was cool. 
 Could we rely with safety on nervous medicines ? Their very 
 stimulus might hasten her to the tomb. The indication was to 
 relieve the brain ; and the question was, what medicine or combi- 
 nation of medicines would effect this with safety ? Under these 
 circumstances, we happily thought of the treatment employed 
 by you in somewhat similar cases. We immediately ordered a 
 mixture containing three grains of tartar emetic, half a drachm 
 of laudanum, and six ounces of water ; of this a tablespoonful 
 was administered every half hour, its effects being watched. We 
 saw her again at one o'clock on the same day, and had the 
 pleasure of finding her much improved. She had taken three 
 doses, and vomited twice. The expression of her countenance 
 was much changed, it had lost its ferocity and wildness ; her 
 tongue was now moist, perspiration was beginning to appear over 
 her body, the pulse was soft and about 100, and the intelligence, 
 which had been absent for a considerable period, now reappeared. 
 She was able to answer our questions, and expressed herself 
 relieved. We ordered the medicine to be continued, giving a 
 tablespoonful every hour. After taking two doses, she became 
 perfectly quiet, fell into a profound and tranquil sleep, perspired 
 copiously, and at our visit next morning at ten o'clock we found 
 her, to our astonishment, almost well. She looked cheerful and 
 refreshed, and spoke of the wonderful relief she obtained ; her 
 pulse was soft, and about 80 ; her skin natural, and her tongue 
 moist and clean. Dr. Beauchamp did not think it necessary to 
 continue his visits, and all that remained for me was to conduct 
 her by proper regimen from convalescence to perfect health. 
 She is now quite well. 
 
 "It is a source of gratification to me to have had the able 
 assistance of Dr. Beauchamp on this occasion, and his presence 
 during the eventful period adds much value to the case. Dr. 
 Beauchamp remarked, at the time when hope had fled, that he
 
 TARTAR EMETIC AND OPIUM IN FE\'ER. 233 
 
 knew of no routine of practice wliicb afforded a probability of 
 being of service, so tbat we may fairly conclude, tliat but for your 
 bappy combination tbe patient must liave died." 
 
 Tbis is a ver}^ strong case ; indeed tbere could scarcely be a 
 more striking illustration of tbe value of tartar emetic and 
 opium in tbe treatment of tbe cerebral symptoms of fever. 
 Tbe case, too, was one of great danger ; tbe patient was of a 
 nervous weakly babit, and during tbe acme of tbe disease sbe 
 bad an attack of convulsions. Tbis is a very important and 
 most formidable symptom in fever, particularly wben super- 
 added to otbers indicating a deranged state of tbe sensorium. 
 We bad a patient bere, some time back, wbo bad two convul- 
 sive paroxysms during tbe course of bis fever, and you recollect 
 tbat I told you tbat it was a symptom of unusual danger. 
 Some time ago a gentleman, in discussing my cases, said 
 tbat convulsions in fever were not so dangerous, but I bad tbe 
 satisfaction of quoting for bim tbe autbority of Hippocrates, to 
 sbow tbat persons wbo bad been attacked in tbis way very 
 seldom recovered. 
 
 I sball next detail a very remarkable case, wbicb was com- 
 municated to me by Mr. Swift : — 
 
 " J. Kinsela, a labourer, aged 23, of powerful make, and 
 robust constitution, was attacked witb fever about tbe 14tb or 
 15tb of January. He complained during tbe ensuing week of 
 intense beadacbe, tbirst, and debility, but bad no medical treat- 
 ment. On Saturday, tbe 21st, be was extremely ill and restless, 
 and on Sunday morning, wbile bis clergyman and several of bis 
 friends were witb bim, be got out of bed in a state of furious 
 delirium, seized a knife, and baving cleared tbe room, rusbed 
 out into tbe street in bis sbirt, wbere be was secured by a police- 
 man and some of bis neigbbours, and brougbt back to bed, 
 baving previously wounded several of bis captors in tbe struggle. 
 He tben fell into a state of coma, and wben I saw bim on 
 tbe following Tbursday, tbe 26tb, be exbibited tbe following 
 symptoms: — Decubitus on tbe back; eyes nearly closed; lips 
 red, dry, and cbapped ; forearms bent and agitated by apparently 
 unconscious movements ; convulsive twitcbes of tbe eyebrows 
 and angles of tbe moutb; breatbing irregular, beavy, and 
 somewbat stertorous (of tbat description wbicb you bave aptly 
 termed cerebral) ; pulse oppressed, unequal, weak, and about
 
 231 CLINICAL MEDICINE. 
 
 110 ; great heat of scalp and face ; temperature of the body 
 normal ; feet very cold. He had no pulmonary symptoms ; his 
 belly was soft and apparently natural, but he gave indications of 
 uneasiness when firm pressure was made over the situation of 
 the stomach and small intestine. He was raised up in bed, 
 shaken roughly, and spoken to repeatedly, but gave no answer ; 
 nor would he put out his tongue, or open his eyes when requested. 
 His tongue, as far as I could see it, appeared red, dry, crusted, 
 and fissured ; and on raising his eyelids, I found the eyes greatly 
 suffused, and the pupils contracted nearly to the size of a pin's 
 head. 
 
 "His face, hands, and head, were bathed with warm vinegar 
 and water, jars filled with hot water applied to his feet, and 
 about two o'clock, p.m., he commenced taking tartar emetic in 
 doses of a quarter of a grain every hour. It was combined with 
 a small quantity of opium. 
 
 " When I saw him again, about nine o'clock in the evening, 
 he was wonderfully improved. He could be easily roused, 
 answered questions distinctly, put out his tongue when desired, 
 and appeared quite rational. He had taken about two grains of 
 the tartar emetic, the effects of which appeared to be chiefly 
 confined to the circulating system. His pulse was now equal 
 and regular, the temperature of his body nearly uniform, and a 
 slight degree of moisture could be felt on his skin, but he was 
 neither vomited nor purged. A mixture, containing nitrate of 
 potash and tincture of hyoscyamus, was substituted for the 
 tartar emetic ; the fomentations of warm water and vinegar were 
 continued, and he had a purgative enema with turpentine, which 
 was followed by a full discharge from the bowels and copious 
 diuresis. On Saturday, the 28th, he had an indistinct but 
 favourable crisis ; his tongue became clean and soft, and his 
 pulse diminished in frequency. On the following Tuesday his 
 pulse was 76, his tongue clean, eyes clear, pupils natural, 
 appetite returning, so that I considered it unnecessary to con- 
 tinue my visits beyond the following day. His convalescence is 
 now completely established. 
 
 "I have been particular in describing the cerebral symptoms 
 in this case, as the patient's head was neither shaved, blistered, 
 nor leeched. A portion of his hair was cut off with a scissors, 
 and this was all that was done in addition to what I have men-
 
 TARTAR EMETIC AND OPIUM IN FEVER. 235 
 
 tioued. I attribute liis recovery to the tartar emetic and opium, 
 as under its use be recovered in a few hours from a state of 
 stupor and coma, which otherwise must have speedily terminated 
 in death, and I think this vahiable remedy has additional claims 
 to notice, if (as it would appear from Kinsela's case) it can be 
 employed as a substitute for all the ordinary and expensive 
 remedies used on such occasions — remedies which, in dispensary 
 practice, and among a pauper population like ours, it is often 
 difficult, and sometimes impossible to procure." 
 
 It is well known that delirium tremens requires very different 
 modes of treatment, varying according to the constitution, 
 strength, age, and habits of the patient. In the young and 
 robust, more especially when it is produced directly by excessive 
 drinking, it often assumes a form exceedingly resembling that of 
 delirium arising from sudden congestion or inflammation of the 
 brain or its membranes, and then demands strictly antiphlogistic 
 measures, such as venesection, leeching, cold to the head, and 
 very active cathartics. These remedies will often speedily arrest 
 the progress of the disease. On the other hand, we most 
 frequently meet with delirium tremens calling for a totally 
 opposite plan ; for when it occurs in the old, debilitated, and 
 confirmed drunkard, who has been repeatedly subject to its 
 attacks, we are obliged to exhibit opium from the very com- 
 mencement, and that in large doses, combined with porter, 
 punch, or some other cordial. These two form the extremes, 
 between Avhich there are many intermediate varieties, each 
 requiring a special modification of practice. 
 
 Thus, some must be treated rather actively, on the anti- 
 phlogistic plan at first, and immediately afterwards opiates may 
 be used with advantage ; while in others, opiates cannot be given 
 alone at any period of the disease, so prominently marked are 
 the symptoms of cerebral congestion ; and yet these cases cannot 
 be cured without narcotics. How then are they to be exhibited '? 
 Do we possess any medicine capable of modifying and diminishing 
 their injurious effects when given where cerebral congestion 
 exists ? Undoubtedly we do ; tartar emetic will often accomplish 
 this desirable object, and in delirium tremens the value of its 
 combination with opium is recognised by every practitioner of 
 experience. Tartar emetic, boldly exhibited, is often our sheet 
 anchor in delirium tremens, especially when the evidence of
 
 236 CLINICAL MEDICINE. 
 
 active determination to the head is undoubted. Then tartar 
 emetic alone, in repeated doses, often powerfully contributes to 
 produce tranquillity and sleep ; but there are other more mixed 
 cases, where we cannot cure without adding opium, sometimes 
 in larger, sometimes in smaller quantities, to the solution of 
 tartar emetic ; and so it is with the delirium and sleeplessness, 
 so often met with in fever. 
 
 Every one is acquainted with the indications denoting the 
 propriety of adopting the antiphlogistic practice when these 
 symptoms make their appearance in the commencement of fever. 
 Then the lancet, leeches, purgatives, cold applications to the 
 head, and finally, repeated doses of tartar emetic, tend powerfully 
 to reduce vascular action, and diminish the violence of symptoms 
 depending on cerebral congestion and excitement. Here the 
 lancet and tartar emetic are our best opiates, our best restoratives 
 of tranquillity and sleep. As the fever progresses, and when we 
 have arrived at a more advanced stage of the disease, when 
 maculae make their appearance on the skin, and symptoms of 
 general debility, announcing the typhoid type, begin to pre- 
 dominate, then we must proceed with more caution, even though 
 our patient is totally deprived of sleep and is violently delirious. 
 The lancet cannot now be resorted to ; leeches, indeed, may be 
 applied, but their effects must be carefully watched, as the 
 patient will not bear copious depletion of any sort ; tartar emetic 
 may, nevertheless, be still given boldly, and will be found to 
 answer our expectations. 
 
 But, if we have to contend with want of sleep and delirium at 
 a still more advanced period of fever, we now often recognise 
 that very combination of symptoms — the union of general 
 debility and cerebral congestion, which in certain varieties of 
 delirium tremens we have seen so successfully treated with 
 tartar emetic and opium. Who will refuse to acknowledge the 
 similarity between these cases of fever delirium and many 
 varieties of delirium tremens ? Are there not in both the same 
 tremor and subsultus of the extremities ; the same trembling 
 of the tongue when the patient endeavours to put it out ; the 
 same starting and sleeplessness ; the same rambling delirium 
 or incoherence, combined, nevertheless, with the power of 
 answering rationally when spoken to ; the same character of 
 the mental wandering, for in both they are extremely apt to
 
 TARTAR EMETIC AND OPIUM IN FEVER. 237 
 
 rave as if employed in their ordinary occupations, and as if 
 surrounded with their usual associates; in short, can any 
 greater resemblance exist between two diseases arismg irom 
 the operation of remote causes so different? \^e need no , 
 therefore, be surprised at finding the same treatment applicable 
 to both.
 
 238 
 
 LECTURE XVII. 
 
 THE USK OF TARTAR EMETIC AND OPIUM IN FEVER — Continued. 
 
 In my last lecture I alluded to the peculiar narcotic power of 
 the preparations of antimony, and dwelt on the benefits derived 
 from a combination of antimonials with those medicines which are 
 strictly termed narcotics. I told you in that lecture that the 
 good effects of tartar emetic in delirium tremens seem to be 
 totally independent of its action on the stomach ; for we have 
 witnessed those effects when it had not excited either nausea or 
 vomiting. I referred also to many instances of delirium tremens, 
 in which opium in every form had failed in procuring sleep, and 
 where a combination of tartar emetic and laudanum had succeeded 
 in tranquillizing the patient and producing sound, refreshing 
 sleep. Bearing this important fact in mind, we shall proceed 
 to a further examination of the circumstances w'hich require the 
 use of tartar emetic in fever. 
 
 There is a peculiar stage in one form of fever, and that exceed- 
 ingly dangerous and threatening, in which I have derived most 
 signal benefit from the use of this remedy. A patient, suppose, 
 gets an attack of fever, he has all the ordinary symptoms, as thirst, 
 restlessness, heat of skin, quick pulse, and headache. You are 
 called in about the third or fourth day, and find that he has all 
 the symptoms I have mentioned still present ; his face is flushed, 
 his head aching, his pulse from 100 to 110, but not remarkably 
 strong ; you find, also, that he has been sweating profusely 
 from the commencement of his illness, but without any propor- 
 tionate relief to his symptoms, and that he is restless and 
 watchful. You are informed that his perspirations are so great 
 that his linen has to be changed frequently in the day, and that, 
 notwithstanding this, the pulse has not come down, the headache 
 is undiminished, and the patient has become more and more 
 sleepless. Here comes a very important practical question. 
 How are you to treat such a case ? The patient has no epigastric
 
 TARTAR EMETIC AND OPIUM IN FEVER. 239 
 
 tenderness, no cough, no sign of local disease in either the 
 thoracic or abdominal cavities ; he has been purged, taken 
 diaphoretics, and perhaps mercurials ; every attention has been 
 paid to regimen, ventilation, and cleanliness ; but still he lies 
 there in a state of undiminished febrile excitement, with persistent 
 headache, quickness of pulse, and sleeplessness. 
 
 In such a case as this you have nothing to expect from sweat- 
 ing ; it will never produce any relief. I was called some time 
 back to see a young gentleman in fever, who was placed in 
 similar circumstances to those which I have just detailed. It 
 was about the sixth day of his fever, and I found him with a 
 pulse of about 110, with considerable restlessness and headache, 
 and was informed that he had perspired profusely from the 
 commencement of his illness. On hinting the necessity of more 
 active treatment than that which had been employed, his 
 physicians appealed to the perspirations as decidedly contra- 
 indicatiug depletion. They said that the profuse sweatino- 
 pointed out the impropriety of active measures, and that it was 
 a symptom which would be speedily followed by relief. I was 
 convinced that they had taken a wrong view of the case, and 
 stated as my opinion that nothing was to be expected from the 
 perspirations ; that when co-existing with a persistent febrile 
 condition of the system, when accompanied by quick pulse, head- 
 ache, and restlessness, perspirations always indicated the necessity 
 of antiphlogistic measures, and in particular for the use of the 
 lancet. I instanced the case of patients labouring under arthritis 
 with profuse perspirations, which gave no relief, and said that it 
 was well known that such cases were most successfully treated 
 by a full bleeding from the arm. I accordingly stated that 
 although the disease was of five or six days' standing, and the 
 pulse not very strong, I would advise immediate bleeding. Six- 
 teen ounces of blood were therefore abstracted, with some relief 
 to the patient, and without increasing his debility ; and it was 
 then a question what further steps were to be taken. 
 
 The young gentleman had been actively purged ; he had no 
 cough or abdominal tenderness ; his symptoms were headache, 
 sweating, and sleeplessness ; and to these nervous agitation had 
 now become superadded. I proposed here what surprised my 
 colleagues very much, and this was, to give our patient large 
 doses of tartar emetic. They said the practice was very strange,
 
 240 CLINICAL MEDICINE. 
 
 but Oil my laying before them the reasons which induced me to 
 prescribe it, consented to give it a trial. I said that in such 
 cases the tartar emetic, forming as it were a part of the antiphlo- 
 gistic treatment which commenced with general bleeding, would 
 have a tendency to cut short instead of increasing the perspiration, 
 by reducing the inflammatory state of the system on which it 
 depended. The rejasoning seemed rather paradoxical — neverthe- 
 less it turned out to be correct, I ordered the tartar emetic to be 
 taken in the quantity and mode in which it is generally prescribed 
 in acute pneumonia ; that is to say, six grains of tartar emetic 
 combined with a little mucilage and cinnamon water, in an eight 
 ounce mixture, to be taken in the course of twenty-four hours. 
 After taking five or six grains, the sweating began to diminish ; 
 on the second day he scarcely perspired any, and his head- 
 ache was greatly relieved ; he began to improve rapidly in 
 every respect, sleep returned, nervous agitation ceased, and 
 convalescence became soon established. 
 
 The next case in which I employed tartar emetic with signal 
 benefit was one of a very insidious character, as many of 
 them are at present ; they exhibit no prominent or alarming 
 symptoms, and yet continue to run on day after day without 
 any tendency to crisis. The gentleman who was the subject 
 of this case got an attack of fever, unaccompanied by any 
 remarkable peculiarity, except that he was very nervous, and 
 alarmed about his situation. His fever went on day after day 
 without any decided symptom ; he had no distressing headache, 
 no cough, little or no abdominal tenderness; there was no 
 vomiting nor diarrhcea ; and his pulse was not much above the 
 natural standard. He had been leeched over the stomach at the 
 suggestion of some medical friends, but this was done rather by 
 the way of precaution, than for the purpose of combating any actual 
 disease. About the eighth or ninth day the pulse began to rise ; 
 he complained of headache and became restless and watchful. 
 On the eleventh day the headache had greatly increased, he was 
 in a state of great nervous excitement, and had not closed an eye 
 for the two preceding days and nights. This state of insomnia 
 and nervous agitation was immediately followed by violent 
 paroxysms of delirium ; his eyes never closed in sleep — wandered 
 from object to object with unmeaning restlessness ; his limbs 
 were in a state of constant jactitation, and he raved incessantly ;
 
 TARTAR EMETIC AND OPIUM IN FEVER. 241 
 
 his voice being occasionally loud and menacing, at other times 
 low and muttering. His friends became exceedingly alarmed, 
 and every remedy which art could suggest was tried : — his head 
 was shaved and leeched until they could leech no longer ; cold 
 lotions were kept constantly applied with unremitting diligence, 
 and he was purged freely and repeatedly. 
 
 At this period, that is to say, about the eleventh day of the 
 fever, I was requested by this gentleman's medical friends to visit 
 him. On examining the patient, I found that he was constantly 
 making violent eflbrts to rise from his bed, and that he had a 
 great deal of the expression of countenance which belongs to a 
 maniacal patient. Under these circumstances, I advised the use 
 of large doses of tartar emetic, in the mode already detailed, 
 except that, in this case, in consequence of the violence of the 
 delirium, I ordered the quantity prescribed for a dose to be taken 
 every hour, instead' of every second hour. The patient took about 
 ten or twelve grains during the course of the night, and next 
 day his delirium had almost completely subsided. Under the use 
 of the remedy he became quite calm, fell into a sound sleep, and 
 began to recover rapidly. 
 
 In the two preceding cases I was guided by ordinary principles, 
 recognised by all physicians, and according to which the exhi- 
 bition of tartar emetic is recommended in fever, wherever there 
 is undoubted evidence of determination of blood to the head, 
 producing headache, loss of sleep, and delirium. In the cases 
 which follow, tartar emetic was exhibited at a period of fever, and 
 under circumstances that were, with respect to the exhibition of 
 this remedy, not less novel than important. The principles 
 which led me to this practice have long been established, but, 
 nevertheless, the practice is entirely new, and (I say it with 
 pride, for it already has been the means of saving many valuable 
 lives) it is entirely my own. 
 
 Shortly after the commencement of our present session, Mr. 
 Cookson, a pupil at this hospital, and remarkable for his diligent 
 attention to clinical pursuits, caught fever while attending our 
 wards, in which many cases of the present epidemic were then 
 under treatment. His fever was of an insidious nature, not 
 characterized by any prominent symptom, not exhibiting any local 
 disease to combat, or any tendency to crisis. For the first seven 
 or eight days, ^\ith the exception of headache, which was much 
 VOL. I. 16
 
 24^ CLINICAL MEDICINE. 
 
 relieved by leeching, he seemed to be going on very well ; his 
 skin was not remarkably hot ; he had no great thirst, nausea, or 
 abdominal tenderness ; his pulse was only 85 ; and he had sweat- 
 ing, which was followed by some relief. About the eighth or 
 ninth day the pulse rose, and he began to exhibit symptoms of a 
 hysteric character. Now, in every case of fever, where symptoms 
 resembling those of hysteria come on, you should be apprehensive 
 of danger. I do not recollect having ever met with a single case 
 of this kind, which did not terminate in nervous symptoms of the 
 most formidable nature. 
 
 I prescribed at the time the usual anti-hysteric medicines, 
 but without any hope of doing good, knowing that these symptoms 
 were only precursory to something worse. I also, as a precau- 
 tionary measure, had leeches applied to his head. The fever 
 went on, the headache became more intense ; he grew nervous 
 and sleepless, and fell into a state of great 'debility. On the 
 fourteenth day of fever his tongue was black and parched, his 
 belly tympanitic ; he was passing everything under him uncon- 
 sciously ; he had been raving for the last four days, constantly 
 attempting to get out of bed, and had not slept a single hour for 
 five days and nights. 
 
 Dr. Stokes, with his usual kindness, gave me the benefit of 
 his advice and assistance at this stage of Mr. Cookson's illness, 
 and we tried every remedy which experience could suggest. 
 Blisters were applied to the nape of the neck, the head was kept 
 cool by refrigerant lotions, the state of the belly attended to, and, 
 as we perceived that the absence of sleep was a most prominent 
 and distressing symptom, we were induced to venture on the 
 cautious use of opium. It was first given in the form of Dover's 
 powder, with hydrargyrum cum creta, with the view of relieving 
 the abdominal symptoms as well as procuring sleep. This fail- 
 ing in producing the desired efi"ect, we gave opium in the form of 
 enema, knowing its great power in the delirium Avhich follows 
 wounds and other injuries. This was equally unsuccessful with 
 the former. He still was perfectly sleepless. We came again 
 in the evening, and, as a last resource, prescribed a full dose 
 of black drop, and left him with the conviction that if this failed 
 he had no chance of life. 
 
 On visiting him next morning at an early hour, we were highly 
 mortified to find that our prescription had been completely
 
 TARTAR EMETIC AND OPIUM IN FEVER. 243 
 
 unsuccessful ; he had been more restless and delirious than ever. 
 Here was the state in which we found him on entering his 
 chamber at eight o'clock in the morning of the fifteenth day of 
 his fever. He had universal tremors and subsultus tendinum, 
 his eye was suftused and restless, he had been lying for some 
 days entirely on his back, his tongue was dry and black, his 
 belly tympanitic, his pulse 140, quick and thready, his delirium 
 was chiefly exhibited in short broken sentences, and in a subdued 
 tone of voice ; and it was now eight days and nights since he 
 had slept. Here arose a question of great practical importance. 
 How was the nervous agitation to be calmed and sleep procured ? 
 Blisters to the nape of the neck, cold applications, and purgatives 
 had failed, opium in various forms had been tried without the 
 slightest benefit ; if sleep were not speedily obtained he was 
 lost. 
 
 At this emergency a mode of giving opium occurred to me 
 which I had never thought of before. Recollect what his symp- 
 toms were at this period, quick, failing pulse, black, dry, tremulous 
 tongue, great tympanitis, excessive prostration of strength, 
 subsultus tendinum, extreme nervous agitation, constant mutter- 
 ing, low delirium, and total sleeplessness. I said to Dr. Stokes 
 that I wished to try what effects might result from a combination 
 of tartar emetic and opium ; I mentioned that I had given it in 
 cases of delirium tremens with remarkable success, and thouffht 
 it worthy of trial under the circumstances then present. Dr. 
 Stokes stated in reply, that he knew nothing with respect to such 
 a combination as adapted to the case in question, that he had no 
 experience to guide him, but that he would yield to my suggestion. 
 We therefore prescribed a combination of tartar emetic and 
 laudanum in the following form, which is that in which I 
 generally employ the remedies in the treatment of delirium 
 tremens : tartar emetic, four grains ; tincture of opium, a drachm ; 
 camphor mixture, eight ounces ; mix. Of this mixture, a table- 
 spoonful to be taken every second hour. The success of this 
 was almost magical. It is true that it vomited him ; after taking 
 the second dose he threw up a large quantity of bile, but it did 
 him no harm. After the third or fourth dose he fell asleep, 
 and awoke calm and refi'eshed. He began to improve rapidly, 
 and soon recovered. 
 
 The next case to which I shall direct your attention is that of
 
 244 CLINICAL MEDICINE. 
 
 Mr. Stephenson, a pupil of Mr. Parr of this hospitaL This 
 young gentleman, as many of you may recollect, was attacked 
 with fever about the middle of January. On Thursday evening he 
 complained of languor and malaise, and on the following day felt 
 himself feverish, but without any prominent or decided symptom. 
 At night he took a dose of calomel and antimonial powder, 
 which had no sensible effect, and the following day complained 
 of shivering, violent headache, pain in the back, thirst, prostra- 
 tion of strength, and sleeplessness. He was ordered to take a 
 combination of tartar emetic and nitrate of potash in camphor 
 mixture, which produced a few loose stools and some diaphoresis ; 
 but in consequence of its effect on the stomach, and his complain- 
 ing much of thirst and epigastric tenderness, the tartar emetic 
 was omitted, and effervescing draughts prescribed. Two days 
 afterwards, the epigastric tenderness still continuing, twelve 
 leeches were applied over the pit of the stomach, followed by a 
 blister which gave relief, and the bowels were kept open by 
 enemata. 
 
 He commenced a second time the use of the tartar emetic and 
 nitrate of potash, with the addition of five drops of tincture of 
 opium to each dose, but was obliged to give it up again in con- 
 sequence of the increase in his gastric symptoms. He now 
 became exceedingly restless, and his delirium began to assume 
 an intense character. Leeches were applied behind the ears, his 
 head shaved, and his temples blistered ; he had also a large 
 blister over the abdomen, which gave him considerable relief, but 
 the cerebral and nervous symptoms became much worse. The 
 delirium went on increasing, accompanied by subsultus tendinum, 
 and picking the bed-clothes ; he was perfectly sleepless, raved 
 incessantly, and had to be kept down in bed by force. On the 
 seventeenth day of his fever he was in the following condition : — 
 tongue brown and rather dry, no remarkable thirst nor abdominal 
 tenderness, eyes red and ferrety, no sleep for five nights, constant 
 muttering and delirium (which had now assumed the character 
 of delirium tremens), subsultus tendinum and jactitation extreme, 
 urine and feces passed under him unconsciously. I directed the 
 combination of tartar emetic and laudanum to be immediately 
 given, carefully watching its effects. He had only taken two 
 doses when a degree of calmness set in, bringing with it relief 
 to all his symptoms, and before a third dose could be admin-
 
 TARTAR EMETIC AND OPIUM IN FEVER. 245 
 
 istered, he fell into a profound sleep, from whieli lie awoke 
 rational and refreshed. The mixture was continued every four 
 hours with increasing benefit, he slept long and soundly, and 
 began to improve in every respect. On the second day after he 
 had begun to use the tartar emetic, he took a little porter, which 
 was changed the next day for claret and chicken broth. In 
 about a week he was able to sit up in bed, and seven days 
 afterwards was able to leave the hospital and go to the country 
 for change of air. 
 
 Another case to which I shall direct your attention is that of 
 Mr. Knott, also a pupil of this hospital, a gentleman remarkable 
 for his unremitting attention to clinical pursuits, and from whom 
 I derived much valuable assistance in conducting various post- 
 mortem examinations. This gentleman was attacked with fever 
 about the latter part of January, which went on for some time 
 without any particular symptom, except considerable restlessness 
 and nervous excitement. He then became perfectly sleepless, 
 complained of violent headache and thirst, raved, and became 
 exceedingly irritable. Opium, in various forms and repeated 
 doses, either alone or combined with musk and camphor, totally 
 failed in producing sleep, and his condition became daily worse. 
 On the thirteenth day he was in a very dangerous condition ; his 
 nervous agitation had risen to an alarming height, and for many 
 days and nights he had never closed an eye. At this period it 
 appeared obvious that if something were not done to calm 
 nervous excitement and restore sleep, he had but little chance of 
 life. Under these circumstances I proposed to Dr. M'Adam, 
 who attended with me, to give tartar emetic and opium. After 
 he had taken about three tablespoonfuls, he had a copious 
 bilious evacuation, and immediately afterwards fell into a sound 
 sleep, during which he perspired profusely, and awoke in about 
 twelve hours with every bad symptom gone. The nervous 
 irritability was completely allayed ; his thirst and headache 
 relieved ; his tongue moist and cleaning ; and his reason quite 
 restored. From that period everything went on favourably, and 
 he rapidly gained his health and strength. 
 
 In many other cases of fever I have recently employed the 
 tartar emetic and opium with the same remarkable success. A 
 man named Christopher Nowlan was admitted into Sir Patrick 
 Dun's Hospital, on the 3rd of February, labouring under fever.
 
 246 CLINICAL MEDICINE. 
 
 He had been ill ten days, had raying, subsultus tendinum, and 
 appeared unable or unwilling to answer questions. His wife 
 stated that he had diarrhoea for the preceding three days, and 
 that he dozed occasionally, but never slept. He appeared exceed- 
 ingly low and prostrated, and lay constantly on his back. A 
 succession of flying blisters was ordered to be applied to the 
 chest and stomach, and wine and chicken broth prescribed. He 
 also got the following draught every third hour : — 
 
 R. Misturte Camphorse, f5J. 
 
 Spiritus iEtlieris oleosis, £588. 
 Spiritus Ammoniae aromatici, f5ss. 
 Moschi, gr. viij. — Misce. 
 
 Under the use of these remedies he began to recover from his 
 prostration ; but as the sleeplessness and delirium still continued, 
 I ordered him to take the tartar emetic mixture in the usual 
 Avay. It produced at first two or three full discharges from the 
 bowels, and after he had taken the fourth dose he fell into a 
 sound sleej), from which he awoke much better, and soon became 
 convalescent. 
 
 In the case of a patient named Michael Murray, who exhibited 
 the same remarkable nervous irritability and sleeplessness, this 
 remedy was also employed with very striking effects. This man 
 had been ill of fever for ten days before his admission into Sir 
 Patrick Dun's Hospital, and appeared so much prostrated that I 
 ordered him arrowroot with beer. He raved a little on the night 
 of his admission, and remained without closing an eye until 
 morning. The same symptoms were observed on the following 
 day, and his nervous irritability became increased. On the 14th 
 of February he had been five days in the hospital, and had not 
 enjoyed a single hour's sleep. I ordered the tartar emetic 
 mixture to be given : three doses produced sleep ; he had no 
 other bad symptoms, and recovered completely. 
 
 In another very bad case of maculated fever, the same results 
 were obtained. The patient, Mary Farmin, had got an attack af 
 fever after a fright. She had been eight days ill at the date 
 of her admission, February 25th. She had irregular pulse, 
 sleeplessness, headache, and suffusion of the ej^es ; moaned and 
 sighed continually, and appeared greatly prostrated. She was 
 blistered, had foetid enemata, and took the chloride of soda
 
 TATtT.m EMETIC AND OPIUM IN FEVER. 247 
 
 internally with some benefit ; but the sleeplessness and nervous 
 excitement continued. In this case, though the tartar emetic 
 was not followed by speedy convalescence, still it produced 
 remarkably good effects ; after taking four doses of it, she fell 
 asleep, and did not awake until next morning. 
 
 Several other cases have occurred both in hospital and private 
 jH-actice, to some of which I now beg leave to direct your 
 attention, observing that I have in every instance been particular 
 in mentioning the names of other professional gentlemen who 
 witnessed the progress of each case : a precaution tending to 
 prevent exaggeration either in detailing symptoms or describing 
 the effects of remedies. 
 
 The case of Mr. William Murphy, an extremely diligent and 
 intelligent pupil at the Meath Hospital, is well worthy of notice. 
 The father of this gentleman, a practitioner of well known 
 reputation at Fermoy, where he has been Physician to the Fever 
 Hospital for many years, arrived in Dublin the very day his son's 
 state appeared to be hopeless, soon after the consultation, when 
 Dr. Stokes and I agreed to use the tartar emetic and opium ; 
 Dr. Murphy admitted afterwards that he never felt so much 
 surprised as he was at this treatment, but having entrusted the 
 care of his son to us, he very properly expressed no opinion on 
 the subject, a mode of proceeding he has never since ceased to 
 congratulate himself on, for had he opposed us, the case was 
 apparently so desperate, that it may be doubted whether we would 
 have ventured to put the plan into execution. 
 
 Mr. Murphy, aged 20, having been engaged in the diligent 
 study of the fever cases in the Meath Hospital, was attacked with 
 violent symptoms of fever on the 6th of January last. He took 
 a dose of calomel and James's powder, and went to bed ; early 
 next morning he was worse, and although he took a purgative 
 draught which operated freely on the bowels, he complained 
 much of headache, and was very feverish ; a copious sweat broke 
 out, but was unattended with relief, notwithstanding that it 
 continued with more or less interruption for several days. His 
 thirst was excessive, and he was very restless, depressed, weak, 
 and nervous ; the autimonial powder and calomel were persevered 
 in during the second day, and on the third he took more 
 purgative mixture, and twelve leeches were applied to the 
 temples, but they gave little or no relief to the pain in the head.
 
 248 CLINICAL MEDICINE. 
 
 In short, he grew worse, and was found to he extremely 
 prostrated. On the fourth, his tongue was foul and dry, his 
 stomach irritahle, often rejecting his medicine, and producing a 
 vomiting of bilious matter, the pulse quick, and his appearance 
 unpromising. I saw him on the fifth day, when everything was 
 still worse, and the pain of head much complained of. I directed 
 a continuation of the James's powder, and effervescing draughts. 
 On the sixth day he was still worse, and was reported to have 
 raved a good deal during the night ; his bowels were loose, and 
 now for the first time the perspiration entirely ceased, and his 
 skin became hot and dry. I gave him small doses of Dover's 
 powder and chalk. On the seventh day, his countenance 
 expressed great anxiety, and in addition to an aggravation of all 
 the other symptoms, his skin became covered with a measles-like 
 eruption of maculae, a circumstance which induced me to give the 
 solution of chloride of soda, in doses of twelve drops every fourth 
 hour, in an ounce of camphor mixture. He got mild diet, as 
 arrowroot and chicken broth, with a little stale bread sopped in 
 tea, night and morning. On the eighth day, no improvement; 
 much raving during the night, symptoms as before, except that 
 the occurrence of some abdominal tympanitis and slight epigastric 
 tenderness induced me to apply six leeches to the pit of the 
 stomach. The bleeding from the leech-bites was moderate, but 
 seemed, nevertheless, to exhaust him. It seemed to check the 
 tympanitic tendency. On the ninth day, was still worse, much 
 stupor, incipient subsultus ; towards evening a very hurried and 
 laboured breathing supervened, and he lay entirely on his back, 
 helpless and weak, respiring about 45 times in a minute. As he 
 had not the slightest affection of the lungs or bronchial tubes, this 
 hurried breathing excited the greatest alarm in my mind, and 
 induced me to apply six leeches behind the ear, with a view of 
 relieving the now increasing stupor, and the evident cerebral 
 congestion. 
 
 On the tenth day, I had the benefit of Dr. Stokes' advice. 
 We found our patient in a state truly appalling. He lay panting 
 on his back, restless and without sleep, every muscular fibre in 
 his face and limbs was agitated with spasmodic twitches, giving 
 rise to the greatest possible degree of subsultus, which distorted 
 his face, caused him to bite his under lip every instant, rendered 
 him quite unable to put out his tongue, although he endeavoured
 
 TART.VR EMETIC AND OPIUM IN FEVER. '249 
 
 to do SO. The subsultus prevented ns from being able to feel 
 the pulse, now weak and rapid, at the wrist. In the meantime, 
 though he often moaned and raved, he muttered indistinctly ; he 
 evidently understood what Avas said to him, and as far as we could 
 collect, he seemed to suffer much less from pain in his head. 
 Still the temporal arteries were turgid, and his eyes suffused. 
 He had retention of urine, and since yesterday it was drawn off 
 with the catheter. 
 
 What was now to be done ? Cold lotions to the shaved head 
 had failed — a blister to the nape of the neck had proved useless — 
 we could not venture to rely on more blistering of the scalp — 
 some more powerful remedy must be instantly brought to bear, 
 or our patient was lost. Alvine evacuations had been pushed to 
 the fullest extent ; leeches could not even be proposed, so great 
 was the debility. Opium we dared not venture on, seeing that 
 so recently the pain in his head had been urgent, and that the 
 temporal arteries and the conjunctiva still seemed to indicate 
 cerebral congestion ; under these circumstances we resolved to 
 try tartar emetic, and we ordered the following mixture : — 
 
 R. Tartari Emetici, gr. ij. 
 Moschi, gr, xxx. 
 Mucilaginis, 
 
 Sjrupi simplicis, aa. f5J. 
 Aquae, fjx. 
 Misce, sumat 5ss. omni hora. 
 
 After he had taken about six doses of this medicine, he 
 seemed rather better, and the symptoms of determination to the 
 head appeared less marked ; we therefore added fifteen minims 
 of patent black drop to the remaining nine ounces of the mixture, 
 and directed small quantities of porter and chicken broth to be 
 given repeatedly during the night. On the eleventh day we found 
 a change for the better truly surprising, the pulse had diminished 
 remarkably in frequency, and had become softer and fuller ; a 
 warm sweat had broken out, he had raved but little, and had 
 slept tranquilly. "We ordered a continuance of the same nourish- 
 ment and medicines, the latter at much longer intervals ; the 
 case need not further be detailed, as Mr. Murphy rapidly recovered, 
 and enjoyed a speedy convalescence. Here then is a case which 
 would assuredly have been lost but for the well-tried application
 
 250 CLINICAL MEDICINE. 
 
 of the new method of treatment. I say this emphatically, for 
 Mr. Glyssan, Mr. Boy ton, Mr. Clarke, and Dr. Murphy, all 
 anxious and competent observers, assured us that from the 
 moment he began the bottle, its good effects were apparent, and 
 increased after each dose. 
 
 The next case I shall mention is that of John Doyle, admitted 
 into the Meath Hospital, May 21st, 1835 ; three or four days 
 ill, a strong young man ; the symptoms were attended with con- 
 siderable reaction at the beginning, his face being flushed, eyes 
 wild, and head aching ; he raved much during the night from 
 the fourth day, and had then a full bounding pulse at 105. 
 Venesection was ordered, but he fainted when four ounces of blood 
 had been drawn. Leeches were then applied to the epigastrium. 
 On the sixth day of his illness, his thirst was great, no sleep, 
 skin moist, belly soft, pulse 120, pain in head severe, copious 
 eruption of maculte. His head was now shaved, and six leeches 
 applied behind the ear, and repeated three times. He was 
 ordered the liquor of the chloride of soda on the seventh day, as 
 the vascular excitement had then diminished, and the maculae 
 constituted a prominent feature in his case. On the eighth day 
 he was not worse, but his skin was very hot. On the ninth day, 
 eyes suffused, face flushed, much thirst, no sleep, bowels free, 
 belly soft, some epigastric tenderness, tongue loaded, but moist : 
 cold lotions to the head. Tenth day, delirium violent during the 
 night, strait waistcoat necessary, eyes suffused, belly soft, skin 
 very hot, pulse 120, respirations 40, considerable subsultus. Six 
 leeches to be applied behind the ear three times successively. 
 
 R. Tartari Emetici, gr. iv. 
 
 Aquae, f5xvj. Misce, sumat semiunciam omni hora. 
 
 Eleventh, slept very little, delirium less violent, one very 
 large stool, heat of skin less, eruption copious. 
 
 R. Misturfe Camplioras, fjviij. 
 Tartari Emetici, gr. iv. 
 Tincturie Opii, f5j. 
 Misce, sumat 5ss. secunda quaque hora. 
 
 Twelfth, slept five hours, seems better, but still he passes 
 his stools under him ; pulse 120, eyes suffused, skin hot, tongue 
 cleaning, belly soft, bowels loose, maculse numerous. The same
 
 TARTAR EMETIC AND OPIUM IN FEVER. 251 
 
 prescription, except that the tincture of opium was increased 
 to siss. in the eight ounce mixture. 
 
 Thirteenth, the medicine was continued for several hours, 
 when he fell asleep, and slept so much and so tranquilly, that it 
 was not thought necessary to repeat it. Pulse 110 ; suhsultus 
 not near so violent ; does not rave ; knows every one, and answers 
 rationally ; light nourishment. 
 
 Fourteenth and fifteenth, improvement continues, hut still 
 there is much fever, and many maculae. About the twenty-first 
 day he was free from fever, but he got no medicine after the 
 night of the twelfth. 
 
 This case exemplifies the treatment adapted to the three 
 difterent stages — 1st, Bleeding, leeches, cold lotions : 2nd, Tar- 
 tar emetic in large doses, combined with leeching : 3rd, Opium 
 boldly administered in combination with tartar emetic. 
 
 The following, communicated by Mr. Knott, excited much 
 interest among the practitioners of the neighbourhood : — 
 
 " On the 20th of July last, I was called to see a comfortable 
 farmer, residing near Boyle, in the county Eoscommon, named 
 J. K. He was aged 30 years, and had been ill twenty-one 
 days. His fever commenced with rigor, headache, and pains in 
 the loins, the headache being particularly severe. In the com- 
 mencement of the fever he had raved incessantly ; slept but little ; 
 had frequent retching ; his bowels were confined. For these 
 symptoms, he was purged with black bottle to excess, and bled 
 largely and frequently, but without any permanent alleviation. 
 On the twenty-first day of his fever he presented the following 
 appearance and symptoms : — his countenance was expressive of 
 great anxiety and ferocity ; his eyes were bloodshot and wild ; 
 teeth covered with eordes ; tongue brown and furrowed with 
 clefts ; he raved violently, and attempted to get out of the bed 
 several times ; great excitement and suhsultus ; his skin was 
 very hot and dry ; all the secretions much diminished ; urine 
 high coloured ; no eruption ; no epigastric tenderness ; abdomen 
 slightly swollen and tympanitic, but pressure seemed to give no 
 pain ; his bowels had not been open for three days. That night 
 he was ordered 40 drops of the tincture of opium, at the same 
 time that an enema was exhibited ; the bowels were once opened ; 
 he slept none during the night, and the excitement was, if any- 
 thing, greater than before. Under these circumstances it was
 
 252 CLINICAL MEDICINE. 
 
 thought advisable to administer the tartar emetic and opium, in 
 the manner I had Been it exhibited whilst acting as clinical clerk 
 under Dr. Graves, in the Meath Hospital. He got an ounce 
 of a mixture, consisting of eight ounces of camphor mixture, four 
 grains of tartar emetic, and a drachm of laudanum every second 
 hour, and after he had taken the third dose he had a large watery 
 evacuation ; after he had taken the fourth dose he fell into a calm 
 sleep, in which he continued for nearly twelve hours ; he awoke 
 much refreshed and covered with a profuse perspiration. He 
 was able now to recognise his friends ; the subsultus and general 
 excitement were greatly, but not entirely allayed ; his pulse, 
 which had been 120, small and wiry, had fallen to 98 ; he 
 continued his medicine during the next night with the greatest 
 benefit. From this period this man's recovery was rapid and 
 unexpected, and at the end of three weeks he was able to attend 
 to his business." 
 
 The next case was reported by one of the pupils of the hospital. 
 Ellen Dowden, aged 18, admitted into the Meath Hospital 
 on the 8th of June ; states that she has been ill twelve days. 
 Her illness commenced with the usual symptoms, headache, 
 rigor, loss of rest and appetite : previously to her admission she 
 had been purged freely without any relief. On the day of her 
 admission she was flushed ; skin dry and very hot ; the whole 
 body was covered with maculne ; she was heavy and stupid ; 
 answered questions incoherently; her eyes were slightly suffused; 
 she called out continually for drink ; her tongue was dry, brown, ' 
 and rough ; seemed to have much pain on making pressure on 
 the epigastrium ; the belly was swelled and tympanitic ; bowels 
 confined; no cough or headache; pulse 108, wiry; eight leeches 
 to be applied to the epigastrium ; head to be shaved and cold 
 lotion applied. 
 
 R. Hydrargyri cum Creta, gr. x. 
 
 Pulveris Ipecacuanba3 compositi, gr. ij. 
 
 Misce ; fiant pulveres quatuor, in die sumendi. 
 
 9th. — Much worse to-day ; slept for about one hour yesterday 
 evening ; lies continually on her back ; seems to take notice of 
 what is going on about her ; raved occasionally during the night ; 
 teeth and mouth covered with sordes ; tongue very dry, rough, 
 and coated with brown ; pulse fallen to 80, very small, but less
 
 TARTAR EMETIC AND OPIUM IN FEVER. 253 
 
 wiry than on yesterday; epigastric tenderness much relieved, 
 headache gone, macuhiB less. 
 
 To have a pint of heer and arrowroot. 
 
 R. Solutionis Chloridi Sodae, min. xv, 
 MisturfB Campborte, fjj. 
 Guttfe nigra3, min. j. 
 Misce, fiat haustus quater in die sumendus. 
 
 10th. — Raved the whole night ; suhsultus general and violent ; 
 pulse 120, sharp ; slightly dicrotous ; slept none ; face much 
 more flushed than on yesterday ; eyes suffused ; passes under 
 her ; maculte much diminished ; has no headache ; bowels rather 
 free ; lies on her hack with her feet drawn up ; has no chest 
 symptoms ; respiration natural ; ordered ioe in bladders to the 
 head ; with a mixture composed as follows : — 
 
 R. Misturae C amphorae, fjviij. 
 Tartari Emetici, gr. j. 
 Misce, sumat fjss. omni semihora. 
 
 11th. — When seen yesterday evening she was very violent ; 
 endeavoured to get out of bed ; screamed loudly, and complained 
 of bad treatment ; she had slept none at this period, her bowels 
 had been freed copiously, but she still continues to pass under 
 her ; she endeavours to throw the ice bags ofl' her head, and 
 requires some violence to hold her in bed ; suhsultus extremely 
 violent ; face much flushed ; eyes red ; she was ordered the 
 following : — 
 
 R. IVIisturse Camphorae, fjviij. 
 Tartari Emetici, gr. iv. 
 Tinctura3 Opii, f5J. 
 Misce, sumat fjss. secundis horis. 
 
 She had taken but two tablespoonfuls when she began to sleep ; 
 she has continued to doze to the hour of visit ; she is much 
 improved in every respect ; she answers questions rationally ; 
 her face is not so much flushed ; eyes less suffused ; has no 
 headache ; pulse 120, not so sharp ; skin still very hot ; tongue 
 moist and cleaning. She was ordered not to take any of the 
 mixture if she continues better. Enema emolliens statim. 
 Improvement went on steadily until convalescence was established.
 
 254 CLINICAL MEDICINE. 
 
 The next case I read from the report of Dr. Dwyer, who was 
 the physician in attendance : — " In compliance with your request, 
 I send you an abstract of the case of Stephens. It was one of 
 spotted fever occurring in a young man of temperate habits, 
 setting in with languor followed by rigor. I saw him on the 
 fourth day, when there was unpleasant heat of surface, with 
 general tenderness all over the body, particularly remarkable over 
 the epigastric region ; the chest, arms, and hands studded with 
 florid maculae ; headache and pain of back distressing ; light 
 disagreeable ; pulse 108 ; tongue moist. He had an oil draught, 
 followed by small doses of hydrargyrum cum creta with Dover's 
 powder. On the sixth day of his fever, being very restless and 
 sleepless, eyes slightly suffused, and pulse 120, I gave him an 
 eight ounce mixture, containing four grains of tartar emetic, and 
 a drachm of tincture of opium ; two tablespoonfuls to be taken in 
 the evening, and one every hour afterwards. On the next day 
 the report was, that he had slept a good deal during the night, 
 having fallen asleep after the third dose, three hours after which 
 a fourth was administered. He is dozing, pulse 120, skin hot and 
 dry, bowels four times moved ; ordered to continue his mixture ; 
 watching its effects. On the eighth day, in consequence of severe 
 purging having set in (he had taken but two doses of the mixture 
 since last report), the epigastrium becoming very tender, and 
 pulse 132, his medicine was omitted and a cretaceous mixture 
 ordered instead, a small quantity of port wine diluted, and a 
 blister to the abdomen ; the blister was not applied, yet the 
 purging was checked. On the evening of the ninth day, as he 
 complained much of want of rest, and there was no headache, 
 I directed him to have two doses of the tartar emetic and opium 
 mixture, within an interval of two hours. 
 
 "I was compelled at this period to give up attendance on this 
 case in consequence of an accident ; it was, however, taken up by 
 Dr. Grant, who kindly kept notes, and with whom I had daily 
 conferences. He reports our patient on the tenth day to have 
 suffered an accession of fever, seemingly caused by abdominal 
 irritation ; he complained much of headache ; the eyes were 
 injected ; skin hot and dry ; tongue brown and crisp ; pulse 144 ; 
 respiration 49 ; throbbing of the temporal arteries ; when undis- 
 turbed, raving and moaning, but answers rationally; abdomen 
 full and tense, tenderness in region of colon, with some tenesmus;
 
 TAETAR EMETIC AND OPIUM IN FEVER. 255 
 
 sleeplessness. He was given four grains of calomel and three of 
 extract of byoscyamus, followed by an oil draught ; a blister was 
 applied to the abdomen, cold to the head, and warmth to the feet. 
 The medicine acted well, producing a number of dark-coloured 
 motions, with some relief of the symptoms ; the sleeplessness, 
 however, still continuing. On the twelfth, raved considerably the 
 previous night, with great restlessness ; headache with darting 
 pain ; pulse 120 ; still answers rationally, but raves when left 
 to himself ; abdomen soft ; he was again put on the use of the 
 tartar emetic and opium mixture, to have one tablespoonful every 
 hour for three doses, and then only every second hour. On the 
 following day there was a considerable improvement ; he liad 
 slept well, and perspired freely in the night ; no raving ; head- 
 ache had gone ; pulse 96 ; heat of skin less ; to continue his 
 mixture. On the fourteenth day he was much better; he wished 
 for food. On the fifteenth he suffered a relapse, from his appetite 
 having been imprudently indulged ; he was given an oil draught, 
 and directed to resume his mixture when the bowels acted. He 
 continued from this time to improve, the interval between the 
 doses of his mixture was gradually lengthened, and on the 
 seventeenth day he was convalescent. 
 
 " In this case the good efiects of this mixture were evidenced 
 by perspiration and rest. This lad's mother and sister were just 
 convalescent from spotted fever ; the former four weeks, the 
 latter a fortnight. In the mother's case I was not applied to till 
 the tenth day ; it went on till the twenty-first. There was not 
 any organ particularly implicated ; she was treated with stimu- 
 lants, carbonate of ammonia, porter, and blisters. In the 
 daughter the fever was very severe to the eleventh day, when 
 it terminated by profuse perspiration. She suifered prin- 
 cipally from pain in her head and back, with intolerance of 
 light, and was treated with mild aperients, followed by 
 diaphoretics with byoscyamus. In neither was sleeplessness 
 distressingly remarkable. Another brother was seized with the 
 same form of fever a few days after the subject of this case had 
 taken ill ; he was on the fifth day transferred to Sir Patrick 
 Dun's Hospital. 
 
 " I experienced marked benefit from this form of prescription 
 in a case of melancholia, occurring in a female aged 45, con- 
 sequent on a severe domestic affliction. The exhibition of it
 
 256 CLINICAL MEDICINE. 
 
 here, however, was followed by considerable debility, requiring 
 stimulants. This effect I consider to have been, in some degree 
 at least, attributable to the patient having for some days previous 
 to its exhibition refused food, and possibly been suffered to 
 remain too long under the sedative influence of this medicine 
 without having been offered nourishment." 
 
 The following is also an interesting example of the efficacy of 
 this plan of treatment : — 
 
 John Dillon, aged 15, a servant, admitted into hospital, 5th 
 June, 1835, several days ill. On the day of his admission he 
 had headache, thirst, heat of skin, loss of appetite and rest ; 
 his face was flushed and bloated ; eyes suffused, red and promi- 
 nent ; skin hot and dry. He complained of slight epigastric 
 tenderness and violent headache ; pulse 120, full and bounding. 
 His whole body was covered with maculae ; bowels regular, 
 tongue brown, furred, and dry. Ordered 
 
 R. Aquge, fjj. 
 
 Liquoris Chloridi Sodae, min. x. 
 Misce, fiat haustus quartis horis sumendus. 
 Applicentur hirudines xii. post aurem, et repetatur applicatio 
 si opus sit. 
 
 7th. — The leeches bled freely; head appears to be relieved; 
 he raved a good deal during the night ; his pulse has fallen to 
 100, but still very full ; has a slight cough, and some bronchitis. 
 Ordered to repeat the draught, and apply four leeches to the 
 larynx. 
 
 8th. — Slept very little ; does not appear improved ; very 
 irritable ; raved, and was rather violent during the night ; cough 
 better; tongue very brown and dry; bowels confined; pulse 100; 
 respirations rather hurried. Ordered to repeat the draught, and 
 to have an emollient enema in the evening. 
 
 9th. — Epigastric tenderness much increased ; raved continually 
 during the night ; slight subsultus ; eyes very red, wild and 
 staring; pulse 114, very full; tongue dry and brown; teeth 
 covered with sordes. To repeat the draughts, and apply eight 
 leeches to the epigastrium. 
 
 10th. — Appears better to-day; epigastric tenderness much 
 relieved by the leeching; his strength is much prostrated;
 
 TARTAE EMETIC AND OPIUM IN FE\'ER. 257 
 
 wishes for more food ; pulse 100, and still full ; slept none. 
 Ordered arrowroot, and to repeat the draughts. 
 
 11th. — The fever is again much increased; raved violently 
 during the night ; great prostration ; slept none ; subsultus very 
 violent ; great thirst ; pulse 130 ; complains of a heaviness, hut 
 no pain in head; skin very hot and dry; eruption undiminished. 
 Ordered to repeat as before. 
 
 12th. — All the symptoms much aggravated ; face flushed and 
 red ; eyes suffused and ferrety ; teeth covered with sordes ; lips 
 parched and cracked ; tongue black and very dry ; subsultus 
 general and violent ; does not sleep either by night or day ; 
 exceedingly irritable ; pulse 130 and jerking ; pupils contracted ; 
 he lies on his back with legs drawn up ; extremities rather cold. 
 He was ordered warm applications to his feet and the following 
 prescription : — 
 
 R. Tartari Emetici, gr, ij. 
 Misturas Camphoras, f^viij. 
 Tincturae Opii, f3ij. 
 Misce, sumat cochleare unum amplum secunda quaque hora. 
 
 13th. — The nurse reported that after he had taken the 
 mixture three times, he slept calmly for nine or ten hours, the 
 first time for the last week. It operated largely after the second 
 dose, the stools being thin and bilious. He has ceased to rave ; 
 the suff'usion has quite disappeared ; tongue is moist and clean- 
 ing. He slumbers continually ; subsultus completely subdued ; 
 answers questions rationally ; pulse has fallen to 98 and soft ; 
 ordered to repeat the mixture. 
 
 14th. — Slept continually since last report ; general appearance 
 much improved ; perspired profusely during the night. He was 
 perfectly sensible from this day till the 17th. He continued to 
 improve rapidly in strength and appearance. 
 
 17th. — Convalescent. 
 
 And with one more case I shall conclude for to-day. Mr. 
 S., residing in College, was attacked with headache on the 
 3rd February, 1836, and fever commenced on that or the follow- 
 ing day. He was judiciously treated by Mr. Barker, of Britain 
 Street, until the fourth day of the fever, when an increase of 
 headache and pain in or behind the ball of the right eye induced 
 him to call me in. A bleeding from the arm much relieved 
 VOL. I. 17
 
 258 CLINICAL MEDICINE. 
 
 the pain, and he spent a tranquil night. He got calomel and 
 James's powder in small doses. On the fifth no change. Sixth 
 day of fever, maculte began to appear, and his state became more 
 alarming. Seventh day, maculae abundant, restlessness, debility, 
 very frequent sighing, thirst, &c., with a sharp pulse, and return 
 of headache. Leeches to head and nostrils were ordered ; the 
 latter because of an evident tendency to epistaxis. Eighth, Sir 
 Henry Marsh saw him along with us. Ninth and tenth, grain 
 doses of Dover's powder added to his medicine four times in the 
 night, but did not procure rest. 
 
 Eleventh, perfectly sleepless night and day ; ordered in the 
 evening one grain of tartar emetic, four ounces of camphor 
 mixture,, and one scruple of laudanum : one tablespoonful every 
 second hour. Twelfth, moisture on skin ; began to sleep after 
 second dose, and slept several hours tranquilly ; is to-day quite 
 free from muttering and raving, which had commenced on the 
 tenth day, and increased on the eleventh ; so that when left to 
 himself he lay on his back, constantly speaking, but not in a 
 loud or boisterous manner, his eyes being all the time open ; 
 when addressed he answered quite rationally, but on our quitting 
 the room began again immediately to ramble. This group of 
 unpleasant symptoms having disappeared, we did not continue 
 the medicine, but ordered palliatives and mild nourishment ; in 
 the evening it was judged right to apply a blister to the nape of 
 the neck. Thirteenth day, maculge abundant ; was quiet during 
 the night, but did not sleep at all ; exhausted and nervous ; 
 other symptoms moderate ; pulse 104 ; tongue moist ; abdomen 
 a little swollen and slightly tympanitic ; turpentine iDJections ; 
 palliative diuretic draughts ; chicken broth ; claret and water. 
 At five p.m. I again saw him, and found him still quite sleepless, 
 but without headache ; bowels moved, but still slightly tympan- 
 itic. Fearing the continued exhaustion from want of rest, I now 
 ordered a mixture consisting of one ounce of mucilage of gum 
 arable, seven ounces of camphor mixture, three grains of tartar 
 emetic, and one drachm by measure of laudanum ; half an ounce 
 every second hour, until sleej) comes on. 
 
 At ten. Sir Henry Marsh and Mr. Barker saw him ; he had 
 slept an hour ; appeared drowsy, and did not complain of head- 
 ache ; two doses of the medicine had been given ; he remained 
 awake until eleven, when another dose caused him to sleep until
 
 TARTAR EMETIC AND OPIUM IX FEVER. 259 
 
 three ; at four another was given, after which he slept until eight, 
 and awoke much refreshed, and much improved in every respect ; 
 his belly had not been moved, and was still slightly tympanitic, 
 a symptom which yielded to the administration of two drachms 
 of castor oil exhibited in the form of an aromatic emulsion. In 
 the evening he was ordered to take four drops of black drop, but 
 this procured no sleep during the night. On the morning of 
 the fifteenth day we found him somewhat exhausted from a 
 sleepless night, but with much less fever and no headache : 
 pulse 94, soft ; for the first time we remarked subsultus : a 
 family idiosyncrasy, rendering musk peculiarly disagreeable, or 
 even intolerable, we ordered a draught containing two drops of 
 black drop, and fifteen of Hoffman's liquor, every fourth hour. 
 In the evening he had slept very little, so that I resolved again 
 to recur to the antimonial opiate, two spoonfuls of which 
 produced sound refreshing sleep for several hours. In the 
 morning he again got castor oil ; and on this, the sixteenth day, 
 his pulse was only 70 ; but still, though the subsultus was 
 diminished, a remnant of it could be perceived, so that he could 
 not be pronounced out of all danger. 
 
 The conclusion of this case is peculiarly instructive, and proves 
 how insidious is the progress of fever, and how unsafe the con- 
 dition of a patient, whose brain and nervous system have received 
 a violent shock, even although the immediate consequences of 
 that shock have been averted by the employment of decided 
 treatment. On the sixteenth day we have seen an abatement, or 
 rather a disappearance of almost every symptom of the disease, 
 save and except a slight, a scarcely perceptible remnant of the 
 subsultus. Great care was taken to prevent his being disturbed, 
 and the strictest attention as to diet was enjoined ; indeed he 
 was remarkably disinclined to taking food, and it was with great 
 difficulty that we could get him to consume a sufficient quantity 
 of mild farinaceous diet. On the night of the sixteenth day he 
 slept tolerably. The seventeenth day was passed without any 
 change ; but he slept none that night. 
 
 The eighteenth day he was perfectly free from fever ; pulse 70 ; 
 tongue moist ; bowels opened by medicine. That day he con- 
 versed too much to his friends about his removal to the country, 
 his future plans, &c. ; but nevertheless he slept several hours 
 towards evening. This sleep was disturbed and chequered by
 
 260 CLINICAL MEDICINE. 
 
 dreams, and on awaking about eleven o'clock, be was wandering, 
 and got eigbt drops of black drop, wliicb procured no rest ; on tlie 
 contrary be got several times out of bed, and spoke incoberently. 
 Tbe raving bad all subsided at 10 a.m. on tbe nineteentb day, 
 wben I was in bopes it was entirely owing to temporary excite- 
 ment, and would not return ; an opinion rendered probable by a 
 total absence of all symptoms of general' or local vascular excite- 
 ment, of beadacbe, &c. In tbis expectation, bowever, I was 
 disappointed, for early in tbe afternoon be became incoberent ; 
 raved more and more every bour ; complained of beadacbe ; could 
 not bear tbe ligbt ; and wben I saw bim at seven, be was quite 
 irrational ; supposed bimself to be travelling ; and wben ques- 
 tioned be seemed not to understand ; bis pulse had fallen below 
 60 ; was soft, irregular, and intermitted very frequently ; skin 
 not hot ; feet cold ; features contracted ; tip of nose cold ; be bad 
 eaten stirabout in small quantity twice during the day, but in 
 a voracious unnatural manner ; his eyes were a little red, and 
 everything wore a most threatening aspect. 
 
 What was now to be done ? In directing his head to be shaved 
 anew, and in applying blisters to his scalp and temples, I felt I 
 was proceeding on sure grounds ; but tbe indications for the 
 internal treatment were less obvious. We had arrived at the 
 nineteenth day, and be bad gone through a debilitating fever, and 
 bad been submitted to a very active mode of treatment. Were 
 we to leech the head ? were we to apply cold ? and should we 
 immediately endeavour to mercurialize tbe system by means of 
 mercurial preparations, given internally and applied externally ? 
 Such would have been the treatment a patient, under similar 
 circumstances, would have undergone at the hands of any prac- 
 titioner a very few years ago ; and I have no doubt that a 
 treatment of tbis nature would have speedily brought matters 
 to a fatal termination. 
 
 The writings of Gooch, however, who pointed out tbe diagnosis 
 and treatment of certain cases, usually confounded with inflam- 
 matory hydrocephalus, and the influence of tbe truth of Dr. 
 Gooch's statement, as illustrated by several examples in our own 
 practice, determined Sir Henry Marsh, Mr. Barker, and myself 
 to rely on the severe blistering locally, while internally we ordered 
 a draught consisting of two grains of carbonate of ammonia, 
 twenty drops of Hoffman's liquor, and one ounce of camphor
 
 TARTAR EMETIC AND ORIUM IN FEVER. 261 
 
 mixture, to be taken every third hour. Warmth was appKed to 
 the feet, and he was supplied with warm whey. Shortly after 
 our visit he fell asleep, slept with little interruption for about 
 seven hours, and awoke perfectly rational ; and at eight o'clock 
 next morning, being the twentieth day, we found him much 
 better in every respect ; the only vestige of this alarming attack 
 that remained being some intermission in the pulse, which had 
 become in other respects much more natural and fuller. The 
 bowels had not been opened ; a circumstance I mention because, 
 no doubt, some would have ordered purgatives on such an 
 emergency, a practice which the fallen, soft state of the belly 
 did not seem to us to call for, and which our view of the nature 
 of the case prevented us from proposing. We ordered farinaceous 
 diet, and a repetition of the draughts, at longer intervals. In the 
 evening of the twenty-first day the pulse had lost all remnant of 
 irregularity or intermission, and the disturbance of the nervous 
 system had entirely subsided : from that period his convalescence 
 commenced. 
 
 One fact connected with the cases just related is very striking, 
 viz., the small quantity of laudanum which, in most of them, was 
 sufficient to induce sleep ; a circumstance only to be accounted 
 for by the presence of the tartar emetic, which no doubt exerts, 
 when given in duly regulated doses, a powerfully tranquillizing 
 effect on the nervous system. It is also deserving of remark, 
 that the combination very seldom gives rise to any of the un- 
 pleasant symptoms that so frequently arise when opium alone, 
 or any of its preparations, are given with a view of producing 
 sleep at an advanced period of fever. The addition of one ounce 
 of mucilage, and one ounce of simple sjTup to the mixture, 
 seems to render it less likely to disagree with the stomach. 
 Towards the termination of fever, it not unfrequently happens 
 that a sudden or gradual determination of blood to the head 
 arises, and which requires a repetition of a modified system of 
 antiphlogistic treatment, aided by blisters. This state, I have 
 reason to believe, may be often prevented from occurring by a 
 timely attention to procuring sleep ; for a patient in fever, who 
 has passed several sleepless nights, is on the verge of cerebral 
 congestion or inflammation, as is testified by headache, wan- 
 dering, and the redness of the conjunctiva. Here it is that the 
 treatment I recommend is so advantageous, when timely applied ;
 
 262 CLINICAL MEDICINE. 
 
 for if it be deferred until cerebral inflammation has set in, opium 
 in any shape is worse than useless. 
 
 The particular state of the nervous system to which this com- 
 bination of remedies is best adapted, may occur along with other 
 symptoms produced by functional or organic lesions of various 
 organs, and which prevent it from producing the wished-for 
 beneficial result. Thus, when the belly is tense and swollen, 
 this remedy will generally fail ; but I think that I am warranted 
 in asserting that in fevers, properly treated from the first, 
 tympanitis may commence, but will never become considerable ; 
 for if the attention of the practitioner be applied to this symptom, 
 the moment it begins to show itself, he can in most cases succeed 
 in arresting its progress. I have likewise seen several cases of 
 fever, where I expected benefit from the tartar emetic and opium, 
 and in which no good result followed the exhibition of these 
 medicines ; such failures must always occur with respect to 
 every remedy we apply in disease, but they do not invalidate the 
 evidence of facts, such as I have brought forward in proof of 
 their frequent utility. 
 
 In connexion with this subject, I beg leave to draw your 
 attention to the occurrence of delirium traumaticum in fevers, 
 in consequence of the irritation produced by blisters, a species 
 of delirium apt to be mistaken, especially in children, for the 
 delirium ushering in hydrocephalus. I shall not do more now 
 than advert to this subject. 
 
 Before concluding, it is right to remark that the relative 
 proportions of tartar emetic and laudanum in the mixture must 
 be varied according to circumstances. When congestion of the 
 brain is known to exist, or is feared, the tartar emetic must not 
 fall short of four grains in the eight ounces, while the laudanum 
 should not exceed half a drachm ; but where nervous symptoms 
 predominate, the laudanum may amount to one drachm, and 
 the tartar emetic to two grains : no general rule, however, 
 can be laid down, and the 'practitioner must in all cases luatch 
 the effects of this medicine, from hour to hour, until he ascertain 
 whether it agrees with the patient or not. Where a life is at 
 stake, we must spare no pains, and must not reject a remedy 
 because its powers render it an instrument of good or evil, 
 according as it is administered carefully or otherwise.
 
 263 
 
 LECTURE XVIII, 
 
 MACULATED FEVER. — TARTAR EMETIC IN LARGE DOSES IN THE 
 ADVANCED STAGES OF MALIGNANT FEVER. 
 
 When I last addressed you, I spoke of a very important topic — 
 the administration of tartar emetic and opium, in the advanced 
 stages of spotted or maculated fever. A few observations de- 
 scriptive of the present epidemic fever,* appear necessary. The 
 commencement is frequently by no means violent in proportion 
 to the subsequent danger, and the patient often appears merely 
 to labour under the symptoms of a common feverish cold, seldom 
 preceded by violent rigors, but attended by a frequently 
 recurring sense of horripilation. The pulse in the very begin- 
 ning seldom exceeds 90, and in nearly half the cases it falls 
 after a few days to 80, 70, or even lower. This slow pulse I 
 observed in many of the pupils, and in all it was found to 
 accompany a very tedious and dangerous form of fever. Mr. 
 Sangster, Mr. Graves, Mr. Harris, and Mr. 'Flaherty, were 
 all so affected ; for none of these gentlemen had a pulse 
 exceeding 70 in a minute, for many days before the period of the 
 greatest danger. In other epidemics similar cases have occasion- 
 ally occurred, but in none near so frequently as in the present. 
 When the pulse was thus tranquil, the skin was not perceptibly 
 hotter than natural, although occasionally a slight degree of the 
 calor mordax could be detected. 
 
 Patients with a slow pulse not unfrequently had little to 
 complain of at first ; for the headache, general pains, thirst, and 
 restlessness, generally underwent a notable diminution, in con- 
 sequence of sweating, which came on in the commencement — 
 the appearance and the good effects of which were well calculated 
 to deceive the practitioner into a belief that the fever had 
 terminated. A more accurate examination, however, showed 
 that this was not the case ; for the tongue still continued much 
 
 * 1834—35.
 
 264 CLINICAL MEDICINE. 
 
 loaded, white in the centre and red at the tip, and the apparent 
 subsidence of the fever was found to be accompanied by a 
 remarkable increase of debility. As the disorder proceeded, 
 a slight rash, like ill-defined or suppressed measles, became 
 observable in some, before the fourth day, but much oftener about 
 the seventh. This maculated appearance of the skin increased 
 rapidly, spreading over all parts of the trunk and extremities, 
 and in many amounted to a well-marked efflorescence of a dusky 
 red colour ; in others it was as it were suppressed, and was less 
 obvious, but was still discernible by an experienced eye, appear- 
 ing beneath as if veiled by the skin. It was not totally absent 
 in one case out of twenty, which induced me to name the disease 
 maculated fever. 
 
 So the patient continued, in general, until the ninth, tenth, or 
 eleventh day, resting sufficiently at night, with a moderate or 
 even a slow pulse, some thirst, foul tongue, little or no nausea, 
 epigastric pain, or abdominal tenderness of any sort, and in fact 
 without a single symptom calculated to excite alarm. About 
 this period of the complaint matters began to assume a more 
 threatening aspect ; debility manifestly increased ; the mind at 
 times was evidently incoherent, particularly after awaking from 
 sleep, and then raving during the night ; restlessness — frequent 
 attempts to get out of bed very generally supervened in the 
 course of a few days. The pulse, meantime, rose very suddenly 
 in many, and continued to be frequent during the period of danger. 
 Thus, on the tenth day, Mr. Syms's pulse rose from 85 to 120, 
 and so continued until about the twentieth day, when improve- 
 ment commenced. The same sudden rising of the pulse took 
 place on the ninth day in Mr. M'Namara, and he died on the 
 fourteenth day. In others, as I have already remarked, the pulse 
 continued tranquil throughout. 
 
 Thus, it was very curious to see a patient with a skin of a 
 natural temperature, a perfectly natural pulse, tranquil respira- 
 tion, clear eye, no headache, a soft and fallen abdomen, without 
 the slightest tendency to epigastric tenderness : it was very 
 curious, I say, to see such a patient in a state, nevertheless, of 
 extreme danger, passing both feces and urine under him ; raving, 
 incoherent, or with a low muttering delirium; subsultus daily 
 increasing until it became excessive ; the greatest possible degree 
 of debility ; a dark macular efflorescence, and at length total
 
 MACULATED FEVEE. '2(35 
 
 sleeplessness. How many theories of fever were refuted by such 
 a case ! Usually, as the disease continued, and w^lien the patient 
 was in a very dangerous state — but seldom or never before that 
 — the intestines began to be inflated, and the belly gradually 
 became tympanitic ; a circumstance of bad omen, and which was 
 often the precursor of hiccup. 
 
 When the symptoms did not yield to the efforts of nature or 
 art, the congestion of the intestinal mucous membrane, indicated 
 by these symptoms, was soon followed by indubitable evidence 
 of cerebral congestion — such as restlessness, sufiusion of the 
 adnata, and contraction of the pupils ; this last was the most 
 fatal of all symptoms. In two or three cases — as, for instance, 
 that of Mr. Cooksou — the cerebral congestion produced repeated 
 fits of convulsions on the thirteenth day, and yet he recovered. 
 The same happened in a young woman in Sir P. Dun's Hospital, 
 in whom the convulsions occurred on the fifteenth day, and were 
 more violent on the right side than on the left, producing strabis- 
 mus, and insensibility of the pupil of the affected eye. This 
 girl lost the use of her left side on that day, but recovered it 
 on the following ; and eventually, though with difficulty, was 
 completely cured. Frequent fits of convulsions, afiecting the 
 right side more than the left, took place on the seventh day in 
 the daughter of a clergyman residing in the Liberty, and were 
 followed by a stupor bordering on coma, which lasted for many 
 hours. All these patients were covered with maculte. 
 
 There is one circumstance connected with this epidemic, 
 which I have also frequently witnessed in other sporadic and 
 epidemic fevers, to which I wish forcibly to draw your attention ; 
 it is the existence of tenderness generally over the body ; and 
 which causes the patient to shrink from the pressure of the 
 finger, applied to any part of the integuments. This tenderness 
 arises from an irritated state of the nervous system generally, 
 and is usually accompanied by severe dorsal or lumbar pain, 
 indicating spinal congestion. Now, in a practical point of view, 
 this tenderness requires attention ; for if it be overlooked, and 
 if the physician applies pressure, in such cases, only to the 
 epigastrium, he will be deceived into the belief that the tender- 
 ness he there discovers is confined to that part, and indicates 
 the application of leeches to the pit of the stomach. 
 
 I am thus particular in dwelling on the symptoms manifestly
 
 266 CLINICAL MEDICINE. 
 
 denoting a combination of primary general nervous excitement 
 with a secondary cerebral congestion ; for, on the successive 
 development of these states the treatment during the latter 
 stages hinged. I wish you clearly to understand, that, after the 
 headache and cerebral excitement which accompanied the very 
 commencement of the fever had been subdued, or had ceased, 
 after sleej) and calm had returned, and had continued for many 
 days, then a new order of things commenced — subsultus, watchful- 
 ness, muttering, raving, involuntary discharges, &c., all denoting 
 great derangement of the nervous system ; but still there was no 
 proof that this derangement depended on cerebral congestion. 
 
 After a few, or after many days, however, unequivocal 
 symptoms of the latter set in ; the face and eyes became suffused 
 and flushed ; the pupils manifested a tendency to become 
 contracted, and occasionally convulsions took place ; the j)atient 
 became also totally sleepless. When the latter and dangerous 
 period of the fever was accompanied by the former nervous group 
 of symptoms alone, they yielded to wine, musk, porter, and 
 opiates ; but when the symptoms indicating cerebral congestion 
 were superadded, then it was that the case assumed so great and 
 striking a similarity, so far as the functions of the nervous 
 system were concerned, to the well-known variety of delirium 
 tremens, accompanied by cerebral congestion, to which I before 
 referred — to that variety of delirium tremens, in fact, which only 
 can be successfully treated by the judicious, but bold exhibi- 
 tion of tartar emetic combined with laudanum. It is the 
 discovery of the utility of this 'practice in the advanced stages 
 of spotted fevers, that I claim peculiarly as my own ; for 
 there is not in the writings of any author on the subject the 
 slightest trace of such a method of treatment to be found. As 
 this method has manifestly saved many, many lives, under a 
 combination of circumstances apparently hopeless, I cannot 
 avoid congratulating myself upon being the first to propose a 
 practice which has not only diminished the rate of our hospital 
 mortality* in a remarkable manner, but has been the means of 
 
 * Seventy-three fever patients — namely, forty-one males, and thirty-two females — 
 were treated in the clinical wards at Sir P. Dun's Hospital during the months of 
 February, March, and April. Of these, more than fifty were cases of maculated or 
 spotted fever, and yet we lost but two females and one male. The latter was in a 
 hopeless condition when brought in, and one of the former was attacked by varioloid 
 just after the crisis of long-continued spotted fever.
 
 MACULATED FEVER. 267 
 
 saving many of my friends and pupils ; for without its adoption 
 our class at the Meath Hospital would have heen more than 
 decimated, whereas at present we have to regret the loss of but 
 one pupil. 
 
 One word more as to the circumstances under which this plan 
 was applicable. They were exactly the circumstances which 
 formerly would have been believed to demand the fresh appli- 
 cation of leeches to the head, of cold lotions, and of blisters ; 
 for it was formerly argued, and justly, we have in this advanced 
 stage of fever not merely debility to combat — not merely general 
 nervous excitement to overcome — but we have also to contend 
 with cerebral congestion. The latter is the most formidable of 
 the whole ; it was therefore said, let us meet it boldly ; let us 
 leech, let us purge, &c. ; but I need not repeat to you the details 
 of cases illustrating the ill effects of this practice. Suffice it to 
 remark, that you might as well attempt to cure delirium tremens 
 with mere leeching, purging, and blistering. Observe, I am 
 now speaking of the advanced stages of fever ; for where cerebral 
 congestion takes place in the beginning or the middle of fever, 
 then there is no room for opium — then will the practitioner have 
 recourse to the well-known remedies for active cerebral conges- 
 tion ; viz., purging, leeches, cold lotions, ice to the head, &c. 
 In the preceding sketch of the present epidemic, many important 
 features have been omitted. The outline is only complete in 
 such parts as were required to be filled up for the purpose of 
 illustrating the principles which directed me in devising and 
 employing this new plan of treatment. I cannot better illustrate 
 these principles and their results for you than by the details of 
 some additional cases ; and first let me call your attention to 
 that of Mr. Thomas O'Flaherty. 
 
 This young gentleman was seized with the usual symptoms 
 of maculated fever, of an insidious character, and not attended 
 with any appearance of danger during the commencement of the 
 disease. His pulse never rose above 1.00, and before the seven- 
 teenth day of the fever it had fallen to 70, at ivhich it remained 
 during the period of greatest danger. The only circumstance 
 which excited alarm in my mind, at an early period of his illness, 
 was a great degree of mental apprehension, manifested in his 
 anticipating an unfavourable result, together with a tendency 
 to sleeplessness from the beginning. On the tenth, abdominal
 
 2G8 CLINICAL MEDICINE. 
 
 tympanitis was observed, but this was removed in two days by 
 a^jpropriate remedies. On the twelfth day he was very restless, 
 and although he was perfectly rational in his answers to 
 questions, and did not complain of headache, had neither flush- 
 ing of face, nor heat of the integuments of the head, yet he 
 frequently talked incoherently when left alone, and towards the 
 latter part of the day began to make repeated attempts to get out 
 of bed. On one occasion he succeeded, and walked down stairs, 
 from his bedroom to the parlour. His tongue was brown and 
 dry. Under these circumstances, I ordered him the mixture 
 containing four grains of tartar emetic and one drachm of 
 laudanum, in eight ounces of camphor mixture ; of this he took 
 two drachms every second hour. The effects produced by this 
 medicine were not very rapid, but still they were decidedly bene- 
 ficial, for he gradually became calmer, wandered less, did not 
 attempt to get out of bed, and, during the night, got some sleep. 
 His bowels being confined, the mixture was now laid aside, and 
 purgatives exhibited ; I should have remarked that the tartar 
 emetic mixture caused profuse sweating. 
 
 On the fifteenth day of the fever, his bowels having been acted 
 on, he was ordered twenty drops of Battley's solution of opium 
 at night, which produced a comfortable night's rest — the first he 
 had enjoyed since his illness. On the sixteenth, the sweating 
 continued, the belly was fallen, and he was quite rational, but 
 had marked subsultus ; he got another dose of Battley, but it 
 produced no sleep ; he had been allowed chicken broth, beer, 
 &c., for some days. On the seventeenth day the sweating had 
 ceased, and his skin had become hot and dry; great restlessness, 
 constant muttering delirium, subsultus, tremors, picking the 
 bed-clothes, involuntary discharges : porter in small quantities, 
 chicken broth, foBtid injection, and twenty drops of Battley at 
 night. On the eighteenth, he was reported to have had no stool 
 from the injection, and no sleep whatsoever. He answered 
 incoherently, thought his bed was covered with lancets, some 
 of which he collected carefully, and reserved for me ; belly not 
 tumid, but obstinately confined ; pulse 100. The whole of that 
 day, and the following, were employed in procuring alvine 
 evacuations, preparatory to again giving opium ; in the mean- 
 time, all his symptoms were aggravated, and when I visited him 
 on the evening of the nineteenth day, his state was anxious
 
 MACULATED FE\'ER. 2G9 
 
 in the extreme, as he had enjoyed no sleep for many days and 
 nights, and Was in a melancholy state of mental incoherence, 
 raving, tremor, and siihsultus. 
 
 Here came the crisis as to treatment. I remember well the 
 time when a patient so situated would have been again purged, 
 his head shaved, a few leeches applied to the temples, and a 
 blister to the nape of the neck, while perhaps wine and musk 
 would have been exhibited internally. How many persons have 
 I seen so treated by the most eminent physicians, and how 
 unsuccessful was the practice ! To have talked of giving opium 
 under such circumstances, and when the marks of cerebral 
 congestion were so evident, would have been regarded as absurd ; 
 my experience on former occasions, however, determined me to 
 give opium, and as the danger was imminent, I gave it boldly. 
 To the eight ounce mixture, with four grains of tartar emetic, 
 we added one drachm and a half of laudanum ; of this he took 
 one ounce every second hour, from eight in the evening until he 
 had taken five doses. This produced copious sweating ; the 
 skin became cooler, he raved less, but still no sleep ; at four on 
 the following morning his pulse became 70, and respiration 
 tranquil ; he got twenty drops of Battley, and at half-past five in 
 the morning, twenty-five drops more. He had now taken, within 
 a short time, about one drachm of laudanum, and forty-five drops 
 of Battley, combined with nearly three grains of tartar emetic. 
 He was tranquil, but did not close his eyes, and muttered 
 occasionally ; subsultus less. His pupils now became more and 
 more contracted, his eyes less expressive and duller, and when I 
 came at eight in the morning, he was evidently deeply narcotized, 
 although not yet asleep. I thought that all was lost ; but still, 
 observing the respiration to be tranquil, and the pulse regular, 
 I indulged a faint hope that sleep might still supervene. His 
 eyes now became still more inexpressive, the lids gradually 
 closed, his breathing became prolonged and deep, and at half- 
 past eight he was buried in a profound and tranquil sleep, which 
 continued for nine hours, when he awoke, spoke rationally, 
 said he had no pain in his head, took some drink, and fell 
 asleep again. Next morning not a single symptom of fever 
 remained. 
 
 The following cases prove that tartar emetic in considerable 
 doses may be administered with advantage at a period of fever in
 
 270 CLINICAL MEDICINE. 
 
 which it was usually thought to be inapplicable, and to an extent 
 which even now I cannot but consider as remarkable. When I 
 first used tartar emetic and opium, I had not pushed the former 
 remedy with the boldness and decision I have since done, for my 
 experience only gradually accustomed mo to a method of proceed- 
 ing contrary to preconceived opinions, and my views of the 
 powers of the remedy only gradually enlarged as I became more 
 confident of its safety. It is but right to add, and I do it with 
 gratitude, that I received much assistance and encouragement 
 from the views of Dr. Marryatt of Bristol, published in 1788, 
 but of which I and the profession in Ireland, and I may add in 
 England, were generally ignorant until they were noticed in the 
 first volume of the British ami Foreign Medical Review, page 
 416. This notice of a work of which I had never before heard, 
 and the testimony it contained that tartar emetic may be exhibited 
 in considerable doses, and with advantage, at advanced stages 
 of malignant fever, led me to attach more importance to this 
 remedy alone, and uucombined with opium, and determined me 
 to adopt a bolder line of practice in future — a determination 
 which the event fully justified. 
 
 Some there are who will take occasion to remark that I can 
 have no claim to originality on this occasion. But all who have 
 watched my practice in the hospital, nay all who have taken the 
 trouble of reading my lectures and successive publications on 
 this subject, will at once acknowledge that I proceeded on this 
 path of investigation with no other guide but an analogy derived 
 from an observation of the effects of tartar emetic and opium in 
 delirium tremens, a disease undescribed in the time of Marryatt. 
 Every one the least conversant with the treatment of fever in 
 private and in hospital practice in Dublin, London, and 
 Edinburgh, will allow that no one, during the present century, 
 ever taught or practised the exhibition of tartar emetic at the 
 stage of typhus fever in which I have recommended it. Not a 
 single hint at such a treatment is given in any of the numerous 
 contributions on the treatment of typhus which form the valuable 
 work edited by Dr. Barker and Dr. Cheyne. Where is there even 
 one allusion to this practice in Armstrong, Smith, Tweedie ? 
 And what is said of it in Good, Thomas, Mackintosh, or in the 
 Cyclopcedia of Practical Medicine ? Where is it mentioned or 
 inculcated in the Edinburgh Medical and Surgical Journal, or in
 
 MACULATED FEVER. 271 
 
 Johnson's Mcdico-Chiriirgical Review ? Nowhere, although the 
 treatment of fever is often the subject of anxious discussion. 
 
 So far suffices with regard to the novelty of the matter, for it 
 is useless to argue with persons so stupid as to confound the 
 practice I recommend with the well known and popular use of 
 tartar emetic as an emetic or a diaphoretic in the commencement 
 of febrile diseases generally. That I did not come upon this 
 method sooner I regret infinitely, for since its adoption my 
 practice in hospital and in private has been much more success- 
 ful than formerly. Nay, shortly before Mr. Cookson's illness, I 
 lost several of my friends, relatives, and patients, who would, in 
 all probability, have recovered if so treated ; and, among the 
 rest, a gentleman the very week before the first trial I made of 
 the practice in Mr. Cookson's case. I mention this fact as the 
 strongest and most convincing proof that I had never even 
 thought of this method until Mr. Cookson's case occurred, for, 
 had I done so, I would have surely been inexcusable in allowing 
 my patients to perish without even trying its efi'ects. But it is 
 time to proceed to the cases themselves. 
 
 A case occurred very lately in the Meath Hospital, where its 
 progress was anxiously watched by many students and several 
 practitioners, all of whom concurred in the opinion that the 
 patient must have died had he been treated according to the plan 
 usually followed under similar circumstances. This patient was 
 attended, under my directions, by Mr. Harnett, who took the 
 following notes of its progress, and visited the patient with 
 unremitting attention both by day and by night. 
 
 Joseph Taylor, aged twenty-one, a strong young man of 
 temperate habits, admitted into hospital on the 7tli May, 1836. 
 Ill seven days ; sickness commenced with rigors, headache, 
 pains in loins, &c. On admission he complained of headache, 
 tinnitus aurium ; face was flushed ; eyes slightly sufi'used ; was 
 constantly frowning ; skin hot and dry, slightly maculated ; 
 abdomen full and soft ; bowels confined. 
 
 Habeat Haustum Rbei. 
 
 9th. — Slept pretty well ; raved little ; ringing in ears con- 
 tinues ; headache increased ; eruption of the macula3 much 
 more copious ; slight cough ; some bronchitic rales over both 
 lungs ; abdomen in every respect natural ; bowels regular ;
 
 272 CLINICAL MEDICINE. 
 
 pulse 100, distinctly dicrotous and sharp ; tongue brown, dry, 
 rough, and furred ; had slight epistaxis three days ago. 
 
 R. Pilulae Hydrargyri, gr, iij. 
 
 Palveris Ipecacuanhse, gr. ss. ; Misce, fiat pilula, 4tis horis 
 
 sumenda. 
 Applicentur hirudines duos naribus, et repetatur applicatio 
 hirudinum vespere, si opus sit. 
 
 Tenth day of fever. Slept tolerably well ; bled copiously from 
 nares ; pain in head diminished ; countenance still flushed and 
 hot ; temperature of rest of body lower than natural ; feet very 
 cold; pulse 112, dicrotous and wiry; tongue parched and furred, 
 dark brown ; great difficulty in protruding it. 
 
 Stupes to feet, blisters to pmecordial region, blisters to calves 
 of legs, in the course of the day. 
 
 R. Misturte Camphorae, f5j. 
 Liquoris Hoflfmanni, f5J. 
 Misce, fiat haustus, 4tis horis sumendus. 
 
 11th. — Became very violent yesterday evening ; attempted to 
 get out of bed frequently, but, when spoken to by the nurse, he 
 remained quiet for a short time ; was constantly raving and 
 gnashing his teeth during the night ; had no sleep ; a short time 
 before visit this morning, had a fit of an epileptic character, 
 which lasted about ten minutes, in which he worked violently 
 and foamed at the mouth. At the hour of visit, nine in the 
 morning, the countenance was flushed, anxious, and expressive 
 of great ferocity ; eyes wild and suffused ; pupils natural ; 
 complains of dimness of vision; eyebrows contracted ; breathing 
 hurried ; is constantly tossing himself from one side of the bed 
 to the other, and tearing the dressings off the blistered surface ; 
 skin hot and dry ; abdomen soft ; no tympanitis ; bowels loose ; 
 tongue parched and furred ; he is incessantly protruding and 
 biting it, and gnashing his teeth ; pulse dicrotous, very quick, 
 and sometimes hard, but small. 
 
 R. Antimonii Tartarizati, gr. \j. 
 AqufB, f^x. 
 Mucilaginis. 
 
 Syrupi Papaveris albi, aa. fjj.; Misce, fiat mistura, sumat 
 fjss. omni semihora.
 
 MACULATED FEVER. 273 
 
 Three o'clock, p.m. Has taken half the mixture, was nau- 
 seated by the second dose, but not since ; he still continues very 
 violent; fancies he has a bone in his mouth, which he is 
 constantly biting; is in a copious perspiration since he com- 
 menced taking the medicine. 
 
 Mr. Harnett ordered 5j. of the mixture every half hour. 
 
 Six o'clock, a.m. Appears a little calmer; has taken the 
 whole of the medicine, no nausea produced ; has bitten his 
 tongue and lip severely ; perspiration continues ; has passed a 
 large quantity of urine in bed ; pulse soft and full. 
 
 R. Antimonii Tartarizati, gr. iij. 
 Aquae, f^vss. 
 
 Syrupi simplicis, fjss. ; Misce, fiat mistura, cujus sumat fjss. 
 omni semihora. 
 
 Eleven o'clock, p.m. Has taken all his medicine without 
 being nauseated; countenance less flushed; is constantly 
 raving ; pulse 100, full and soft. 
 
 R. Antimonii Tartarizati, gr. iv. 
 Misturae Camphora3, f^viij. 
 
 Tincturae Opii, f5J. ; Misce, fiat mistura, cujus capiat fjss. 
 omni semihora. 
 
 12th. — Continued raving during the night ; had no sleep ; 
 appears much quieter this morning ; face less flushed ; eyes 
 still wild and staring, but very slightly suffused ; brows con- 
 tracted ; pupils natural ; speaks rationally ; pulse 80 and regular, 
 has lost the dicrotous tone which it had yesterday ; bowels 
 confined. 
 
 Habeat enema emolliens, et repetatur mistura ; 
 
 To have one pint of porter and chicken broth. 
 
 Three o'clock, p.m. Having taken the whole of the mixture, 
 containing tartar emetic and opium, the simple tartar emetic 
 mixture was again prescribed ; after taking two doses of which 
 he fell into a tranquil sleep, in which he is at present. 
 
 Eight o'clock, p.m. Has slept continually all day; awakes 
 occasionally, but falls into a deep sleep very soon again. 
 
 Omittatur tinctura opii. 
 13th. — Slept soundly during the night ; appears calm and 
 
 VOL. I. 18
 
 274 clinicaij medicine. 
 
 collected ; conversation quite rational ; maculae have disap- 
 peared ; pulse 84, soft and regular ; omit medicine ; a glass of 
 porter ; light nourishment. 
 
 He has taken more than twenty grains of tartar emetic within 
 thirty hours, and has been nauseated but once. 
 
 There are some circumstances in this case which require to 
 be considered more at length. In the first place, it is well to 
 bear in mind that the patient was affected with genuine macu- 
 lated fever, the true typhus, in the form many years present in 
 Great Britain and in Paris ; for in the latter city this peculiar 
 eruption, somewhat resembling measles in the crescentic shape 
 of the blotches, is considered quite pathognomonic of typhus. 
 This is important, particularly with reference to the use of 
 tartar emetic in such large quantities. Again, it is worthy of 
 remark that symptoms of collapse, so alarming as to excite con- 
 siderable apprehensions, and calling for the immediate application 
 of blisters, and the use of stimulants, occurred on the tenth day 
 of the fever. It was immediately after this collapse that the 
 violent cerebral excitement commenced, and certainly this 
 previous collapse left an impression on my mind that no directly 
 evacuating remedies could be borne ; that they would at least be 
 attended by great danger of speedily reproducing a fatal degree 
 of debility. For this reason I did not repeat the application of 
 leeches. 
 
 The delirium in this patient was extremely violent, requiring 
 the use of the strait waistcoat, and the constant superintendence 
 of the nurse : the contortions of face, and the ferocity of his 
 countenance, the constant biting of his tongue and lips, pre- 
 sented a frightful picture of excitement, which evidently could 
 not be controlled except by the prompt and energetic use of 
 powerful remedies. As the blistered surface of his chest seemed 
 to add much to the state of excitement, for he was constantly 
 tearing it, I did not think of applying blisters to the head, being 
 persuaded that they might aggravate tbe evil, since in many 
 they seem to act so as to produce a sort oi delirium traumaticum. 
 His pulse being frequent and sharp, together with the evident 
 determination to the brain, seemed to indicate the exhibition of 
 tartar emetic, nor was there anything in the state of the intes- 
 tinal canal to forbid its being given in frequently repeated doses. 
 The result more than realized our expectations, for during its
 
 MACULATED FE\'ER. 275 
 
 use the delirium gradually abated, and the pulse, becoming 
 much less frequent, changed its character from a short and 
 small, to a full soft stroke. This prepared the way for the safe 
 trial of opium, which was not commenced until he had taken 
 twelve grains of the tartar emetic. The opium was afterwards 
 laid aside, and the tartar emetic alone completed the cure ; but 
 it may be doubted whether alone it would not have induced 
 sleep. 
 
 I have made these remarks for the purpose of rectifying an 
 erroneous impression, which I fear has gone abroad concerning 
 the use of tartar emetic and opium in the delirium of fever, and 
 to prevent, as far as I can, the exhibition of opium, except when 
 certain precautions have been taken by the practitioner to remove 
 or diminish cerebral congestion by means of proper evacuations 
 or tartar emetic. No man can justly be held responsible for the 
 abuse by others of remedies he recommends ; but since the pub- 
 lication of my observations on this subject, I have had lament- 
 able proofs that I have been misunderstood ; and lately was 
 called to see a gentleman in the vicinity of Dublin, who, the 
 practitioner in attendance said, had been treated according to 
 my method ; whereas the patient was killed according to his 
 own, by opium injudiciously given during delirium with evident 
 cerebral congestion. 
 
 It has been asserted, that after all this case was not so 
 dangerous, nor its recovery very remarkable. For a full refuta- 
 tion of so groundless an opinion, I refer with confidence to the 
 written history of the case itself, a history which is far from 
 laying before you an adequate picture of the deplorable state 
 of the patient at the time that my treatment was about to be 
 commenced, but which, nevertheless, is still faithful enough to 
 convince every one at all acquainted with the symptoms and 
 progress of fever, that the case was almost hopeless. What ! is 
 it possible that any one can be found, who has witnessed fifty 
 cases of bad fever, and who is bold enough to say, that because 
 the patient is young, and was previously healthy, he could not 
 be considered in imminent danger, when on the tenth day of 
 spotted fever, a state of collapse requiring blisters and stimulants 
 is followed on the eleventh day by delirium of the most violent 
 description, rendering it necessary to tie the patient down in 
 bed, and accompanied by a fit of convulsions of frightful violence,
 
 276 CLINICAL MEDICINE. 
 
 lasting more than ten minutes, and resembling an epileptic 
 seizure ? 
 
 This last symptom alone is more than enough to denote 
 extreme danger. For the truth of this assertion I appeal to my 
 own experience, to the experience of every practical man, and 
 to the writings of every author who has written on fever. 
 Hippocrates has four aphorisms, all testifying the danger of 
 convulsions in fever ; and in his book of prognostics, he says, 
 that various causes may, in fever, produce convulsions in 
 children under seven years of age, without great danger to life ; 
 but he adds with great emphasis, in adults, convulsions never 
 take place unless " tl tcov aTj/jbeicov 7rpoa<yevr)Tac tcov ca-^vporrarcov 
 re Kai KaKicrTcov.^' It is scarcely possible to describe the danger 
 of anything in stronger terms than these. 
 
 Those who assert that the possession of previous good health, 
 or of a robust frame, renders violent fevers less dangerous, know 
 little of the matter. The strongest and most powerful men I 
 ever knew were Dr. Clarke, jun., and Dr. Duigenan ; they both 
 died before the end of the third day. 
 
 I cannot pass over in silence the remark, that my cases only 
 prove how much the powers of nature are able to bear, an 
 observation involving the insinuation that I was very culpable in 
 giving such an example to others, and in countenancing the 
 exhibition of strong medicines, such as tartar emetic, in un- 
 warrantably large doses. Now with all due deference, I may be 
 permitted to observe, that in acute diseases threatening imme- 
 diate danger to life^ we gain little by waiting for Nature's 
 assistance. Powerful remedies must be employed ; but mark, if 
 they are employed judiciously, their powers are only exerted in 
 controlling the disease ; this happened in all the cases I have 
 related ; none of the patients were injured in any way ; in truth 
 the physician w^ho orders one-fourth or one-half of a grain of 
 tartar emetic to be given repeatedly until the disease yields, and 
 who diminishes the frequency of the dose and quantity of the 
 medicine, in proportion to the diminution of the symptoms, to 
 curb which was his object, that physician cannot be justly 
 accused of giving heroically large doses of the medicine in 
 question. To give it in smaller and less frequently repeated 
 doses than are found sufficient to make an impression on the 
 symptoms, would be mere trifling. The doses of medicines
 
 MACULATED FEVER. 277 
 
 must be pronounced to be large or small, not according to their 
 weight or measure, but according to their effects, and when 
 confessedly moderate doses are frequently given, and the effects 
 of each carefully watched, surely caution herself can require no 
 more. The same remark applies to my directions concerning 
 opium. 
 
 The next case I have peculiar satisfaction in laying before you, 
 inasmuch as its progress and treatment were witnessed by Sir 
 P. Crampton, who was struck by the benefit resulting from a 
 mode of practice he had never before seen applied, and that 
 under circumstances which he considered as indicative of the 
 greatest danger. Dr. Campbell, too, had an opportunity of 
 witnessing for the first time this mode of treatment, and he 
 since assured his class, that when I recommended it, he had 
 scarcely a hope that our patient's life could be saved. 
 
 Mr. C, residing in Fitzwilliam Square, a surgeon, formerly an 
 apprentice of the Surgeon-General, a young man of a powerfully 
 athletic make, was attacked with the rigor of fever on Monday, 
 9th May, 1836. He was attended from the commencement by 
 Dr. Campbell, and had a copious eruption of measles-like 
 maculie on the sixth day of the fever, when I first saw him. No 
 unusual symptom occurred on the seventh day, and the head- 
 ache, of which he complained much at the commencement, had 
 disappeared in consequence of the application of a few leeches. 
 On the morning of the eighth day we observed that every now 
 and then he respired irregularly, as if repeatedly and gently 
 sighing, a variety of respiration often indicating a disturbance of 
 the nervous system, and which I have repeatedly observed as a 
 precursor of cerebral excitement, and to which, consequently, 
 I have been in the habit of drawing your attention, under the 
 name of cerebral respiration. 
 
 On the afternoon of the eighth day we had the benefit of Sir 
 P. Crampton's advice, who thought his case a very bad one 
 indeed, for his pulse was almost 140 in a minute, and remark- 
 ably shabby, while he lay on his back thickly covered with 
 maculiB ; and we found that a rapid tumefaction of the abdomen 
 had commenced within a few hours — a very bad symptom, 
 inasmuch as the belly had been in the morning quite soft and 
 fallen, and there was no cause to account for the sudden 
 development of tympanitis, unless we supposed it, as it too
 
 278 CLINICAL MEDICINE. 
 
 frequently is, a harbinger of dissolution at no very distant 
 period. 
 
 His tongue was parched, and he complained of thirst. The 
 usual treatment by means of chloride of soda was determined 
 on, in consultation ; after which Sir P. Crampton expressed to 
 the gentleman's friends the fears he entertained for the result. 
 Scarcely had he gone out of the house, and just as Dr. Campbell 
 and I were preparing to leave it, Avhen a sudden change took 
 place in our patient, who jumped out of bed, and nearly 
 ■succeeded in throwing himself out of a garret-window. We 
 found him violently delirious ; but this state did not last for 
 more than a few minutes, when it subsided into a delirium of 
 a comparatively gentler description. He refused, however, to 
 return to bed, and we were obliged to allow him to walk about 
 in his shirt, supported, for he was feeble, by two attendants ; 
 his eyes became at times very prominent and ferocious ; now 
 and then he threatened all those about him, in a loud and 
 terrifying tone of voice, and he seemed every moment on the 
 border of frantic madness. Nothing could induce him to go to 
 bed or allow even a blanket to be thrown over his cold and naked 
 extremities. Thus seated on his chair, he presented a frightful 
 picture, while his pulse became so quick that it could scarcely 
 be counted, and was at the same time exceedingly weak. 
 
 What was to be done ? The state of his circulation did not 
 admit our endeavouring to control the cerebral excitement by 
 arteriotomy or even leeches, and the last remark Sir P. Crampton 
 made, was, that a very few leeches would kill him ; blisters 
 would be too slow in their action, and might even aggravate the 
 disease ; cold effusion seemed inadmissible. In short, it seemed 
 that our patient was beyond the reach of all resources ; as to 
 tartar emetic, I felt at first unwilling to order it on my own 
 responsibility, in a case apparently so desperate, and after Sir 
 P. Crampton had left the house ; in fact neither Dr. Campbell 
 nor I thought it probable that our patient would survive twelve 
 hours : yet, as I saw no possible means of saving him but the 
 tartar emetic treatment, and determined at all risks to make a 
 strenuous effort, I did not think myself justified in any longer 
 hesitating about the matter, and ordered a mixture containing 
 one ounce of syrup of white poppies, one of mucilage, and six of 
 water, with eight grains of tartar emetic. Of this solution he
 
 MACULATED FEVER. 279 
 
 was to get half an ounce every half hour, until a manifest 
 impression on the cerebral excitement was produced. 
 
 The medicine was administered by the late Mr. Ferguson of 
 Kildare Street, who told me afterwards that he was quite sur- 
 prised at the treatment adopted, and was sure that neither 
 it nor any other could save Mr. C.'s life. The first six doses 
 seemed to sicken him a little, but he did not vomit until after 
 the seventh dose ; the eighth also produced very copious 
 vomiting of mucus and bilious fluid. After the second vomit- 
 ing he was prevailed on to go to bed, and was evidently more 
 tranquil, but from having remained up uncovered for so many 
 hours, much trouble was necessary before warm applications 
 succeeded in restoring the natural temperature of his limbs and 
 skin generally. 
 
 At 10 p.m. we saw him again, and finding that the medicine 
 had produced so powerful an efi'ect, we ordered it to be repeated 
 only every second hour. 
 
 May 18th. — Ninth day of fever : 8 a.m. Has taken five doses 
 since last visit ; stomach quiet since the eighth dose. He slept 
 several hours quietly in the beginning of the night (he had not 
 slept for several nights before), but seems more excited now ; 
 he threatens some of his attendants, and appears likely to be 
 unruly. It was therefore judged right to repeat the medicine 
 every hour and a half. 
 
 1 p.m. Has taken eight grains of tartar emetic since six 
 o'clock yesterday evening. A solution of the same strength in 
 plain water was now directed to be given in the dose of half an 
 ounce every fourth hour. He slept a good deal during the day, 
 and the medicine operated on the bowels, bringing down very 
 large fluid stools, consisting of a great quantity of healthy 
 yellow faecal matter. This efi'ect is often produced by the tartar 
 emetic in the advanced stages of fever, and is always a good 
 sign. Although he was evidently more tranquil than before, it 
 was thought advisable still to keep two strong, steady men con- 
 stantly in the room, ready to assist the nurse in case of emergency. 
 He still raved occasionally, and would not allow certain persons, 
 me among the rest, to approach him, having conceived a strong 
 aversion for us. 
 
 At 7 p.m. we found that the fever was again rising, and that 
 the cerebral excitement was on the increase ; we therefore again
 
 280 CLINICAL MEDICINE. 
 
 had recourse to lialf-hour doses, until the excitement yielded ; 
 after which it was given only every second hour. 
 
 May 19th. — Tenth day of fever : 10 a.m. He took six doses 
 during the night. He got out of bed and eluded the vigilance 
 of his attendants at a very early hour in the morning, but walked 
 peaceably about the house, and when asked, returned quietly to 
 bed. He slept well afterwards. As so much had been gained, 
 we thought it unnecessary to persevere in the use of the tartar 
 emetic ; it was discontinued. He took in all twelve grains ; it 
 diminished the frequency of the pulse notably ; and, what was 
 very striking during the forty-eight hours we employed it, the 
 pulse not only became slower, but much softer and much fuller ; 
 the skin became softer and moist ; the belly was fallen and soft ; 
 and the maculae much diminished. His fever, notwithstanding, 
 still continued ; he spoke incoherently, but did not again get 
 out of bed. 
 
 On the fourteenth day an evident abatement of general fever 
 commenced ; the pulse fell, and the respiration, which, when he 
 was at the worst, had been about 50 in a minute, fell to 25. 
 This improvement continued progressive, and on the seventh 
 day precisely, all fever left him ; his pulse being then 60. 
 
 The after treatment consisted merely in giving a mild aperient 
 every second day, until convalescence commenced. After the 
 use of the tartar emetic had cured the cerebral excitement, he 
 slept almost continually until the termination of the fever. 
 
 The next case is that of Mr. M., a gentleman of sedentary 
 habits, full and corpulent, 40 years of age, who was lately 
 attacked with violent symptoms of fever. He was very actively 
 and judiciously treated by Dr. Ireland from the commencement. 
 The measles-like eruption appeared about the fifth day. He 
 had been copiously bled from the arm twice, and leeches were 
 repeatedly applied to the forehead for the purpose of relieving 
 pain in the head. He was likewise very freely purged. About 
 the time the eruption appeared, his restlessness and debility in- 
 creased, and he scarcely slept at night. In the course of a few 
 days his state had become very alarming, and I saw him, in 
 consultation with Dr. Ireland, on the ninth day of his fever. 
 
 We found that he had raved constantly during the preceding 
 night, and was bathed in an exhausting perspiration, while the 
 pulse rose to about 130 ; his perspiration was very frequent, and
 
 MACULATED FEVER. 281 
 
 his face wore an evident expression of excitement, not of a violent 
 but of a very restless character. His tongue was parched, and 
 his body thickly covered with maculse. In short, notwithstand- 
 ing the active measures of depletion, general and local, applied 
 in the beginning of the disease, it was evident that cerebral 
 excitement had come on, and that too at a period of fever when 
 debility forms a considerable obstacle to the further use of direct 
 evacuants. His exceedingly gross habit of body, and prominent 
 abdomen, were concomitants of the worst omen, for it is well 
 known that very fat people seldom recover from typhus of a bad 
 character. In this state of things tartar emetic was given to 
 about the extent of three grains in the twenty-four hours ; it was 
 continued forty-eight hours, or until a satisfactory calm of the 
 nervous system had been produced. Besides diminishing the 
 delirium and inducing sleep, the remedy here brought away 
 numerous and copious bilious stools, and diminished notably the 
 frequency of the pulse and of the respiration. It is worthy of 
 remark also, that, in proportion as he came under the influence 
 of the tartar emetic, the useless and profuse perspiration began 
 to abate, and after some hours ceased. 
 
 This gentleman's life was evidently saved by the treatment, 
 for though his fever continued many days after, yet he never was 
 in danger except from hiccup, which came on about the thir- 
 teenth day, and tormented him day and night. Claret, iced, 
 seemed to have more power in relieving this symptom than any 
 other expedient resorted to. His fever terminated about the 
 nineteenth day. 
 
 Dr. Ireland, who has had the most extensive experience in 
 fever, testified the pleasure he felt at witnessing the good eifects 
 of a mode of cure to him quite new, and applied in a case he 
 thought almost desperate. 
 
 The following case presents so .striking and convincing an 
 illustration of the efficacy of my treatment, that I have thought 
 it right to lay it before you also. The progress of the case was 
 witnessed by several practitioners, who all declared, and I myself 
 concurred in this opinion, that nothing would save the patient's 
 life. His recovery was, without exaggeration, a matter of aston- 
 ishment to us all; while at the same time it was so evidently 
 the effect of the remedies employed, that many who had been 
 wavering in their minds as to the utility of tartar emetic
 
 282 CLINICAL MEDICINE. 
 
 exhibited in the advanced stages of spotted fever, could no longer 
 refuse their assent, and unhesitatingly declared their conviction 
 that by no other plan of treatment could a favourable issue have 
 been brought about. The patient was most diligently watched 
 by Mr. Kooney, an attentive pupil, who visited him many times 
 during the day and night, and reported to me the effect of the 
 medicines. 
 
 Edward Meylagh, a stout, muscular peasant, aged 25, was 
 attacked about the 23rd May, 1836, with the usual symptoms of 
 commencing typhus. He was admitted into the Meath Hospital 
 on the 1st of June, after the usual hour of visiting the wards. 
 It was ascertained that he had been repeatedly and violently 
 purged since the commencement of his illness by pills and 
 aperient mixtures. I saw him at 9 a.m. on the second of June ; 
 he had passed a most restless night, muttering incessantly, and 
 becoming at times so unmanageable, that it was necessary to put 
 on the strait waistcoat. Now he is obstinately silent, will not 
 answer questions, or put out his tongue when desired. His 
 countenance is at once morose and haggard, and at times 
 assumes a suspicious, ferocious aspect ; eyes glazed, and slightly 
 suffused ; general surface of skin rather dry and hot, but his ex- 
 tremities are cold and livid ; pulse 132, small and compressed ; 
 respirations 42, irregular ; abdomen neither swollen nor tender ; 
 he passes urine and feces in bed ; his tongue is dry, and dark- 
 brown in centre, moist and red towards the edges. The whole 
 surface of his body is covered with maculae. Immediate attention 
 was paid to restore the warmth of the extremities, and I directed 
 him to get every hour half an ounce of a mixture, consisting 
 of eight ounces of water, four grains of tartar emetic, and two 
 scruples of laudanum. 
 
 1 p.m. At mid-day he began to gnash his teeth, knit his- 
 brows, screw his lips, and spit at every person that approachedl 
 his bed. The expression of the face was rendered worse by the 
 rapid motions of the eyeballs and a frequent squinting. In facti 
 he became so ungovernable that the restraint of a strait waistcoat! 
 was no longer sufficient, and his legs and thighs were tied down: 
 to the bed. His carotids pulsated violently, and he alternately 
 laughed and screamed aloud. Pulse 132, still small and wiry. 
 As no perceptible action had been produced by the medicine, it; 
 was ordered in double doses.
 
 MACULATED FEVER. 283 
 
 6 p.m. Countenance much improved ; less morose ; he con- 
 tinues, however, to speak unconnectedly, but jocularly ; is in a 
 copious warm perspiration : pulse 120, soft and compressible ; 
 respirations 36, regular. To continue the double doses. 
 
 9 p.m. Has been in a composed, tranquil sleep since half-past 
 six o'clock ; perspiration continues ; has passed a large quantity 
 of urine ; extremities are now naturally warm and moist ; the 
 pulsation of the carotids has subsided. He has taken four grains 
 and a half of tartar emetic since morning, and twenty-three drops 
 of laudanum. The medicine was now directed not to be given at 
 regular intervals as before, but according as the symptoms seem 
 to require it ; it had neither nauseated nor purged him. 
 
 3rd June. — He has slept tolerably during the night, and got 
 three doses of the bottle. About five in the morning he became 
 somewhat restless, when a double dose was immediately adminis- 
 tered, after which he slept composedly until nine o'clock, the 
 hour of visit. His tongue is red, dry, and parched, fissured 
 towards the tip ; his thirst is increased, and he drinks very freely 
 of cold water ; skin moist and warm ; pulse 96, dicrotous ; 
 respirations 30, regular ; he seems inclined to sleep. His ideas 
 are somewhat confused, although he answers rationally ; bowels 
 confined ; abdomen a little tumid and slightly tympanitic. Has 
 taken two grains and a half of tartar emetic and ten drops of 
 laudanum since yesterday evening. I now thought it unne- 
 cessary to persevere any longer in the use of this mixture, and 
 directed my attention to the state of the bowels, which soon 
 yielded to emollient lavements. The alvine evacuations so 
 procured were very copious, and were followed by immediate 
 subsidence of the belly, and evident amelioration of the symp- 
 toms. He continued to sleep quietly during the day ; at six in 
 the evening his pulse was 90, soft and natural ; respirations 30 ; 
 skin warm and perspiring ; maculae have nearly disappeared. 
 
 7th June. — Much natural sleep ; pulse 65, soft, of good strength, 
 and without any of the dicrotous character ; intellectual faculties 
 rapidly improving ; now passes urine and feces voluntarily ; 
 abdomen soft and fallen ; tongue cleaning, and nearly moist. 
 In fact, convalescence has almost commenced. 
 
 With one case more I shall conclude. A gentleman about 20 
 years of age was attacked with measles of an irregular form. 
 The eruption did not come out favourably ; and notwithstanding
 
 28i CLINICAL MEDICINE. 
 
 lie was treated from the beginning by the late Dr. O'Brien, so 
 well known as an excellent writer on the subject of fever, his 
 state became daily worse, and Dr. O'Brien pronounced his case 
 hopeless when he sent for me on the sixth day. It mast be 
 borne in mind that Dr. O'Brien was physician to the Cork Street 
 Fever Hospital for thirty years. 
 
 The combination of symptoms which caused him to form this 
 unfavourable opinion, was an exceedingly rapid, shabby pulse, 
 violent delirium, total sleeplessness, and an evident sinking of 
 the vital powers, manifested by coldness of the skin, &c., &c. 
 As he was young, and the disease recent, we ventured to draw a 
 little blood from the arm, but he fainted before many ounces 
 could be obtained ; we leeched his forehead without any percep- 
 tible effect. On the morrow he was worse : I then proposed the 
 exhibition of small doses of tartar emetic, in frequently repeated 
 doses. He took two grains in the course of ten hours ; was 
 nauseated or vomited by almost every dose ; became more tran- 
 quil ; finally fell asleep ; and in twenty-four hours was out of 
 danger. 
 
 Dr. O'Brien expressed to me in the strongest terms his 
 gratification and surprise at the striking and beneficial appli- 
 cation of a medicine he had never before seen given in like 
 circumstances. 
 
 Another case of spotted fever, to which I was called by Mr. 
 M'^SIalty of Britain Street, afforded an equally favourable result 
 within this last week ; as did also a very dangerous case of the 
 same disease, which I treated along with Mr. Mulock. 
 
 I have thus fully brought forward the result of my experience 
 on this subject, convinced that I have not deviated in the slightest 
 degree from the strict and naked truth in any of the preceding 
 details. I have not in a single instance related what was not 
 witnessed by other medical men of judgment, well known to the 
 profession. If my treatment be not useful, it has singularly 
 deceived me in curing my patients. If it be not new, it is 
 strange that so many others in Dublin, that the whole body of 
 practitioners, should have been fully as ignorant of it as I was 
 myself. 
 
 I need scarcely again observe, that the proportions of the two 
 powerful medicines which compose this mixture must vary 
 according to the circumstances of the disease, and the age of the
 
 MACULATED FEVEK. 285 
 
 patient. In young persons of tender age, the opium must he 
 .^ivcn in smaller quantities. 
 
 Before concluding I may mention that since this practice was 
 lirst proposed, it has continued to afford me the greatest satis- 
 faction, and that I have reason to believe that those who have 
 tnijDloyed it in this country, and at the other side of the channel, 
 have had no reason to lose confidence in it. 
 
 In a paper on typhus fever by Dr. Kilgour, we find that the 
 experience of Dr. Dyce, of the Aberdeen Infirmary, is strongly in 
 favour of this practice. He says: — "For months together the 
 }iulmonic symptoms prevailed almost entirely, then came those 
 marked by gastric and intestinal irritation, and less often, though 
 still continuing for a length of time in succession, those with 
 high cerebral action. The first set, as is too well known, were 
 by far the most intractable and fatal ; the last, though sufficiently 
 alarming, and always requiring restraint, were more amenable to 
 treatment than either of the others, if anticipated in their 
 approach, or seen soon after their onset. By the way, the 
 medicine I solely relied on in this latter class, you do not include 
 among your list — I mean tartar emetic. Given as described by 
 Dr. Graves, I have found it eminently successful, and have the 
 greatest confidence in it.''^ — Edinburgh Medical and Surgical 
 Journal, vol. Ivi. p. 389. 
 
 And in the eleventh volume of the Dublin Medical Journcd, 
 you will find an interesting paper on " Certain Eemedies in 
 Typhus Fever," by Dr. Hudson of Navan. Speaking of the 
 treatment by tartar emetic and opium, he says: — "It seems 
 best adapted to that restless kind of delirium tremens, in which 
 the patient cannot be restrained from attempting to leave his 
 bed, and walk about the ward ; when every muscle is tremulous, 
 the eye is red from want of sleep, the tongue dry, and the patient 
 presenting that kind of spurious excitement which might induce 
 the attendant (injudiciously, no doubt) to order the local 
 abstraction of blood, by leeching the temples, or opening the 
 temporal artery. I could here give reports from my note -book 
 of several cases thus treated, but that I consider it would be 
 rendering tedious a paper already too long. In prescribing this 
 medicine, I find it advisable to use great caution in two ways : 
 1st, Not to give it after it has produced sleep ; 2nd, To follow 
 it up by the prompt and frequent exhibition of wine, and such
 
 286 CLINICAL MEDICINE. 
 
 nourishment or cordials as the more or less advanced stage of 
 the disease and debility of the patient may require, as it seems 
 to me that there is increased risk of the patient sinking unless 
 timely supported after sleep thus induced." 
 
 To conclude, I must observe that I by no means wish to re- 
 commend tartar emetic as a specific in fever. I only use it in 
 the complication above described. In fever the physician must 
 use an almost endless variety of treatment according to the cir- 
 cumstances of the individual case before him ; and he only will 
 be successful who watches narrowly the progress of the cases 
 intrusted to his care, and applies the appropriate remedies at 
 the proper moment. Bleeding, leeches, purgatives, mercurials, 
 absorbents, acids, stimulants, tonics, blisters, chloride of soda, 
 may each be necessary in the treatment of different cases at 
 different stages of their progress, or in different types. In fine, 
 the treatment of fever will be always difficult, always complex, 
 but it ought to be successful.
 
 287 
 
 LECTURE XIX. 
 
 THE ADMINISTRATION OF WINE IN FEVER. — SEQUELJE OF FEVER. 
 
 I CANNOT conclude the remarks I have to make on different 
 points connected with the treatment of fever, without directing 
 your attention, in an especial manner, to the phenomena of tlie 
 heart's action as an index for the administration of wine. In 
 the fifteenth volume of the first series of the Dublin Medical 
 Journal you will find a paper on this subject from the pen of 
 my distinguished colleague Dr. Stokes. From numerous obser- 
 vations he concludes that certain phenomena, which I shall 
 presently detail, indicate a softened state of the heart, and that 
 as soon as these phenomena present themselves, we should 
 resort to stimulation by wine, &c. Dr. Stokes is of opinion 
 that the pulse is a fallacious guide in fever, and that our atten- 
 tion should always be directed to the impulse and sounds of the 
 heart for guidance either for the administration or withholding 
 of stimulants, and he then details the peculiar characters by 
 which this weakened condition may be recognised. I shall now 
 read from Dr. Stokes's paper the leading doctrines contained 
 in it : — 
 
 " We may thus arrange the cardiac phenomena obtained in 
 our typhus fever : — 
 
 "1. Impulse and sounds remaining unaltered; the action of 
 the heart corresponding with that of the pulse. 
 
 " 2. Vigorous impulse, with distinct and proportionate sounds, 
 with absence of pulse for many days. 
 
 " 3. Diminution of both sounds of the heart, with absence or 
 great diminution of the impulse (foetal character). 
 
 "4. Diminution of the first sound, with cessation or great 
 feebleness of the impulse. 
 
 " 5. Complete extinction of the first sound, the second 
 remaining clear. 
 
 " 6. Predominance of the first sound, the second being ex- 
 tremelv feeble.
 
 288 CLINICAL MEDICINE. 
 
 *' In the great majority of cases, however, the following were 
 the phenomena observed : — 
 " 1. Diminished impulse. 
 
 " 2. Diminished first sound, particularly of the left cavities. 
 " With respect to the impulse, we arrived at some unexpected 
 results. In most cases, considered through the whole progress, 
 the diminution and return of the first sound were accompanied 
 with the diminution and return of the impulse. So far the 
 phenomena Avere what we might expect. But in some instances, 
 at ijarticular 'periods of the case, this accordance between the 
 impulse and sound did not exist. In one case, the sounds 
 became distinct before the impulse returned. In another the 
 impulse became distinct on the eleventh day, while the second 
 sound greatly preponderated. In a third case, we found that on 
 the eighth day the sounds were not in proportion to the impulse ; 
 and on the tenth the impulse continued, but the first sound was 
 totally absent. On the next day no impulse could be felt, yet 
 the first sound was feebly audible. In the fourth case, the 
 impulse on the twelfth day was less perceptible than on the day 
 previous, but the first sound had more strength." 
 
 Dr. Stokes adds — " It is difficult or impossible, in the present 
 stage of the inquiry, to ofi'er any satisfactory explanation of these 
 apparent anomalies ; but it seems certain that, under the influ- 
 ence of the typhoid condition, the heart may have sufficient 
 force to give an impulse with little or no sound, on the one hand ; 
 and on the other, its contractions may be accompanied by a 
 sound, although the impulse be absent. Whether we are to 
 explain these facts by referring to particular states of innervation 
 of the heart, or to organic alteration of the muscular fibres or 
 their connecting cellular membrane, is still to be determined." 
 
 Farther on Dr. Stokes says — " That the cause of the want of 
 impulse, and feebleness or cessation of the first sound, is a 
 softening of the heart, I have no doubt. The evidence in favour 
 of this opinion may be thus stated : — 
 
 "1. That softening of the heart exists in typhus fever, as a 
 local disease, and without any analogous condition of the muscles 
 of voluntary life. 
 
 " 2. That in our dissections in the last epidemic, we met with 
 this softening of the heart in cases which during life had pre- 
 sented the phenomena in question.
 
 ADMINISTRATION OF WINE IN FEVER. 289 
 
 " 3. That the physical signs indicate a debility of the left 
 ventricle principally, and it is this portion of the organ which is 
 most often altered in consistence. 
 
 "4. Laennec has stated that, in proportion to the severity of 
 the putrescent phenomena is the liability to softening of the 
 heart ; and the same observation is found to be true of the 
 physical signs now described. 
 
 " The average period when these phenomena appear is about 
 the sixth day, and they cease about the fourteenth day." 
 
 Dr. Stokes considers it highly probable that this softened 
 state of the heart depends on an infiltration through its muscular 
 structure of a peculiar secretion, identical with, or closely 
 resembling that mentioned by Dr. Staberoh as occurring on the 
 surface of the intestinal mucous membrane in cases of follicular 
 ulceration. 
 
 " This, occurring in the heart, seems to impair its functions 
 to a great degree ; but the rapid restoration of the heart to health 
 points out that the disease has not materially impaired its 
 organic condition. 
 
 " Finally," sa3^s Dr. S., " I would draw the particular atten- 
 tion of my readers to the fact that, in the great majority of these 
 cases, the use of wine was followed by the happiest effects. I 
 may safely refer to the cases in proof of this proposition, a7id I 
 believe that in the diminished impulse, and in the feebleness or 
 extinction of the first sound, ive have a neiv, direct, and impor- 
 tant indication for the use of wine in typhus fever.'" 
 
 I will now read the conclusions at which Dr. Stokes has 
 arrived : — 
 
 " I. That the condition of the heart in typhus fever must be 
 determined by the application of the hand and stethoscope, the 
 pulse being an uncertain guide. 
 
 " II. That a diminished impulse, or a complete absence of 
 impulse occurs in certain cases of typhus fever. 
 
 " III. That in such cases we may observe a diminished first 
 sound, or even an absence of the first sound. 
 
 " IV. That both these characters may exist with a distinct pulse. 
 
 *' V. That although in most cases the diminution of the 
 impulse and first sound co-exists, yet that impulse may exist 
 without corresponding first sound, and conversely, that the first 
 sound may be heard although unaccompanied by impulse. 
 VOL. I. 19
 
 290 CLINICAL MEDICINE. 
 
 " VI. That these phenomena are most evident as connected 
 with the left side of the heart. 
 
 " VII. That when the impulse or first sound are lessened or 
 lost, the return to the healthy character is observed first over the 
 right cavities. 
 
 " VIII. That in some cases both sounds are equally diminished. 
 
 *' IX. That in a few cases the first sound preponderates. 
 
 " X. That these phenomena indicate a debilitated state of 
 the heart. 
 
 " XI. That they may occur at an early period of the disease, 
 and thus enable us accordingly to anticipate the symptoms of 
 general debility. 
 
 " XII. That the existence of these phenomena, in a case of 
 maculated adynamic fever, may be considered as pointing out a 
 softened state of the heart. 
 
 " XIII. That this softening of the heart seems to be one of 
 the local lesions of typhus. 
 
 "XIV. That the diminution or cessation of impulse, the pro- 
 portionate diminution of both sounds, or the preponderance of 
 the second sound, are direct and nearly certain indications for 
 the use of wine in fever." 
 
 Though these doctrines are entirely new, and may appear to 
 some rather fanciful, yet for their general accuracy I can vouch. 
 I cannot agree, however, with Dr. Stokes, in attributing the 
 phenomena of a dchilitated heart to a softening of that organ, 
 much less to the interstitial infiltration of a peculiar secretion 
 analogous to that which Staberoh states he has observed on the 
 mucous surface of the intestines in dothonenterite. On the 
 contrary, I consider the heart, in typhus fever, to be affected with 
 debility from the same cause which induces a debility of the 
 voluntary muscles, and of the bladder and sphincter ani — that 
 cause is a general prostration of nervous energy. That Dr. 
 Stokes has seen the heart softened in the examination of subjects 
 that had been affected with typhus fever, I have no doubt ; but 
 I would impute this condition to the efiect of putrescence, a pro- 
 cess which it is well known sets in with great rapidity in cases 
 where death has been caused by any malignant disease. It 
 seems difficult to conceive how the heart could contract in a case 
 where " the right cavities were softer than natural, admitting the 
 fingers through their walls without much resistance; and in
 
 ADMINISTRATION OF WINE IN FEVER. 291 
 
 which, in the muscular structure of the left cavities, this change 
 was much more remarkable, the weight of the finger being 
 almost sufficient to penetrate its walls, they were so exceedingly 
 softened ; it was very easily torn, and the edges thus separated 
 htad no longer the moistened appearance, but seemed as if quite 
 dry. The septum cordis was equally softened ; there was some 
 dark fluid blood in the right cavities." 
 
 But the fact cannot be denied, that in many cases of typhus 
 the heart becomes weak, that this weakness is manifested by a 
 decrease in the strength of its impulse, or in the intensity of its 
 sounds, or a change in their relative loudness and duration — and 
 though I have never witnessed these changes without accompany- 
 ing debility of the entire muscular system, and other evidences 
 of prostration, yet I fully agree with Dr. Stokes, " that in the 
 diminished impulse, and in the feebleness or extinction of the first 
 sound, loe have a new, direct, and bnportant indication for the 
 use of wine in typhus fever,^^ and one from which the junior 
 practitioner in particular will derive the greatest assistance. 
 
 But I also agree with Dr. Bell, the distinguished American 
 editor of Dr. Stokes's Lectures, that, " important as is the guide 
 thus furnished by the state of the heart for the use of stimu- 
 lants, it may not be in the power of all, without some experience, 
 to avail themselves of it. The practitioner will, therefore, do 
 well to attend to the following points, as directed by Dr. Arm- 
 strong, in forming his opinion of the propriety of persevering in 
 the administration of wine to a patient in typhus fever : — 
 
 "1. If the tongue become more dry and baked, it generally 
 does more harm ; if it become moist, it does good. 
 
 "2. If the pulse become quicker, it does harm ; if it be 
 rendered slower, it does good. 
 
 "3. If the skin become hot and parched, it does harm ; if it 
 become more comfortably moist, it does good. 
 
 "4. If the breathing become more hurried, it does harm ; if it 
 become more deep and slow, it does good. 
 
 "5. If the patient become more and more restless, it does 
 harm ; if he become more and more tranquil, it does good." 
 
 I have long endeavoured to impress on the minds of students 
 the great importance of studying with attention that stage of 
 fever in which wine and opium are occasionally the best remedies, 
 with a view of learning what symptoms indicate their exhibition.
 
 292 CLINICAL MEDICINE. 
 
 In the commencement of fever, we can decide with a good deal 
 of certainty upon the most proper course of proceeding, but, as 
 the disease advances, the symptoms become more complicated, 
 the indications more confused, and the plan of treatment con- 
 sequently doubtful. In this stage of fever it is that we must rely 
 on the tact acquired by previous experience and reflection, and 
 must often depend more upon a correct estimation of the general 
 state of the patient, than upon the appearance or absence of any 
 particular symptom. It is not my intention at present to do 
 more than prove the truth of this assertion, by showing that the 
 presence of some symptoms, commonly supposed to contra- 
 indicate the exhibition of wine and opium, ought not to deter 
 the practitioner from their use, provided that other circumstances 
 seem urgently to require it. 
 
 1st, In the first place, as to the tongue, at an advanced period 
 of fever I have often derived the greatest advantage from wine 
 and opium, although the tongue was dry, the colour of old 
 mahogany, or else coated with a yellowish brown fur, and pro- 
 truded with difficulty, while the teeth and gums were covered 
 with sordes. Wine and porter in moderate quantities seem 
 generally to agree better with this tongue than opium ; in some 
 cases, however, the latter is indispensable. 
 
 For fear of misleading you, I must again remark, I by no 
 means wish to assert that such a tongue uniformly, or even fre- 
 quently, indicates the use of these medicines ; on the contrary, 
 this state of tongue and mouth will often be observed at a time 
 when leeches and antiphlogistic treatment are required. Let 
 it be clearly understood, however, that, at an advanced period 
 of fever, this state of the tongue may exist, and yet wine and 
 opium may be given boldly, provided, as I have said before, the 
 general state of the patient seems to require it. 
 
 2ndly. The observations I have made concerning the tongue 
 are applicable to suffusion of the eyes. The eyes may be heavj% 
 a little red, very much suffused, and may have the singular ex- 
 pression of watchfulness, combined with great redness of the 
 conjunctiva, which is termed a ferrety eye, and yet wine or 
 opium may be the only remedy capable of saving the patient's 
 life. It should always be borne in mind that the want of sleep 
 tends to make the eye red, and that this condition is often, 
 when it occurs in maculated typhus, analogous to the similar
 
 ADMINISTRATION OF WINE IN FEVER. 298 
 
 appearance of the eye which is observed both in measles and 
 scarlatina, in which diseases it is merely a part of the general 
 erythema, and does not contra-indicate the use of wine and 
 opium if other circumstances call for their exhibition. 
 
 3rdly. A hot and dry skin does not necessarily contra-indicate 
 the exhibition of wine and opium, particularly where there is at 
 the same time a tendency to coldness of the extremities. 
 
 4thly. The presence or absence of delirium must always excite 
 our attention when the question of giving wine or opium arises. 
 I believe that these medicines are never applicable when the 
 delirium is violent and continuous, but the patient may rave a 
 great deal, particularly at night ; he may mutter and speak to 
 himself; he may point to various imaginary appearances, and 
 may fancy himself surrounded by persons or things which have 
 no real existence ; he may be restless and irritable, constantly 
 endeavouring to leave his bed for the purpose of walking about 
 the room, or sitting at the fire ; and yet he may be in a state 
 urgently demanding wine and opium. On a more accurate 
 examination, we find that his delusions are not so strong as 
 to leave no room for the exercise of his reason. When spoken 
 to emphatically, he answers in some cases incoherently, but in 
 others with perfect precision and presence of mind, and does not 
 for some minutes relapse into his former wanderings. This state 
 of mind is usually accompanied by an almost total want of sleep, 
 and, in many, by a great anxiety about their illness. To pro- 
 cure sleep, as has been well remarked by Latham, in a late 
 number of the Medical Gazette, is here one great object, and this 
 can only be done by means of wine and narcotics. In some the 
 mental aberration is scarcely perceptible, and they have all the 
 characters of great excitement of the nervous system, without any 
 actual raving or delirium. There is general tremor and subsul- 
 tus. The tongue is tremulous when protruded, or when moved 
 in speaking, and consequently the articulation is uncertain and 
 interrupted, while, in general manner and mode of answer- 
 ing questions, the patient strongly resembles a person afl'ected 
 with delirium tremens.* This group of symptoms is likewise 
 accompanied by want of sleep, and best treated with wine and 
 opium. 
 
 * It is in these particular forms of fever that I have discovered the great utility of 
 tartar emetic and opium ; see last lecture.
 
 294 CLINICAL MEDICINE. 
 
 5thly. The appearance of the face has been much rehed on by 
 some, as capable of guiding us in forming our decision. Heat of 
 head and face, redness of the cheeks, and strong pulsation of the 
 carotids, are well known as contra-indicating wine or opium ; but 
 in the advanced stages of fever, the face, like the eye, may be 
 suffused, it may be seen occasionally flushed, and when flushed, 
 it may be hot, and yet wine and opium may, nevertheless, be our 
 only resource. 
 
 6thly. Headache, when violent, is at any period of fever a 
 decisive circumstance. Sleep cannot be obtained while the pain 
 is unmitigated, and we must, therefore, attempt to conquer it by 
 the most active treatment, by local applications to the head, by 
 depletion from the vascular system, and by purgatives. Some- 
 times, however, these means fail, and the physician feels that he 
 cannot pursue this mode of treatment any further. Under such 
 circumstances, a dose of opium boldly exhibited will occasionally 
 succeed in procuring sleep, from which the patient awakes 
 nearly free from headache. Before having recourse to this 
 remedy, the effects of a blister to the nape of the neck ought to 
 be tried. In the more advanced stages of fever, the headache, or 
 rather the heaviness felt in the head, is something very different 
 from the throbbing, acute headache just spoken of, and con- 
 stitutes no contra-indication to the use of wine and opium. 
 
 7thly. The state of the pulse requires to be duly considered. 
 Its frequency is not of much importance, for I have seen wine 
 and opium prove highly serviceable in all its varieties, from 70 
 to 130, or even upwards. No one would ever think of exhibiting 
 these remedies when the pulse is strong, and more particularly 
 when it is strong and hard ; but the case is otherwise when 
 it possesses only a certain degree of hardness, and is at the 
 same time small and thrilling, not resisting compression with 
 the force the sensation of its hardness leads us to expect. 
 
 Such are the chief observations I have made on the particular 
 circumstances and symptoms supposed capable of throwing light 
 on this important practical question. They may serve to prevent 
 the student from being misled by rules of practice dogmatically 
 deduced from the observations of any single symptom, and may 
 lead him to turn his attention more accurately to the previous 
 progress of the fever, and the general state of the j^atient. It is 
 almost superfluous to add that, when any doubts exist concerning
 
 ADMINISTRATION OF WINE IN FEVER. 295 
 
 the propriety of giving wine and opium in fever, tbey should not 
 be tried unless their effects be carefully watched by the physician 
 himself. 
 
 Permit me next to call your attention to some of the sequelae 
 of fever, and first to some points connected with sudden and 
 violent delirium succeeding maculated typhus fever. It may be 
 doubted whether any writer has illustrated with sufficient details 
 the fact that delirium of a most violent and dangerous description 
 sometimes suddenly supervenes in patients who, to all appear- 
 ance, have passed favourably through the various stages of 
 maculated fever. I published on a former occasion the case of a 
 student in Trinity College, who was thus attacked on the 
 eighteenth day, at a time when he seemed to have passed the 
 crisis favourably, his pulse having fallen to 60, and all other 
 symptoms of fever having disappeared ; since that observation 
 was made, I have seen so many cases of a similar description, 
 that I think it right to impart whatever additional experience has 
 taught me concerning the history and treatment of this singular 
 species of delirium. It will appear evident, from the nature of 
 the means successfully employed in treating this affection, that 
 it has little or no affinity to the delirium which, in the first 
 stages of fever, so often accompanies true inflammation or con- 
 gestion of the brain, but is rather allied to delirium tremens, 
 delirium traumaticum, and acute puerperal madness. As in each 
 of these the delirium is preceded by the operation of some cause, 
 which acts unfavourably on the nervous system ; so in the 
 delirium we are now about to consider, the pre-existence of fever 
 may be assumed to act in a similar manner. Neither does 
 maculated fever seem more inadequate to produce so serious an 
 effect, than the act of parturition, the presence of a wound or 
 fracture, or the long-continued abuse of intoxicating liquors ; for 
 no severe typhus fever ever runs its course without bearing 
 heavily on the nervous system. The facts I am to relate ought 
 to make physicians extremely cautious about pronouncing fever 
 patients out of danger ; for even after a crisis, occurring in due 
 time, and apparently the most satisfactory and complete, delirium 
 may suddenly arise, and may place the patient in the greatest 
 peril, the physician having, perhaps, taken his leave, in the full 
 assurance that his visits were no lon<'er necessarv.
 
 296 CLINICAL MEDICINE. 
 
 Four years ago I attended, with the late Mr. King, a gentle- 
 man in Grafton Street, who had fever without any remarkable 
 symptom, or anything that required the adoption of active mea- 
 sures. He had maculae, it is true, but the patient was young, 
 and went through the disease favourably ; on the sixteenth day 
 his pulse had fallen to sixty, and all danger seemed over. He 
 had no thirst ; his tongue was moist ; eyes clear ; and not the 
 slightest headache, or appearance of cerebral determination : in 
 fact, when I visited him on the morning of the seventh day, 
 everything betokened a speedy recovery. I must observe, how- 
 ever, that in this, as well as in most cases of the kind I have 
 witnessed, there was a certain degree of nervous excitement 
 present, tending to produce want of sleep, and consequently on 
 leaving him at my evening visit, I directed the nurse to give him 
 an opiate draught. This was unfortunately omitted ; the young 
 gentleman became gradually more restless and agitated, began to 
 rave, and was found by Mr. King, next morning, in a state of 
 high delirium. His pulse was still rather slow, not more than 
 60 in a minute ; his skin was cold ; his countenance collapsed ; 
 and he had been during the night wholly sleepless. We had 
 great difficulty in managing this patient ; and it was only by 
 means of great attention, stuping his legs, a nutritious diet, 
 wine, and black drop, exhibited freely and repeatedly, that his 
 life was saved. 
 
 Another case of the same kind, and calculated to excite great 
 interest, was that of a pupil of the Meath Hospital. This gentle- 
 man was attacked with the prevailing fever, and like most 
 patients, exhibited maculae about the fifth day. There was, 
 however, nothing very remarkable in his disease, no symptoms 
 of anomalous character, or of a severity requiring very active 
 measures. When first attacked, he felt rather nervous ; but 
 this was very little to be wondered at in a person who had been 
 studying intensely for a considerable time. 
 
 At a very early period he exhibited a tendency to tremors and 
 subsultus tendinum ; but all his other symptoms were mild, and 
 by strict attention, and the kind care of his fellow-students, he 
 went through the disease favourably, and appeared quite free 
 from danger on the sixteenth day. On the seventeenth day I 
 found him, at my morning visit, in a very promising condition, 
 his pulse down to 60 ; his tongue moist ; his skin of a natural
 
 ADMINISTBATION OF WINE IN FEVER. '297 
 
 temperature ; and his eye clear, and nothing present but a cer- 
 tain degree of nervous excitement. To counteract this tendency 
 the hite Dr. M'Dowel and I had found it necessary to give him 
 every night an enema containing twenty-five drops of tincture of 
 opium. Unfortunately this was omitted for one or two nights 
 about this period. The fever resolved itself ; but resolved itself 
 during the period of sleeplessness, and a certain degree of nervous 
 excitement. I saw him on the morning of the eighteenth ; I 
 thought there was a good deal of anxiety and quickness of 
 manner about him, with some slight increase in the muscular 
 tremors. I therefore wrote to Dr. M'Dowel, and begged him 
 to see that he took his opiate that night. Before this was done, 
 he grew much worse ; in the evening he became highly excited, 
 then quite delirious, and towards morning it was necessary to 
 call in the assistance of three or four persons to keep him in bed. 
 Dr. M'Dowel continued to attend him with great care and skill, 
 and had sufiicient influence over him to make him swallow the 
 requisite medicines, which no one else could. Opiates were at 
 first tried, but failed ; we then commenced with the free exhi- 
 bition of tartar emetic, and extract of belladonna ; in the course 
 of twenty-four hours he took five or six grains of the latter ; we 
 afterwards omitted the tartar emetic, and substituted black drop 
 in its place : this succeeded, and after a violent attack of delirium, 
 which lasted for thirty-eight or forty hours, he fell into a deep 
 sleep, from which he awoke refreshed and rational. It was 
 necessary, however, to repeat the narcotics for several nights, and 
 they were not omitted until his convalescence became so confirmed 
 as to remove any apprehension of a relapse. 
 
 Here are two cases in which the disease declines, and the 
 patient is regarded as nearly convalescent, when suddenly 
 cerebral symptoms of a most alarming character manifest them- 
 selves. The fever subsides, but with nervous excitement and 
 insomnia, circumstances which have been long observed as 
 characteristic of an imperfect crisis. The point, however, to 
 which I wish to direct attention is, that a person not thoroughly 
 acquainted with the nature of this affection might be led into a 
 very important error. He might, perhaps, suppose this to be 
 inflammatory excitement, to be treated by leeches, cold to the 
 head, and other antiphlogistic measures. In the first case, 
 indeed, the symptoms were so violent that I advised leeching ;
 
 298 CLINICAL MEDICINE. 
 
 but Dr. M'Dowel did not apply them, and perhaps it was well 
 that he did not. I do not mean to say that leeches and the 
 antiphlogistic treatment are never indicated in the delirium 
 which occurs at an advanced period of maculated fever, or in 
 that which follows the stage in which the pulse falls to the 
 natural standard, and thirst ceases, and the skin grows cool. 
 Such an assertion would lead, in some instances, to an injudicious 
 and even dangerous method of treatment ; for cases do occur 
 where, under these circumstances, topical antiphlogistic measures 
 are absolutely called for. My object in making these remarks is 
 to point out, not the rule, but the exceptions, the numerous 
 exceptions to the method of treatment usually employed. In 
 the delirium I am now describing, the feet and legs must be 
 constantly stuped, the head must be diligently sponged with 
 warm water and vinegar, the bowels relieved by injections, while 
 opium is exhibited by the mouth or in lavements ; where there 
 is warmth of the scalp, and the temporal arteries full, leeches 
 are required, but where the scalp is not hotter than natural, they 
 would prove hurtful ; in a state of collapse, wine may be neces- 
 sary ; blisters to the nape or head seem to increase the delirium. 
 When leeches are indicated, their good effects are much enhanced 
 by combining tartar emetic with the opium, provided no diarrhoea 
 or other symptom of abdominal irritation can be detected. 
 
 The next case is even more remarkable than the preceding, 
 for the delirium came on quite suddenly and without any premo- 
 nitory symptom, and did not commence for several days after 
 the fever had entirely ceased, which it did about the seventeenth 
 day ; neither was the termination, in this instance, rendered 
 suspicious by any previous want of sleep. 
 
 Mr. was attended by Dr. Brereton, who found him 
 
 labouring under the usual symptoms of fever, which commenced 
 about the 27th of January, 1835. He was a young man of 
 excellent constitution, and temperate, active habits : soon after 
 the commencement of the disease, some bronchitic symptoms 
 appeared, and at the usual time the maculated eruption was 
 observed. Nothing remarkable occurred until towards the 
 fourteenth day, when a notable and steady improvement com- 
 menced, and consequently I left off my attendance, having been 
 called in about the seventh day of the disease. As the patient's 
 constitution was sound, his friends were not likely to permit any
 
 ADMINISTRATION OF WINE IN FEVER. 299 
 
 error of diet, and I did not anticipate a relapse, especially as 
 there bad been no serious affection of tbe brain, cliest, or bowels 
 during the course of tbe fever. I left him cool, cbeerful, and 
 self-possessed, bis pulse regular, about sixty in the minute, and 
 head entirely free from pain or flushing ; bis tongue had become 
 clean ; thirst gone, and appetite returning. All these particulars 
 were of the most encouraging description, and were not counter- 
 balanced by any symptom indicative of the fast approaching 
 danger. On the following day, the eighteenth from the begin- 
 ning of bis fever, I was again sent for in haste, and found that 
 the patient had become suddenly and outrageously delirious during 
 the night, an occurrence which seemed the more surprising, as 
 no other symptom existed denoting a return of fever. This 
 gentleman's life was saved with great difficulty, for the delirium 
 continued several days, and was at last only appeased by con- 
 siderable doses of tartar emetic, combined with musk and opium. 
 There is one fact connected with the history of fever which 
 should never be forgotten by those who are occupied in its treat- 
 ment : I allude here to the occurrence of sudden accidents, or 
 the supervention of other diseases, producing a material altera- 
 tion in the circumstances of the case, and leading to new and 
 more alarming dangers. You should not divest yourselves of all 
 further anxiety for the patient, or relax in your attentions, 
 because the fever has exhibited a tendency to decline, and a 
 favourable crisis has taken place : crisis may occur, and con- 
 valescence may be established, and yet the patient may relapse, 
 or he may be struck down again by the unexpected incursion of 
 a new and dangerous malady, or he may expire suddenly in the 
 course of a few minutes. The functions of the brain and heart 
 may suddenly give way, and death may take place unexpectedly 
 and at once. Thus, it not unfrequently happens that a patient 
 during his convalescence falls into a state of syncope, from 
 remaining too long in the erect posture, and if assistance be not 
 promptly afforded, life is speedily extinguished. In the state of 
 debility which follows acute and exhausting diseases, and where 
 the patient is very liable to syncope, tbe most assiduous attention 
 is required. During tbe epidemic of 1826, death took place 
 under such circumstances in five or six instances, and the conva- 
 lescents lost their lives from incautiously sitting up or walking 
 about the room too long, or attempting to reach the night-chair
 
 300 CLINICAL MEDICINE. 
 
 without assistance. There are many other causes capable of 
 producing a sudden and alarming change in the state of conva- 
 lescents from fever. One of the most obvious of these is error 
 or excess in diet, which is apt to bring on a return of the fever 
 in an aggravated form, accompanied by symptoms of gastro- 
 enteric inflammation, and sometimes terminating fatally in 
 forty-eight hours. 
 
 I shall now proceed to lay before you a sketch of a very 
 important form of disease which attacks convalescents from 
 fever, and runs a course of remarkable intensity and rapidity. 
 I am not aware that this form of disease has been described by 
 pathological writers : the nearest approach to a description of it 
 is an account of the swelled leg which occurs after fever, given 
 by a Glasgow physician. Dr. Stokes and I have given a descrip- 
 tion of a swelled leg after fever, as observed during the epidemic 
 of 1826, but the important and fatal form of the disease which I 
 am about to describe, did not come under my notice until within 
 a more recent period. 
 
 Before the commencement of the present session, a fine young 
 woman, aged twenty-four, previously healthy and robust, was 
 admitted into our fever ward. She was admitted on the 26th 
 of September, having been at that time eight days ill, and 
 labouring chiefly under gastric and cerebral symptoms. Her 
 treatment consisted in the application of leeches to the epigas- 
 trium and head, cooling drinks, and blue pill combined with 
 James's powder. Under the use of these and other appropriate 
 remedies, the fever declined, and on the 1st of October the 
 cerebral and gastric symptoms had disappeared, and the patient 
 complained merely of a slight degree of feverishness. On the 
 2nd of October she was seized with rigors and horripilation, 
 followed by intense pain of the left mamma, accompanied by 
 numbness and loss of power of the corresponding arm. She was 
 leeched with some relief, but passed a sleepless night, and next 
 day an oblong patch of redness was seen extending upwards 
 from the nipple ; the pain was still violent, and she could not 
 bear the slightest touch on the affected parts. The breast was 
 leeched again, and fomented assiduously during the day. On 
 the fourth the erysipelas was spreading, and the pain was still 
 agonizing. She screamed out whenever it was touched, and 
 could not bear even the weight of her dress or covering. On
 
 ADMINISTRATION OF WINE IN FEVER. 301 
 
 examining the breast, no enlargement or hardness could be 
 observed ; there was no remarkable heat or tension, and with 
 the exception of a slight erysipelatous redness, and pain rivalling 
 that of tic douloureux in severity, there was nothing to indicate 
 the presence of the disease. The left arm continued numb and 
 powerless. 
 
 This state of things was accompanied by remarkable increase 
 of fever, as manifested by foul tongue, accelerated pulse, and 
 sleepless nights. She now began to complain of dull pain in 
 the calf of the right leg, aggravated by pressure or motion, but 
 not attended with any apparent increase of heat, swelling, or 
 induration. On the fifth she is reported to have passed a 
 sleepless night, although the watery extract of opium had been 
 administered freely on the preceding day and evening ; the 
 erysipelatous redness had extended nearly as high as the clavicle, 
 and the affected parts had now begun to swell considerably. On 
 the sixth she is stated to have had some sleep, and the erysipelas 
 was extending, in some parts covered with vesicles. She again 
 complained of cramps in the right leg, and on making an 
 examination we found considerable tenderness on making deep 
 pressure, but no external indication of disease. Her debility 
 was increasing, accompanied by a tendency to looseness of 
 bowels, for which she was ordered enemata of sulphate of quina 
 and laudanum. On the following night she was attacked with 
 intense pain in the leg, accompanied by exquisite tenderness to 
 the touch, but no redness, swelling, or increase of temperature. 
 The erysipelatous affection of the breast had now become pale, 
 and ceased to spread. The enemata were continued, the parts 
 dressed with mercurial ointment and extract of belladonna, and 
 wine freely allowed. 
 
 She passed the night in great agony from the intense pain in 
 the leg, and complained of frequently recurring rigors followed 
 by perspiration. She also stated that for the last two or three 
 days she had experienced repeated attacks of tremor in the 
 affected limb ; one of these tremors attacked the limb on the 
 night of the eighth, and continued for three or four hours, 
 terminating in copious general perspiration. These increased 
 on the following day, attended with increase of fever, thirst, and 
 debility, and the pain in the leg continued with unabated violence. 
 It is worthy of remark that at this time there was no erysipelatous
 
 302 CLINICAL MEDICINE. 
 
 redness or discolouration of the affected limb, and scarcety any 
 swelling. On the ninth she is reported to have passed the night 
 screaming and sleepless, she vomited three or four times, com- 
 plained of intense pain in the abdomen, and had a violent rigor 
 which continued from one o'clock to six in the morning, followed 
 by profuse perspiration. The right leg continued exquisitely 
 painful as before, became somewhat swollen, and its veins 
 appeared more prominent than natural, but there was no dis- 
 colouration of the integuments. Both arms were now painful on 
 motion, and the left leg became painful and tender on pressure. 
 Under this complication she sank rapidly, and died at three 
 o'clock in the afternoon. 
 
 On dissection, purulent matter was found under the integu- 
 ments covering the left breast, but the gland itself appeared 
 healthy. There was no vascularity nor other traces of peritoneal 
 inflammation, and the abdominal viscera were healthy. The 
 right leg was infiltrated ; its veins were pervious and elastic, but 
 their internal coat exhibited a rose-coloured tinge. 
 
 Here, then, we have a very remarkable and formidable train of 
 symptoms, arising without auy obvious cause, running a rapid 
 and fatal course, and exhibiting a character of singular intract- 
 ability. From all that we had previously seen or heard, this 
 young woman's constitution was robust and healthy, her fever 
 had been treated successfully, and she appeared to be getting 
 over it without any sinister accident, or any complication capable 
 of disturbing her convalescence ; yet at this period she is 
 attacked with fever of a new type, accompanied by local affec- 
 tions of the breast and extremities, which run a rapidly fatal 
 course, and exhibit phenomena of a new and extraordinary 
 character. She is first attacked with erysipelas of the left 
 mamma, accompanied by pain and loss of power of the cor- 
 responding arm ; then she gets exquisite pain of the right leg, 
 and then of the left leg and right arm ; in fact the whole four 
 extremities are more or less implicated. 
 
 Now by what name should we designate this affection, or what 
 would be the most appropriate term to apply to it ? Was it 
 phlebitis, or erysipelas, or phlegmasia dolens ? The affection of 
 the mamma certainly resembled erysipelas, but differed from it 
 in the agonizing character of the pain, and I have already 
 observed that in the legs or arms there was no appearance of
 
 ADMINISTRATION OF WINE IN FEVER. 303 
 
 redness or discolouration. That it was pure phlebitis I think we 
 are not authorized in concluding, from the phenomena observed 
 on dissection. There was no pus in the veins (an occurrence 
 which might naturally be expected from the acute character of 
 the disease), no thickening or induration, the coats of the veins 
 were elastic, and to all appearance healthy, with the exception 
 of a rose-coloured tinge. Now considering the previous state of 
 the woman's system, I do not think that we can conclude as to 
 the existence of pure phlebitis on such slight grounds, or say that 
 the whole group of symptoms which characterized the secondary 
 attack depended solely on inflammation of the veins. 
 
 The disease of which I speak simulated in many points 
 phlegmasia dolens, but diflered from it in the phenomena 
 observed in the breast, as well as its more general effusion, and 
 the absence of that peculiar whiteness of the afl:ected limb which 
 characterizes the latter afi'ection. It appears to be a form of 
 disease resulting from the generation of a morbid j)oison in the 
 system, and manifesting itself in diffuse subcutaneous inflamma- 
 tion of a low and cachectic nature, affecting^primarily the skin 
 and subcutaneous areolar tissue, and afterwards involving all 
 the subjacent parts more or less according to their different 
 susceptibilities. It was accompanied from the commencement 
 by increased irritability of the muscular and cutaneous nerves ; 
 indeed in the case just detailed, the nerves appear to be parts 
 primarily affected. Another remarkable circumstance connected 
 with this case is the loss of power observed in the affected limbs. 
 In all cases where a severe and painful afiection of the nerves is 
 present, you have more or less loss of power, but as far as my 
 observation has gone, there appears to be a difference in the 
 derangement of muscular motion connected with painful affections 
 of large nervous trunks, and that which accompanies an affection 
 of the terminating fibrils or nervous extremities. In the latter 
 case the degree of paralysis is always more considerable ; of this, 
 phlegmasia dolens affords a good illustration. In this disease 
 the extremities of the nerves are chiefly aflected, and the loss of 
 power is always greater than when a large nervous trunk is 
 affected, as for instance in sciatica. In the latter affection the 
 pain is often extremely violent, but the motion of the limb is 
 never so much impeded as it is when the nervous extremities are 
 the parts chiefly engaged.
 
 304 CLINICAL MEDICINE. 
 
 You perceive, then, that the aflfection which I have just 
 described consists in the development of low, malignant, and 
 irregular inflammatory affections in various parts of the body, 
 but particularly in the extremities, commencing probably in the 
 subcutaneous areolar tissue, but subsequently extending to all 
 the neighbouring parts, and exhibiting many of the characters 
 of those inflammations which result from the presence of an 
 animal poison in the system. A peculiar feature of this affec- 
 tion, also, is the intense neuralgic pain which accompanied it, 
 and I think it might with some propriety be designated as 
 neuralgic diffuse inflammation after fever. It is accompanied 
 by fever of a peculiar type, ushered in by rigors, and cha- 
 racterized by remarkable derangement of the digestive canal, 
 debility, and sleeplessness. A point, also, which deserves 
 notice in this case was the recurrent rigors and perspirations, 
 marking the occurrence of new and additional mischief, and 
 indicating the malignant and intractable nature of the disease. 
 
 One word as to the connexion of this disease with phlebitis. 
 Some pathologists are of opinion that phlegmasia dolens and 
 swelled leg after fever are nothing more than modifications of 
 phlebitis. I cannot, I must confess, agree with this opinion, 
 nor am I prepared to admit that the symptoms in the foregoing 
 case were referable to mere inflammation of the veins. I do not 
 deny that the veins may be affected, but phlebitis is not the first 
 link in the morbid chain, and is itself merely a consequence of 
 the same unknown cause which determined the inflammation of 
 other tissues. I beg leave to observe here that the affection I 
 have just described seems like others capable of existing in very 
 different degrees. Thus, I have seen some instances in which 
 there was no other symptom but severe pain of the extremities, 
 generally about the calves of the legs, and which was relieved by 
 warm fomentations and mild aperients. Again, I have seen, in 
 addition to this symptom, swelling and tenderness of the legs, 
 which, however, generally yielded to leeching and other appro- 
 priate means. Probably we are authorized from this and other 
 facts in concluding that the disease is not always of a malignant 
 and fatal character, and that there are at least certain forms of 
 it amenable even to simple and ordinary treatment : you should, 
 however, be always on your guard when patients recovering from 
 fever are attacked with pain, in the lower extremities particularly,
 
 ADMINISTRATION OF WINE IN FEVER. 305 
 
 as this symptom not uufrequently ushers in a serious and 
 alarming disease. 
 
 The next case of this disease observed in our wards occurred 
 also in a young woman, named Dillon, aged 23, and apparently 
 of good constitution. She was admitted into the fever ward on 
 the 2nd of September, being at that time about seven or eight 
 days ill. She had on admission the usual symptoms of fever, 
 accompanied by intense bronchitis, dyspnoea, costiveness, and 
 loss of sleep. Under the use of cupping, blisters, calomel, and 
 other appropriate means, the fever and pulmonary symptoms 
 declined, and she was pronounced convalescent on the 12th. 
 On the 18th she had been up as usual, but towards evening 
 complained of rigors, and said she felt her right leg very painful. 
 The pain of the limb continued next day, intermitted during the 
 following night, but returned on the morning of the 20th with 
 increased violence. She was leeched without much relief, and 
 on the 21st she is reported to be extremely feverish, her pulse 
 frequent, her tongue foul, bowels loose. She had passed a bad 
 night, and the leg was still exquisitely painful and somewhat 
 swollen. She had twelve leeches again applied with some 
 relief, but on the 22nd the left shoulder became similarly 
 affected with pain, and so tender as not to admit of the slightest 
 pressure. On the 23rd there was some diminution of pain in 
 the leg and shoulder, but her pulse was jerking and unequal ; 
 her tongue parched ; her countenance anxious ; and she com- 
 plained of intense pain in the small of the back. She passed a 
 sleepless night, and next day complained of exquisite pain in 
 the left lower extremity. This was accompanied by an ex- 
 acerbation of the febrile symptoms ; she moaned constantly ; 
 her pulse became excessively feeble and rapid ; and she died on 
 the 24th. 
 
 On dissection, the peritoneum, particularly that portion of it 
 attached to the abdominal parietes, was found remarkably 
 vascular, the vascularity being most intense over the hypogastric 
 region. There was no effusion of lymph or serum, but about 
 half an ounce of purulent fluid was discovered in the cavity of 
 the pelvis. The viscera were healthy. The internal surface of 
 the principal venous trunks was tinged red, and there was a 
 small quantity of coagulated blood in their cavities. On making 
 an incision into the right leg, along the course of the internal 
 VOL. I. 20
 
 306 CLINICAL MEDICINE. 
 
 saphena, the subcutaneous areolar membrane was found infil- 
 trated with sero-sanguineous fluid ; the texture of the veins was 
 here apparently natural, their cavity pervious and filled with 
 fluid blood, without any lymphy or purulent admixture. No 
 distention or enlargement of the lymphatics was observed. 
 
 Here you have a case corresponding in its main points with 
 the former, and differing from it chiefly in being complicated 
 with peritoneal inflammation and synovitis of the shoulder- 
 joint. Its origin was similar ; it exhibited the same kind of 
 intense neuralgic pain ; the same fever ; the same extensive 
 diffusion of local inflammation, and the same unfavourable ter- 
 mination. The chief points of diff"erence were that in the latter 
 case the disease attacked the synovial membrane of the shoulder- 
 joint, and the serous membrane of the abdominal cavity. This, 
 however, is by no means unusual. As to the synovitis, I have 
 observed it in more than one instance after fever. I have wit- 
 nessed a very remarkable instance of it in a man in this hospital 
 who was attacked with swelled leg after fever. In addition to 
 the affection of the leg, he had also synovitis of the knee-joint 
 of so severe and intractable a character that he recovered with 
 diflftculty, with an anchylosed state of the joints. On the whole, 
 the disease which we have been considering is one of great im- 
 portance, and deserves particular attention. It is sometimes 
 of a very unmanageable character, and baffles our best directed 
 efforts. The treatment which appears best adapted for it con- 
 sists in leeching, fomentations, and the application of mercurial 
 ointment with extract of belladonna to the affected parts : these 
 combined with the internal use of quina and opium, with occa- 
 sional doses of calomel, seem to comprise the chief remedies on 
 which we can place any reliance. 
 
 Before I conclude this lecture I shall allude briefly to the very 
 interesting case of Sarah O'Neil, This young woman was ad- 
 mitted on the 17 th of February, having been attacked on the 
 10th with fever of the ordinary type. On the day after her ad- 
 mission she complained of want of sleep, and pain of the forehead 
 and temples ; but she had no raving, tinnitus aurium, intolerance 
 of light, or other symptom of inflammation of the brain. She 
 had been confined about a fortnight before she came in, and com- 
 plained that her breasts were very troublesome to her. Her belly 
 was soft and fallen, quite free from tenderness or soreness, and
 
 ADMINISTRATION OF WINE IN FEVER. 307 
 
 she stated that her bowels were free. Her tongue was furred, 
 her pulse 130, the lochia suppressed for the last two davs. 
 Things went on tolerably well for four or five days, when her 
 belly became tympanitic, she began to complain of pain on 
 pressure. The action of the heart now became more violent ; 
 her pulse rose to 140, and blood began to appear in her stools. 
 On the 24th of February — that is to say about the fourteenth day 
 of her illness — her pulse was 150 ; she passed a large quantity 
 of blood from the bowels, and the tympanitis subsided. 
 
 In cases of fever accompanied by tympanitis and signs of 
 intestinal congestion, hemorrhage from the bowels, particularly 
 when it occurs on one of the critical days, should not be interfered 
 with. It is in this way that nature very frequently brings about 
 relief of the congestion and irritation of the gastro-intestinal 
 mucous membrane, just as she relieves congestion of the head 
 by bleeding from the nose. In the case of a lady whom I 
 attended along with Mr. Palmer, some time ago, at Drumcondra, 
 the occurrence of intestinal hemorrhage was followed by the most 
 marked effects; her belly became soft, the tympanitis disappeared, 
 and all her febrile symptoms were speedily removed. The 
 appearance of blood, therefore, at such periods and under such 
 circumstances, is to be looked on as a favourable occurrence; nor 
 should it be interfered with in any way until, from its con- 
 tinuance or its quantity, it appears likely to produce debilitating 
 effects. 
 
 In the present case, however, this hemorrhage will require to 
 be very carefully watched. The woman's system is that which 
 is favourable to profuse fluxes of blood, for it is not long since 
 her accouchement, and she has suppression of the lochia. She 
 has had but little fever for the last two or three days, but the 
 action of the lieart still continues extremely violent, and her 
 pulse is still rising. Respiration, too, has been considerably 
 accelerated, and, where this occurs, you have always reason to 
 apprehend danger. I have accordingly endeavoured to moderate 
 the hemorrhage by the use of acetate of lead and opium. A 
 draught composed of acetate of lead, eight minims of tincture of 
 opium, and fifteen minims of wine vinegar, in six drachms of 
 water, has been prescribed to be taken as occasion requires. A 
 large blister has been applied, so as to cover the epigastrium 
 and sternum, and she has been allowed port wine and chicken
 
 308 CLINICAL MEDICINE. 
 
 broth. Where a patient, debilitated by previous fever, has been 
 attacked with hemorrhage, you should be careful in supporting 
 the system by small quantities of wine and light nutritious food; 
 for there is always more or less danger to be apprehended of a 
 sinking of the powers of life. In cases of this kind the cautious 
 use of acetate of lead, with opium and wine, are the only means 
 on which we can rely with any confidence.
 
 300 
 
 LECTURE XX. 
 
 NERVOUS FEVER. — CAUTION AS TO PROGNOSIS. — PRESCRIPTIONS IN 
 FEVER. CONCLUDING REMARKS. 
 
 Permit me to make one or two observations on a case of which 
 I have ah-eady spoken, and which, as I expected, has terminated 
 fatally. A man named Lynam has been lying ill for a long time 
 in a large fever ward; I wrote at the top of his card " Nervous 
 Fever," and remarked to the class that his disease was pure 
 fever, of a nervous type, unaccompanied by any symptoms 
 indicating decided local inflammation. You will recollect that 
 his symptoms were heat of skin, quick, weak, compressible pulse, 
 thirst, watchfulness, and low muttering delirium, unattended 
 with any appreciable sign of visceral disease, or any symptoms 
 denoting a putrescent state of the fluids. It was not congestive 
 or putrid, or gastro-enteric, or petechial fever ; neither could it 
 be called a cerebral fever ; it was only by separating from it the 
 idea of each of these species, and by studying its negative 
 characters, that you could arrive at something like an accurate 
 conception of the type of the disease. It was, as I have already 
 stated, nervous fever, modified by the patient's previous habits 
 of long-continued intemperance. When a patient addicted to 
 intemperate habits gets an attack of fever from cold, fatigue, or 
 exposure to contagion, you will generally find the disease exhibit 
 a compound or mixed character, the phenomena of fever being 
 combined with those of delirium tremens. And so it was in 
 this case ; the man had general tremors, with persistent watch- 
 fulness, and muttering delirium. 
 
 His treatment consisted in the employment of medicines 
 calculated to soothe the nervous system, and I kept a constant 
 watch over the state of the principal viscera. About a week 
 after he came under my care, and about five weeks from the com- 
 mencement of his fever (for he was nearly a month ill before he 
 came to the hospital), he was attacked with erysipelatous inflam- 
 mation of the face and scalp. The disease commenced on the
 
 310 CLINICAL MEDICINE. 
 
 face, and, travelling upwards, very rapidly attacked the whole 
 scalp and back of the neck, its progress being accompanied by 
 great aggravation of symptoms. At that time I remarked to the 
 class that I did not entertain any apprehension of a metastasis of 
 the erysipelas, that 1 had no fears of the supervention of inflamma- 
 tion of the brain, and its train of alarming consequences, but that 
 no good was portended by this attack of cutaneous inflammation, 
 •and no relief of the internal parts could be expected from it, for 
 every symptom appeared aggravated from the moment that the 
 erysipelas commenced. I pointed out the total inadmissibility of 
 anything like vigorous or antiphlogistic treatment, in a case where 
 the disease had appeared in an individual of broken constitution, 
 fabouring under a combination of delirium tremens with low 
 fever ; and said that even the remedy which we had found most 
 successful in similar cases, namely, sulphate of quina and opium, 
 offered but a feeble hope of arresting the malady. It failed, as 
 we expected, and the man died yesterday, worn out by long suffer- 
 ing and exhaustion. Eighteen hours after death we made a 
 most carefal examination of all the viscera of the three great 
 cavities ; not a single organ exhibited the least mark of inflam- 
 mation ; we could not find anywhere even the slightest trace of 
 local congestion. The man had all his viscera in an apparently 
 sound and normal condition, and died of pure nervous fever. 
 
 Some persons look upon the existence of fever independent of 
 topical affections as purely imaginary, and deem those who have 
 recorded such forms of disease as too ignorant or too lazy to 
 make the necessary pathological investigations, I have not time 
 at present to enter into this subject, but of nothing am I more 
 convinced, than that fever may exist without any appreciable 
 local lesion, that it may affect every organ and every tissue of 
 the body alike, and yet that the most accurate symptomatologist 
 cannot put his finger on any one single part and say, here is 
 local inflammation of a decided character. I have met with 
 many instances confirmatory of this fact in hospital practice. I 
 recollect a case which occurred some time ago at this hospital, 
 which was equally as remarkable for its extraordinary duration, 
 as for the total absence of anything like visceral lesion. The 
 patient was admitted into the small fever ward, laboui-ing under 
 an attack of nervous fever ; he had thirst, hot skin, pulse from 
 110 to 120, occasional delirium and watchfulness, and these
 
 NERVOUS FEVER. 311 
 
 symptoms went on week after week, and month after month, 
 unaccompanied, during the whole course of the disease, by any 
 phenomena indicating the existence of local inflammation. His 
 treatment was purely expectant and temporizing ; we had no 
 cerebral, abdominal, or thoracic lesion to combat ; there was no 
 organ in which the febrile derangement could be said to have 
 fixed itself exclusively, no threatening disorganization calling for 
 the employment of prompt, new, and energetic means. At last, 
 after the fever had continued for very nearly three months, the 
 man complaining all the time of more or less thirst, hot skin, 
 watchfulness, and headache, with occasional delirium, the disease 
 terminated in a well-marked crisis, accompanied by sweating. 
 He fell asleep, began to perspire, awoke with a pulse nearly 
 reduced to the natural standard, and perfectly recovered. I may 
 observe that I have never seen fever last so long as this, nor 
 have I ever observed a perfect crisis in any case after the forty- 
 second day. Some time ago I attended the brother of a gentle- 
 man now present, who had a long and very severe attack of fever; 
 though he never had a remission during his illness, and was in 
 very urgent danger, he got a perfect crisis Avith profuse perspira- 
 tion on the forty-second day, and is now in the enjoyment of 
 excellent health. 
 
 You perceive, then, that the case of Lynam presents some 
 circumstances worthy of notice. His fever went on to its 
 termination without any symptoms of inflammation in any 
 viscus, and his actual condition, as carefully ascertained by an 
 accurate post-mortem examination, affords a useful lesson to 
 the pathologist. His case is also interesting as showing how 
 previous habits will modify in a remarkable degree the character 
 of fever ; for in him you have seen fever combined with the 
 phenomena of delirium tremens, a state of things which it was 
 natural to expect in a man of extremely intemperate habits. 
 The termination of the erysipelas without any sign of disorgani- 
 zation within the cranium is also worthy of notice. In such 
 cases you have it frequently followed by inflammation of the 
 brain and its membranes, and an exudation of pus on the 
 surface of one or both the hemispheres ; but here you perceive 
 that there has been no extension of the disease, nor anything 
 that should have induced us to give up the plan of treatment we 
 adopted, and direct our therapeutic means to the head.
 
 312 CLINICAL MKDICINK. 
 
 There is another man, named Vero, in the fever ward, whose 
 case I heg you will study with attention. He applied for admis- 
 sion here some time ago, labouring under violent and general 
 bronchitis, accompanied by high inflammatory fever ; we took 
 him in at the time, as his case was one of the most urgent 
 danger, but were obliged, by the crowded state of the hospital, 
 to put him into the large fever ward. It is unnecessary for me 
 to detail the treatment employed, as you have all witnessed it. 
 By the most energetic measures, we succeeded in arresting the 
 disease, but his convalescence was rendered tedious in conse- 
 quence of his having been suddenly affected by a small quantity 
 of mercury. His mouth became very sore, his breath foetid, his 
 gums spongy, the inside of his lips covered with lymph, and his 
 system exhibited all the marks of mercurial irritation ; but, under 
 the care of Mr. Grady, a gradual but decided improvement in his 
 condition was going on, and he was advancing rapidly in conva- 
 lescence, when, unluckily for himself, he was persuaded to leave 
 the hospital for the sake of voting at the city of Dublin election. 
 In doing this he was necessarily much fatigued, and was exposed 
 to cold on returning from the heated booth. 
 
 Now, mark the consequences of this indiscretion. This man 
 just arrived at the period of convalescence from a severe and 
 dangerous inflammatory fever, and greatly debilitated both by the 
 disease and the venesections and other remedies necessarily 
 employed, improvidently exposes himself while his frame was 
 still emaciated and weak, and while his mouth was still sore in 
 consequence of severe mercurial salivation : in this condition he 
 exposes himself to the operation of mental excitement, great 
 bodily fatigue, and cold — and what have been the consequences '? 
 — Why, that a new attack of fever immediately struck him to the 
 ground with a heavy hand, and, after an absence of ten days, he 
 returned to the hospital on the 24th of January, complaining of 
 rigors, and other symptoms indicative of commencing fever. 
 We saw him next morning, that is, before this new fever had 
 lasted more than twenty-four hours, and we found him affected 
 in a most remarkable manner ; we found him labouring under a 
 number of severe symptoms, which would have led the most 
 experienced, if asked to guess how long his fever had already 
 lasted, into the commission of a gross error, for he would answer 
 that it must be at least the eleventh day. It is, indeed, very
 
 NERVOUS FE\KR. 318 
 
 rare to find fever at once commencin}^ with symptoms such as we 
 observed on the first day in Vero. Great prostration of strength, 
 hot skin, dry tongue, pulse 108, nervous agitation, restlessness, 
 together with subsultus tendinum, were present from the com- 
 mencement. The subsultus was very remarkable, and increased 
 to such a degree, even on the second day, that Mr. Grady found 
 it very difficult to count the pulse at the wrist ; and yet, though 
 his muscular system was thus irregularly excited, and its nervous 
 influence deranged, he had not even a tendency to delirium, and 
 he slept soundly ; neither had he the least headache. 
 
 I called your attention to this circumstance at the bed of the 
 patient, and I endeavoured to impress strongly on your minds 
 how forcibly this case opposes the doctrines of those who attri- 
 bute all the nervous disturbance of every part of the system, and 
 amongst the rest subsultus, to congestion or to inflammation of 
 the brain. When the subsultus had attained to a degree of 
 violence in Vero's case such as we seldom witness, we remarked, 
 nevertheless, that he slept well, had a clear eye, without the 
 least approach to suffusion, and that he was free from headache, 
 heat of scalp, or throbbing of the temporal arteries. Neither 
 were we able to detect the slightest indicatioii of inflammation, 
 or even of congestion, in the chest or abdomen. The breathing 
 was indeed quickened, but only in proportion to the acceleration 
 of the pulse, and there was no cough or thoracic pain or uneasi- 
 ness. The belly was fallen, soft, and quite free from tenderness, 
 and there were no griping pains, flatulence, nausea, or diarrhoea, 
 and yet the patient Avas evidently very dangerously ill. Agitated 
 with subsultus, he was in a constant state of restlessness when 
 awake ; his skin was hot, his tongue dry, and his weakness was 
 sudden and excessive ; in short, he was labouring under intense 
 nervous fever. This is a rare form of disease, and one the very 
 existence of which most modern pathologists have been in the 
 habit of denying ; but, as I told you before, I have seen several 
 examples of it. 
 
 I may remark that, in the present epidemic fever,* the ter- 
 mination of the disease by a well-marked crisis never occurs. 
 Now, in the epidemic fever of which I have spoken in a former 
 lecture, and which committed such devastations in 1826, a crisis 
 was observable in the majority of the cases, and was almost 
 
 * ] 83-1— 5. '
 
 314 CLINICAL MEDICINE. 
 
 always preceded by rigors and a hot fit, attended for a few hours 
 with marked exacerbation of the symptoms, and followed by a most 
 profuse warm, general perspiration, bringing perfect relief, and 
 often so excessive that the steam of it could be seen issuing 
 forth in vapour through the blankets in which the patient lay 
 wrapped. In the beginning of the epidemic, the critical rigor 
 often took place on the fifth day, and oftener on the seventh, 
 but, as the disease continued, these short fevers, which, by the 
 bye, always left the patient very liable to relapse, entirely dis- 
 appeared ; and when the epidemic reached its acme, the crisis 
 rarely took place so early as on the eleventh day, and most 
 generally on the fourteenth or seventeenth day. 
 
 You perceive that, in judging of the truth of the doctrines 
 held by the ancients, concerning the existence of critical days in 
 fevers, an observer of the present epidemic might be led into 
 error, and might, by generalizing too hastily, arrive at the false 
 conclusion that this doctrine of critical days is totally destitute of 
 foundation. But, to return to our patient Vero, it is not very 
 difficult to explain why, in him, the moment fever was excited 
 it assumed the nervous type. He had been debilitated by severe 
 inflammatory fever and by the active antiphlogistic treatment, 
 and, above all, his nervous system had been severely tried by an 
 unexpected mercurial salivation, brought on by an unusually 
 small quantity of calomel. 
 
 You are aware that various nervous symptoms attended with 
 irregular muscular action, and simulating chorea, or paralysis 
 agitans, are frequently the result of metallic salts, whether lead 
 or mercury. For this reason, I look upon the previous mer- 
 curialization as the chief cause of the nervous type of Vero's 
 fever. In spite of all our efforts, he died exhausted on the tenth 
 day. 
 
 As long as life lasts, no matter how fatal the symptoms may 
 appear to be, you should never despair of recovery in fever. 
 You will find many examples of recovery in the most hopeless 
 cases in the lectures which I have given you on this disease, but 
 I cannot forbear quoting the following striking illustration which 
 occurred in the practice of Dr. Hudson of Navan. He consulted 
 me as to the treatment during convalescence, and I shall read 
 for you his report : — 
 
 " Miss B appears to have sickened about the 9th or 10th
 
 NERVOUS FEVER. 315 
 
 of June, 1844, but I did not see her until the 20tli. She had then 
 some very serious symptoms. She compLxmed of extreme debility, 
 had much subsultus, constant sweatings, diarrha3a and me- 
 teorism, and unusually severe headache. I ordered a few leeches 
 to be applied behind the ears, and for some days endeavoured to 
 keep the diarrhoea in check by small doses of hydrargyrum cum 
 creta and Dover's powder. It increased, however, and I applied 
 a blister over the ccecum, and gave acetate of lead until a check 
 was given it. By this time (five or six days after my first visit) 
 the head had become more seriously engaged. She had low 
 muttering, lay on her back, had involuntary evacuations, &c,, 
 and diarrhoea set in more smartly than ever. I applied a blister 
 to the nape of the neck, gave port wine in small quantities 
 pretty frequently, and decoction of bark, with aromatic confec- 
 tion, and occasional doses of musk and camphor. I ceased 
 giving acetate of lead by the mouth, and ordered an enema of 
 four grains of the acetate and four drops of laudanum to be 
 given on each return of the diarrhoea. This treatment gave it a 
 final check, and though the poor patient's weakness was now 
 extreme, still I had hopes that she would fight it out ; but on 
 the night of June 30th a fearful change came on. Cold skin, 
 succeeded by heat and excessive greasy perspirations, laborious 
 breathing with loud rales, fluttering pulse, at times imper- 
 ceptible, &c., &c. I was sent for early on the following morning, 
 and found her breathing loudly and hurriedly, with stertor ; 
 the eye fixed and glassy, pupils contracted to a point, face 
 bloated and livid, loud rales throughout the chest. I found 
 it not possible to arouse her to consciousness. The abdomen 
 was swelled and tympanitic to an enormous extent. She had 
 convulsive twitchings of the mouth, a commencing puft' in the 
 respiration. In fact, she seemed dying ; and as the closing 
 act of the fever seemed to be a sudden pulmonary congestion, 
 1 proposed to try the desperate chance of a bleeding, if only to 
 gain a little time for further measures. I accordingly took away 
 four ounces from the arm, and immediately applied sinapisms 
 to the spine and feet, and relays of hot flannel, sprinkled with 
 turpentine, to the belly, giving a few drops of the oil of turpen- 
 tine in brandy punch. The turgescence and livid colour left 
 the face after the bleeding, and never returned ; but in any other 
 respect, save that the breathing was a little easier, I did not
 
 31G CLINICAL MEDICINE. 
 
 see any improvement during three hours that I stayed, and I 
 left without a hope of her surviving many hours. Hearing, 
 vision, and cow^ciousncss were lost, and notlting hut the power of 
 sivallowing remained. While this continued, I directed hrandy 
 and water to be given every half hour. 
 
 " During the following night she seemed to be getting gradu- 
 ally weaker, and the pulse toward morning became irregular and 
 fluttering ; but as she continued to live on, and even began to 
 show that she saw and knew those about her, her mother again 
 sent to me, stating how she was, and leaving me to decide 
 whether anything more should be done. As the respiration still 
 continued to be laborious and accompanied by rales, I recom- 
 mended flying blisters over the course of the eighth pair which 
 you used formerly to advise in certain cases — a practice which I 
 have often seen followed by the best effects, and apparently so 
 here ; for, as I remained with the patient during the night, I 
 marked a gradual improvement as the blisters produced their 
 effect, and, though T was still most anxious about her, she was 
 nevertheless incomparably better, for the pulse became steady 
 and full, and averaged very little over 100. The breathing was less 
 hurried and laborious, though still far from easy ; the meteorism 
 had entirely subsided ; and in the morning she passed some solid 
 feces. The urine passed during the day of the 1st of August 
 was the most remarkable I ever saw. It exactly resembled 
 porter with a thick layer of chalk deposited. The horrible 
 sweat ceased, and the skin became moderately warm and soft. 
 I now withdrew my stimulants, except a little brandy punch at 
 longer intervals, and gave small doses of senega and carbonate 
 of ammonia." 
 
 From the date of Dr. Hudson's report, which closes here, this 
 young lady gradually but slowly recovered. No case could teach 
 you more decidedly the necessity for a cautious prognosis in 
 fever, and that you should never relax your treatment in despair 
 of recovery. 
 
 Before concluding the subject of fever, I wish to speak of some 
 prescriptions which I am in the habit of using. In the treat- 
 ment of fever it is frequently of importance to gain time, and 
 periods will occur in every long fever, in which there may be 
 no direct indication for the exhibition of any powerful remedy ; 
 at the same time, such is the ignorance of non-medical persons,
 
 NERVOUS FEVER. 317 
 
 and the anxiety of the patient's friends is so intense, that they 
 cannot imagine how it is possihle for an attentive physician to 
 let twelve hours pass away without doing something. The mere 
 circumstance of seeing the fever going on is sufficient proof to 
 them of the necessity of making renewed efforts for its removal. 
 This, however, is very excusable. If any of you happened to be 
 ill, I dare say you could scarcely bear to pass many hours with- 
 out taking something which you supposed might prove either 
 immediately or remotely useful. Consequently, we could not 
 treat fever in a satisfactory manner without medicines of what 
 may be termed an expectant character, and calculated to fill up 
 the spaces intervening between those periods when active treat- 
 ment is necessary. You are not to suppose that in ordering 
 such medicines you are acting a dishonest part, and practising a 
 deception unworthy of your profession ; on the contrary, you,r 
 conduct is perfectly just and proper ; and though you are con- 
 vinced that no medicine is required, still it will be necessary to 
 prescribe something, if you do not wish to lose the confidence of 
 the patient and his friends. 
 
 Again, if, at a period when you say that no medicine is neces- 
 sary, and when the patient has passed twenty-four hours or two 
 days without taking anything, an unexpected turn in his dis- 
 order should take place, people will be very apt to say, either 
 that you did not know what to do, or that you took no steps to 
 obviate the threatened change, and that one or two days were 
 completely lost. Conduct like this has frequently brought down 
 a great deal of censure on medical men. It may be said that 
 these are mere prejudices, and above the dignity of a man of 
 firm and consistent character ; but since prejudices are intimately 
 blended with human nature, and constitute, as it were, a part of 
 it, it is much better in many cases to submit to them, particu- 
 larly when compliance does not involve a sacrifice of principle. 
 In cases of acute disease of any considerable duration, and espe- 
 cially in private practice, there are periods when medicines of an 
 expectant and temporizing character must be employed ; and 
 hence the introduction of a class of remedies extensively used 
 in fever and other complaints, and generally denominated pallia- 
 tives. These are remedies which have a general tendency to 
 assuage thirst, act as diluents, gently promote the secretions of 
 the skin, intestinal canal, or kidneys, and which are known to
 
 318 CLINICAL MEDICINE. 
 
 possess at least the negative quality of doing no harm. They 
 are most commonly prescribed in combination with a consider- 
 able quantity of fluid, and hence are administered either in the 
 form of draught or mixture. The medicine in most general use 
 among the physicians of Dublin is one which was introduced by 
 Dr. Cheyne, It is prepared by dissolving a drachm of carbonate 
 of ammonia in three ounces and a half of water, with as much 
 lemon juice as will saturate it ; the mixture is then sweetened 
 with syrup of orange peel, and given in doses of two table- 
 spoonfuls every third or fourth hour. In this way a solution of 
 the citrate of ammonia is formed, which possesses the properties 
 of a mild anti-febrile and gently stimulant diaphoretic. 
 
 Now it cannot be denied that this mixture answers the purpose 
 of an expectant remedy, calculated to pass away the time, and do 
 no injury ; but it appears to labour under one considerable dis- 
 advantage, it is not agreeable to the taste. If you taste the 
 citrate or acetate of ammonia, you will find that its flavour is by 
 no means pleasant, and I need not tell you that, in cases where 
 there is no actual indication to be fulfilled, it is of importance to 
 have something that will not be disagreeable to the patient. 
 Feeling, therefore, the necessity of altering this prescription, I 
 have lately introduced another, which I am happy to find has 
 been extensively adopted, and which is formed by substituting 
 the carbonate of soda for the carbonate of ammonia. The mode 
 in Avhich I generally employ it is the following : — carbonate of 
 soda, a drachm ; water, four ounces ; lemon juice, a sufficient 
 quantity to saturate the alkali ; syrup of orange peel, half an 
 ounce ; tincture of orange peel, two drachms. A little more 
 than an ounce and a half of lemon juice will be sufficient to 
 saturate this quantity of carbonate of soda, whereas it would 
 take from two and a half to three ounces to saturate the same 
 quantity of carbonate of ammonia. If you wish to have a 
 weaker solution, and I believe it is the better way, you can 
 dissolve a drachm of carbonate of soda in five ounces of water 
 instead of four. Nothing can be more agreeable in flavour than 
 this mixture. The citrate of soda which is formed, does not, 
 it is true, exert any active influence on the animal economy, but 
 it partakes in the properties of neutral salts, determines gently 
 to the kidneys, tends to keep up a soluble state of the bowels, 
 and forms a most grateful and refreshing beverage. The syrup
 
 NERVOUS FEVER. 319 
 
 of orange peel gives the mixture an extremely pleasant flavour, 
 and this is further heightened hy the agreeable aromatic bitter 
 of the tincture. Since I commenced using it, I have found it to 
 answer all the necessary purposes extremely well, and I can 
 recommend it to you with great confidence. 
 
 A woman named Anne Scarlet was admitted on Saturday, 
 concerning whose case it may be necessary to make a few 
 observations. She states that she has been ill for the last 
 eight days, and that her illness originated in cold, preceded by 
 rigors, and followed by feverish symptoms. The general pyrexia 
 had subsided at the period of her admission ; but she had 
 some sj'mptoms worthy of attention. Her pulse was 72, and 
 regular ; her skin rather cool, and her bowels natural ; but she 
 complained of acute pain in the left side, which, she said, came 
 now and then, catching her breath, and preventing her from 
 taking a full inspiration. This pain was so intense, and seemed 
 to aflect respiration so considerably, that, looking to its situation 
 and its eilects, you would at first sight be inclined to think that 
 it arose either from pleurisy or pericarditis. On examining the 
 chest, however, by the stethoscope and percussion, we found the 
 sound was clear and normal : there were no rales present, and 
 the respiratory murmur was heard distinctly over the whole 
 lung. In fact, auscultation showed that the cause of the pain 
 was not connected with pleuritis, pneumonia, or pericarditis. 
 What then was it ? A variety of pleurodynia, well worthy of 
 your attention as being connected in her ease with retention of 
 the milk and engorgement of the left mamma. At the time she 
 was attacked with cold, she happened to be only a few days after 
 childbirth ; the feverislmess which ensued obliged her to give up 
 nursing, and in this way a sudden and unnatural check was put 
 upon the secretion of milk. When an occui-rence of this kind 
 takes place, and proper means are not taken to obviate the 
 mischief, a high degree of local irritation is the consequence, 
 producing inflammation of one or both the mammae, which, if 
 not treated well and energetically, will certainly end in mammary 
 abscess. 
 
 What I wish to draw your attention to, however, at present, is 
 this — that inflammation of the mamma, arising from retention 
 of milk, is very apt to be attended with pleurodynia in one or 
 more parts of the chest. The flow of milk to the breasts, three
 
 320 CLINICAL MEDICINE. 
 
 or four days after delivery, is very often accompanied by flying 
 pleurodynia ; and the formation of mammary inflammation, from 
 the arrest of lacteal secretion, is also very frequently attended 
 with fixed pains of a pleuritic character. 
 
 The treatment adopted in this case was very simple. In the 
 first place, you endeavour to check the determination of fluid to 
 the breast ; and for this purpose you exhibit a purgative of a 
 hydragogue kind, calculated to act briskly on the bowels. We 
 gave a combination of infusion of senna, sulphate of magnesia, 
 tincture of senna, and electuary of scammony, which acted six 
 or seven times on the bowels, and tended materially to relieve, 
 by derivation, the mammary congestion. In the next place, we 
 directed our attention to the breast, and endeavoured to remove 
 the milk by the use of the syringe employed for that purpose. 
 The milk may be removed from the breast by means of the 
 syringe, or by sucking with a breast-bottle, and where the 
 tenderness of the part is so great that neither of these modes 
 can be employed, the next best means is diligent fomentation. 
 This produces a constant oozing from the breast, and if the 
 fomentation employed be made with a decoction of poppy-heads, 
 it has considerable eff"ect in abating pain and inflammation. We 
 also applied leeches in this case, not with the view of removing 
 the pleurodynia, but with the intention of removing its cause, 
 mammary inflammation. By the use of means directed to the 
 breast, you will find that we can remove all symptoms of pleuro- 
 dynia, and that the pain and difiiculty of breathing will soon 
 disappear. This is a simple case, but it is one of frequent 
 occurrence, and it requires some tact and management for its 
 successful treatment. 
 
 You have probably observed that, in the treatment of all the 
 cases of fever that came before me, I have not prescribed altogether 
 a dozen grains of calomel, that I have very seldom ordered any 
 kind of purgative medicine, that I have been sparing in the use 
 of leeches and cupping, and that I have not ordered a single 
 patient to be blooded. This I am sure will appear strange to the 
 various sects of pathologists and theorists whom I have seen, 
 like so many waves succeeding each other, and whose doctrines 
 were equally doomed to break on the solid and immovable shore 
 of truth. I recollect how each doctrine arose, and made converts, 
 and influenced practice ; how each had its diiy. aiul then sank
 
 NERVOUS FEVER. 321 
 
 into that obscurity and neglect to which vain and profitless 
 speculations are always destined. 
 
 I recollect when it was the custom to commence the treatment 
 of fever by prescribing ten grains of calomel, to be followed by a 
 bolus containing fifteen grains of jalap, or by a large draught 
 composed of infusion of senna, Epsom salts, and electuary of 
 scammony. I remember the time when it was the fashion to 
 bleed every case of fever which came into hospital, no matter 
 what the stage of the disease might be, or what the condition of 
 the patient was at the time of admission. I recollect, too, when 
 the prostration and weakness which accompanies local inflamma- 
 tion, particularly of the digestive system, used to be treated with 
 wine and stimulants. 
 
 Every epidemic is peculiar and distinct in its nature, and each 
 consequently requires a distinct and peculiar mode of treatment. 
 Hence the necessity of studying fever unbiassed by any precon- 
 ceived notions, and independent of the trammels of dogmatism. 
 With a person who observes in this way, who studies the disease 
 as it is, and not as it is described ; whose practice is regulated, 
 not by the doctrines of the schools, but by the results of inves- 
 tigation, carefully weighed and considered ; with such a person, 
 the treatment of fever will be simple and successful, and I believe 
 that there is no disease in which success so much depends on 
 treatment as fever. It is difficult to explain how it came to 
 pass that a contrary opinion could be promulgated in Dublin. 
 Something must be attributed to the neglect or incapacity of 
 those whose duty it was to teach the truth. 
 
 The chief cause may, however, be traced to the activity and 
 zeal which inspired some, not only to uphold their own branch 
 of the profession, but to decry, I had almost said to defame, that 
 which they were pleased to call jjiwe medicine. With character- 
 istic inconsistence, however, these gentlemen, who declared that 
 the treatment of fever was at best useless, readily engaged in its 
 management in private practice, and while they professed openly 
 their disbelief in the efficacy of any medicines, they busily 
 employed themselves in prescribing pills and draughts without 
 number for their own fever patients. That they thought their 
 treatment of some value might be gathered from their acceptance, 
 their invariable acceptance, of pecuniary remuneration from the 
 sufferer's grateful friends, who little dreamed the while that the 
 VOL. I. 21
 
 322 CLINICAL MEDICINE. 
 
 hands which, with automatic movement, so readily grasped their 
 fees, belonged to persons who held, nay, who maintained, the 
 opinion that the treatment of fever was all a farce. Posterity 
 will scarcely give credence to this fact, and will probably refuse 
 to believe that such an opinion could have been advanced in what 
 we are pleased to call an enlightened age, and an enlightened 
 city. They will scarcely think I speak the truth in assuring 
 them, that a spirit of medical intolerance existed to such a degree 
 at the time of the discovery of the stethoscope, that whoever 
 in Dublin actively occupied himself in verifying the researches 
 of the immortal Laennec, whoever availed himself of the new 
 resources invented by this great physician, was sure to become 
 an object, not merely of dislike, but of animadversion and ridi- 
 cule, on the part of those who ought to have exerted their 
 influence in endeavouring to advance, and not to retard, the 
 progress of science. Happily for the character of the country, 
 their endeavours have been frustrated, and the cause of truth has 
 triumphed. Happily for the students and their future patients, 
 those teachers are now most followed who best explain and most 
 diligently illustrate the phenomena observed by means of mediate 
 auscultation.
 
 323 
 
 LECTURE XXI. 
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 
 
 In the epidemic of 1826, we had several cases in the Meath 
 Hospital that presented all the characters of yellow fever. This 
 is a very remarkable fact, for this form of fever has been very 
 rarely witnessed in this country, nor does it seem to have been 
 observed in any part of Europe to the north of Cadiz, Gibraltar, 
 and other towns of Andalusia. The last epidemic of yellow 
 fever in Gibraltar is described by Louis, who with Trousseau 
 and Cherrin was sent by the French Government to investigate 
 the disease. I shall quote from his report an account of the 
 symptoms and post-mortem appearances which they observed, 
 and compare it with the description of the yellow fever of 182G, 
 printed by myself and Dr. Stokes, for the use of the pupils of 
 the Meath Hospital. 
 
 "The disease," says Louis, *' spared neither age nor sex; 
 men and women, young and old, were alike its subjects. Those 
 only were exempt from its influence who had been affected with 
 the disease in a former epidemic. 
 
 " It commenced at different hours of the day, sometimes in 
 the night, sometimes fasting or soon after eating, usually with 
 an intense headache, accompanied by chills, shivering, pain in 
 the limbs, and soon after pain in the back. A heat, rarely 
 intense, succeeded to the chills, and was sometimes followed by 
 perspiration. At the same time the countenance became red 
 and animated ; and in some cases, as it were, swollen. The 
 eyes were red, glistening, suffused, and in many cases the 
 patients complained of a smarting sensation in them. The 
 thirst was intense, the anorexy complete. It was rare that the 
 patient suffered any pain in the epigastrium at this period. 
 
 " The first symptoms, the headache, the pain in the limbs, 
 the anorexy, the thirst, the heat, the redness, and the pain in 
 the eyes, continued ; the headache during half the disease, the
 
 324 CLINICAL MEDICINE. 
 
 pains in the limbs a little longer, and the heat, which in many 
 cases was but slightly increased, continued so during nearly the 
 same time. 
 
 " The pain in the epigastrium, so rare at the commencement, 
 came on usually fifteen or twenty hours later. It was generally 
 inconsiderable, and very few patients complained of severe or 
 acute pain. With the epigastric pain came the nausea and 
 vomitings, excited by drinks and purgatives in several cases, 
 spontaneous in others. The dejections were infrequent, that is 
 where no laxatives had been administered. The abdomen pre- 
 served its form, was supple and indolent, except in the epigastric 
 region. The sleep was inconsiderable — some patients were 
 restless, in some there was a good deal of jactitation during the 
 night ; others, and the smaller number, experienced, as early as 
 the third day, a real anxiety, could not remain quiet in any 
 posture, and in some cases there was delirium. But this 
 symptom did not usually come on till the last day of life ; and 
 for this reason it is to be considered rather as belonging to the 
 agony than to the disease ; otherwise, with few exceptions, there 
 was neither prostration nor stupor. The pulse was moderately 
 accelerated, regular, generally bearing relation to the degree of 
 heat, which was almost always slight, as I have before said. 
 The skin of the thorax was injected in some cases. This redness 
 and that of the eyes diminished toward the middle period of the 
 disease, or a little later, and new symptoms appeared. To the 
 injection of the integuments of the chest there succeeded a slight 
 yellow tint of that part, and the eyes were the same colour. 
 When this colour appeared thirty-six or forty-eight hours before 
 death, it became rapidly brighter, so as to be of considerable 
 intensity at the time of the fatal termination. In other cases 
 where it came on only just before death, it was slight at the 
 autopsy, and commonly limiLed to the trunk. At about the 
 same period, or a little later, the matter vomited and the dis- 
 charges from the bowels, which up to that time had i^resented 
 nothing remarkable^ took on a certain character, which they 
 have not in the course of the acute diseases of Paris. The 
 dejections were blackish or bluish, and the matter vomited, 
 from being of a yellow colour, became brown or black. At the 
 commencement of this change of colour, the vomit was a liquid 
 matter, more or less greyish, mixed with a greater or less
 
 YELLOW FEYKll OF THE BlUTISH ISLANDS. 3'25 
 
 quantity of mucus, in which were to be seen bLackish particles, 
 hke soot. 
 
 " At this period of the disease, the uncomfortable feelings and 
 the anxiety continued during different lengths of time, and in 
 difterent degrees, the strength diminished, the temperature fell, 
 so that the limbs were cold before the agony ; in a certain 
 number of cases there was a suppression of urine. Sometimes 
 also we observed a sort of remission, an apparent amelioration of 
 the symptoms, and death took place when it would least have 
 been expected, had not experience taught us to distrust this 
 deceitful remission. In some subjects the violence of the head- 
 ache, that of the pains of the limbs, the marked febrile symptoms, 
 the numerous vomitings, the uncomfortable feelings, the anxiety, 
 the bright redness of the eyes, gave to the disease a truly serious 
 aspect ; whilst in others the mildness of the fever, and of the 
 pains wherever seated, the absence of agitation and delirium, 
 the slight diminution of the strength, impressed on the disease 
 a character of mildness, calculated to deceive at once the patients, 
 their attendants, and the physician. It is under this form of 
 the disease that patients died without taking to their beds — on 
 foot, as it was expressed by their friends. Thus Dr. Mathias, 
 who died after an illness of four or five days, experienced no 
 other symptoms but severe pains in the calves of the legs, and a 
 suppression of urine. He had no nausea ; he did not vomit ; 
 his mind was perfectly clear during the whole course of the 
 disease. 
 
 "This kind of latent condition of the yellow fever does not 
 distinguish it from the acute diseases of Paris, which also are 
 often obscure, and their symptoms mild ; but it is remarkable 
 on account of the rapid progress of the disease, usually fatal 
 fi'om the fourth to the sixth day. And this latent form reminds 
 us at once of certain facts of poisoning by arsenic, in instances 
 of individuals who have retained their clearness and calmness of 
 mind from the moment of swallowing the poison until their death. 
 
 " I add, that the severity of the symptoms does not correspond 
 always with that of the lesions. Of these last, one only was 
 constant, the specific alteration of the liver. The inflammatory 
 state of the mucous membrane of the stomach comes next in 
 frequency, and sometimes explains in a manner sufficiently 
 satisfactory the symptoms that had been observed."
 
 326 CLINICAL MEDICINE. 
 
 The following are the appearances which Louis found in the 
 fatal cases of yellow fever at Gibraltar* : — 
 
 ** The stomach was larger than natural in seven subjects, 
 smaller than usual in three. It contained a clear or dark red 
 coloured liquid, a blackish or perfectly black fluid, in different 
 quantities, in three-quarters of the cases. Its mucous membrane 
 was red, through a greater or less extent, in six cases ; rose 
 coloured or orange in eight cases ; greyish, yellowish, or whitish 
 in the others. It was thickened through a greater or less extent 
 of surface in half the cases ; softened and yellow to an extreme 
 degree in the same number ; at the same time thickened, soft- 
 ened, and red in a third part of the cases ; mamelonated in two- 
 thirds ; ulcerated in two cases ; and natural in five cases. 
 
 " The mucous membrane of the duodenum was red in a little 
 more than half of the cases ; softened in the same number ; and 
 thickened in one case. 
 
 " The small intestines contained a greater or less quantity of 
 reddish, brownish, blackish, or perfectly black matter, in two-thirds 
 of the cases. Its mucous membrane was slightly injected or 
 red in spaces, in a little less than half the cases. Its consistence 
 was more or less diminished through its whole length, or through 
 a part of its extent only, in rather a greater number of cases. 
 It was partially thickened in one case ; in no case was it ulcer- 
 ated ; and Peyer's glands were always natural. 
 
 " The large intestine was of greater size than usual in two 
 cases. In fifteen cases it contained a matter of a wine lees 
 colour, or blackish, or brownish, or chocolate-coloured, or 
 entirely black. Its mucous membrane was of a pale or bright 
 red colour in five cases ; greyish, yellowish, or whitish in the 
 others. Its consistence was more or less diminished in three- 
 fourths of the subjects. Its thickness was increased in three 
 cases ; and twice we found it slightly ulcerated. 
 
 " The mesenteric glands presented traces of inflammation in four 
 cases ; the cervical glands in one case ; in another case one of the 
 glands above the biliary ducts was red, softened, and very large. 
 
 " The liver was of greater size than natural in two cases ; a 
 little firmer than usual in three cases ; a little less firm in three 
 
 * I have intentionally omitted the very minute description of the thoracic viscera, 
 the brain, spinal cord, &c. ; suflB.ce it to say, there was nothing observed worthy of 
 note.
 
 YELLOAV FEVER OF THE BRITISH ISLANDS. 327 
 
 others. Its cohesion was increased in six cases, diminished in 
 seven. Its colour iras altered in every case ; sometimes it ivas of 
 the colour of fresh butter, sometimes of a straw yclloiv, a clear 
 coffee and milk colour, sometimes a gum yellow, sometimes of an 
 orange colour. 
 
 " The spleen was softened in eight cases, and to a moderate 
 degree, with one exception. It was larger than usual in five cases. 
 
 " The lesions which we have thus placed before the reader 
 were rarely considerable, very often insufficient to explain the 
 death, and when this explanation was afforded, it was by a com- 
 bination of several lesions. 
 
 " These lesions may be divided into two classes, some of them 
 peculiar, or almost exclusively peculiar, to subjects dying of 
 yellow fever ; others common to those subjects, and to subjects 
 who have died of other acute diseases. The red or black 
 matter found in the alimentary canal, and the remarkable 
 alteration of the liver, are of the first class, all the other lesions 
 of the second. 
 
 " The red or black matter of the stomach or intestines not 
 having been found in all the cases of yellow fever, it cannot be 
 considered an anatomical character of the disease. But it is 
 not so icith the alteration of the liver, ichich was more or less 
 exactly the same in all the cases, and which, for that reason, 
 ought to be considered as the essential anatomical character of 
 the yellow fever of Gibraltar of 1828. 
 
 "Amongst the lesions of the second class, the yellowness and 
 the inflammation of the mucous membrane of the stomach should 
 be especially remarked, as well from their frequency as on account 
 of the rapidity with which they come on. The inflammation of 
 the mucous membrane of the stomach not having taken place in 
 all the cases, and Peyer's glands not having ceased to be natural, 
 it follows on the one hand, that the yellow fever of Gibraltar, of 
 1828, is not a gastritis, and on the other hand that it is not a 
 typhoid fever. This last conclusion is even more strict ; for not 
 only was there an absence of the lesions of typhoid fever in the 
 bodies of the victims of yellow fever, but these bodies presented 
 other lesions which are not found in the victims of the first 
 disease, and which are peculiar to the second disorder. 
 
 " What, then, is the nature of the yellow fever of Gibraltar, of 
 1828, and where is the seat of it '? If it bo neither a gastritis
 
 328 CLINICAL MEDICINE. 
 
 nor a typhoid fever, neither is it a hemorrhage, as it has laUAy 
 been said to be, for the hemorrhage did not take place in all 
 cases. Is it a disease of the liver ? Undoubtedly the liver was 
 the organ principally and essentially affected ; still we cannot 
 regard the yellow fever as simply a disease of the liver, because 
 its lesion, at least in the present condition of science, does not 
 explain the febrile symptoms in the cases where this was the 
 only lesion ; and in the second place, because it is entirely 
 insufficient to explain the death. 
 
 " As, then, a strict analysis of the anatomical appearances of 
 the yellow fever of Gibraltar of 1828, proves the existence of a 
 cause unequal in its operation, and of which but one effect is 
 constant, the specific alteration of the liver, and, as in a third 
 part of the cases, it is directly to this cause that we are obliged 
 to refer the death, we naturally ask how does this act, through^ 
 the medium of what system does it exert its influence on the 
 economy ? Is it through the nervous system ; is it through the 
 blood, in which, however, we have not detected any especial 
 modifications ? " 
 
 Let us now compare with this description the epidemic I wit- 
 nessed in Dublin in 1826. The first case I shall speak of is 
 that of John Gall, aged 35. Admitted about the 10th of 
 January. Date of illness unknown ; probably about seven or 
 eight days. Tenderness of epigastrium chief symptom, and 
 with it costiveness ; skin hot ; tongue very dry and brown in 
 centre, edges white, a little moist ; much debility ; appeared 
 stupid, but no delirium ; memory uncertain ; at one time he said 
 he was two days ill ; at another, for several ; belly hard, full. — 
 Leeches to epigastrmm, and pui'gatives with apparent relief. — 
 Next day he got effervescing dravgJUs, and began to complain of 
 cough. — Blister on the chest on the following day. — That night 
 he became yellow, being convulsed in the abdominal muscles, and 
 died at 5 a.m. yesterda}^ 
 
 Dissection 30 houi's after death. — Body well made, strong, 
 muscular ; skin and conjunctivfe yellow ; posterior parts livid. 
 Dura mater yellow ; no fluid between dura mater and arachnoid ; 
 considerable quantity of fluid under arachnoid, between convolu- 
 tions, of amber-yellow colour ; brain remarkably firm ; substance 
 white ; yellow fluid in right ventricle, and also in left, in anterior 
 cornua in considerable abundance, particularly in left. Abdo-
 
 y;:llow f;:ver of the British islands. 8*21) 
 
 men : liver natural ; no obstructions in ducts ; bile in gall- 
 bladder ; stomach of a dark purple colour universally ; mucous 
 membrane increased in thickness, bleeds when torn, is evidently 
 a little softened, villous coat like velvet ; when in water, villosities 
 whitish and floating. Near the pylorus we observed a very 
 curious and beautiful appearance ; the mucous membrane was 
 here, as in other parts, of a purplish-red colour, marked in many 
 places by rings of a white colour, and perfectly circular, and 
 about half an inch in diameter. These rings, formed by a circle 
 about half a line in breadth, included a space purple like the 
 rest of the mucous membrane ; and in many places intersections 
 of these white circles were observed : white serpentine lines were 
 also apparent in this part of the stomach. On placing the 
 stomach in water, we discovered that these white circles and 
 serpentine lines were formed by the extremities of villous pro- 
 cesses, which had not a purple colour like the rest. Duodenum 
 was also red, but the redness decreased gradually. One i)t.tiis- 
 smceptlon, incliuling a portion of intestine six inches in lenijtli, 
 was found in the small intestines. The invaginated jtortion of 
 intestine ivas easily withdrawn from within that which had 
 enclosed it, and there ivas not the slightest mark of inflammation 
 in either. 
 
 This is a good example of the morbid appearances exhibited by 
 those fatal cases of fever which had been so frequent in the 
 epidemic of 1826. We lost nearly twenty patients, in whom the 
 symptoms ran nearly the course above detailed. In all, the 
 abdomen became hard and tender about the epigastrium and 
 hypochondria, and often without any premonitory symptoms 
 indicative of the approaching danger. This hardness and knotted 
 feel of the abdominal muscles was followed by an appearance 
 of general jaundice of a bright yellow colour, accompanied by 
 uneasiness and anxiety of countenance, a very quick and hurried 
 pulse, and coldness of extremities. Death generally took place 
 in such cases within twenty-four hours from the appearance of 
 the jaundice, and was preceded in some cases by general convul- 
 sions (as was reported, but we ourselves did not observe any 
 general convulsions); in most, by spasms limited to the abdomen, 
 and which obtained among the nurses the appropriate name of 
 " Twisting of tlie gats,'" a name which agrees singularly with the 
 intestinal intus-susceptions found in almost all. Before entering
 
 330 CLINICAL MEDICINE. 
 
 into the subject of the pathology of this singular form of fever, I 
 shall detail a few more examples of it. 
 
 John Rochford, aged 50, was admitted into shed No. 4, with 
 low fever ; became convalescent after a few days without any 
 regular crisis ; appetite returned, and he continued well for about 
 six days, when he relapsed. Belly a little hard, and tender 
 to the touch ; complained only of costiveness ; some purgative 
 medicine was directed, which not having the desired effect, an 
 oil draught was prescribed, and having operated freely, patient 
 appeared much relieved at next visit; but between 11 and 12 
 p.m. was seized with convulsions of belly, but not of extremities; 
 suddenly became jaundiced, and died next morning. The tip of 
 his nose became of a deep purple colour. The friends having 
 taken away the body, we had not an opportunity of examining 
 the morbid appearances. 
 
 We have had several cases in which the nose became purple 
 in fever, and, with one exception, they all proved fatal. When 
 the purple nose is combined with general jaundice, the patient 
 presents a truly frightful appearance ; this has happened in five 
 or six instances. Sometimes the purple colour is limited to the 
 tip of the nose, while in other cases it spreads from the nose to 
 the upper portion of the cheeks. The parts about to become 
 purple assume at first a pale appearance ; this paleness is 
 gradually converted into a livid leaden hue ; and the part 
 becomes quite purple generally in the course of twelve or twenty- 
 four hours. It is to be observed that the parts thus affected 
 preserve their natural heat until shortly before death, when, of 
 course, the tip of the nose is among the first parts to grow cold. 
 In the case of a girl in shed No. 2, whose nose and cheeks 
 became purple, this change took place more slowly than usual. 
 At first the parts were observed to be covered with broad patches 
 of a wax-like whiteness, somewhat elevated above the surround- 
 ing surface, which so much resembled urticaria that it was 
 considered to approach, in its nature, to that eruption ; the 
 following day, however, these spots were found to have become 
 of a red colour, and on the next day the redness was converted 
 into a deep purple. During the whole of this time the heat of 
 these parts was not less than that of the rest of the body. She 
 died on the following day. 
 
 In the case of a woman, also in shed No. 2, in whom the tip
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 331 
 
 of the nose and the ends of some of the toes became purple, these 
 parts were tender to the touch ; this woman recovered. Leeches 
 were apphed to the tip of the nose, and tepid stupes or poultices 
 kept constantly applied to the discoloured parts ; a small portion 
 of the nose separated and came away in the form of a slough. 
 These facts prove that this purple colour of the nose and other 
 parts, in many instances, at least, arises from a condition of the 
 vascular system of these parts closely allied to inflammation. 
 We possess a drawing of a patient in whom, from the effects of 
 cold, the tops of the fingers became purple and excessively 
 tender when exposed even to the common temperature of the 
 wards in winter. Great relief from pain, and some diminution 
 of intensity in the colour was obtained by keeping the fingers 
 immersed in tepid water. This case, which was treated by Mr. 
 M'Namara, had lasted for some weeks before admission, and 
 ^•ielded, but not until the lapse of a considerable time, to the 
 employment of tepid applications, &c. 
 
 Patrick Mahon, aged 45, a stone cutter, strong habit. 
 Admitted into shed No. 4, labouring under fever of a typhoid 
 character. Tongue loaded ; teeth covered with sordes ; abdomen 
 hard ; tenderness of epigastrium, and hypochondria on pressure ; 
 complained of weakness. — Twenty leeches ivere applied to the 
 epigastrium, and purgative injections administered. The follow- 
 ing morning the skin and conjunctiva appeared slightly yellow ; 
 abdomen still hard ; pulse weak and quick ; much debility. — 
 Was ordered some blue pill, and to repeat the injections. — At the 
 next visit, the yellow colour continuing, the abdomen being still 
 hard, and the epigastrium tender, twenty leeches were again 
 applied, and the former medicines repeated. At four o'clock in 
 the evening was seized with convulsions, and died early next 
 morning. The convulsions only appeared to aftect the abdomen. 
 — Body not examined. 
 
 John Gaven, aged 22. This man's case diff"ered in no material 
 circumstances from the preceding cases. — Dissection twenty 
 hours after death. Body extremely well made, strong, and 
 muscular. Nothing morbid in head or thorax, except dilatation 
 of some bronchial tubes. Abdomen : Jive intussusceptions in 
 si7iall intestines, ivitJiout any adJiesion or marks of recent injiam- 
 mation ; other parts of the intestines considerably contracted ; 
 mucous membrane of stomach, from cardiac orifice to within
 
 332 CLINICAL MEDICINE. 
 
 about two inches of the pylorus, of a brownish-red colour. Here 
 the mucous membrane yields readily to the back of the knife, 
 and may be scraped off in a semi-fluid state ; it contains several 
 patches of ecchymosis. The whole of the intestinal tube, with 
 the exception of the duodenum and the lower half of the large 
 intestines, has its mucous membrane of a dark red colour, with 
 numerous ramifications of vessels engorged with blood. In many 
 parts the mucous membrane is very soft, and almost semi-fluid. 
 Liver perfectly healthy : no obstruction in gall-ducts. 
 
 As time will not permit me to detail more dissections of this 
 truly curious and fatal form of fever, I shall merely sum up some 
 of the principal points connected with its pathology. 1st. In 
 none did we find inflammation of the liver, or obstruction of the 
 gall-ducts. 2ndly. In all, evident marks of inflammation were 
 found in the mucous membrane of the stomach, such as redness, 
 softness, &c. 3rdly. In almost every instance, we found one or 
 more intus-susceptions in the small intestines. 4thly. All these 
 were without any mark of inflammation of the serous membrane, 
 and the invaginated portion of the intestine could be always 
 easily drawn out of the other. Sthly. In several we found 
 efi"usion of a yellowish or amber coloured fluid between the 
 arachnoid and pia mater, at the base of the brain, and sometimes 
 in the ventricles, but in these only in small quantity. 6thly. 
 In none did we find inflammation of the brain or its membranes. 
 7thly. We found the spleen very much enlarged in almost all. 
 When the spleen, in acute diseases, is thus engorged and dis- 
 tended, it is invariably softer than natural. In but one case did 
 we find a considerable quantity of a dark red fluid in the stomach, 
 together with a good deal of a substance resembling cofi'ee 
 grounds, and in this case the mucous coat of the stomach was in 
 many places of a very dark colour, and a slimy consistence, so 
 that there could be but little doubt concerning the origin of the 
 contained fluid, and the coffee grounds substance, which must 
 have proceeded from the diseased and almost disorganized 
 mucous membrane. Such have been the principal appearances 
 observed during the dissection of about fifteen fatal cases of fever 
 combined with yellowness of the skin. The following cases will 
 convey a more exact idea of the symptoms which characterize 
 this form of fever than those already related, which proved too 
 suddenly fatal to allow a full development of the symptoms.
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 333 
 
 Peter Kelly, aged 28, on the 29th Deccmher was admitted 
 iinto No. 4 fever shed ; stated that for two days previously he had 
 severe cough without expectoration; pulse 110, strong; face 
 flushed ; tongue white, moist ; pain across forehead, and 
 general disti'ess ; great tenderness of epigastrium and right 
 hypochondrium ; costive ; thirsty ; abdomen hard : on examina- 
 tion no morbid rale was perceptible ; respiratory murmur 
 natural, — 30th Dec. Vencesectio ad .f xv. Hirudines xx. ephjas- 
 trio. Piliilce purgantes et mistura purgans. — 31st. Cough very 
 severe. Vesicatormm pectori. Mistura pectoralis. — 1st January, 
 1827. During last night became jaundiced ; considerable distress 
 this morning ; black stools ; great tenderness of epigastrium 
 and right hypochondrium ; cough very troublesome. Vencesectio 
 ad Jxii. Hirudines xxx. hypnchondrio et epigastrio. Ahra- 
 dantur capilli et applicetur vesicatorium vertici. Sumat omni 
 Jiord calomelanos grana duo. — 2nd January. Much relieved ; 
 skin not nearly so yellow ; tenderness greatly diminished ; some 
 sweat last night. Repetantiir pihdce. — 3rd. Considerably im- 
 proved ; skin nearly natural. — 4th. Mouth affected with 
 mercury; skin natural. Omittantnr medicamenta. — 5th. 
 Removed to convalescent ward. — 7th. Convalescence continues, 
 having now no complaint but slight soreness of mouth. 
 
 Here the yellow colour appeared about the fifth day, and 
 sweat attended with much relief on the seventh day. The 
 symptoms chiefly worthy of notice are, the violence of the febrile 
 reaction, pain of forehead, great tenderness of epigastrium and 
 right hypochondrium ; blackness of stools, and hardness of the 
 belly. We shall just now see the great importance of these 
 symptoms in determining the true nature of the disease. 
 
 January 14th. — Thomas Kearney, aged 38, labourer ; has 
 been ill for eight days ; was first attacked with rigor and pains 
 of loins and limbs, which still continue. He also complains of 
 cough and pain of chest ; head first attacked on fifth day ; was 
 taken into hospital the following day ; got some purgative, which 
 operated powerfully. Present symptoms : skin dry and hot ; 
 eyes and skin yellow ; great pain of head ; tongue dry and 
 white; pulse 60; the colour of stools very dark; epigastrium 
 tender. — January 15th. Ap)plicentnr hirudines xx. epigastrio et 
 vesicatorium pectori. R. Pilulce Jiydrarggri, gr. ix. ; extracti 
 hyoscyami, gr. vi. ; M. in pilulas tres divide ; sumat i. ter in die.
 
 334 CLINICAL MEDICINE. 
 
 Habeat haustus effervescentes cum carbonate ammonia, et enema 
 emolliens vespere. — Jan. 16. Pain of chest and cough removed, 
 and j^ain of epigastrium diminished since the application of 
 leeches, which still continue bleeding ; ordered to be stopped by 
 the application of caustic ; tongue moist, looking like mercurial 
 ointment ; pulse 60, strong ; countenance much improved ; 
 stools much more natural ; yellowness nearly gone ; sweated 
 much. Rcpetantur pilidce liydrargjjri et extracti hyoscyami. — 
 January 17th. No fever ; yellow colour quite gone ; many loose 
 stools. Omittantur medicamenta. — January 18th. Convalescent. 
 
 The state of the pulse in this case was remarkable. It did 
 not exceed 60 at a time when the existence of many other 
 symptoms left no doubt of the febrile and inflammatory nature 
 of the complaint. 
 
 December 30th, 1826. Esther M'Quillan, aged 33. Com- 
 plains of general pains ; has been subject to violent pains for the 
 last three years, after having laboured under fever in Cork 
 Street Hospital ; was there also about four months ago, and was 
 discharged cured. Present state : great headache ; tongue 
 brown in centre ; pulse small and weak ; great tenderness of 
 abdomen on pressure ; bowels very free ; blooded last night for 
 cough and stuffing of chest ; finds herself much relieved ; blood 
 slightly buffed, no separation of serum ; respiratory murmur 
 natural ; complains of pain across her back. Appliccntur hiru- 
 dines xx. epigastrio. — December 31st. Tongue parched, furred, 
 and brown in centre ; tenderness of epigastrium still remains, 
 but much diminished; is very slightly jaundiced; leech- bites 
 bled well ; pulse 100, regular ; great thirst ; pains of joints and 
 small of back excessive, and preventing motion in bed ; breathing 
 free; urine very light coloured. R. Nitratis potassa, 5ij. ; 
 decocti hordci, lb. ij. ; acidi nitrici diluti, 5J. ; misce ; con- 
 sumatur in die. — January 1st, 1827. Colour more yellow ; 
 great tenderness of epigastrium and right hypochondrium ; 
 pains as before ; fever unabated. Habeat calojnelanos gr. iij. ; 
 opii gr. I, ter in die ; Misturce camphor ce 5j. ter in die. — 
 January 2nd. Pulse 72, weak, at times almost imperceptible, 
 but regular ; i*espiration easy ; yellow stools, passed under her ; 
 belly very tense ; abdominal muscles contracted and hard ; 
 tongue black and parched ; raves, but is sensible when spoken 
 to ; lies on side. Ilepetantur pilidce et mistura ; applicctur
 
 YELLOW FKVER OF THE BllITISlI ISLANDS. 335 
 
 vesicatorium hypochondrio ; rini .^vi. — January 3rd. A good 
 deal of cough ; raves continually ; yellowisliness deeper ; many 
 yellowish stools passed under her ; debility much increased ; 
 thirst continues ; tongue hlack and parched ; heat natural ; 
 tremor ; pulse 84 ; blister rose but little ; deglutition impeded 
 by a spasm ; just before visit was seized with a fit, attended 
 with spasms and rigidity of joints, which lasted about a minute ; 
 feet cold. Vini rubri 5vj. ; applkentur sinapismi pcdibus ; 
 repetatur mistitm camphorce. — January 4th. Sensible when 
 spoken to ; puts out tongue when desh-ed ; but at all other 
 times raving ; seems to suffer extremely when joints are moved ; 
 frequent tremor and shuddering ; rested scarcely any ; other 
 symptoms as yesterday ; some swelling of ankles. Applicentur 
 vesicatoria suris ; rtni .^vj. — January 5th. Moaning and raving 
 during the whole night ; no vomiting ; cough looser ; slept a 
 little this morning ; stools yellow ; tongue parched ; blisters rose 
 well ; drinks abundantly ; less yellowness ; no headache ; eyes 
 suffused ; pulse 84, scarcely to be felt, regular ; no coldness 
 of extremities ; flatulence. Reiuiatur vinum. — January 6th. 
 Slept well ; no raving ; countenance improving ; fever much 
 diminished in every respect. — January 7th. Tongue clean ; pulse 
 80, stronger than before ; a large purple spot, not elevated, 
 occupies the whole of the outside of right instep ; it is in some 
 places vesicated ; appetite good ; slept well ; smaller spots on 
 other foot ; camphorated spirit to be applied to spots. Hahcat 
 sulpliaiis quince granum tcr in die.— January 8th. Edges of 
 large spot more vesicated ; whole surface has a redder and 
 less purple colour ; three stools during night ; little sleep. 
 RejJctdntnr pilaUe sulphatis quince et vinum. — January 9th. 
 Redness of right eye, not painful ; foot better. AppUcentur 
 hirudines ii. conjunctirce. — January 10th. Convalescent ; re- 
 mained for about a week, and was discharged cured. 
 
 The symptoms of this case were very alarming ; so much so, 
 indeed, that on the 2nd and 3rd of January we had little expec- 
 tation of her recovery. At this period the involuntary discharge 
 of stools, the extreme weakness of pulse, black parched tongue, 
 general debility, raving, tremors, spasmodic affection, which 
 supervened when she attem])ted to swallow, and finally, the 
 hard and knotted state of the abdominal muscles, together with a 
 fit of general tonic spasms ; all these symptoms, combined with
 
 336 CLINICAL MEDICINE. 
 
 the yellow colour of the skin, rendered her recovery very impro- 
 bable. The treatment was in the commencement antiphlogistic. 
 The nitre was prescribed in order to relieve the rheumatic pains ; 
 but on the following day it was abandoned, and a preference 
 given to calomel and opium for obvious reasons. Nitre does not 
 act favourably in cases where much debility is present, or where 
 the stomach is weak. 
 
 In several of the cases attended with jaundice which proved 
 fatal, the symptoms were very similar to those described. The 
 case of M'Quillan may be looked on as presenting a good 
 example of this peculiar species of fever. In her case, as well 
 as in several of the fatal cases, the alv'ine discharges were of a 
 healthy colour ; and in several of the latter the bile found in the 
 gall-bladder after death was in its properties quite natural. 
 About one-half of the persons so affected raved, betrayed great 
 restlessness, and their countenance had a peculiar expression of 
 anxiety ; others seemed in perfect possession of their intellectual 
 faculties to the last, but at the same time appeared in a most 
 nervous, irritable, and desponding state of mind. They could 
 not rest for a moment tranquil, but tossed their arms about, and 
 regarded their attendant with a look expressive at once of 
 nervous suffering and despair. Many vomited very often ; all 
 complained of extreme tenderness of the epigastrium. 
 
 Here I may observe that, in the epidemic of 1826, we opened 
 many bodies in which peritoneal inflammation might have been 
 expected, judging from the extreme epigastric and abdominal 
 tenderness during life : and yet we found no marks of peritonitis 
 whatsoever. The large purple spot in the instep seemed at first 
 of a similar nature with the purple colour of the nose and lips 
 before described ; it proved, however, to be erysipelas, and ended 
 in vesication. It differed from common erysipelas in its dark 
 livid purple colour, and in having a well-defined abrupt boundary, 
 and in the colour disappearing but little on pressure. In fact, 
 it seemed to be as it were intermediate between purpura and 
 erysipelas. The advantage of wine and stimulants towards the 
 conclusion of this fever was very apparent. 
 
 January 15th, 1827. Robert Farmer, aged 19. Has been 
 ill five days ; was employed in a brewery, where he was exposed 
 to hot steam, producing a copious perspiration, during which 
 he drank a great quantity of cold beer ; was immediately seized
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 337 
 
 with a violent rigor and fulness of head ; the rigor lasted for 
 an hour ; a comparative calm ensued. The head, however, still 
 continued uneasy ; loss of apjietite followed ; but he endeavoured 
 to work for two or three days, when he Mas obliged to remain in 
 bed ; has been in a violent heat since, unless he gets a cold drink, 
 which causes a rigor ; was admitted into hospital yesterday. 
 Previous to this had taken no medicine. 
 
 Present symptoms : violent pain or rather fulness of head ; 
 throbbing of temporal arteries ; pulse 110 ; thorax free from 
 pain ; no cough ; epigastrium and abdomen very tense ; no 
 tenderness on pressure ; skin, hot, dry, and tinged yellow ; 
 tongue, white and dry, somewhat moist at edges ; got some 
 purgative medicine, which procured two stools, foetid, and of a 
 dark colour; urine natural. Aiipllcentur hirudincs xx. temporihus. 
 ft. Liquoris acetatis ammonice, aqiue fontanel, singulorum, 
 .fiij. ; tartari emetici, granum ; Syrupi jj. misce. sumat Jss. 
 omni hord. Haheat enema emolliens vespere. — January 16th. 
 Leeches were applied at 6 p.m. ; many still bleeding ; eyes and 
 skin less yellow ; headache less ; pulse 70, regular ; a slight 
 tendency to diaphoresis. Repcntantur medicamenta ut heri. — 
 January 17th. Not much headache ; heat and pulse natural ; 
 much debility ; tongue clean and moist ; countenance improved ; 
 no appetite ; bowels free ; convalescent. — January 26th. Left- 
 hospital the day before yesterday ; and that evening experienced 
 rigor and headache. Tongue white and furred ; pulse 100 ; 
 skin not very hot ; abdomen soft ; bowels free ; great thirst ; no 
 headache at present. Haheat haustus effervescentes cum car- 
 bonate ammonia. — January 27th. Respirations 36 ; pulse 120 ; 
 abdomen soft and natural : a good deal of headache ; thirst ; heat 
 of skin ; flushing of face ; tongue as yesterday. Applicentur 
 Jdrudines xx. temporihus. — January 28th. Head somewhat re- 
 lieved ; bled all night from leech -bites ; much tenderness of 
 epigastrium ; pulse 125 ; great thirst; no vomiting ; some yellow- 
 ness of skin, but not of eyes. R. Piluke hydrargyri, gr. ix. ; 
 extracti hyoscyami, gr. vj. misce ; Jiant pilulce ires ; sumat unam 
 quartis horis. — January 29th. Fever diminished ; was extremely 
 weak last night, and had great distention of belly, with swelling 
 and tenderness ; this attributed to taking too large quantities of 
 drink ; was relieved by a large oil injection three times repeated ; 
 very little yellowness to-day. Haheat Jiaustus effervescentes cum 
 VOL. 1. ' 22
 
 338 CLINICAL MEDICINE. 
 
 carbonate ammonice. — January 31st. Skin hot ; pulse 110, 
 rather weak ; all the symptoms exacerbated since yesterday ; 
 much thirst ; tremor ; no cough nor tenderness of belly ; no 
 headache nor raving ; but little sleep ; respirations 40 ; bowels 
 free ; much nausea, but no vomiting. Haheat haustum oleosum ; 
 repetantnr haustus effervescentcs cum carbonate ammonice. — 
 February 1st. Face flushed ; no headache ; a good deal of 
 epistaxis last night ; dry burning heat of skin ; tongue very red 
 at tip and edges ; parched in centre ; vomited last night ; much 
 thirst ; no tenderness of epigastrium ; respirations 36 ; pulse 
 112 ; no cough ; complains at times of sense of distention of 
 stomach. Habeat mistura camphone cum magnesia, 5J. ter in 
 die. — February 2nd. No fever ; pulse 72. Convalesced slowly 
 and was dismissed cured. 
 
 Here the crisis of the relapse was better marked than that of 
 the first attack, and occurred on the ninth day of his relapse. 
 One of the most prominent features of this fever was the distended 
 state of the epigastric region, in the first attack unattended with 
 tenderness, but in relapse accompanied by much epigastric ten- 
 derness. It is probable, therefore, that the distended state of 
 the epigastric region proceeded in both instances from the 
 same cause, namely, inflammation of the mucous membrane 
 of the stomach. We have already seen that this inflammation 
 may, and generally does produce very great tenderness ; this 
 case, however, seems to prove that inflammation of the mucous 
 membrane of the stomach may occasionally exist without pro- 
 ducing tenderness. We have found both the extract and tincture 
 of hyoscyamus extremely useful in abating irritability and 
 procuring sleep in the advanced stages of fever. In the fevers 
 attended with jaundice, we were induced to combine it with mer- 
 curials, from observing the frequent occurrence of intus-susception 
 in the fatal cases — still bearing in mind that means calculated to 
 abate the inflammation of the stomach and intestines, by lessen- 
 ing the cause, would strike at the root of the spasm, and thus 
 prove the best anti-spasmodics. This plan has been successful in 
 several instances, but in the majority of the yellow cases, we 
 regret to say that the progress of the disease was so sudden, 
 most terminating in twenty-four hours after the appearance of 
 the jaundice, that all our efi"orts proved ineffectual. In the 
 second report we made will be found the history of the dissection
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 83*J 
 
 of several of those cases which occurred after February. It is not 
 to be supposed that the report affords specimens of all the 
 varieties of fever treated during the time it embraces — we have 
 omitted to detail any but those calculated to convey an accurate 
 idea of the general character of the epidemic and its peculiarities, 
 omitting any account of the more ordinary forms of maculated 
 and typhus fever, which were not unfrequently observed. It con- 
 cludes with some remarks on that form of fever which was 
 accompanied by jaundice. 
 
 Cases of probably a similar nature have been observed by Dr. 
 Cheyne and others in former epidemics, but in no other epidemic 
 were they so frequent or so fatal in this city. Those who are 
 familiar with the symptoms and morbid appearances observed in 
 the yellow fever of America, the West Indies, and of Spain, will 
 at once perceive many striking points of resemblance between 
 yellow fever, properly so called, and that variety of fever we have 
 described. In both the yellow colour depends upon the presence 
 of bile, and in both the absorption of bile into the system seems 
 independent of hepatic inflammation or obstruction in the biliary 
 ducts. We are aware that Tommasini, in his excellent work 
 upon the fever which occurred at Leghorn in 1804,* proves that 
 the liver is inflamed not unfrequently in yellow fever, and he sup- 
 poses that it is inflamed in all cases, arguing that where no very 
 risible or external marks of hepatic inflammation have been 
 observed, still inflammation may have existed in the internal 
 parts of the liver, attacking chiefly its vascular system and the 
 pori biliarii {page 239). As, however, no such inflammation to 
 our knowledge has been detected in those cases of yellow fever 
 which present an apparently healthy state of the liver, and as the 
 most accurate descriptions of the morbid anatomy of yellow fever 
 with which we are acquainted f report a healthy state of the liver 
 in the majority of cases, we must, for the present at least, con- 
 sider the jaundice of yellow fever as independent of hepatitis. 
 
 An inflamed state of the mucous membrane of the stomach, 
 often amounting to its absolute disorganization, is the most con- 
 stant and the most essential morbid appearance in yellow fever : 
 — a similar state of the duodenum is likewise frequent ; now in 
 
 * Sulla Febbre di Livomo, e sulla Febbre Gialla, io. 
 
 t See Laurence's very accurate Dissections of subjects dead of the Yellow Fever, 
 made at New Orleans during the years 1817 — 18—19. — Philadelphia Journal, vol. i. 
 new series.
 
 340 CLINICAL MEDICINE. 
 
 both these respects our cases agree with yellow fever, except 
 indeed that in the latter the disorganization of the mucous mem- 
 brane is greater ; still, however, this is only a difference in 
 degree ; and in one of our cases we have seen that the dis- 
 organization of the mucous membrane was fully equal to that 
 described in yellow fever attended with the black vomit ; and in 
 that case the stomach contained matter very similar to, if not 
 absolutely identical with, the black vomit. We should recollect 
 also, in comparing these two forms of disease together, that in 
 many instances of yellow fever there is no black vomit, and the 
 inflammation has in such persons been found to have attained a 
 degree not greater than was observed in our cases. The tender- 
 ness of the epigastrium, so prominent a feature in yellow fever, 
 occurred in all our patients ; and, if space permitted, I could 
 point out many other circumstances of similarity between these 
 two forms of fever. It may appear to many ridiculous to maintain 
 a similarity between these cases and yellow fever, a disease of 
 warmer climates, and which commits such fearful ravages wher- 
 ever it appears. I need, however, only refer to the works of 
 Tommasini, Bancroft, Dr. James Johnson, Bartlett, and Clymer, 
 which contain ample proofs that even in the warmest latitudes 
 epidemics of yellow fevers are always mixed with fever of a bilious 
 character, but of a milder type, a circumstance which renders it 
 highly probable, that were such an epidemic influence at any 
 time, from a particular combination of circumstances, to spread 
 to temperate latitudes the reverse would happen, and this influ- 
 ence would then produce an epidemic of bilious or gastric cha- 
 racter, with comparatively few cases approaching in violence to 
 yellow fever. 
 
 Tommasini and the best modern pathologists consider it as 
 now placed beyond all doubt that yellow fever cannot be con- 
 sidered as a specific disease, but merely as the maximum of 
 bilious or gastric fever. By some it has been considered as a 
 variety of remittent, but nearly all the late writers agree in 
 regarding it as a continued fever.* In proportion to the warmth 
 of the climate these fevers increase in intensity. Thus, in Cadiz 
 and Gibraltar we need not be surprised at the occasional appear- 
 ance of the yellow fever, approaching in violence to that of the 
 southern parts of North America and the West Indies. At Leg- 
 
 * CI3 irer on Fevers, Philadelphia, 184'?, p. 349,
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 341 
 
 liorn the resemblance, although still striking, was not so perfect : 
 and again, in the bilious epidemics of France, Holland, and 
 Germany, the difference, as to intensity, is still greater (Tom- 
 masini, 81, 82, 83), but still the disease, in its essential cha- 
 racters, remains the same in all, and the same symptoms, and 
 the same morbid lesions are found ; they differ only in degree. 
 Hitherto we have not made any remarks on the frequent occur- 
 rence of spasmodic action of the intestines, as proved by the 
 intus-susceptions so constantly observed in our cases ; a circum- 
 stance, we believe, peculiar to tliose cases, for ive have not met 
 wlili any account of a similar occurrence in other epidemics. 
 How far such spasms, either by directly causing a temporary 
 constriction of the ductus communis choledochus where it enters 
 the intestine, or by extending to that duct itself, may have con- 
 tributed to obstruct the passage of the bile and produce the 
 jaundice, is a question worthy of consideration. 
 
 On looking over my papers, I found the following notes of a 
 clinical lecture delivered at the Meath Hospital in the year 1827. 
 As they have especial reference to the subject under considera- 
 tion, I shall make no apology for introducing them in this place, 
 merely premising that they are printed as they stand in the 
 manuscript, and must be regarded as the heads of a lecture, and 
 not as conveying all that I may have said on the occasion : — 
 
 In fact there is not so much difference between the diseases of 
 Ireland and warmer countries as has been imagined. They differ, 
 it is true, as to their degrees, but not as to their pathology. 
 
 It was an opinion long ago advanced by the late Dr. Whitley 
 Stokes, that almost all fevers pass into each other — thus, inter- 
 mittent may become continued, and typhus fever, perhaps, but 
 an inferior grade of plague. Be this as it may, each particular 
 epidemic has a grade peculiar to itself. The present fever in 
 Dublin, the most worthy of notice we have had here, strongly 
 proves that our diseases differ only in degree from those of 
 warmer latitudes. We have had numerous cases which in their 
 sj^mptoms and their morbid anatomy agree essentially with the 
 gellow fever. This is an opinion I have never before expressed, 
 as I was unwilling to do so until after careful examination and 
 study. Passing events always make a deep impression when the 
 attention is properly directed towards them. I stand here to 
 improve you, if I can, in the pathology and practice of physic.
 
 342 CLINICAL MEDICINE. 
 
 and scruple not to deviate a little from my course, if that 
 deviation be calculated to awaken your attention to an important 
 subject. 
 
 1st. In both, patients become yellow from absorption of bile 
 into the system ; but observe, in epidemics of yellow fever it 
 never happens that all, or even most, of the cases turn yellow. 
 
 2nd. These yellow cases are here equally fatal. 
 
 3rd. Tenderness of epigastrium, and vomiting in both. 
 
 4th. The strongest die. 
 
 5th. Jaundice does not depend on hepatitis in either. 
 
 6th. Nor on any ijermanent obstruction in gall ducts. 
 
 7th. In both, the essential character of the disease is a violent 
 inflammation of the mucous membrane of stomach and duodenum ; 
 which becomes dark purple, soft, and semifluid. 
 
 8th. Black vomit in true yellow fever consists of a sanguineous 
 fluid, the mixed vitiated secretion of the stomach and the blood 
 forming the cofi'ee-grounds appearance. This black vomit we 
 found in one of our patient's stomach. 
 
 9th. Enlarged state of the spleen. 
 
 What is the cause of yellowness in yellow fever ? Absorption 
 of bile. But what causes bile to be impeded — there is no 
 obstruction in the liver itself — as in hepatitis, or in the ducts^ 
 as in gall-stones, &c. ? 
 
 It has been ascribed to vomiting, but this is not the true 
 cause. 
 
 1st. It has appeared in yellow fever when there w'as no 
 vomiting. 
 
 2nd. We do not find that constant vomiting, as in sea-sickness, 
 however long it lasts, produces jaundice. On the contrary, 
 vomiting is often used as a cure for jaundice, as it produces a 
 greater flow of bile from the ducts. 
 
 The opinion of Broussais seems most correct, that the yellow 
 colour depends solely on the violent irritation of the duodenum, 
 which is propagated to the secreting organ, the liver. 
 
 This is nearest the truth, but still does not seem quite satis- 
 factory. If the irritation or inflammation of the duodenum 
 was propagated to the liver, w^e must expect to find that organ 
 inflamed. However, no such thing occurs in cither case. 
 
 Now our dissections have, I think, thrown a new light on the 
 subject, and shown the true nature of the obstruction to the
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 343 
 
 flow of the bile which exists in this complaint. In almost all 
 the cases of fever with jaundice which have proved fatal, we 
 have found one or more intussusceptions of the small intestines, 
 without any inflammation of the invaginated part (serous mem- 
 brane). Now let us consider what aid we receive from the 
 finding of these intus-susceptions, towards explaining the origin 
 of the jaundice. But, first, what is the origin of spasm ? 
 Inflammation of the mucous membrane of duodenum, and small 
 intestines, and stomach. In dysentery we find evident spasm of 
 large intestines from inflammation, tenesmus, &c. Well, then, 
 having rendered it probable that spasm exists, depending on 
 inflammation, how does this bear on jaundice ? We have all 
 heard of spasm of the gall-ducts causing jaundice, and best 
 treated by opium, baths, &c. 
 
 We must suppose spasm in the duodenum capable of being 
 propagated to the ducts, or of directly shutting the duct. 
 
 This spasm, constantly occurring, produces, every time it 
 takes place, a constriction of the duct, while the quantity of bile 
 is not diminished, the consequence of which is jaundice. 
 
 Having thus proved a remarkable coincidence between these 
 diseases, if not their absolute identity, let us see how their 
 treatment agrees. We have found by experience that the only 
 treatment which will serve patients in these cases, is that which 
 has been adopted in yellow fever by the most enlightened and 
 experienced physicians — depletion by lancet and leeches, and 
 large doses of calomel, blue pill, hyoscyamus, &c. 
 
 At the time these remarks were penned, I, in common with 
 others, believed that all efierent ducts possessed a vital con- 
 tractility, because we had observed many phenomena which could 
 only be explained on this supposition. Since then, physiologists 
 have applied themselves to the solution of this question, and it is 
 now generally admitted that these ducts do possess the power of 
 contraction, for which they are indebted to a muscular coat. I 
 shall here quote from the highest authority we possess : — 
 
 " The efferent ducts of glands are lined by a mucous membrane, 
 which has on its exterior an extremely thin layer of muscular 
 substance. The existence of muscular fibres cannot, it is true, 
 be demonstrated anatomically, but physiological observations 
 place it beyond dispute. The efferent ducts of most glands have 
 the power of contracting when irritated. The contractile power
 
 341 CLINICAL MEDICINE. 
 
 of the ductus choledochus in birds was known to Rudolplii. By 
 irritating mechanically, or by galvanism, the ductus choledochus 
 of a bird just dead, I have frequently produced a very strong 
 contraction of it, which continued some minutes, after which the 
 duct resumed its previous state. I have often excited strong 
 local contraction of the ureters likewise, both in birds and in 
 rabbits, by the application of a powerful galvanic stimulus. 
 Tiedemann also has seen motions in the vas deferens of a horse 
 ensue on the application of a stimulus. It appears, indeed, 
 that periodic vermicular motions are performed by the efferent 
 ducts, at least by the ductus choledochus in birds ; for once, in 
 a bird just killed, I observed contractions of the duct to occur 
 regularly in pauses of several minutes ; the tube dilating again 
 in the intervals. It was here remarkable, that the contractions 
 took place in an ascending direction, namely, from the intestine 
 towards the liver ; which seems to throw some light on the mode 
 in which the bile at certain times, instead of being expelled into 
 the intestines, is retained and driven into the diverticulum of 
 the duct, namely, the gall-bladder ; the complete closure of the 
 mouth of the duct contributing, perhaps, to this effect. 
 
 " The discharge of the bile from the gall-bladder during 
 digestion results probably from the mere pressure of the sur- 
 rounding parts, and the action of the abdominal muscles, while 
 the mouth of the duct is open : for I doubt if the bladder is 
 contractile : I could produce no contraction of it in mammalia 
 and birds, even with the most powerful stimulus of a galvanic 
 battery ; and in this respect it differs from the other diverticula 
 of efferent ducts, namely, the ui-inary bladder, and the vesiculae 
 seminales, which it resembles in all its characters. 
 
 "Dr. G. H. Meyer however states that, by means of a 
 galvanic battery of fifty pairs of plates, he has caused the gall- 
 bladder of an ox to contract so as to diminish its capacity one- 
 fourth. 
 
 " How far the contractility of the ducts may contribute to the 
 frequently sudden expulsion of the saliva and tears, is a question 
 which I mention merely as requiring further investigation. I 
 may, in conclusion, remark that, since the contractility of the 
 ducts of glands is proved experimentally, the spasm of these 
 parts, spoken of hy physicians, ceases to be a mere hypothesis."* 
 
 * Miiller's Physiology, translated by Baly, 2iid edition, p. 520.
 
 YELLOW FEVER OF THE BRITISH ISLANDS. 345 
 
 It may be well now briefly to cousicler how far the Dublin 
 fever of 1826 — 7 agreed with that since observed at Gibraltar, 
 by Louis. 
 
 The prominent symptoms in the yellow fever of Gibraltar 
 were, flushing of the face, headache, suffusion and pain in the 
 eyes, pains in the limbs, thirst, and loss of appetite ; it icas rare 
 that the patient complained of any pain in the epigastrium at 
 first, hut this generally came on fifteen or sixteen hours from the 
 ■ commenccinent of the disease, and was then inconsiderable, and 
 very few patients complained of severe or acute pain. The 
 abdomen preserved its form, was supple and indolent, except 
 in the epigastric region. The yellow appearance of the skin 
 did not come on till late in the disease, and was seldom very 
 intense, and it was about the same period that the vomiting and 
 dejections assumed their peculiar character ; the dejections were 
 black or bluish, and the matter v'omited, from being of a yellow 
 colour, became black or brown. You will at once perceive that 
 the symptoms which attended the cases of yellow fever we 
 witnessed in 1826, indicated a more intense disease of the 
 abdominal viscera — in all there was tenderness over the epigas- 
 trium, which in some was excessive — black vomiting did not 
 occur in all, but even in the yellow fever of tropical countries it 
 is not constant ; but the symptom which presented the greatest 
 difterence in the two epidemics was the yellowness of the skin, 
 which in the fever of Gibraltar came on towards the latter period 
 of the disease, and was seldom very intense, but in our fever 
 it came on suddenly, immediately after the tenderness of the 
 epigastrium was complained of, and was in all very intense. 
 This shows that whatever lesion produced the yellowness in the 
 Gibraltar fever was either diff"erent in kind or in degree from 
 that which caused it in ours, and I think we cannot doubt but 
 that it was here produced by spasm of the ducts leading from 
 the liver and gall-bladder. 
 
 It is well known to pathologists since the time of Broussais, 
 that jaundice is as frequently produced by duodenitis as hepatitis, 
 if not more so — but I do not think that the explanation he gives 
 is applicable to our cases. He concludes that when the mucous 
 surface of the duodenum is thrown into a state of excitement, 
 we may have a consequent aff'ection of the liver, for the duodenum 
 bears the same relation to the liver as the mouth does to the
 
 34G CLINICAL MEDICINE. 
 
 parotid gland ; and we know that an irritation of the orifice of 
 the ducts leading from this and other salivary glands is ino me- 
 diately followed by an increased flow of their secretions. But 
 our dissections have shown that the small intestines were affected 
 not only by inflammation, but were acted upon by violent spasms, 
 producing invaginations of different portions of the canal ; and 
 there can be no doubt that the ducts (possessing such consider- 
 able vital contractility) participated in these spasms, and thus 
 prevented the flow of bile into the duodenum as efl"ectually as if 
 they were tied by a ligature, or their canals obstructed by calculi, 
 and this explanation obtained great support from the fact, that 
 the jaundice came on suddenly in most of the cases, and was 
 always preceded, or accompanied, by violent and convidsive 
 contractions of the abdominal muscles and intestines. 
 
 There is another point to which I am anxious to direct attention. 
 
 The yellow fever I have now described occurred in the course 
 of an epidemic of continued fever, whose type was a severe and 
 very fatal form of gastro-duodenitis. Does not this circumstance 
 tend to confirm the opinion of Tommasini and others, that 
 yellow fever is but a more severe form of the gastric variety of 
 typhus ? The appearance of the liver described by Louis has 
 not been noticed by other pathologists, and cannot be considered 
 the essential anatomical character of yellow fever generally ; for 
 we read that Eush, Lawrence, Jackson, and Ashbel Smith, the 
 learned writers on the yellow fever of America, seldom found the 
 jaundice connected with liver disease, but that in all cases there 
 was inflammation of the digestive surface : and in the late 
 epidemic of j'ellow fever which prevailed in Martinique from 
 1839 to 1841, M. Kuiz states that he observed the yellow 
 appearance of the liver, described by Louis, only in two 
 instances, and that this organ, like the rest of the solid 
 viscera, w^as very often gorged with blood. 
 
 Dr. Nott says: — "Of eight cases dissected during the 
 epidemic of 1843 in Mobile, the livers in two only corresponded 
 with the description of M. Louis. They were pale, and when 
 torn resembled very closely gingerbread or new leather ; and 
 the six others were of a dark blue or dark chocolate, presenting 
 different shades of colour, and, instead of being dry, they were 
 excessively engorged with blood. The latter cases correspond 
 with the description given by Dr. Hulse of the cases dissected
 
 YKLLJW FEVER OF THE BRITISH ISLANDS. 347 
 
 in the Marine Hospital at Pensacola in 1841. Of the eip;ht 
 dissections in 1844, the livers of four corresponded with the 
 description of Louis, two were of a dark olive, and two were 
 perfectly natural. Taking the whole sixteen cases collectively, 
 six were some shade of yellow, dry, and friahle ; two olive ; two 
 normal ; and six darker than natural, and much engorged." 
 Dr. Nott also thinks that Louis has fallen into another error 
 in supposing this liver to be peculiar to yellow fever, for he has 
 repeatedly met with it in individuals dying of other diseases, and 
 who never had yellow fever. 
 
 In the Martinique epidemic the principal pathological appear- 
 ances were the following: — "The stomach contained matter of 
 a black colour, generally in great quantity, and the raucous 
 membrane was colo.ured by this substance ; but when the con- 
 tents were removed, and the mucous membrane washed, he 
 found that it presented a beautiful rose-coloured hue, extending 
 all over its surface, and not produced by distinct vascular 
 arborizations. In the midst of this redness, he observed several 
 round and distinct spots, produced by the effusion of small 
 quantities of dark-coloured blood, having all the appearance of 
 spots of inirpura hemorrJiagica. The mucous membrane was 
 neither thickened nor softened, but was evidently much more 
 easily detached than in the natural condition. The small intes- 
 tines contained a greyish white matter, particularly the jejunum ; 
 the mucous membrane presented precisely the same appearance 
 as the stomach, but the hemorrhagic spots were more numerous 
 and much larger. The glands of Brunner were in a few cases 
 enlarged to the size of millet seeds, but in no instance were the 
 glands of Peyer in the least altered," 
 
 During the prevalence of the yellow fever in 18^6—7, a captain 
 of a West Indian vessel was admitted into hospital with the 
 disease. He had yellow fever in Jamaica, and stated positively 
 that he was, when under our care, affected in precisely the same 
 manner as he had been in Jamaica ; and he also remarked that 
 the other patients seemed to labour under exactly the same kind 
 of fever as he had then witnessed. 
 
 The correctness of the views here propounded as to the identity 
 of the cases of yellow fever occurring in the Irish epidemic of 
 1826 — 7, with the yellow fever of warmer climates, has been
 
 348 CLINICAL MEDICINE. 
 
 singularly and remarkably proved by the Scotch epidemic of 
 1843 — 4, in which cases of yellow fever were very frequent. Dr. 
 Arnott, physician to the Dundee Infirmary, says : — " The simi- 
 larity of the symptoms during life, and of the morbid appearances 
 observed after death, so nearly agree with the description of the 
 yellow fever of the West Indies, and with the minute accounts of 
 the Gibraltar epidemic of 1828, given by Louis, as to leave little 
 doubt on my mind, that the only difference between these diseases 
 and the Dundee epidemic, if difference there be, is a difference 
 in degree and not in kind." And Dr. Cormack, in his essay on 
 this fever, remarks, " That in all stages of this disease, it is the 
 affection of the stomach that affords the most distinguishing and 
 important symptoms. As it advances, an unconquerable irrita- 
 bility of this organ comes on. Whatever is swallowed, whether 
 solid or fluid, of whatever quantity or quality, is immediately 
 rejected by vomiting. An almost incessant retching takes place 
 even without any extraneous irritation, which commonly, on the 
 third day, ends in what is called the black vomit, the most hope- 
 less of all the symptoms attending it." 
 
 In June, 1846, during the very hot weather which then 
 prevailed, I saw two fatal cases of yellow fever. The first was a 
 very athletic gentleman, 24 years of age, who overheated himself 
 by violent exercise, after having travelled without resting during 
 the night. Being exposed to a thorough air he was chilled, and 
 having spent a restless night, on the following day was attacked 
 with intense fever, nausea, vomiting, thirst, pain in the head, 
 &c. ; he became yellow on the third day, and died on the fifth, 
 without black vomit. 
 
 The second I saw with Mr. O'Reilly of Sackville Street. It 
 was the case of a captain of one of the Liverpool mail packets, 
 who got a chill in the railway carriage coming from Kingstown, 
 when in a perspiration, and was attacked next day with violent 
 fever ; gastric and cerebral symptoms predominated, and about 
 the sixth day he became tympanitic, had black vomit, and died 
 on the eighth day. 
 
 I also saw a third case in the summer of 1847, in a young 
 girl, aged about 14, which terminated fatally ; the only morbid 
 appearance to be observed on post-mortem examination which 
 could have any connexion with the disease, was that the gall- 
 bladder was completely empty of bile.
 
 349 
 
 LECTURE XXII. 
 
 SCARLATINA. — EPIDEMIC OF 1801 — 2—3 — 4. — EPIDEMIC OF 1834. 
 
 It is my inteution to-day to make some observations on the 
 scarlet fever which now prevails as a destructive epidemic, in 
 Dublin and many other parts of Ireland.* The history of such 
 epidemics is very interesting, and tends to shed much light, not 
 only upon the changes which diseases undergo, but upon the 
 fluctuations of medical opinions and treatment. 
 
 In the year 1801, in the months of September, October, 
 November, and December, scarlet fever committed great ravages 
 in Dublin, and continued its destructive progress during the 
 spring of 1802. It ceased in summer, but returned at intervals 
 during the years 1803 — 4, when the disease changed its character ; 
 and although scarlatina epidemics occurred very frequently 
 during the next twenty-seven years, j-et it was always in the 
 simple or mild form, so that I have known an instance where 
 not a single death occurred among eighty boys attacked in a 
 public institution. The epidemic of 1801 — 2 — 3 — 4, on the 
 contrary, was extremely fatal, sometimes terminating in death 
 so early as the second day, as appears by the notes of Dr. 
 Percival, kindly communicated to me. It thinned many families 
 in the middle and upper classes of society, and even left not a 
 few parents childless. Its character seems to have answered to 
 the definition of the scarlatina maligna of authors, for a descrip- 
 tion of which I beg leave to refer you to the Ci/clojycedia of 
 Practical Medicine, where you will find an article on the subject 
 by Dr. Tweedie. In making this reference, however, I do not 
 wish to be understood as expressing my unqualified appi'obation 
 of the article in question, for I must in candour confess that it 
 falls far short of what we might have expected from a physician 
 of Dr. Tweedie 's learning and experience. 
 
 The long continuance of the period during which the character 
 
 * This lecture was delivered during the session of 1831—5.
 
 350 CLINICAL MEDICINE. 
 
 of scarlet fever was either so mild as to require little care, or so 
 purely inflammatory as to yield readily to the judicious employment 
 of an antiphlogistic treatment, led many to believe that the fatality 
 of the former epidemic was chiefly, if not altogether, owing to 
 the erroneous method of cure then resorted to by the physicians 
 of Dublin, who counted among their numbers not a few disciples 
 of the Bruuonian school ; indeed, this opinion was so prevalent, 
 that all those whose medical education commenced at a much 
 later period, were taught to believe that the diminished mortality 
 of scarlet fever was entirely attributable to the cooling regimen, 
 and to the timely use of the lancet and aperients, remedies 
 interdicted by our predecessors. This was taught in the schools, 
 and scarlet fever was every day quoted as exhibiting one of the 
 most triumphant examples of the efi&ciency of the new docti-ines. 
 This I myself learned — this I taught ; how erroneously will 
 appear from the sequel. It was argued, that had the cases which 
 proved fatal in 1801 — 2 been treated by copious depletion in 
 their very commencement, the fatal debility would never have 
 set in, for we all regarded this debility as a mere consequence of 
 previous excessive reaction. The experience derived from the 
 present epidemic has completely refuted this reasoning, and has 
 proved that, in spite of our boasted improvements, we have not 
 been more successful in 1834 — 5, than were our predecessors in 
 1801—2. 
 
 Before I detail more particularly the symptoms that accompany 
 the present epidemic, I wish to enter a little at large into the 
 subject of the changes and variations which the same disease is 
 observed to undergo at diS'erent periods of time. This is a 
 topic which occupied some of the master minds of antiquity, 
 and upon which the greatest of modern physicians, the illus- 
 trious Sydenham, bestowed considerable labour. It has been 
 too much neglected of late, and consequently I consider it my 
 duty to call your attention to it, and I cannot do this better or 
 more forcibly than by communi(^ating to you a literal translation 
 which I have made from the German of my friend Dr. Auten- 
 rieth's observations on this subject. The task of translation 
 is always not only difficult but irksome ; but if, as in the present 
 instance, I can by this means convey to you valuable informa- 
 tion not before presented to my class, or to the public in Eng- 
 land, I never decline the labour. What I am now about to read
 
 SCARLATINA. 851 
 
 is indeed most important, and well deserves the deep attention 
 of every practical physician. 
 
 " The third cause, connected with time and capable of modi- 
 fying diseases, is of infinite importance, both in a theoretical 
 and practical point of view, but has seldom attracted much 
 attention. Its existence is attested by its effects alone, for its 
 nature remains unknown. I allude to the constitutio morhorum 
 stationaria, first noticed by Sydenham, but since his time nearly 
 forgotten, or else confounded with the permanent influence of 
 the seasons, or the accidental atmospherical changes spoken of 
 above. All diseases, contagious or non-contagious, acute and 
 chronic (the latter, however, seldom, except when attended with 
 some degree of general excitement), have been observed to pre- 
 serve a certain constitution or general character, which continues 
 for a number of years in succession, with occasional interrup- 
 tions, until it is displaced by another constitution of a different 
 character. Thus, during one period diseases are remarkable 
 for being frequently accompanied by a sensation of extreme weari- 
 ness, sudden sinking of the strength and vital powers, unpre- 
 ceded by any evident marks of excitement, and attended by a 
 disposition to pass into true typhus. During another period, 
 the tongue is in general loaded with a thick white or yellowish 
 coat ; and many other symptoms of derangement in the diges- 
 tive organs, such as a bitter taste, costiveness, or diarrhoea, are 
 constantly observed. 
 
 " During a third period, diseases are characterized by a 
 remarkable degree of vascular excitement, an evident tendency 
 to local determinations, a frequent formation of morbid pro- 
 ductions ; in a word, by all the symptoms of inflammation. 
 
 "It is not known whether the transition from one of these 
 periodic constitutions to another takes place suddenly or gradu- 
 ally ; but the latter supposition appears more probable except 
 when the transition is accompanied by unusually gi'eat atmos- 
 pheric changes. The erysipelatous affection, which, both in 
 England and Germany, succeeded the gastric and accompanied 
 the first appearance of the inflammatory period, seems to have 
 been an example of the gradual transition. Accurate observa- 
 tions are still wanting to determine whether this periodic con- 
 stitution is confined to certain parts of the world or extends 
 over the whole, and whether its different species follow each
 
 352 CLINICAL MEDICINE. 
 
 other in a regular order of succession. If their order of suc- 
 cession should at any time be determined, it will enable the 
 physician to foretell the character and most appropriate treat- 
 ment of future diseases. The above questions cannot be 
 answered without very great labour spent in the investigation of 
 the history of diseases in all ages and all countries, and are 
 therefore foreign to the present work. 
 
 " The general indications of course vary with the nature of 
 the prevailing constitution ; and, consequently, during one 
 period stimulating remedies, during another alvine evacuations, 
 and during a third venesection and the antiphlogistic plan, will 
 constitute the most effectual treatment. 
 
 " This very circumstance has caused much confusion in 
 medical opinions, and has occasioned the reputation and the 
 downfall of many an infallible system, each of which is in its 
 turn consigned to oblivion, and perhaps again revived as a 
 novelty at some future period. The English boast much of the 
 astonishing improvements in science, and deride the ignorance 
 of their predecessors, regardless of the old proverb, — ' Every- 
 thing has its day.' Whenever, therefore, the periodic constitu- 
 tion undergoes an alteration, they either obstinately uphold their 
 usual plan of treatment, to the manifest injury of their patients, 
 or else blindly embrace some system, to them new, but which 
 really rests upon ancient and established principles. In general, 
 they do not fail to make use of so much exaggeration in support 
 of their opinions, and thus succeed in misleading so many, that 
 none but very well-informed physicians can distinguish the fallacj^ 
 of their arguments. 
 
 " The medical history of Great Britain affords many striking 
 proofs of the truth of these assertions, and is replete with 
 examples of the singular obstinacy with which the English cling 
 to opinions once formed, a circumstance which has materially 
 contributed to obstruct their attaining to general views and 
 impartial conclusions. Even to this day, a warm contest is 
 carried on (less, however, in books than in the debates of learned 
 societies) between the senior and the junior parts of the profes- 
 sion, the former still inclining to Brunonianism, while the latter 
 attribute nearly all diseases to inflammation. Both, indeed, 
 appeal to experience to prove the justice of their principles, and 
 seem entirely to forget that while the propriety of their practice,
 
 SCARLATINA. 353 
 
 as applied to particular cases, remains unimpcaclied, the very 
 nature of the diseases themselves may have heen changed. A 
 summary review of the character assumed by diseases during 
 the last twenty years, both in England and other countries, will 
 perhaps afford a solution of this question. About the end of the 
 last and during the three or four first years of the present cen- 
 tury, the proportion of nervous fevers to other diseases was as 
 one to eighteen in Pl3'mouth (Woolcombe), as one to sixteen in 
 London (Willan), as one to ten in Newcastle (Clarke), and in 
 Liverpool, one to five (Curry). Nor was this scourge of man- 
 kind less severely felt upon the Continent, where typhus, and 
 diseases closely allied to it, committed extensive devastations, 
 particularly during the epidemics of Erlangen, Jena, Kiel, Ratis- 
 bon, and Vienna. Cadiz and Seville were at the same period 
 depopulated by the yellow fever, and Europe in general suffered 
 much from repeated visitations of influenza. An inclination to 
 a sudden sinking of the vital power, unpreceded by violent reac- 
 tion, and unaccompanied by any marked symptoms of a gastric 
 or inflammatory nature, constituted at that period the character- 
 istic form of acute diseases, which were always preceded and 
 attended with an unaccountable degree of debility. Stimulating 
 and tonic medicines obtained, therefore, much celebrity, and 
 every physician who practised during that period attests the 
 injurious or even fatal effects which were produced by the use of 
 venesection, and other depletory remedies. What is still more 
 remarkable, an epidemic typhoid pneumonia prevailed in many 
 parts of Germany during the years 1800 — 1 — 2, in which the 
 speedy production of an inflammatory state, by means of bark 
 and ether, was the only method which aftbrded a chance of 
 recovery. These facts must impress every impartial mind with 
 the conviction, that the constitution of diseases has undergone 
 much alteration since that period, and explain why physicians 
 did not then employ copious venesection, but were obliged to 
 content themselves ordinarily with cold affusions, acids, and 
 mercuiy. 
 
 " The reign of typhus appears to have ceased with the influenza 
 of 1804, when a new constitution began, at first more remark- 
 able for the disappearance of nervous fevers and other contagious 
 diseases, than for any peculiar character of its own. Catarrhal 
 and rheumatic complaints, partly attributable to the weather, 
 VOL. I. 23
 
 354 CLINICAL MEDICINE. 
 
 prevailed for some time, and fevers of an intermitting type 
 became more frequent, forming an evident transition from the 
 purely typhus constitution to that of the vascular excitement of 
 the following years. Some remnant of the typhus constitution 
 was indeed still perceptible in the pectoral complaints which pre- 
 vailed in London during the winter of 1804 — 5, and were attended 
 with remarkable debility, requiring the greatest prudence in the use 
 of the lancet. Venesection was indeed often entirely contra-indi- 
 cated, and Bateman states it sometimes even proved fatal. The 
 constitution, however, soon developed itself more decidedly, 
 became more universally diffused, and obliged physicians to 
 relinquish their former plan of treatment and adopt other 
 measures. Derangement of the alimentary canal became its 
 prominent feature in the summer and autumn of 1804, and 
 diarrhoea, terminating in dysentery, was often met with. 
 
 " This constitution suffered indeed a check from the cold of 
 1805, but it increased again during the following years, and 
 afterwards became still more prevalent, manifesting itself by 
 headache, a bitter taste in the mouth, a loaded yellow tongue, 
 irregularity of the bowels, nausea, and anorexia. The utility of 
 purgatives now became so obvious, that Hamilton's doctrines 
 soon obtained as much celebrity as had been before enjoyed by 
 the stimulating system. The nervous fever at Nottingham in 
 1807, the dysentery at London in 1808, the scarlatina at Edin- 
 burgh in 1805, and the measles at the same place in 1808, all 
 required the purgative plan of treatment, and calomel became 
 the favourite cathartic. The advantage then derived from the 
 use of purgative medicines is abundantly testified by the writers 
 of that period. This gastric constitution appeared also on the 
 Continent, but its progress was less rapid there than in England, 
 where the inhabitants live in a manner calculated to augment 
 or even to produce a tendency to gastric diseases. There were 
 likewise other circumstances which impeded the formation of 
 this constitution on the Continent. Thus in Germany, the 
 purely nervous constitution had scarcely yielded to catarrhal and 
 rheumatic affections, when it was again revived in that unhappy 
 country by the political occurrences of 1805 — C — 7. Typhus 
 seldom, however, assumed the character of exquisite, for the 
 rheumatic and catarrhal affections with which it was mixed par- 
 took somewhat of a gastric nature, as was proved by the great
 
 SCAHLATINA. 355 
 
 benefit derived from the exhibition of emetics and calomel. 
 This appears in accordance with the fact, that the gastric consti- 
 tution was more fully developed wherever the ravages of war had 
 not extended, although it still required less attention in the 
 treatment than the rheumatic symptoms, then likewise prevalent. 
 Thus the agues wliich were common at Tubingen about the end 
 of 180G commenced in general with pain in the belly, vomiting, 
 and irregularity of the bowels ; a yellow furred tongue, head- 
 ache, and tumors of the parotids were of frequent occurrence, 
 and in general gastric symptoms were by no means rare. These 
 symptoms gradually gained ground, and the reputation of ipeca- 
 cuanha and cathartics increased in the same proportion. At 
 Ratisbon the constitution was remarkably gastric in the autumn 
 of 1809, and a nervous fever prevailed at Weimar in 1809 — 10, 
 which was accompanied by bitter taste in the mouth, diarrhoea, 
 nausea, and vertigo. Active catharsis was injurious in this 
 epidemic, but much benefit resulted from the exhibition of castor 
 oil. The advantage derived about the same time in Berlin from 
 the treatment of fevers by emetics and cooling purgatives, 
 proved that they were there also complicated with gastric 
 derangement. 
 
 " The gastric constitution had scarcely established itself, or 
 become pretty generally diffused, when a new character, viz., the 
 inflammator}^, appeared upon the stage, and has ever since con- 
 tinued, sometimes combining itself with the gastric to form 
 diseases of a mixed character, such as erysipelas, and sometimes, 
 when favoured by the seasons or local circumstances, raising 
 itself to the rank of the chief performer. With its appearance, 
 venesection, which had previously fallen into disrepute, became 
 once more a favourite remedy, and in the course of a few years 
 was pushed so far, particularly in Great Britain, that Sangrado's 
 maxim, ' C'est une erreur de penser que le sang soit necessaire 
 a la conservation do la vie, on ne pent trop saigner un malade,' 
 seems to have been the general rule of practice. The same in- 
 flammatory constitution became also general in Germany, but 
 there it neither attained such a height, nor required such active 
 treatment as in Great Britain, where many circumstances 
 favoured its more perfect development ; with us it generally 
 yielded to the use of acids, cold applications, and mercury, but 
 in England it called for copious blood-letting. Even in 1810,
 
 356 CLINICAL MEDICINE. 
 
 diseases had become more inflammatory at Tubingen than they 
 had been previously ; but the change was still more perceptible 
 in 1813, when the antiphlogistic treatment required the aid of 
 small venesections, and nervous fevers were accompanied both by 
 inflammation and derangement of the digestive organs. Erysi- 
 pelatous afi"ections were also frequent, and in many cases were 
 of a marked inflammatory character. Erysipelas and true in- 
 flammatory fever, requiring the use of the lancet, were common 
 at Ratisbon in 1811. Parrot exhibited acids, especially the 
 acetous, with great success in the epidemic nervous fever which 
 raged at Dorpat in 1812, and a diarrhoea of a bilious inflamma- 
 tory nature prevailed at Konigsberg during the same year. 
 This important change in the constitution became very evident 
 in the nervous fever at Berlin in 1813, as well as in the formid- 
 able epidemic described by Hufeland, which ensued after the 
 war, and raged in the north of Germany during that and the 
 preceding year. Although but a few years before the strongest 
 stimulants had been necessary to obviate the paralysis which 
 supervened even in the beginning of the disease, yet an opposite 
 practice was now required, and antiphlogistic remedies were 
 alone found capable of preventing the vascular excitement from 
 terminating in inflammation of either the head or chest. In 
 short, the inflammatory constitution has been prevalent in 
 Germany ever since the years 1810 — 11, sometimes in its pure 
 and marked form, and sometimes complicated with gastric and 
 rheumatic symptoms. 
 
 " This constitution became general at the very same period in 
 Great Britain. Dr. Clutterbuck, of London, had indeed ascribed 
 the origin of fever to inflammation of the brain, so early as 1807, 
 and about the same time Dr. Steiglitz, of Hanover, had recom- 
 mended the antiphlogistic treatment of scarlet fever, in preference 
 to the stimulating plan then in vogue. But as the inflammatory 
 was then still subordinate to the rheumatic and gastric consti- 
 tutions, their opinions did not gain many converts. But the 
 inflammatory constitution had increased so much in the autumn 
 of 1809, and the winter of 1810, that even Bateman was obliged 
 to prescribe venesection in fevers — a practice quite at variance 
 vs^ith his former views. Erysipelatous inflammation became 
 common in London, Aberdeen, and Leeds, and numerous cases 
 of puerperal fever occurred in the latter towns, which, according
 
 SCAKLATINA. 357 
 
 to Gordon and Hey, never terminated favourably, except when 
 bleeding and purgatives were employed with freedom. But it was 
 not until 1813, when the inflammatory constitution had fully 
 developed itself, and the bad consequences arising from violent 
 determination of blood to the head in nervous fever could not be 
 averted except by decisive measures, that venesection came into 
 general use in Great Britain, in consequence of a publication by 
 Dr. Mills, who had prescribed it with much success since 1810. 
 In the same year that truly estimable physician, Dr. Thompson, 
 published his admirable work upon inflammation. Blackall 
 recommended blood-letting in several species of dropsy, and 
 Armstrong employed the same remedy, combined with large 
 doses of calomel, in the inflammatory puerperal fever which was 
 prevalent in Sunderland. Venesection became from this time as 
 great a favourite as ever in England, not, however, to the exclu- 
 sion of purgatives, which were indicated by the derangement 
 of the stomach and bowels that accompanied the inflammatory 
 constitution. Both these remedies were found extremely bene- 
 ficial in the nervous fever which was epidemic in Ireland in 
 1813 — 14 ; its inflammatory character being clearly evinced by a 
 hard and full pulse during its first stage, and a violent deter- 
 mination of blood to the head, by which the headache and raving 
 are increased, while its gastric type was not less strongly marked 
 by tenderness of the epigastrium, costiveness, or else frequent 
 and unnatural alvine discharges, together with a loaded tongue 
 and bilious vomiting. The latter symptoms were, in Dr. Grattan's 
 opinion, of such importance, that he gave a decided preference to 
 the purgative plan. The fever, which had previously been con- 
 fined to Ireland, became generally diffused over the rest of Great 
 Britain after the famine of 1816, and continued without inter- 
 mission for four years. Its inflammatory character being pecu- 
 liarly favoured, both in England and Scotland, by the habits of 
 the inhabitants and the situation of these countries, venesection 
 attained an unexampled degree of celebrity, notwithstanding the 
 representations of the Irish physicians, who used that remedy 
 with more moderation. It was soon believed that there is, 
 literally speaking, no disease whatever in which the lancet ought 
 not to be used, and, as the human mind is ever prone to ex- 
 tremes, it was soon generally considered, both in England and 
 Scotland, to be a well-founded pathological inference, " there is
 
 358 CLINICAL MEDICINE. 
 
 but one species of fever, viz., the inflammatory, and consequently 
 venesection is the only true anti-febrile remedy. Such is the 
 case in England at present, and it must have been so always, 
 and in every part of the world." I flatter myself, however, that 
 the preceding observations and statement of facts, drawn from 
 authentic sources, sufficiently negative these assertions, and 
 establish the real existence of a change in the constitution of 
 diseases, notwithstanding what Dr. Duncan once said to me, 
 " that such changes existed only in the imagination of phy- 
 sicians." 
 
 It is now twelve years since Dr. Autenrieth, in his Account 
 of the State of Medicine in Great Britain, made the foregoing 
 interesting observations ; and to me it appears that the history 
 of the diseases which have since prevailed, affords convincing 
 proofs that the then inflammatory constitution has again sub- 
 sided, and is now replaced by a typhous type : indeed, it cannot 
 be denied that a very great difference exists, not only between 
 the present and the former scarlatina, but also between the fever 
 of the present day and that which prevailed shortly before 
 Dr. Autenrieth published. But this is too important a question 
 for us to decide without more reflection and thought than I have 
 been able to bestow on it, and without more facts than I have 
 been able to collect. The opinion I have brought forward I do 
 not wish to be received as established ; I look upon it as probably 
 well founded, but as yet not proved, except so far as to merit 
 further consideration and excite further discussion. 
 
 Indeed, I have for the present been obliged, by the pressure of 
 other engagements, to postpone a more accurate examination of 
 this subject, and a more severe scrutiny of the facts which just 
 now crowd into my memory ; but I conclude with remarking, that 
 the wide-spreading epidemic of influenza, which in 1833 visited 
 the whole of Europe, including the British Isles, was not only 
 truly remarkable, both for the violence of the feverish symptoms 
 and of the local congestions of the chest and heart which accom- 
 panied its attack, but likewise for the unexpected relation which 
 it was found to bear to all measures of active depletion. I appeal 
 to the profession for their testimony on this matter — I ask 
 whether all our preconceived opinions as to the a 'priori in- 
 dications for venesection, leeching, and purging, were not found 
 to be contradicted by the efi'ects of these remedies in that
 
 SCARLATINA. 359 
 
 epidemic. The sudden manner in wbicli the disease came on, 
 the heat of skin, acceleration of the pulse, and the intolerable 
 violence of the headache — together with the oppression of the 
 chest, cough, and wheezing — all encouraged us to the employ- 
 ment of the most active modes of depletion, and yet the result 
 was but little answerable to our expectations, for these means 
 were found to induce an awful prostration of strength, with little 
 or no alleviation of the symptoms. In some who were thus 
 treated, recovery was protracted and doubtful, and the strength 
 was not restored for several months. Indeed, nothing was more 
 curious than the length of time which was necessary for some 
 persons, in order to recruit tbeir strength after an attack of 
 influenza, although that attack had not continued more than a 
 few days, and had been judiciously treated, without blood-letting 
 or unnecessarily debilitating remedies. I have known some who 
 lapsed into a cachectic state of long-continued debility from which 
 they never recovered ; for, while thus reduced, they fell victims 
 to the first acute complaint which seized them. The influenza 
 above referred to fully confirmed the opinion I had long enter- 
 tained, that in acute diseases debility and exhaustion of the vital 
 power are by no means in every case either caused by, or jn-o- 
 portioned to, a state of previous excitement. This opinion 
 received further support from the symptoms and phenomena 
 exhibited hj the Asiatic cholera, in which the stage of debility 
 and collapse commenced, and too often closed the scene ; and 
 has been still more powerfully corroborated by the epidemic of 
 influenza of 1837 and 1847, as also by the Irish epidemic fever 
 of 1846 — 47. Why do I dwell upon these occurrences, and why 
 have I so frequently referred to the opinion above expressed ? 
 Simply because the prevalence of the contrary opinion laid the 
 foundation for the injudicious and exclusive application of the 
 lancet, and of the antiphlogistic method generally in Great 
 Britain, and was, consequently, the cause of working excessive 
 mischief. 
 
 I have already mentioned that the disease called scarlet fever 
 assumed a very benign type in Dublin soon after the year 1804, 
 and continued to be seldom attended with danger until the year 
 1831, when we began to perceive a notable alteration in its 
 character, and remarked that the usual undisguised and inflam- 
 matory nature of the attack was replaced by a concealed and
 
 360 CLINICAL MEDICINE. 
 
 insidious form of fever, attended with great debility. We now 
 began occasionally to hear of cases which proved unexpectedly 
 fatal, and of families in which several children were carried off ; 
 still it was not till the year 1834 that the disease spread far and 
 wide, assuming the form of a destructive epidemic. The nature 
 of the disease did not appear in the least connected with the 
 situation or aspect of the patient's dwelling, for we observed it 
 equally malignant in Rathmines as in Dublin ; on the most 
 elevated habitations on mountains, as in the valley of the Liffey. 
 It raged with similar violence at Kingstown, and the neighbour- 
 hood of Killiney and Bray. The state of the Aveather seemed to 
 exercise no influence either upon its diffusion or its symptoms, 
 which continued to exhibit equal virulence, no matter whether it 
 was wet or dry, warm or cold, calm or stormy. The contagion 
 seemed to act as a more deadly poison on the individuals of 
 some families than upon those of others, and consequently, when 
 one member of a family died, there was always much reason to 
 fear for the others when attacked. At first I thought that its 
 greater severity in such cases could be traced to strumous habit, 
 but subsequent experience did not confirm this suspicion, for 
 the most scrofulous family I ever saw went through the disease 
 without a death, whereas in some others the mortality was great, 
 although not a single indication of a strumous diathesis could be 
 detected. Many parents lost three of their children, some four, 
 and in one instance which came to my knowledge, five fine 
 children were carried off. As usual in such epidemics, the 
 degree of intensity with which different persons were attacked 
 varied exceedingly, some exhibiting the mildest form of scarlatina 
 simplex, which required no treatment, and scarcely confinement 
 to the room, while the majority were severely affected. When 
 the disease was violent, it assumed one or other of the following 
 forms : — 
 
 First. — It at once produced not merely fever with sore throat 
 and headache, but such violent congestion of the brain, and deter- 
 mination to the head, as occasioned convulsions and apoplectic 
 coma on the first or second day. This happened to a young 
 woman of robust habit in Werburgh Street, to whom I was called 
 by Dr. Brereton. She was attacked with convulsions on the 
 second day, and died comatose on the third. In her the scarlet 
 eruption was extremely vivid and general, a fact I notice as a
 
 SCARLATINA. 361 
 
 proof that the congestion of internal organs was not caused by 
 any retrocession of the eruption. In truth, as will appear 
 hereafter, the worst cases had the most general and most intense 
 cutaneous efflorescence. When this tendency to the head took 
 place in so violent a manner at the very outset, the patient was 
 seldom saved ; sometimes, however, very active measures of 
 depletion, general and local, relieved the brain, and the case 
 then went on favourably. This happened in a young gentleman 
 residing in Upper Baggot Street, to whom I was called by the 
 late Mr. Nugent, of Merriou Row. When the scarlet fever 
 attacked a person subject to epileptic fits, the tendency to the 
 head was increased by the epileptic habits, and fits of convulsions 
 at once supervened. Thus, in the case of a gentleman, aged 
 22, who had been for several months treated by Mr. Colles 
 and myself for epilepsy, the fits commenced on the second day 
 of scarlatina, and continued with frightful violence until the 
 fifth day, when they proved fatal. In a young lady residing 
 near Blackrock, to whom I was called by Dr. Wilson, precisely 
 the same thing occurred. She had been subject to epilepsy for 
 many years, and when the scarlet fever commenced, she was at 
 once seized with frequently recurring fits, which, in spite of the 
 most active measures, ended in fatal coma on the fifth day. 
 
 In the second form of the disease which I noticed, the symptoms 
 were exceedingly violent and intense from the beginning, and the 
 disease set in with the usual symptoms of severe exanthematous 
 pyrexia, remarkable in the very commencement for the violence 
 of the accompanying headache and spinal pains, and for the great 
 irritability of the stomach and bowels. Indeed one of the very 
 first symptoms in such persons was nausea, vomiting, and bowel 
 complaint. Large quantities of recently secreted bile were 
 thrown up, and the patient passed frequent stools, curdled green 
 or saflron yellow, at first semi-fluid and afterwards fluid, and 
 evidently composed of bile suddenly effused into the intestinal 
 canal, with a copious and hurried secretion of mucus from the 
 internal membrane of the bowels, and mixed with some true 
 faecal matter. It was surprising what quantities were thus 
 thrown up and passed from the bowels, by some individuals 
 during the first day or two of the disorder ; neither the constant 
 repetition of the nausea and vomiting, nor the abundance of the 
 discharge from the stomach and bowels, in the slightest degree
 
 3G2 CLINICAL MEDICINE. 
 
 mitigated either the violence of the fever or of the headache, or 
 seemed to prevent the full formation of the eruption. It was 
 curious to observe that this obstinate vomiting and purging were 
 unaccompanied by the slightest epigastric or abdominal tender- 
 ness ; during its continuance the belly became fallen and soft. 
 In fact its cause was situated not in the belly, but in the brain, 
 a fact I did not perceive until I had an opportunity of watching 
 the progress of five or six such cases. It depended on cerebral 
 irritation and congestion, and was in nature very similar to the 
 irritability of stomach and bowels which so often accompanies, 
 and too frequently masks the progress of acute hydrocephalus. 
 As soon as I had become aware of the pathological relations of 
 this vomiting and purging, I did not confine my endeavours to 
 check these symptoms, to measures intended to act directly on 
 the stomach and bowels, such as eftervescing draughts, chalk 
 mixture, stupes, leeches to the epigastrium, &c., but I changed 
 my plan of treatment, and turned my attention to the state of the 
 cerebral circulation. Having in a former lecture referred to this 
 topic, and having explained to you the manner in which derange- 
 ment of the stomach and bowels of a properly gastric origin is 
 to be distinguished from disorder of the digestive apparatus, 
 originating in a sympathetic derangement of function, itself 
 caused by a morbid condition of the brain, and having already 
 pointed out the importance in practice of not confounding these 
 two states, one or other of which is so common in the com- 
 mencement of violent fevers, phlegmasia, and exanthemata, I 
 shall not at present dwell any longer on this subject. 
 
 The second form of scarlatina was likewise remarkable for the 
 violent excitement manifested from the very beginning in the 
 circulating system, and in the production of animal heat. The 
 pulse at once rose to above 100, it was seldom less than 120, 
 and in many cases, particularly in young people, it ranged from 
 140 to 150. I have never in any other disease witnessed so 
 many cases of excessively rapid pulse. In general the pulse in 
 this form was regular, but in two cases it became irregular. 
 One was that of a gentleman living in Upper Mount Street, 
 whom I attended with Sir Henry Marsh ; his pulse became 
 intermitting and irregular on the third day, and continued to be 
 thus affected more or less for about a week. This gentleman 
 was attacked with subsultus, delirium, jactitation, and various
 
 SCARLATINA. 363 
 
 nervous symptoms, at a very early period, and complained con- 
 stantly of bis throat and head. The former was violently 
 inflamed, and his skin was covered with a bright red eruption. 
 On the ninth day be was seized with convulsive fits of great 
 violence, and which returned very frequently during the night ; 
 his case apj)eared utterly hopeless, and yet be perfectly recovered. 
 In a young lady who was attended by Dr. Nolan, great irregu- 
 larity and intermission of the pulse commenced about the eighth 
 day, and continued during the state of danger ; she also 
 recovered. Of course irregularity of the pulse was in many 
 not so much a symptom of disease as of approaching death, but 
 then the state of the patient could not be mistaken, judging 
 from all the other circumstances of the case. The acceleration 
 of the pulse abated in all when an evident improvement in 
 the general condition took place, but in few did the pulse become 
 quite natural for many days after the favourable change, and in 
 none did it fall to its usual standard in the course of twelve or 
 twenty-four hours, as it not unfrequently does after the crisis of 
 continued fevers ; in fact, the scarlatina never ended with a well- 
 defined crisis. 
 
 As to the temperature of the body, I have already observed 
 that in the cases I am now describing it was from the first con- 
 siderable, and continued elevated until a very short period before 
 death. Both the pulse and heat of skin, however, were very easily 
 reduced in energy by the use of the lancet, or by the repeated 
 application of leeches, and it was not uncommon to observe 
 that even the judicious use of these means induced a general 
 coldness of surface, very great sinking of the strength, and a 
 faltering state of the pulse. This was remarkably the case in a 
 young lady whom I attended along with Mr. Wilkinson in 
 Blackrock, and also in one of the family for the history of whose 
 cases I am indebted to Dr. Nolan. In both, these eftects were 
 very obstinate and alarming, for reaction was not restored until 
 after the lapse of more than twelve hours, but both finally 
 recovered. The pulse was sharp but not strong, and resembled 
 the pulse of great irritation rather than that of true inflamma- 
 tion. 
 
 The most distressing symptom at the commencement of this 
 form of scarlatina was the sore throat ; the fauces were violently 
 inflamed, and deglutition consequently much impaired, while
 
 364 CLINICAL MEDICINE. 
 
 a general soreness was felt in the back of the head and neck ; 
 urgent headache was complained of by all, and from the second 
 day the eyes became suffused ; great restlessness, anxiety, jacti- 
 tation, moaning and interrupted raving soon made their appear- 
 ance, and in many sleep was banished or utterly broken by 
 startings and delirium before three or four days had elapsed. 
 The eruption had now arrived at its height, which it did with 
 great rapidity, dating from the first moment of its appearance, 
 so that the skin, everywhere covered with a scarlet eruption, 
 resembled in appearance the hue of a boiled lobster. 
 
 In these violent cases the efflorescence was perfectly con- 
 tinuous, and never broken into spots or patches ; the skin 
 appeared as if evenly dyed with one uniform colour ; the surface 
 of the tongue was likewise much affected with the same exanthe- 
 matous redness, and soon became foul, and afterwards dry and 
 parched. The sudden drying of the tongue on the fifth or sixth 
 day indicated in this form a rapid aggravation of the disease, and 
 death in several cases was observed to follow this change in less 
 than twenty-four hours, when it was, as in a young gentleman 
 Mr. Ptumley and I attended in French Street, accompanied by a 
 sudden acceleration of the pulse and increase of the jactitation 
 and delirium. In this form the brain and nervous system 
 seemed to be the parts which suffered most, and many became 
 insensible for several hours before death ; others had convulsions. 
 When the patient survived the seventh day there was a fair 
 chance of recovery, but many, too many, died on the fourth, 
 fifth, or sixth days. 
 
 After I had witnessed a few examples of this form of scarlatina, 
 I consulted with several of my friends and colleagues, and we 
 determined to use the most active measures of depletion in the 
 very first instance that occurred to us. A case was not long want- 
 ing. Sir Henry Marsh and I were engaged in prescribing for 
 some children labouring under the epidemic, in a house in 
 Pembroke Street, where our attention was directed to a fine boy, 
 G years old, and hitherto perfectly healthy, who was, while we 
 were paying our visit, attacked with the first symptoms of the 
 complaint ; we immediately resolved that as soon as the stage of 
 rigor and collapse which preceded the febrile action had passed, 
 to visit him again and act energetically, if circumstances seemed 
 to permit it. Accordingly we came again in the course of a few
 
 SCARLATINA. 365 
 
 hours, and found reaction already established, attended with 
 vomiting, purp;ing, and headache. The sore throat, too, was 
 much complained of, and there was great tenderness of the external 
 fauces. "We ordered relays of leeches, eight at a time, to the 
 neck, for the purpose of relieving both the throat and brain, and 
 we administered James's powder and calomel internally. On the 
 next day the skin was burning, in spite of a copious loss of 
 blood from the leech-bites, the eruption vivid and already esta- 
 blished, the pulse 140, and there had been little or no sleep. 
 Relays of leeches were again ordered, and persevered in until 
 considerable and lasting faintness was produced, and yet no 
 impression seemed to be the result, for the raving became more 
 incessant on the second night, and on the third day suffasion of 
 the eye commenced, and the tongue became parched. Shaving 
 of the head, the most industrious application of cold to the 
 scalp, and various other remedies were in vain applied; the pulse 
 became weaker, the breathing quicker, the strength failed rapidly, 
 raving and delirium gave place to insensibility and subsultus, 
 and the patient died on the fifth day. In this case depletion was 
 applied at once and decidedly, for we blanched and weakened the 
 boy by loss of blood as far as it was possible to venture, and 
 yet the disease was not in the least degree checked, nor the 
 symptoms even mitigated. 
 
 A fine boy, 13 years of age, was attacked in the county of 
 Wicklow, where he was placed under the care of a very judicious 
 practitioner, who did not use either venesection or leeches, but 
 relied chiefly on the exhibition of diaphoretics, particularly anti- 
 monials. The boy died on the seventh day, having suffered 
 much from delirium, subsultus, want of sleep, &c. His brother, 
 who was one year older, and a very strong boy, was seized with 
 the disease in Dublin, and placed immediately under my care. I 
 had the advantage of Mr. Rumley's assistance, and we determined 
 to prevent the supervention of the cerebral symptoms, if it were 
 possible to do it, by means of anti})hlogistic treatment : we failed, 
 and our patient died on the sixth day. In short, this form of the 
 disease, where the pulse, without becoming strong, became at 
 once extremehj rapid, bore venesection badly, and required great 
 caution even in the application of leeches; the nervous symptoms 
 appeared only accelerated by the system of depletion, although 
 the heat of the skin suggested its employment.
 
 366 CLINICAL MEDICINE. 
 
 The derangement of the brain and nerves in this form depended 
 on something more than the violence of the circulation, and 
 originated in something altogether different from mere cerebral 
 inflammation or congestion. What that something was I cannot 
 even conjecture : but it was probably the result of an intense 
 poisoning of the system by the animal miasma of the scarlet fever. 
 Every tissue of the body seemed, if I may use the expression, 
 equally sick, equally overwhelmed, and it is probable that the 
 capillary circulation in every organ was simultaneously deranged. 
 It was not gangrene of the throat which proved fatal, for in this 
 form it never occurred ; it was not inflammation of any internal 
 viscus, for such was not found on post-mortem examination of 
 the fatal cases ; but it was a general disease of every part. In 
 many, another state of things, which required to be carefully 
 distinguished from that just described, existed, and the disease 
 was evidently attended with an inflammatory state of the constitu- 
 tion, requiring energetic measures. In such cases the symptoms 
 were severe in the commencement, the throat very sore, the 
 efflorescence, however, not quite so sudden or so perfect, and the 
 pulse not so quick, never excessively rapid, and always strong 
 and distinct. Such bore bleeding and leeching well, and experi- 
 enced from their use almost immediate alleviation of the sore 
 throat, headache, and restlessness, and were not much weakened 
 by the depletion. It must be confessed that it was often exceed- 
 ingly difficult to determine, a priori, whether the depletory 
 system ought or ought not to be tried. Where doubt existed, 
 my custom was to try moderate leeching, and from its eff"ects I 
 judged of the propriety of persevering. 
 
 The disease very frequently occurred in a third form, more 
 singular still than the two first, and much more insidious in its 
 commencement. This form was evidently very common in the 
 epidemic scarlet fever described by Withering, as cited by Dr. 
 Tweedie. In this form the disease was ushered in by the usual 
 symptoms of pyrexia, together with sore throat, slight headache, 
 and in due time a very moderate and normal eruption. The 
 symptoms continued moderate ; the patients, after the first few 
 days, slept tolerably well during the night, had no raving, and 
 were quiet during the day. About the fourth or fifth day all the 
 febrile symptoms had eo far subsided that a most accurate exami- 
 nation could detect nothing urgent, nothing in the slightest
 
 SCARLATINA. 3G7 
 
 degree either alarming or calculated to excite the least anxiety 
 in the patient's condition. His skin became nearly of the 
 natural standard, his thirst diminished, and the pulse was now 
 scarcely accelerated ; a calm, nearly complete in fact, seemed to 
 have followed the first onset of the disease ; and, on entering the 
 room, the physician might easily be deceived, as I myself .was 
 more than once, into the pleasing hope that all danger was past, 
 and that perfect recovery might confidently be anticipated. 
 
 This hope was, in truth, founded on such circumstances as we 
 can usually rely on ; for who would prognosticate danger, where 
 his little patient, sitting up in bed, and perhaps eating a dry 
 crust with some appetite, had a placid countenance, and had 
 enjoyed a night of tranquil sleep ? Regular alvine evacuations, 
 diminution of thirst, sore throat, headache, and fever, together 
 with the normal state of the cutaneous eruption, all conspired to 
 confirm a favourable prognosis ; and so matters proceeded, the 
 family dismissing all apprehensions as to the result, and the 
 physician most probably discontinuing his attendance about the 
 seventh day, in the belief that all danger was over, and that his 
 interference was no longer necessary. Matters proceeded thus 
 until the eighth or ninth day, when a certain degree of restless- 
 ness was observed to occur, and in the morning a slight return 
 of fever might be noticed. Then it was that a peculiar train of 
 symptoms set in. The nostrils assumed a sore and irritated 
 appearance about the edge of the alas, and a serous moisture 
 began to flow from their internal cavities. Sore throat was 
 again complained of, the skin became hot, great debility and 
 prostration of strength came on suddenly, a painful tumefaction 
 commenced in the region of the parotids and submaxillary 
 glands. This tumefaction increased rapidly, becoming every 
 day harder, more elevated, diffused, and exceedingly tender, but 
 without much redness. In the course of a few days it surrounded 
 the neck like a collar, and being attended with swelling of the 
 face, the poor little patient's countenance was sadly disfigured. 
 In the meantime the discharge from the nose had increased 
 considerably, and become more viscid and foetid ; the internal 
 membrane lining the nasal passage was affected throughout, its 
 entire surface everywhere inflamed and tumefied, so that a 
 snufiiing sound was produced when the patient breathed through 
 his nose : at length the discharge increased to such a degree,
 
 368 CLINICAL MEDICINE. 
 
 that the nostrils hecame completely impervious to the air in 
 hreathing. The state of the throat generally began to alter for 
 the worse at the very commencement of this change ; and a 
 similar inflammation, attended with an ill-conditioned secretion 
 of lymph and fluid, occupied the entire surface of the mouth and 
 tongue, and at last spread deeply into the pharynx. 
 
 While this was going on, the fever freshly lit up, at once 
 exhibited the most decided symptoms of the worst form of typhus 
 and subsultus, constant muttering, raving, anxiety, want of 
 sleep, restlessness, moaning mingled with an occasional screech, 
 reminding one of that which is so ominous in hydrocephalus. 
 Great difficulty was now experienced in swallowing, and the 
 drink was frequently spurted out of the mouth after a vain 
 attempt at deglutition. Matters now proceeded rapidly from 
 bad to worse, and at last, after much suff'ering, death closed the 
 scene, being preceded many hours by a state of extreme restless- 
 ness, during which it was impossible to determine whether the 
 patient was still sensible. The swelling of the neck went on 
 increasing to the last, but seldom exhibited any tendency to 
 point ; it continued, on the contrary, everywhere hard, or, at 
 most, became indistinctly softened, or, to use a technical phrase, 
 " boggy." When cut into, no matter was found ; blood, serum, 
 and a diffused cellular slough, not separated from the living 
 tissues, were observed on making the incision. 
 
 Some notes on this epidemic I received from Mr. O'Ferrall 
 are extremely valuable, more especially where he describes a 
 most important sequela of scarlatina, not hitherto mentioned by 
 any writer ; I shall therefore give you a brief statement of his 
 observations. 
 
 "Of seventeen cases," says he, "of which I possess notes, 
 four occurred in adults, three in children under four years of 
 age, and the remainder at different ages between the latter and 
 fourteen or fifteen years. I seldom saw the cases in the com- 
 mencement. The mode of attack was occasionally similar to 
 that of common sore throat followed by rigors ; sometimes 
 violent pyrexia and shiverings, with intolerable headache, and 
 even delirium, preceded by other signs. In some few cases, the 
 efflorescence first attracted notice, the fever in these instances 
 being throughout so mild as scarcely to demand attention. 
 
 " The progress of the disease was various, but usually bore a
 
 SCARLATINA. 3G9 
 
 relation to the character of the incipient fever. In general, the 
 fever increased in intensity as the disease advanced, or as now 
 parts became engaged ; but this was not always the case. In 
 two instances, which I saw in a state of great vital depression on 
 the third or fourth day, I was assured that the early fever was 
 very high, although it had passed rapidly into the typhoid state. 
 ** The danger sometimes appeared to arise from the condition 
 of the entire system, sometimes from that of important parts. 
 Of two cases which I saw when dying, one was sinking like a 
 person in typhus fever ; the other, a boy thirteen years old, was 
 moribund in the coma, which succeeded to violent phrenitic 
 delirium. The latter case was remarkable in this, that the 
 phrenitic state occurred while the eruption was in its prime, 
 the whole body retaining its deep scarlet colour until a short 
 time before his death. The disease in this instance set in with 
 delirium, which had been subdued, I have reason to believe, by 
 the most active means. Death occurred in one instance from 
 croup, the disease of the throat having passed into the trachea 
 and bronchial tubes. In another, sloughing of the fauces, with 
 low fever, carried off the patient on the sixth day. 
 
 "In several, who ultimately recovered, life was seriously 
 endangered by local inflammatory attacks. In one instance, a 
 girl about seven years old, enteritic symptoms sprang up sud- 
 denly while the patient was in a very weak state, and were with 
 difficulty subdued. In another, a boy ten years old, acute pain 
 in the region of the heart occurred when the eruption was on 
 the decline ; it was accompanied by short cough, palpitations, 
 dyspnoea, rapid though not irregular pulse, and sudden accession 
 of fever. There was no perceptible frottement, but the action of 
 the heart was violent, and there was acute pain on pressure. It 
 yielded to leeching, followed by calomel with James's powder, 
 till the gums were slightly touched. 
 
 "Another patient, a girl twelve years old, narrowly escaped 
 the effects of sloughing of the throat. Croup occurred in two 
 instances, in which, notwithstanding the opinions of M. 
 Trousseau, I could not doubt its origin in scarlatina. It 
 happened, no doubt, in cases which had exhibited the diphthe- 
 ritic patches, without much surrounding inflammation on the 
 tonsils, but the eruption was sufficiently marked to remove all 
 obscurity. One child, who recovered, ejected the false mem- 
 voL. I. 24
 
 370 CLINICAL MEDICINE. 
 
 brane (which I still preserve) in a tubular form, and presenting 
 a cast of the trachea a little beyond its bifurcation. In the 
 child before mentioned, who died, patches of false membrane 
 were also ejected ; but she sank exhausted, and the disease was 
 afterwards discovered to have extended far into the bronchial 
 ramifications. 
 
 " Although the treatment was generally antiphlogistic, this 
 plan was not always applicable, even in the commencement of 
 the disease. In all instances which I had an opportunity of 
 observing, it was necessary to watch the effects of local bleeding. 
 It was easy to pass the boundary of relief, and then most difficult 
 to repair the loss, and meet the symptoms of exhaustion when 
 they had actually set in. Wine and diffusible stimuli were 
 often required from this cause alone, even when the cases had 
 nothing of the malignant or typhoid character in their nature. 
 
 " Tepid sponging appeared in many instances preferable to 
 cold, and I think the soothing effects were of longer duration. 
 Keaction and the distressing sense of burning heat did not 
 appear to recur so soon as when cold fluids were employed. 
 Purgatives, except of the mildest kind, were not well borne, but 
 cooling diuretics were clearly indicated, and, when persevered 
 in, had, in many cases, the apparent effect of anticipating the 
 sequelae of the complaint. 
 
 " The ulcerations and sloughings of the throat were treated 
 by nitrate of silver, alum, and the chlorides, according to their 
 states. But none of these applications were to be depended on 
 when the colour of the fauces was intensely red, unless a few 
 leeches had been previously applied. In one gentleman, twenty- 
 eight years of age, free leeching externally (to the number of 
 forty) failed in removing the sense of suffocation or enabling 
 him to swallow. A few leeches applied to the inside of the 
 nostrils were followed by copious bleeding and immediate relief. 
 The latter expedient was indicated by the tumid state of the 
 velum and pituitary membrane, the stertorous breathing, and 
 complete occlusion of the nares. 
 
 "Its mode of spreading in families was uncertain. It some- 
 times attacked children within a few days of each other ; at 
 other times a fortnight has elapsed before I was again requested 
 to see a new patient. Some children escaped the disease 
 altogether.
 
 SCARLATINA. 371 
 
 " Among the sequelae which I had occasion to see, diarrhoea 
 occurred in two or three instances, chronic bronchitis in one, 
 and anasarca in four. The urine was sHghtly albuminous in 
 two of the latter cases before the face and limbs began to swell ; 
 in the other two it exhibited this character when the disease was 
 formed, but I did not see them previously. The treatment of 
 the anasarca was antiphlogistic and diuretic, and succeeded in 
 restoring three to pex'fect health. The fourth still remains an 
 invalid, but not from this cause ; the apex of the right lung 
 affords evidence of tubercular disease. 
 
 " I have now to mention a peculiar affection of the neck, 
 which I have not before seen in connexion with scarlatina, but of 
 which four cases have occurred during my observation of the 
 epidemic in question. 
 
 "Case 1. — About the beginning of August, 1834, I was 
 requested by my friend. Dr. Davy, to see a young girl, ten 
 years old, in Upper Baggot Street. Her convalescence was 
 tedious, some degree of fever still existing at the end of six 
 weeks from the commencement of the attack. But her principal 
 complaint was severe pain of the right side of the neck, close to 
 the head, and extending as high as the vertex, on the least 
 motion of the part. She could not raise her head from the 
 pillow without putting a hand at each side for its support, and 
 when taken out of bed, instinctively sought a resting-place for 
 the chin. The face was awry, its vertical diameter passing 
 from above downwards, and from right to left. Posteriorly, the 
 upper cervical vertebrae were curved, the convexity of the curve 
 being situated a little to the left of the middle line : there was 
 considerable swelling of the soft parts covering the bones. 
 Pressure here was intolerable, and the least attempt to rotate 
 the head occasioned severe pain. Deglutition was now tolerably 
 easy, but there had been considerable difficulty of swallowing 
 during the early period of the complaint. There was here 
 obviously a carious state of the articulation of the atlas and 
 deutata, and we did not expect to remove the curvature. Perfect 
 rest was, however, enjoined, and the usual remedies employed 
 with a view to arrest the further progress of the disease. She 
 gradually recovered her health, and is now lively and well 
 grown, but the curvature is permanent. 
 
 " Case 2.— Early in August, 1834, Mary Inglesby, of Piussell
 
 372 CLINICAL MEDICINE. 
 
 Place, aged 7, was sent to me by Mr. Long, of Summer Hill. 
 She was confined to bed in scarlatina for a fortnight. At the 
 end of this time she was taken out of bed, and then the head 
 was observed to be turned to one side. It was now five weeks 
 altogether from the beginning of the disease, and the parts were 
 still in the same state. The face was awry. She complained of 
 pain in the concavity of the curve and that side of the head, and 
 could not bear the slightest motion or shock. Leeches were 
 prescribed, and calomel given afterwards in doses of a grain 
 three times a day, till the gums were touched. As soon as 
 this effect was produced, the pain subsided, and the head 
 gradually acquired its natural position. Her recovery was 
 complete. 
 
 " Case 3. — A younger brother of Mary Inglesby was sub- 
 sequently under the care of Mr. Long for scarlatina. The same 
 state of the head and neck was detected on the thirteenth day, 
 and treated by Mr. Long on the same plan as that adopted in 
 the former case. The pain disappeared as soon as the mouth 
 was made sore, and the position of the head became natural. 
 He is now in good health. 
 
 " Case 4. — I met Mr. Edgar, of Arran Quay, in February, 1835, 
 in the case of a young gentleman about six years old, whose 
 convalescence from scarlatina was tedious, and in whom the 
 difficulty of swallowing persisted after the redness of the fauces 
 was removed. On taking him out of bed it was remarked that 
 he was quite unable to keep the head erect. The symptoms were 
 similar to those of the two last cases, but in a milder degree. A 
 few leeches were applied, and evaporating lotions instantly used 
 to the part, on account of considerable local heat. The leeching 
 was repeated in a day or two, but as the symptoms yielded 
 rapidly, and as he had some tendency to diarrhoea, calomel was 
 not employed. Li about a fortnight the natural position of the 
 head and neck was restored. 
 
 "I can offer no better explanation of the occurrence of this 
 affection during the progress of scarlatina, than by supposing 
 that the inflammation of the fauces and back of the pharynx 
 was propagated to the adjoining parts. In all these cases there 
 had been marked and prolonged difficulty of deglutition, as a 
 symptom of the disease ; and it is to this circumstance I am 
 desirous of calling attention, as affording an index for a careful
 
 SCAELATINA. 373 
 
 review of the condition of the spine during the period of con- 
 valescence. Should a child be observed to lie more on one side 
 than the other, and evince an unwillingness to be disturbed, it 
 would be an additional reason for suspecting a tendency to this 
 complaint."
 
 374 
 
 LECTUKE XXIII. 
 
 SCARLATINA. — ITS DIFFUSION AND TYPE IN THE COUNTRY DISTRICTS 
 
 OF IRELAND. 
 
 Since the preceding lecture was delivered, scarlatina has raged 
 every winter and spring with undiminished virulence, resisting, 
 as hefore, nearly every kind of treatment, until the last two years, 
 1847 and 1848, when it was much less severe both in extent and 
 character, and consequently much less fatal. A letter which I 
 received in 1842 from Dr. Gumming, of Armagh, stating that 
 scarlatina had rarely been witnessed in that city since he settled 
 there, eleven years previously, and that he had never seen the 
 malignant form of the disease, induced me to forward a circular 
 to the principal medical men in the provinces, to ascertain if the 
 disease prevailed in their respective districts, and if it had 
 assumed the fatal form we had observed in so many instances in 
 Dublin. 
 
 I shall now briefly state the principal facts contained in the 
 answers to my queries. Dr. Geop;hegan, of Kildare Infirmary, 
 says that, during his residence there for ten years, scarlatina 
 never prevailed as an epidemic, and the sporadic cases he met 
 with were exceedingly mild, until just about the period of the 
 receipt of my letter, when many cases of it occurred at Newbridge, 
 four miles from his residence, on the Dublin road, and, to judge 
 from the number and rapidity of the deaths, of the malignant 
 kind. It was nearly confined to the children of the labouring 
 class, but, not having the dispensary there, he did not see them. 
 One case, however, which he did attend, that of a boy aged five 
 years, then three weeks ill, he describes as follows : — On the 
 right temple was a large ecchymosis, about two inches in 
 diameter ; arterial blood trickling from the nose, mouth, and 
 ears ; he was greatly emaciated, and quite sensible ; had diarrhoea 
 and the hemorrhacje only from the preceding day ; the cervical 
 glands were enlarged, but had not suppurated, nor was there 
 anasarca or dropsy; he died the following morning.
 
 SCARLATINA. 375 
 
 Dr. Astle, of Edenderry, does not remember its occurrence as 
 an epidemic, and the sporadic cases he has seen have been mild. 
 Dr. Woodward, of Kells, has not seen it epidemically, but 
 isolated cases were remarkably fatal, some dying within the first 
 twenty-four hours. Dr. Chfiord, of Trim, mentions that it has 
 latterly been prevalent in his district and very fatal. Dr. Clarke, 
 of Rathdrum, states that it has been on the increase for the last 
 three years, but has been very mild. Dr. Lloyd, of Malahide, 
 says, " In reply to your circular relative to the prevalence of 
 scarlatina in my district, I beg to say, the year ending May, 
 1839, no case occurred ; May, 1840, one case in an adult ; May, 
 18-11, no case; May, 1842, thirty-two cases are registered, three 
 of which were fatal, one twenty-four hours after the appearance 
 of the eruption ; the others were a brother and sister, aged eight 
 and six, scrofulous, and after a period of from twelve to sixteen 
 days they died of diseased brain and abscesses in the throat. 
 Since May, up to this date (August, 20, 1842), six cases have 
 been under my care. The only cases of moment were those 
 mentioned above as fatal, and some of the same family in which 
 the urgent symptoms were extensive ulceration of the fauces — • 
 they recovered rapidly. During the past year there were 
 numerous instances of the disease, but so slight that the indi- 
 viduals were under no restraint ; so that I was not applied to, 
 save occasionally to treat some of the sequelae. I may here 
 allude to a curious fact. My district joins on one side that of 
 Baldoyle ; on the other, Swords ; in both, epidemic diseases 
 have frequently appeared for the last twenty-five years, with 
 virulence, and after a long period commenced in Malahide dis- 
 trict, in a mild and subdued form : many of the poor inhabitants 
 are aware of the circumstance." 
 
 Dr. Glover, of Philipstown, never saw or heard of a case of 
 scarlatina during the four years he has resided there. Dr. 
 Brunker, of Dundalk, mentions that the disease has only pre- 
 sented itself in one instance within the last five years, and was 
 very mild. Dr. Hudson, of Navan, has not met with the disease 
 often ; and during a term of eight years has had only one 
 fatal case ; whilst Dr. Byron, of the same town, states that the 
 disease "was very prevalent, and in several localities unusually 
 malignant, during the last two years, up to a period of about 
 two months ago, when it was observed to be on the decline. At
 
 376 CLINICAL MEDICINE. 
 
 present there are very few cases within twelve or fifteen miles of 
 Navan, and these are less virulent, generally speaking, than 
 formerly." From Wexford, Dr. Boxwell writes, that there 
 " they have had but a few scattered cases in the town for the last 
 six years, and not one fatal." In Ai'klow, Dr. Wright mentions 
 that scarlatina has been very prevalent in that town and neigh- 
 bourhood for several years past, particularly 1840 — 41 ; but it 
 did not frequently prove fatal." In Athy, as appears from the 
 letter of Dr. Clayton, it has prevailed, and some of the cases 
 have proved fatal. Dr. Macartney, of Enniscorthy, states that 
 it was prevalent and fatal during 1837 and 1838, and that it 
 was, at the time of writing, breaking out again. 
 
 The communication of Dr. Ridley, of Tullamore, I will read 
 at length. 
 
 " Scarlatina," he writes, " appeared here in the latter part of 
 November as an epidemic, and continued to be very prevalent 
 until June following. During this period it prevailed most in 
 the month of March. I saw a great number of cases in this 
 town and the neighbourhood, which were mostly all of the 
 benign or simple form. Some cases occurred in full plethoric 
 subjects, of an inflammatory nature ; but I did not meet with a 
 case of the malignant or typhoid disease, such as I have seen 
 in Dublin. This epidemic raged chiefly amongst children and 
 young people — the oldest subject I am aware of having had it 
 was a person of forty years. It commenced with rigors, lassi- 
 tude, loss of appetite (in some cases with soreness of the throat 
 as a first symptom), and the usual symptoms of approaching 
 fever, which continued to increase until the third or fourth day, 
 during which time, in some instances, the fever ran high, with 
 raving and other symptoms of cerebral disturbance. The erup- 
 tion generally appeared on the second day in the form of small 
 distinct spots like flea-bites, which did not run together, and 
 declined suddenly on the fourth or fifth day without desquamation. 
 In some instances the character of the eruption was an efflor- 
 escence, which remained out until the sixth or seventh day, and 
 was followed by desquamation. The fever was equally high in 
 both these forms of eruption, but of greater duration in the 
 latter. The throat was very slightly affected in the majority of 
 cases, being nothing more than a slight erythematous blush on 
 the velum and tonsils ; however, in some robust, plethoric per-
 
 SCARLATINA. 377 
 
 sons, there was much inflammation, demanding active treatment. 
 The symptoms had usuall}' so much subsided as to enable the 
 patient to leave the bed on the sixth or seventh day. 'The fatal 
 cases which I icitnessed here were caused by congestion of the 
 brain, occurring on the third day. While the eruption was well 
 out and everything appeared favourable, slight drowsiness set 
 in, which ivas quickly followed by coma and stertor ; and in 
 two cases death ensued in thirty hours from the commencement 
 of the symptoms : they were all in young persons of full habit, 
 who had no previous delirium or inflammatory affection of the 
 brain. The sequelae were anasarca (which was very general, and 
 occurred after the mildest form of the disease), pneumonia, 
 bronchitis, acute rheumatism, remittent fever, and enlargement 
 of the submaxillary and parotid glands. In one instance pneu- 
 monia proved fatal in eighteen hours. It was the case of a boy 
 nine years old, who had been three weeks recovered from scar- 
 latina. The treatment was that usually practised. Emetics 
 and purgatives, diaphoretics, attending to ventilation, &c., were 
 sufficient in the generality of cases. In the inflammatory form, 
 venesection, autimonials, and calomel were prescribed ; when the 
 throat was affected, the free application of nitrate of silver was 
 found to be the best remedy. Leeches, acid gargles, application 
 of powdered alum, blisters, &c., were also beneficial. When 
 anasarca followed it generally yielded to smart hydragogue 
 purgatives ; but in some cases I gave calomel and squill with 
 advantage : as a prophylactic I was induced to try belladonna, 
 but without success. 
 
 " There was at this time a very prevalent inflammatory affec- 
 tion of the throat, which appeared and disappeared with the 
 scarlatina. This disease commenced with slight fever, stiffness 
 of the neck and dysphagia, which afterwards increased to a great 
 degree. The pharynx, tonsils, and velum assumed a deep scarlet 
 hue, and were in some cases covered with patches of lymph, which 
 could be raised off with a probe, like the membrane of diph- 
 therite. The tonsils became greatly enlarged ; also the parotid 
 and submaxillary glands ; the jaw became fixed, so that the teeth 
 could not be separated ; there were inability of swallowing, hurried 
 breathing, and high fever. These symptoms increased to the 
 fourth or fifth day, when the fever subsided with diaphoresis, 
 the jaw became relaxed, copious salivation came on, and the
 
 378 CLINICAL MEDICINE. 
 
 ability of swallowing was in some degree restored ; and, finally, 
 in the course of eight or nine days from the commencement of 
 the attack this inflammation ended in resolution. In some few 
 cases one or both tonsils suppurated, and in other still rarer 
 instances ulceration of the pharynx followed. Such are the 
 symptoms of the most severe form of this disease ; but it was 
 sometimes so mild as not even to confine patients to the house. 
 
 " At any other time this disease would have been looked on 
 merely as an epidemic cynanche ; but in this instance there was 
 a very decided connexion observed between it and the prevailing 
 scarlatina. It was, in the first place, even popularly remarked, that 
 a person who had suffered from this cynanche had not been after- 
 wards attacked with scarlatina, and that an attack of the latter 
 vvas not in any instance followed by one of the former. It was 
 likewise observed that when one member of a family was seized 
 with cynanche, scarlatina soon showed itself amongst some of 
 the rest ; and in the same manner, when scarlatina appeared 
 first, cynanche very frequently followed, so that one was con- 
 sidered the forerunner of the other. The following few brief 
 cases may serve to show this connexion. 
 
 " Case 1. — Master S. came home from school (where scarla- 
 tina had prevailed), complaining of soreness in swallowing, slight 
 headache, and nausea. The next day the tonsils were enlarged, 
 and he complained of greater pain in swallowing ; pulse quick, 
 skin hot; hut no appearance of eruption. These symptoms re- 
 mained, not getting worse, for three days, when they gradually 
 subsided. Before he was perfectly well, scarlatina seized two of 
 his sisters and his father. In the former, the eruption appeared 
 as an efflorescence and ended in desquamation ; in the latter 
 it was in the form of distinct spots, and without any subsequent 
 desquamation. 
 
 " Case 2. — Master 0. came home from the same school with 
 scarlatina. Two of his sisters and his brother were seized with 
 it while he was ill. The eruption came out well in the spotted 
 form. At the same time the man and maid-servant were attacked 
 violently with cynanche, which was attended with high fever for 
 several days. 
 
 " Case 3. — Visited Mr. B., who had been suffering from severe 
 cynanche for four days. He cannot articulate or swallow ; the 
 jaw is so fixed as to prevent the teeth being separated to more
 
 SCARLATINA. 379 
 
 than a quarter of an inch ; fresh tumefaction of the neck ; pulse 
 quick ; skin hot and dry ; breathing hurried ; face swollen and 
 flushed ; eyes suffused (on inquiring if any of the family had 
 scarlatina, I found his son, who was lying in the same room, 
 just recovering from it). After a few days perspiration appeared 
 over the surface of the body, the fever became less, and he was 
 able to open his mouth and swallow a little. On first seeing the 
 tonsils and velum, I found them coated over with a thick white 
 membrane, which extended to the hard palate, and could be raised 
 off easily with a probe. 
 
 " Case 4. — P. N. has been complaining of headache and nausea 
 since yesterday, feels a stiffness in his throat, and fears he is 
 getting the scarlatina, as three of his children are only recovering 
 from it. The throat symptoms increased to a great degree, with 
 a smart fever attending them. No eruption appeared, and he 
 was well in eight days. 
 
 " It is now almost generally admitted that the eruption is not 
 a necessary symptom of scarlatina, which disease may occur 
 independently of any affection of the skin. In this case the 
 throat is supposed to be invariably affected, and the disease has 
 received the name of ' scarlatina faucium.' But it may be a 
 matter of some difficulty to diagnose this scarlatinous affection 
 of the throat from a common cynauche : the fact of scarlatina 
 being prevalent in the neighbourhood, and the probability of the 
 infection of it having been in some way communicated, must in 
 such cases be taken into consideration. If it be found, however, 
 that exposure to the infection of one disease gives rise to the 
 other, and that one proves a preventive of the other, there are 
 fair reasons for concluding that it is the same disease, in the 
 one case affecting the skin, and in the other the throat only." 
 
 In Water-ford, Dr. Elliott announces that for several years 
 scarlatina has appeared occasionally in an epidemic form, some- 
 times assuming great malignity during the congestive stage, 
 whilst its peculiar diagnostic characters were as yet barely dis- 
 cernible. Dr. Bewley, of Moate, mentions that it has not pre- 
 vailed in his district for eleven years, and that during the whole 
 of this period he had not a fatal case. Dr. Thorpe, of Listowel, 
 has seen very few cases of the disease, and has not had a single 
 death. Dr. Gogerty, of Nobber (County Meath), has had many 
 fatal cases, and the disease has been very prevalent. In Pomeroy,
 
 380 CLINICAL MEDICINE. 
 
 as appears from the statement of Dr. Harvey, the disease has 
 been rare and mild. 
 
 Dr. Connor, of Carlow, writes as follows : — " I delayed answer- 
 ing your circular until I could send you the combined opinions 
 of some other practitioners, two of whom agree with me in 
 saying that there is annually a pretty general attack of scarlatina 
 in this district, but nearly confined to the juvenile and infantile 
 j)ortion of the community ; at least we do not recollect many 
 adults affected with it, and only one fatal case amongst those, 
 and that was the case of a lady just confined, and whose children 
 had the disease, but recovered. As to the malignity of the type, 
 we can say that, whilst five children were carried off by it in one 
 family, others in the same house had it slightly ; and although 
 several lost two or more children, numbers of families have been 
 so slightly affected that, were it not that medical men recognised 
 the disease, it would have passed away without any notice, 
 requiring in some cases only the little patient to remain one day 
 or two in bed. When many members of one family have been 
 taken away, we have had reason to think that the constitution of 
 the sufferers had more to do with the fatal result than the original 
 type of the disease." 
 
 Dr. Long, of Arthurstown, states that during the years 1841 — 2 
 he has not observed a single case of scarlatina in his extensive 
 district, although at New Ross, which is but ten miles distant, 
 the disease has prevailed in its most malignant form, and been 
 attended with frightful mortality ; but that, in the summer of 
 the year 1839, scarlatina raged with him epidemically for some 
 months. Its general character was at that time of a mild type, 
 yet in some cases the malignant symptoms were present. He 
 had then occasion to remark, that in the same family were to be 
 found individuals presenting well-marked cases of every form of 
 the disease, from the simple fever with bright efilorescence of the 
 skin, to the sloughing tonsils and typhoid type ; and that in 
 many the disease appeared to attack the throat alone, presenting 
 symptoms that would, under other circumstances, have been 
 considered indicative of simple cynanche tonsillaris. 
 
 Dr. Russell, surgeon of the County Tipperary Infirmary, 
 reports that in the year 1846 scarlatina was very prevalent 
 during the spring, and assumed a most fatal form. It appeared 
 also to be most infectious, as almost every individual, except
 
 SCARLATINA. 381 
 
 those who had the disease previously, who came near the infected 
 were seized with it. The fever was of a typhoid character, and 
 the throat appeared as if aflected with gangrenous crysipehxs. 
 The treatment that appeared most useful was warm bathing and 
 the carbonate of ammonia with bark. He has had occasional 
 cases of it since, but not at all of the same fatal form. 
 
 In Ballina, Dr. Whittaker says the disease has been rare and 
 mild. Dr. Stewart, of Lifford, states that two epidemics have 
 visited that district within the last six years : both were very mild. 
 Dr. Croly, of Mountmellick, says " that scarlatina has at inter- 
 vals prevailed in this locality for the last few years. Latterly it 
 has assumed a malignant and fatal type, especially among chil- 
 dren. The eruption was of a dark hue, with early tendency to 
 spacelated ulceration of the fauces and pharynx, cerebral con- 
 gestion with coma and convulsions." 
 
 From Dr. O'Brien, of Ennis, the following particulars were 
 received : — " In reply to your circular relative to the prevalence 
 of scarlatina in this county, I have not many observations to 
 make, as it is only within the last seven or eight years that much 
 of that disease has been seen here. 
 
 " My father, who has been forty years in practice in this county, 
 told me that he has seldom seen the disease, and that it never 
 prevailed as an epidemic here. About seven years since a few cases 
 appeared here together, and it did not re-appear until the spring of 
 the year 1840, when it broke out in a large school in this town, 
 and four persons died of it. I was in attendance on them, and 
 was seized with it myself, and had a very narrow escape. It was 
 evidently brought to the school on this occasion by a boy who had 
 just come from the King's County, and who showed the disease 
 in a day or two after his arrival. It spread with such rapidity 
 through the school, that (notwithstanding the greatest pre- 
 caution) the establishment had to be broken up for some time. 
 It again reappeared about Christmas in the same year, to a 
 slight extent ; was not fatal, and has not been seen since." 
 
 In Boyle, Dr. Hall says, it has lately been prevalent but very 
 mild. Dr. Taylor has seen very few cases at Ferns, all of which 
 were mild. Dr. Griffin, of Limerick, writes as follows : — 
 *' We had some bad cases of scarlatina in Limerick last winter 
 (1841 — 2), and about two years ago, but they were few in com- 
 parison to the mild cases ; and at any time within the last eight
 
 382 CLINICAL MEDICINE. 
 
 or ten years I have not known it to spread extensively as an 
 epidemic. Those who died of the complaint suffered chiefly 
 from the sloughing of the throat ; but I saw one young girl die 
 last year on the third or fourth day, aj)parently from the intensity 
 of the fever and great prostration of strength." 
 
 From Dr. Roe, of the Cavan Infirmary, I received the following 
 full and very satisfactory particulars. His letter was dated 29th 
 August, 1842. " Scarlatina," he writes, '' has been more than 
 usually prevalent during the last few months. I have only seen 
 two cases of it in adults. Amongst children I cannot say that 
 those cases I met with were unusually severe or unmanageable. 
 The soreness and swelling of the throat, with ulceration, were 
 also very prominent and painful symptoms in several cases I 
 saw ; the sore throat appeared almost the only symptom, and 
 the cutaneous affection very trifling and evanescent. I cannot 
 say that the type of the disease here, as far as I met with it, 
 was of a malignant character, nor did it put on that congestive 
 inflammatory form which produces such an awfully fatal disease. 
 I have also seen two or three examples of the dropsical or 
 anasarcous symptoms which sometimes succeed ; and in one 
 very fine healthy child, which I had an opportunity of seeing the 
 evening before its death, and of making a post-mortem examin- 
 ation, I found the entire cellular substance of the body pervaded 
 with the dropsical effusion, and a very large quantity, amounting, 
 I think, to nearly a quart, effused into the thorax. From the 
 great dyspnoea, and very unequal action of the heart, I presumed 
 there must be structural disease of the heart — which was not 
 the case — and all the viscera, both of the thorax and abdomen, 
 appeared perfectly sound, so that the dropsy was entirely the 
 result or the consequence of the original disease three weeks 
 before, and from which the child appeared to have perfectly 
 recovered. 
 
 "Scarlatina, mixed up with small-pox, has appeared also in our 
 poor-house, but not of a very fatal or malignant character ; and 
 I find from the physician of the poor-house that the scarlatina 
 was rather of a low type, and required cordials, as wine, &c., and 
 that bleeding was had recourse to only in a few cases. Some 
 years ago, when it appeared in an epidemic and very severe form, 
 I had an opportunity of seeing much more of it, and then I 
 found the most beneficial effects from full and early bleeding;
 
 SCARLATINA. 383 
 
 and in two remarkable instances, one an adult lady and the other 
 a fine healthy girl, I think it put an end to the disease, and pre- 
 vented the congestive stage from coming on." 
 
 It is unnecessary to give the particulars of the many letters I 
 have received on this subject ; but from all may be collected the 
 facts that scarlatina has, generally speaking, prevailed to an 
 unusual extent in Ireland from 1836 to IS-ii — that it has, in 
 many instances, been singularly rare in districts immediately 
 adjoining others in which it has been equally prevalent — that 
 there is no geological or physical difference in many of the 
 localities alluded to, which can in any way account for these 
 anomalies — that we are equally at a loss to explain its mildness 
 in some districts in which it has extensively prevailed, and its 
 malignity in others. 
 
 Even in this city, during the period of its greatest virulence, 
 whole families have been attacked with the mildest forms of the 
 disease I have ever seen ; and I have been assured by many of the 
 physicians connected with our dispensaries, that they have for a 
 certain period met with several cases, all extremely mild ; and 
 suddenly the character of the disease has changed, and the cases 
 then coming before them were as remarkable for their malig- 
 nancy, and undue proportion of mortality. This was seen in a 
 remarkable degree in the practice of Dr. Osbrey, physician to St. 
 Mary's Dispensary, whose very important communication I shall 
 read for you. 
 
 " The number of cases of scarlet fever," says he, " which were 
 under my care, from the close of the year 1840, the period at 
 which that epidemic first appeared in my dispensary district, 
 until its decline at the commencement of the present year, 
 amounted to somewhat above two hundred. 
 
 " When it first appeared the epidemic was of so mild a 
 character that I treated above forty cases without the occurrence 
 of a single fatal one ; merely attending to the state of the bowels 
 and secretions was sufficient to eftect a cure. It soon, however, 
 assumed a more formidable character. The cases which mostly 
 proved fatal were those afl'ected with diffuse inflammation of the 
 neck ; they were generally children under four years of age. As 
 it may be interesting, I shall describe to the best of my recollec- 
 tion the progress of that affection, together with the treatment 
 which I found to be most successful.
 
 384 CLINICAL MEDICIXE. 
 
 " Those cases of scarlatina in which this form of inflammation 
 presented itself I was usually not requested to attend until 
 some time after its commencement, which generally took place 
 at the decline of the eruption on the third or fourth day. The 
 attending, or I may say secondary fever, was principally marked 
 by the occurrence of cerebral and nervous symptoms ; the child 
 either lay in a comatose state, or was excessively irritable and 
 restless, and constantly whining. In those who were a few 
 years older, a peculiar wildness of manner was occasionally 
 observed, and if this were absent, the expression of the counte- 
 nance was stupid and vacant. A common remark of their 
 mothers was ' that they did not consider them in their right 
 mind.' The children were affected with tremors of the ex- 
 tremities ; the pulse was generally quick, and the tongue furred, 
 but neither invariably so. 
 
 " The progress of the inflammation was very insidious, in most 
 cases commencing as an indurated swelling behind the angle of 
 the jaw on one side, which was at first very indolent, without 
 any discolouration of the integuments ; but as the aff'ection ad- 
 vanced, the swelling increased much more rapidly, often extend- 
 ing to the opposite side : the integuments then assumed a dusky 
 red appearance, and became very tender to the touch ; there was 
 much oedema, so that the part readily pitted when j)ressed by 
 the finger, and there was an obscure sense of fluctuation com- 
 municated to the touch. In the advanced stage of the 
 complaint, sensibility, which was previously great, diminished 
 to such a degree that the child did not seem to sufi'er 
 much pain if incisions were made into the swelling. When 
 the patient survived till about the tenth day from the 
 commencement of the affection, sloughs frequently formed, com- 
 mencing in dark purple specks over the surface of the swelling ; 
 the sloughing rapidly spread; diarrhoea then set in; the abdo- 
 men became tympanitic ; spots of purpura at times appearing 
 over the surface of the body, with the occurrence of passive 
 hemorrhage from the mouth and bowels. The child either died 
 comatose or exhausted by diarrhoea, in case dissolution was not 
 quickened by the supervention of sudden hemorrhage from some 
 of the large vessels of the neck giving way in sloughing. An 
 attack of convulsions sometimes preceded death, the period of 
 which, unless when precipitated by the exhausting treatment to
 
 SCARLATINA. 385 
 
 which it had been submitted previous to my seeing the child, 
 varied from the seventh to the twenty-eighth day, the medium 
 time being about the twelfth day from the commencement of the 
 inflammation. 
 
 " In those cases which fell under my observation I did not 
 notice anything differing from the common, either in the 
 appearance or duration of the eruption, except that it was 
 occasionally somewhat more faint than usual, and that the 
 desquamation of the cuticle did not take place after its dis- 
 appearance. Though what I have just described was the usual 
 progress of inflammation when it ran a fatal course, yet sometimes 
 it commenced earlier, on the first or second day of the eruption, 
 the fever being of a more inflammatory type, the skin being hot, 
 pulse strong, tongue furred, and much thirst being present. 
 
 "It is well known that this disposition to slough in scarlatina 
 is not confined to difi'use inflammation of the neck, and that an 
 inflammation of a similar character may attack other parts of the 
 body. This was well exemplified in two cases which were under 
 my care — one that of a boy, aged six years, in whom scarlet 
 fever immediately succeeded an attack of hooping cough, for the 
 relief of which I had found it necessary to apply a blister to the 
 chest — the other that of a fine child, his sister, aged four, who 
 had received a slight scald in the ham of the left leg ; such 
 portions of the vesicated surfaces which had not as yet healed were 
 attacked by the inflammation, they were rapidly covered with 
 ash-coloured sloughs, and the sloughing extended by livid 
 margins. The boy, exhausted by the previous attack of hooping 
 cough, which had been unusually severe, died ; the little girl 
 recovered. The treatment, which was the same in both, con- 
 sisted, locally, in the ulcers being kept constantly covered with 
 fermenting poultices, and in the margins being occasionally 
 touched with strong muriatic acid. The cautious exhibition of 
 mild tonics, and of stimulants, both diffusible and permanent, 
 carbonate of ammonia, of course, being used amongst the former, 
 constituted the general treatment. Another case, which I con- 
 sidered very remarkable, fell under my observation, in which, 
 simultaneously with the (fangrene of the neck, sloughs fanned on 
 both corneas, which rapidly extended, involving all the other 
 textures of the eyes. This case my friend Dr. Battersby saw 
 with me. The destruction of the eyes took place two days 
 vjL. I. 25
 
 386 CLINICAL MEDICINE. 
 
 before dissolution. In each three of these cases the appearance 
 of the part, when destroyed, closely resembled that of hospital 
 gangrene. I did not notice any depots of purulent matter in 
 the joints, or any other parts of the body. 
 
 " Having now described the more formidable characters of the 
 inflammation, I shall state the treatment which I found most 
 efficacious in arresting its progress, and in bringing about the 
 more favourable terminations of resolution and abscess, and shall 
 also take a short review of other modes of treatment that are 
 occasionally resorted to. Mine simply consisted in the constant 
 application of common oatmeal or linseed poultices, supporting 
 the child's strength by nourishing diet, and in the cautious 
 exhibition of permanent and diffusible stimulants ; carbonate of 
 ammonia, as I have already said, being included in the latter. 
 The practitioner should not I think swerve from this line of 
 practice, though he may sometimes be urged by the parents, 
 alarmed at the progress of the inflammation, to treat the child 
 more actively, particularly with respect to the local applications. 
 
 *' When an abscess forms, the swelling previously diffused 
 becomes more prominent, soft, and fluctuating, there is no 
 pitting on pressure with the finger, and the surface is usually of 
 a rose-red colour. Incisions may be then made to give exit to 
 the matters. The symptoms of general disturbance, such as 
 coma, convulsions, and such others as have been described in 
 such cases disappear, tremors of the extremities alone remaining, 
 and the child gradually recovers from the extreme debility from 
 which it had hitherto sufi"ered. I have said that stimulants should 
 be given with much caution, for when used at all freely they are 
 almost sure to induce convulsions, to which there is a great 
 tendency throughout the progress of the complaint. After the 
 formation of abscess, however, they may be exhibited with 
 ereater boldness. In cases where there is much restlessness 
 
 o 
 
 and irritability, or when diarrhoea has set in, which usually does 
 not take place until the sloughing has commenced, I have given 
 opiates, either in the form of Dover's powder, or the pulvis cretae 
 compositus cum opio, the doses being carefully graduated 
 according to the age of the child. When the cases became 
 complicated with purpura and passive hemorrhage, it is almost 
 unnecessary for me to say that I gave the mineral acids. 
 
 "I have ordered chloride of soda both internally and as a
 
 SCAKLATINA. 887 
 
 lotion. Its internal exhibition did not appear to be productive 
 of any benefit, but as a lotion and gargle it was highly useful in 
 destroying fcetor. When I apprehended internal sloughing, I 
 occasionally touched the throat with muriatic acid lotions by 
 means of a camel's-hair pencil or a piece of a sponge. 
 
 "Having had frequent opportunities of seeing the eftects 
 produced by the use of mercury, and also by local bleeding, in 
 the practice of others, I carefully avoided having recourse to 
 such methods of treatment myself ; the former, with rare excep- 
 tions, inducing purpura, passive hemorrhages, and sloughing, 
 the accession of which is so much to be dreaded, and which are 
 so liable to supervene of themselves ; the latter precipitating 
 dissolution by increasing the disposition to coma and collapse. 
 
 "I have in some cases made incisions into the swellings 
 extending beneath the fascia of the neck, but I do not consider 
 it good practice in the case of young children, however useful it 
 may be in that of adults, for the following reasons : when made 
 in the early stage of the inflammation, they have a tendency to 
 prevent the occurrence of either of those most favourable results 
 — resolution or abscess ; and when made in the advanced stages, 
 unless when abscess or diffuse suppuration takes place, they are 
 of no use ; they do not appear to check the sloughing of the 
 integuments. The parents, moreover, to whose feelings such 
 practice is generally repugnant, are very apt to attribute what- 
 ever ill afterwards befalls their child to these incisions having 
 been made ; a consideration which I think should weigh with us 
 in determining against the practice, when no good is likely to 
 arise from it. In case, however, abscess or diffuse suppuration 
 of the cellular membrane occur, we should not hesitate to make 
 free openings. Diffuse suppuration of the cellular membrane, -a 
 result which I have only now alluded to, is almost as formidable, 
 when the children are very young, as gangrene, inasmuch as 
 they are scarcely ever able to bear up against the extensive 
 suppuration, and consequently die of hectic. 
 
 " Blisters and mustard cataplasms, merely apj^lied as rube- 
 facients, did not appear to me to be injurious, but I did not 
 place much confidence in them. 
 
 " It is obvious from what has been already observed, that we 
 should be most cautious in making a prognosis when we meet 
 this form of inflammation, as it often, when most mild at its
 
 38S CLINICAL MEDICINE. 
 
 commencement, subsequently runs a most fatal course, and when 
 apparently of a most formidable character, terminates kindly. I 
 have known many a practitioner, from mistaking its nature, sup- 
 posing it to be nothing more than common scrofulous inflam- 
 mation, to augur favourably as to its termination, when its 
 subsequent course showed how very erroneous such an opinion 
 was. The constitutional symptoms, however, even though we 
 have no very clear evidence of the child having had scarlet fever, 
 will, when carefully attended to, always enable us to form a 
 correct diagnosis of the disease. Perhaps it is from not recog- 
 nizing this disease, which is one of the most formidable con- 
 sequences of scarlet fever, that such discrepancies have occurred 
 in the returns made by practitioners of the relative mortality of 
 scarlatina in their practice. The children are frequently not 
 brought to them till all traces of the eruption have disappeared, 
 and in some cases, where it has been so faint as to have escaped 
 the observation of the parents, or even that of the physician. In 
 such cases it is easy to conceive that it might be mistaken for a 
 disease sui generis, and that the previous existence of scarlatina 
 might be entirely overlooked. 
 
 " When sloughing of the integument has commenced, the 
 chances of the child's recovery are greatly diminished, and 
 when it is under a year old, it is, I think, almost hopeless. 
 To have an opportunity of observing the sloughing stage, it is 
 requisite that the child should survive some time. When death 
 is precipitated by injudicious treatment, or if the child does 
 not undergo any, dissolution occurs so early from the secondary 
 fever, that no further local appearances than the more diffused 
 swelling will be observed. I should here mention that, in the 
 worst cases, there is no attempt at suppuration, and the part, 
 when cut into, resembles somewhat the cut surface of a rotten 
 apple. 
 
 " Even when resolution or abscess occurs, we must not be 
 too hasty in giving a favourable prognosis ; for there is occa- 
 sionally much subsequent debility, which may lead to a fatal 
 result. 
 
 " I have observed instances of this form of inflammation which 
 succeeded other exanthemata. The following case is, I think, 
 an interesting example. It is that of a child aged two years, 
 that had an attack of the natural small-pox ten days previous to
 
 SCARLATINA. -380 
 
 my seeing it, and had been treated by another physician, who, 
 on the occurrence of the inflammation of the neck (I understood 
 from its mother), despaired of its recovery ; and indeed, when I 
 myself visited it, I had no better hopes. It was then lying in 
 a state of coma, with its head quite motionless and thrown back, 
 a large diffused swelling being behind the angle of each jaw 
 and extending down the neck. The pulse was remarkably quick 
 and weak, the tongue furred, abdomen tympanitic. On the child 
 being submitted to the mode of treatment which I have described, 
 it recovered from the state of coma it was in, and two very large 
 abscesses formed in the situation of the swellings, which I sub- 
 sequently opened. The tympanitic state of the abdomen was 
 relieved by injections of castor-oil and turpentine. When the 
 sensibility and intelligence of the child returned, it was attacked 
 with convulsions, consisting in constant motion of the extremities 
 and twitchings of the face, which continued for two days. These 
 convulsions I ascribed to debility, and treated as such. In this 
 case purulent depots formed over the back of the hand and one 
 foot ; also a large one over the scapula. The two former have 
 been absorbed ; but as the one over the scapula still continues, 
 and as there is no chance of its absorption, the recovery of the 
 child is still doubtful. A few spots of purpura appeared in 
 different parts of its body, and it has been frequently attacked 
 with diarrhoea. Its mother states that it was a strong child 
 before the attack of small-pox. It is, however, apparently of 
 scrofulous habit, and had once suffered from rickets."
 
 390 
 
 LECTURE XXIV. 
 
 SCARLATINA. ABSENCE OF ERUPTION. — DROPSY AFTER. 
 
 Any one who has studied our old authors with care, will perceive 
 the identity that exists hetween some forms of our malignant 
 scarlatina and the epidemics described by the name of the 
 "Ulcerous Sore Throat,'"^ and the "Putrid Sore Throat.'' f 
 But in these epidemics, the principal and fatal symptoms were 
 inflammation and sloughing of the throat, ulceration of the 
 schneiderian membrane, attended with profuse ichorous ' dis- 
 charges, &c. The eruption was either disregarded, or only 
 mentioned as a curious phenomenon, and death was produced 
 by the " sore throat." But, as was before observed, many of 
 our cases died without a single lesion that we could detect — 
 they ivere poisoned hy the inrus of the scarlatina. 
 
 I shall now bring before you the particulars of a few fatal 
 cases that were lately under my care, from which you will be 
 enabled to form a better idea of the malady. The following 
 notes were taken by Dr. Henry Kennedy, by whom the patient 
 was first seen : — 
 
 Case 1. — "I first saw J. K., aged 14, on Friday evening, 
 March 22, 1842, He had been at school the previous day, but 
 had come home complaining of not being well. His mother 
 had given him an emetic of ipecacuanha, which not only vomited 
 but appeared also to have purged him. When visited about 
 twenty-seven hours from the beginning of his illness, the 
 purging had ceased, but the vomiting continued incessantly. 
 He was throwing up quantities of dark greenish bile, and this 
 occurred whether he took any drink or not. The thirst was 
 insatiable, and the desire was for what was cold ; the fever 
 ran very high, the skin hot, pulse 140, and when left to him- 
 self he was inclined to rave ; he referred his distress to the 
 stomach, and said he believed his throat was sore ; on looking 
 
 * Huxham on Fevers, p. 260. London, 1772. 
 
 t Fothergill'a Works, vol. i. p. 341. London, 1783.
 
 SCARLATINA. 391 
 
 into the mouth the internal fauces appeared inflamed, and the 
 tongue was densely loaded, hut there was nothing of that 
 specific nature which would lead one to pronounce on the 
 nature of the disease. At this time I looked very particularly 
 to the state of the skin, but no eruption was visible. His 
 position in bed was changed every moment, as he said for the 
 purpose of giving himself relief. I had intended putting a few 
 leeches over the stomach, but at the patient's own urgent 
 request was induced to bleed him from the arm to about seven 
 ounces. A sinapism was applied to the epigastrium, a mouthful 
 of cold water given frequently, and the extremities sponged with 
 vinegar and water. On the following morning (Saturday) all 
 the symptoms had increased in severity, the treatment of the 
 night before had only temporary effect, in fact for about four 
 hours, after which all the symptoms had reappeared. In addi- 
 tion, the body w^as now covered with an eruption which could 
 not be distinguished from the maculne of bad typhus fever ; it 
 was best marked, however, on the chest and back ; it was quite 
 distinct on the face. The raving w\as now of a more decided 
 character, and it was more difficult to make him give a direct 
 answer. At this period Dr. Graves visited the patient, and 
 recommended internal stimulants, with blisters to the surface. 
 It is enough to add, that all treatment appeared to be quite 
 useless, and from this time to the period of the patient's death, 
 every symptom went on increasing, the raving becoming every 
 hour more violent in its character, and the pulse rising to 170 
 and even 180. One or two points are, however, worthy of 
 notice. During the last day of life the bowels were once affected, 
 the discharge quite natural, and from this moment all vomiting 
 ceased. During this day, also, a second crop of eruption made 
 its appearance ; it was perfectly distinct from the first, being of 
 a reddish colour, and the spots much more circumscribed. I 
 have often had occasion to meet with the same since ; it was 
 now that the tongue put on its characteristic appearance. That 
 the nervous system was profoundly engaged there was but too 
 much evidence of, for, though no convulsions came on, I observed 
 strabismus, and the mouth was distinctly drawn to one side. 
 There were also very violent fits of shuddering, almost amount- 
 ing to rigor ; the eyes were not at all injected. The entire 
 duration of this patient's illness was about sixty-eight hours."
 
 392 CLINICAL MEDICINE. 
 
 In the patient whose case has been detailed, we have a remark- 
 able example of scarlatina terminating rapidly in death, without 
 the sloughing of the throat, which usually caused death in the 
 epidemics narrated by Huxham and Fothergill. 
 
 Case 2. — Miss H., a strong healthy lady, aged 28, was 
 attended at the commencement of her illness by Mr. Nicholls ; 
 when I saw her, there were intense redness of the throat, great 
 dysphagia, and pain in swallowing. These symptoms induced 
 me to bleed once freely ; the blood was buffed and cupped to an 
 extreme degree. After the disease had lasted for about thirty- 
 six hours, an eruption of a vivid bright colour appeared. She 
 obtained no relief from the bleeding, the pulse became quicker, 
 debility increased, and she died with symptoms of poisoning in 
 less than two days. 
 
 The occurrence of arthritis as a complication of scarlatina 
 we have frequently witnessed in the Meath Hospital. In a 
 man named Pierce, we had the greatest difficulty to save both 
 wrist joints from ulceration. And in another case, the motion 
 of the elbow joint was almost lost from the effects of inflam- 
 mation. 
 
 I have noticed that when any of the viscera became engaged 
 during the progress of this disease, that there is the greatest 
 difficulty in subduing the local affection, and that it runs its 
 course with great rapidity ; this was unfortunately too well 
 illustrated by the case of P. B., attended by Surgeon Smyly, of 
 Merrion Square, and myself. The notes of the case were taken 
 by Mr. Smyly : — 
 
 Case 3.— Miss P. B., aged 20, of a full habit of body, 
 in December, 1841, was attacked with a very severe form of 
 scarlatina. The eruption appeared on the 20th, and was very 
 intense in its character ; in the progress of the complaint her 
 head became much engaged, requiring the application of leeches ; 
 her throat also was very bad, to relieve which leeches were again 
 applied. Considerable prostration of strength accompanied the 
 affection from the commencement. On the 30th she was so far 
 recovered that I took my leave. 
 
 It may be worthy of remark that her sister, who was first 
 affected with the disease, had it so mildly that the nature of the 
 affection was not discovered, nor did she require medical aid. 
 
 January 9, 1842, I was again called to see Miss B. ; she
 
 SCAELATINA. 30:5 
 
 then complained of severe piiin in her loft side, which she first 
 felt on going to bed, which became so violent during the night 
 as to banish sleep. She had been till then going on as well 
 as possible, recovering her strength daily, and was in excellent 
 spirits. On the 8th, she ate heartily of beef-steaks for dinner, 
 and drank some wine. 1 saw her sixteen hours after the com- 
 mencement of the pain, when I found all the lower part of the 
 left lung densely hepatized. 
 
 The treatment consisted in repeated cupping, attended each 
 time with much relief, the exhibition of mercury so as to affect 
 the mouth, antimonials ; by all which means the acute symp- 
 toms disappeared, but no improvement took place in the con- 
 dition of the lung. Her strength began to fail, and she died on 
 the morning of the 19th of January, 1842. 
 
 In this case the most remarkable feature was the rapidity with 
 which the lung was solidified, and the obstinate manner in which 
 it refused to yield to treatment. 
 
 The following case was also attended by Mr. Smyly and I ; 
 it presents an usual sequela of scarlatina, namely, aphthous 
 ulceration of the anus, which, though not sufficiently pointed out 
 in the late works on practice of medicine, was recognized and 
 described by Huxham, and I introduce our case with Huxham's 
 description, to show more clearly the identity of the two 
 epidemics. 
 
 After alluding to the profuse discharge that took place from 
 ulcerated surfaces in the mouth and nostrils, he says : — " A 
 sudden stoppage of this rheum from the mouth and nostrils 
 actually choaked several children ; and some swallowed such 
 quantities of it, as occasioned excoriations of the intestines, 
 violent gripings, dysentery, &c., nay even excoriations of the 
 anus and buttocks.''* 
 
 Case 4. — Master James F., aged 12, was aflected with a 
 very severe form of scarlatina, in July, 1841. The eruption 
 began to appear the second day of his illness, and became very 
 intense in its character, the whole surface of the skin being 
 almost of a uniform redness. The accompanying fever ran very 
 high, demanding venesection to reduce it. The throat presented 
 the usual appearance ; but in this case the inflammation 
 extended into the mouth, and we suspected throughout the 
 * Huxham on Fevers, p. 280. London, 1772.
 
 394 CLINICAL MEDICINE. 
 
 intestinal canal, indicated by the great irritability of the stomach 
 and bowels, and the circumstance of the anus presenting the 
 same aphthous appearance that the mouth did. The inflamma- 
 tion also extended into the left ear, and caused the destruction 
 of the membrana tympani. In less than a month's time this 
 young gentleman was so far recovered as to return to England, 
 and has since enjoyed good health. 
 
 In the writings of Huxham and Fothergill you will also find 
 frequent allusions to cases where death was produced by un- 
 controllable epistaxis, during the epidemic of " sore throat " 
 described by these authors. Thus Fothergill, after speaking 
 of the usual mode of death in these cases, says : — " Though this 
 was the common progress of the disease where it terminated 
 unhappily, yet it often varied from this type, and was attended 
 with very different symptoms. Some had an extreme difficulty 
 of breathing almost from the first ; some had a violent cough ; 
 some were comatous ; others had a delirium ; some died in a 
 lethargic stupor; others hied to death at the nose,''* The 
 following is an example of this form of the disease : — 
 
 Case 5. — I was called to see the Rev. Mr. C, aged 25, of 
 regular temperate habits, and healthy constitution. He was then 
 labouring under severe fever with sore throat. On examining 
 the fauces I found the tonsils extensively ulcerated. These 
 were touched with nitrate of silver, and the next day they 
 appeared much improved. On the third day of his illness an 
 eruj)tion appeared, neither too red nor too pale ; in short, as 
 favourable as could be wished for, and perfectly normal as to its 
 duration. During all this time the heat was intense ; and on 
 the third day of the eruption the cold affusion was employed, and 
 was followed by marked relief ; but the pulse still remained 
 sharp and quick, never falling below 96. In this state he con- 
 tinued till the seventh day of his illness, when epistaxis occurred 
 (to this he had been subject for a long time), and was followed 
 by considerable relief of his head. The epistaxis was not ex- 
 cessive, and from the fact of its being habitual excited but little 
 alarm. About the thirteenth day the fever had almost gone ; 
 his sleep was good, and his tongue moist and clean. At this 
 time a small tumor, situated at the angle of the left jaw, and 
 which had been there from the beginning, was observed to 
 
 * Fothergill's Works, vol. i. p. 353. London, 1783.
 
 SCAKLATINA. 395 
 
 enlarge. The next day it had spread considerably, was very red 
 and painful. The fever increased, the tongue became dry, and 
 his sleep was disturbed. On the sixteenth the tumor was 
 examined and opened by Mr. Cusack, 
 
 A large quantity of good healthy pus escaped, and the patient 
 experienced great ease. On the eighteenth day a deeper incision 
 was made by Mr. Cusack, and again a large quantity of good pus 
 escaped ; but on this occasion no relief followed. On the next 
 day the constitutional symptoms were much more severe ; the 
 epistaxis returned, and the tongue was now dry, black, and 
 bleeding. There was no raving, nor was he at any time during 
 the illness in the least delirious. 
 
 Notwithstanding that the nares were plugged, and every 
 measure which Mr. Cusack and I could think of employed, the 
 epistaxis continued, the bleeding from the tongue could not be 
 arrested, the tumor in the neck became gangrenous, and on the 
 twentieth day of his illness death terminated his sufferings. 
 
 The next very interesting case was communicated to me by 
 Professor Porter, and as it illustrates another sequela of scar- 
 latina, I shall read it for you. There can be no doubt that 
 the hemorrhage originated in the way pointed out by Dr. Porter, 
 and it shows in a convincing manner the assistance in diagnosis 
 which we derive from an accurate knowledge of anatomy. It 
 will also be recollected, that this case differs in the manner in 
 which the bleeding occurred, from that mentioned in a preceding 
 lecture by Dr. Geoghegan of Kildare. The older writers make 
 frequent allusions to examples of this latter form of hemorrhage. 
 
 "On or about the 18th of September, 1841, Master , 
 
 aged 11, was attacked with scarlatina. He was of remarkably 
 fair complexion, thin, almost transparent skin, and hair nearly 
 white. The. disease assumed rather a mild form, the eruption 
 came out abundantly, and began to disappear about the evening 
 of the fifth day. The throat was slightly engaged — very little 
 difficulty in swallowing ; but there were three or four external 
 tumors, exactly resembling scrofulous glands about to sup- 
 purate, and there was discharge of puriform matter from both 
 ears, with slight deafness of the left. 
 
 " At the end of about ten days he seemed to be progressing 
 favourably as to health ; two of the little glands on the left 
 side suppurated and were opened, discharging healthy pus ; his
 
 396 CLINICAL MEDICINE. 
 
 appetite was pretty good and bis sleep sufficient, but be always 
 rested during tbe day, and remained awake during tbe nigbt. 
 Tbe discbarge from tbe ears continued, and be bad become quite 
 deaf at tbe left side. 
 
 " Soon after (I cannot be particular as to dates) a gland on 
 tbe rigbt side suppurated, and was opened. Tbe discbarge was 
 bealtby ; but tbat from tbe rigbt ear began to be tbin and 
 abominably foetid, tbe smell evidently indicating its connexion 
 witb some diseased bone. He was now totally deaf of botb 
 ears. Our communications witb bim were altogetber by signs, 
 and be was becoming paralytic on tbe rigbt side of tbe face ; 
 all bis features being drawn frigbtfully to tbe opposite side wben 
 be eitber laugbed or cried. At tbe end of about six weeks, 
 bowever, be seemed in some respects to be greatly improved. 
 He slept well, be was exceedingly cbeerful and even lively, and 
 bis appetite almost voracious. He bad so far recovered bis 
 bearing, tbat we could communicate easily witb bim ; but tbe 
 foul discbarge continued in great abundance from tbe rigbt ear, 
 and tbe paralysis of tbe face increased. He continued apparently 
 to improve in general bealtb and even in strengtb until tbe end 
 of tbe nintb week, and bad occasionally been up and dressed 
 for a few bours in tbe day, wben in tbe middle of tbe nigbt a 
 new symptom appeared. 
 
 " Tbe cbild bad been asleep, wben be suddenly awoke, 
 screamed out ' Ob, my ear, my ear ! ' wben almost instantly a 
 gusb of blood took place from tbe rigbt ear. Tbis blood was 
 florid, and bad tbe appearance of being arterial. It came gusb- 
 ing fortb most profusely, as if poured from tbe lip of a jug or 
 ewer, and was sufficient in quantity to soil several towels before 
 it ceased, wbicb it did ratber from tbe exbaustion of tbe patient, 
 tban from tbe means employed to control it. I was not called 
 during tbis first bleeding, but saw bim early next morning. He 
 complained of dreadful pain in tbe left side of tbe bead, re- 
 sembling bemicrania. Tbe discbarge from tbe ear was a tbin 
 foetid serum, mixed witb flakes of unbealtby matter, and dis- 
 coloured witb blood, and tbe paralysis of bis face greatly 
 increased, tbe features being distorted even wben at rest. I 
 attempted to plug tbe ear ; but tbe pressure interfering witb 
 tbe discbarge of matter, caused intense pain, and could not be 
 endured even for a few minutes. From tbis time be continued
 
 SCARLATINA. 397 
 
 to bleed at irregular intervals until his death ; and as I was 
 present on three or four occasions, I shall endeavour to describe 
 one of the attacks of hemorrhage. 
 
 " He seemed to have no previous warning whatever : some- 
 times the bleeding commencing during sleep, sometimes while 
 he was amusing himself with his toys. He generally gave 
 a single scream at the instant, and then the blood burst forth 
 with a gush that really astonished me. I never saw blood lost 
 so rapidly in any surgical operation I ever witnessed, and only 
 once in an accident where the deep jugular vein had been 
 opened. This bleeding could hardly be controlled by pressure, 
 and the attempt to do so caused intense pain, so that at times 
 the nurse did not interfere, but allowed it to stop spontaneously, 
 which it generally did in about a minute. The blood was always 
 florid. The attacks occurred at irregular periods, and there 
 never was hemorrhagic fever. 
 
 '* About a week before his death, I observed that the blood 
 was beginning to make its way by the eustachian tube into the 
 pharynx, some of which passed into the stomach, and some was 
 expelled by the mouth, and then he bled sometimes by one pas- 
 sage, sometimes by the other, and occasionally by both. I need 
 not say that he became pale, ex-sanguine, and exhausted, except 
 to express surprise that any child of his age could have endured 
 so long. The palate and inside of his mouth were as pale as 
 any part of the external surface of his body. Exactly at the 
 end of the thirteenth week from the commencement of his 
 illness, he died after a slight gush of blood. 
 
 " There was no post-mortem examination, and knowing the 
 feelings of the child's parents I did not ask it ; therefore the 
 pathology of this case must be matter of conjecture. I think 
 there can be. no doubt there was caries of some portion of the 
 base of the skull, and from the symptoms, I always imagined it 
 to be seated in the petrous portion of the temporal bone. The 
 spot at which the carotid artery enters this bone is immediately 
 adjacent to the bony portion of the eustachian tube, and it is 
 probable that this latter was the original seat of the disease 
 from which it spread until it implicated the vessel. The extra- 
 ordinary size of the stream satisfied me of its being famished 
 by some large vessel ; its colour showed it to be arterial ; its 
 escape by the ear, and afterwards by the mouth and nose, proved
 
 398 CLINICAL MEDICINE. 
 
 its passage by the eustachian tube ; and I know of no .vessel 
 that would be sufficient to explain all the symptoms, unless the 
 one I have mentioned — the internal carotid." 
 
 With reference to the diffuse inflammation of the neck that 
 follows scarlatina, as described by Dr. Osbrey, my experience 
 accords with his ; and the recommendation to direct all our 
 efforts to the support of the patient until the period of slough- 
 ing arrives, deserves the greatest attention. The following case 
 occurred a short time ago at the Meath Hospital : — A child four 
 years old was admitted on the fourteenth day of its illness, with 
 the integuments in the front of the neck in a state of gangrene. 
 In a day or two the sloughs separated, leaving the muscles of the 
 neck completely bare, and as distinct from each other as if dis- 
 sected. The common carotids were also laid bare, and could be 
 seen pulsating at the bottom of the ulcer. A few days after, 
 granulations sprung up, and the ulcerated surface soon cica- 
 trized. I have not been able to ascertain if any, or what amount 
 of contraction of the neck followed the healing of the ulcer. 
 
 Sir H. Marsh and I attended, not long since, a lady who had 
 been affected for some days with fever and sore throat. She had 
 no eruption on any part of her body ; but from the character of 
 the fever, and the peculiar appearance of the throat, we suspected 
 she was labouring under an attack of scarlatina. Her family 
 were very anxious to ascertain the precise nature of her com- 
 plaint ; and I visited her twice a day for the first four or five 
 days of her illness, carefully examining the skin at each visit, but 
 could not discover the slightest trace of an efflorescence of any 
 description. She continued for several days to suffer from the 
 fever and sore throat, and was at one time in a dangerous con- 
 dition, but ultimately recovered by great care, and the use of 
 appropriate remedies. 
 
 Now I watched this case from the sixth hour after its com- 
 mencement to its termination, and repeatedly examined the skin, 
 particularly that of the breast, abdomen, and inside of the knee 
 and elbow joints, places in which the eruption shows itself when 
 it appears at all, but could not discover any vestige of it. You 
 will often find a diffused redness about the knees and elbows in 
 cases where the eruption does not appear on any other part of 
 the body ; but in this instance there was not the slightest devia- 
 tion from the natural hue. Yet the result proved that it was
 
 SCARLATINA. 399 
 
 scarlatina; for the desquamation of the cuticle, which always 
 attends this disease, took place, and the lady communicated the 
 infection to several members of the family. A young gentleman 
 residing in the house got a bad attack of scarlatina ; two of the 
 servants were also attacked, and the lady's father got sore throat ; 
 in fact, there could be no doubt as to the nature of the disease. 
 During her convalescence she had desquamation of the cuticle ; 
 and this is a point to which I would particularly call your atten- 
 tion. Wo are taught to look upon desquamation as the result 
 of cutaneous affections of an inflammatory character ; and it is 
 an opinion very generally maintained, that in scarlatina, as in 
 psoriasis, the peeling off of the cuticle depends on the peculiar 
 state of the skin produced by inflammation. It is stated that 
 the increased vascularity of the skin occasions a morbid secretion 
 and subsequent detachment of the epidermis, and that the same 
 phenomenon is observed in all cutaneous aff'ections of an inflam- 
 matory character. This may be generally, but not universally 
 true ; for here we had an extensive desquamation of the cuticle 
 without any eruption, without any previous redness, pain, or 
 remarkable heat ; in fact, without any of the phenomena which 
 are regarded as constituting inflammation. This seems to prove 
 that there is something more than inflammation concerned as 
 preparatory to that process which is termed desquamation, and 
 the change which the skin undergoes is not to be looked upon 
 as a mere consequence of inflammation occupying the external 
 surface of the corium. 
 
 I observed another curious fact in this lady's case. Since the 
 attack which I have just described, she has been shedding her 
 nails ; that is to say, the nails of the fingers are all dropping off, 
 and yet there is no appearance of inflammation of any kind about 
 the hands to explain the occurrence. You are, of course, all 
 aware that the dropping off of the nails is a species of desqua- 
 mation. From the peculiar structure of the nail, and the mode 
 in which it is formed in the matrix, it does not drop off at once 
 like a scale of epidermis ; still I think we are authorized in 
 looking upon the shedding of the nails as a species of desqua- 
 mation. This affords a very curious subject of investigation, as 
 connected with the history of fever. It is an opinion entertained 
 by many persons, that desquamation of the skin takes place at a 
 particular period of typhus ; and that this is not an occasional,
 
 400 CLINICAL MEDICINE. 
 
 or varying, but a constant and general phenomenon. This 
 statement has been put forward most strongly by Dr. Perry of 
 Glasgow ; and he is also of opinion that the period in which 
 typhus is most contagious is during the desquamation of the 
 cuticle. It is also asserted that scarlatina is more contagious 
 during desquamation than at any other period of the disease. 
 This is, at least, the popular idea. How true it may be, my 
 experience or observation does not enable me to decide ; nor am 
 I prepared to offer anything like an explanation of the occurrence. 
 All I shall say on the present occasion is, that the occurrence of 
 desquamation of the cuticle in typhus, and in cases of scarlatina 
 without eruption, has greatly altered my ideas as to the connexion 
 between it and cutaneous inflammation. I think, at least, that 
 the process of desquamation in such cases is very different from 
 inflammation, and that the morbid action of which desquamation 
 is the result has very little in common with the ordinary process 
 of inflammation of the cutaneous surface, 
 
 A gentleman who is in the habit of attending my lectures 
 informs me that he has seen three cases of this form of scarlatina, 
 characterized by the absence of the external efflorescence. They 
 occurred in young persons after puberty, and between the ages 
 of fifteen and twenty-five. Each of these cases exhibited a 
 considerable degree of fever, with increased quickness of pulse, 
 thirst, heat of skin, diminution of the urinary secretion, and, 
 after the first or second day, much depression, which continued 
 for two or three days, and then yielded to treatment. The 
 tongue was moist, but pointed, tremulous, red, and injected. 
 The velum, isthmus faucium, tonsils, and upper part of the 
 pharynx were somewhat swollen, and of a very peculiar dark-red 
 colour ; the redness being general, and equally diffused over the 
 whole of the upper part of the pharynx, as far as it could be 
 examined. 
 
 But the following case, which was very lately communicated 
 to me by a practitioner of very great eminence in this city, is 
 still more curious. Some years ago scarlatina broke out in this 
 gentleman's family, and attacked all his children with the excep- 
 tion of one young lady, who, although in constant attendance on 
 her sisters during their illness, did not exhibit any symptoms 
 whatsoever of the disease. When all the children had become 
 convalescent, they were removed to the country for the benefit of
 
 SCARLATINA. 401 
 
 air, wliitlier she also accompanied tliem. Here she was, much 
 to the astonishment of her family, attacked with the peculiar 
 anasarca observed in persons who have recently laboured under 
 scarlatina. Her father, under whose observation she had been 
 during the whole time, was very much struck with the occur- 
 rence ; he paid particular attention to the case, and feels 
 convinced that it was the result of latent scarlatina. This case, 
 connected with those already detailed, is of great interest in a 
 general pathological point of view. It appears to prove the fact, 
 that in some instances diseases produced by contagion do not 
 give rise to the whole train of phenomena by which they are 
 ordinai'ily characterized. 
 
 Let us turn for a moment to some of those diseases caused by 
 the action of animal poisons on the system, as, for instance, 
 measles. The symptoms which generally attend and characterize 
 measles are universally known. After an attack of fever, on the 
 third or fourth day, coryza, sneezing, hoarseness, and cough are 
 complained of, and then a rash appears, first on the face, and 
 afterwards on the body and limbs. But it is not necessary that 
 all these symptoms should appear, and that the sequence of 
 morbid phenomena should be uninterrupted throughout. On 
 the contrary, it frequently happens, at particular periods and in 
 certain constitutions, that some of the most usual symptoms are 
 scarcely observed or altogether absent. You will find this point 
 insisted on by Dr. Bateman, who has given a detailed description 
 of a form of measles in which the catarrhal symptoms are 
 wanting, and which he has termed rubeola sine catarrho. Thus 
 we may have pneumonia without cough, and pleuritis without 
 pain in the side. Those who have witnessed the course of 
 epidemic cholera in this country, will recollect that many cases 
 occurred in. which vomiting, purging, or cramps were not 
 observed. 
 
 If we turn to fever, we find that the animal poison to which it 
 owes its origin generally exhibits a certain number of symptoms 
 congregated together, or observing a determined order and 
 succession ; and these we meet with in most of the cases which 
 come before us in practice. But we now and then see fever 
 patients in whom one or more of the most prominent symptoms 
 are absent. Thus occasionally there is no quickness of pulse or 
 appearance of vascular excitement ; in some there are no cerebral 
 VOL. J. 26
 
 402 CLINICAL MEDICINE. 
 
 symptoms ; in others no increase in the temperature of the skin. 
 Indeed, I might go through the whole group of symptoms which 
 accompany fever, and show that almost every one of them may 
 be occasionally absent, and yet the fever of a severe and danger- 
 ous type. I recollect pointing out to the class last year the case 
 of a man labouring under chronic enlargement of the spleen. 
 He had been working for two or three seasons in some of the 
 marshy districts of England, and had been occasionally ill, 
 but never had symptoms of regular intermittent ; in fact, he 
 had escaped the intermittent itself, but not what are usually 
 deemed the consequences of it. We have been in the habit of 
 explaining the enlargement of the spleen by referring it to the 
 conflux of blood towards the internal organs, particularly the 
 liver and spleen, during the cold stage of intermittent ; and we 
 have endeavoured to explain the subcutaneous oedema which 
 follows scarlatina, by attributing it to previous inflammation of 
 the skin and subcutaneous areolar tissue ; but the observations 
 and facts which I have now brought forward will show that these 
 opinions were founded on erroneous ideas. 
 
 Turning to cases of chronic disease, we find in some, as for 
 instance syphilis, that the poison taken into the system gives 
 rise in most cases to a determinate order of symptoms, e.g., bubo, 
 sore throat, eruptions on the skin, nodes, and syphilitic cachexy. 
 Mr. Hunter has been at great pains in determining the order of 
 the parts, and pointing out the tissues which are successively 
 affected, and it is of considerable importance to have correct 
 notions on this point. But, although the number and order of 
 symptoms marked out by Mr. Hunter and others may be observed 
 in most cases, they are not so in all ; and the same remark 
 which has been made on the occasional absence of one or more 
 important symptoms in scarlatina will apply with equal force to 
 syphilis. Now, when this morbid poison which excites syphilis 
 does not affect the constitution in such a manner as to occasion 
 the production of all the symptoms which usually characterize 
 this disease, a variety of venereal is formed which often proves a 
 source of great embarrassment, not only to the young and inex- 
 perienced, but even to the senior members of the profession. 
 
 It is of great importance, in a practical point of view, to bear 
 in mind the general proposition I have announced, viz., that in 
 both acute and chronic diseases a constitutional affection may
 
 SCARLATINA. 403 
 
 display its existence by only one or two of the mnnerous symptoms 
 which usiiaUy accompany it ; and this occurrence seems more 
 frequent in the case of diseases produced by contagion and mor- 
 bid animal or vegetable poisons, than in the case of maladies 
 generated by causes developed in the system itself. 
 
 The case of William Young, who was admitted on Wednesday 
 last, has some claims to your attention, and demands a few 
 observations on my part. This boy, who is about twelve years 
 of age, had an attack of scarlatina some time ago, and had been 
 dropsical for a week or ten days at the period of his admission. 
 He was somewhat feverish, had thirst, heat of skin, and slight 
 headache, cough, and difficulty of breathing, and, on making an 
 examination with the stethoscope, we detected numerous bronchial 
 rales ; his lower extremities were anasarcous, and he had some 
 effusion into the peritoneal sac. We could not ascertain exactly 
 the time when this train of symptoms commenced, but it is very 
 probable that it was a week or ten days after the disappearance 
 of scarlatina. When patients who have been recently labouring 
 under an attack of scarlatina take cold, the anasarcous symptoms 
 appear in a very short time after the attack ; but, even where 
 they are not exposed to cold, the dropsy appears generally about 
 ten days or a fortnight after scarlatina, and is very often accom- 
 panied by some pectoral affection. The disease sets in with 
 febrile exacerbations more or less marked ; anasarca of the 
 extremities is next noticed, and at the same time the patient 
 has slight cough and difficulty of breathing, which generally 
 proceeds from congestion of the bronchial mucous membrane, 
 but may be the result, though less frequently, of pleuritis or 
 pneumonia. 
 
 If called to a case of this kind in the commencement, and 
 where the patient is not greatly exhausted by previous disease, 
 the treatment is exceedingly simple. By opening a vein in the 
 arm, and abstracting a quantity of blood proportioned to the age 
 and strength of the patient, you remove the inflammatory state 
 of the constitution, and arrest at once the anasarcous and pectoral 
 symptoms. It may occasionally happen that active measures of 
 this kind cannot be taken, in consequence of the great debility 
 of the patient from previous disease ; but, generally speaking, 
 cases of anasarca after scarlatina bear antiphlogistic treatment 
 well. It is not after cases of violent scarlatina, or where the
 
 404 CLINICAL MEDICINE. 
 
 patient's life has been in imminent danger, that the supervention 
 of dropsy is most commonly observed. The majority of dropsical 
 cases of this kind are met with in patients who have had the 
 disease mildly, and without any remarkable intensity either of 
 the local or general symptoms. Hence venesection is borne well, 
 and its performance attended by the most decided good effects, 
 particularly where the dropsy is complicated with pleuritis or 
 pneumonia. 
 
 In the case before us, however, being uncertain as to the exact 
 duration of the disease, and finding several symptoms present 
 indicative of weakness, we were obliged to proceed with more 
 caution. The boy had been ill a week, and appeared to be under 
 the influence of digitalis administered before his admission, for 
 his pulse was intermittent and wavering. Under these circum- 
 stances, I determined to limit the antiphlogistic measures to the 
 application of a few leeches over the abdomen. I did this with 
 less hesitation, as an accurate examination of the chest showed 
 that there was neither pleuritis nor pneumonia present. The 
 internal remedies were calculated to increase the secretion from 
 the kidneys. The boy's urine was remarkably albuminous, and 
 of the specific gravity of 1027. This is a point worthy of remark. 
 In many cases of dropsy after scarlatina, the urine is albuminous. 
 Now, almost every case of this kind will get well, and, as con- 
 valescence progresses, you will observe that the urine ceases to be 
 albuminous. These facts, of the truth of which I can speak with 
 the fullest confidence, are quite sufficient to show that those per- 
 sons are wrong who assert that albuminous urine is always the 
 result of organic disease of the kidneys. Albuminous urine is 
 here, as Dr. Blackall observes, merely an indication of a peculiar 
 inflammatory condition of the whole system, and not of degen- 
 eration of the kidneys.* I may observe, however, that this is 
 not invariably the case ; for I could point out examples where 
 albuminous urine is connected with an apparently opposite 
 condition of the system, in fact, a condition demanding the use 
 of generous diet and tonics. 
 
 Hence there must be great diversity in the treatment of dropsy 
 with albuminous urine. Where it occurs after scarlatina, and is 
 
 * These opinions have been since advocated by Dr. Burrows, in his admirable essay 
 on Scarlatina, published in the Library of Medicine, vol. i., and which I feel great 
 pleasure in recomme'd'ng.
 
 SCARLATINA. 405 
 
 accompanied by febrile symptoms, it is best treated by the lancet^ 
 nitre, purgatives, and digitalis ; but where it occurs in chronic 
 cases, without any remarkable excitement of the vascular system, 
 without organic disease, and with more or less debility, it requires 
 to be treated with tonics, generous diet, and full doses of opium. 
 In the present case I only applied a few leeches to the belly, and 
 kept the bowels gently open for the first few days, being deter- 
 mined to wait until the pulse became regular before I ventured 
 on any decided plan of treatment. I then ordered mercurial 
 frictions to the abdomen and axilkie, and gave mercury internally, 
 combined with small quantities of digitalis. He also got a 
 draught twice a day, composed of carbonate of soda, tincture 
 of squill, and syrup of orange peel. These remedies we shall 
 continue for some time, carefully watching their effects. 
 
 From the state of weakness this boy was in at the period of 
 his admission, and the length of time the disease has lasted, 
 I have not thought it advisable to bleed him. When cases of 
 this kind become chronic, they are very difficult of cure, and 
 require very delicate management. You will frequently have 
 to run through the whole list of remedies employed on such 
 occasions, before you can hit on one that proves successful. I 
 recollect a case of this kind, in which the anasarca was extreme, 
 and the boy's legs were enormously swollen ; the dropsy was ac- 
 companied by scanty secretion of urine, but without any distinct 
 febrile excitement. After having used every remedy I could 
 think of for nearly three months, without any benefit, I resolved 
 to try the efi'ects of cold affusion, from which I had experienced 
 much advantage some time previously in another case. I ordered 
 a large vessel tilled with pump water, in which a quantity of salt 
 had been dissolved, to be poured over him twice a day, for the 
 space of two or three minutes each time, immediately after which 
 the boy was wiped perfectly dry and put to bed. The good 
 effects of this measure became soon evident ; a copious discharge 
 of urine took place, the swelling of the limbs subsided, and in 
 about six or seven days the child was able to run about as usual. 
 
 This case went on unfavourably, and the boy died, after 
 lingering several weeks in a state of extreme dropsical swelling, 
 and great suffering, distention, and dyspnoea. As his urine 
 continued highly albuminous throughout, we were excessively 
 curious to learn what was the condition of his kidneys. The
 
 40G CLINICAL MEDICINE. 
 
 post-mortem examination was made a few hours after death, and 
 the kidneys were found in every respect healthy ; their size, 
 shape, consistence, and colour were perfectly normal. The 
 long-continued presence of albuminous urine, in a case where no 
 such state of kidney existed, forms conclusive evidence that this 
 state of urine is not necessarily the result of that renal degener- 
 ation first described by Dr. Bright ; the occurrence of one positive 
 exception is sufficient to disprove such a conclusion, even though 
 supported by a thousand cases, and consequently, when albumin- 
 ous urine in chronic dropsy is found to occur along with Bright's 
 kidney, I consider this particular state of urine and of kidney as 
 depending upon diff'erent causes, which often co-exist in chronic 
 dropsy, and consequently I regard albuminous urine as a sign of 
 Bright's kidney, but not as its result. 
 
 It has been already observed that anasarca seldom occurs after 
 severe and dangerous scarlatina, but it is not unfrequent as a 
 sequela of the very mildest forms of that disease ; a fact of which 
 every practitioner should be aware, and a knowledge of which 
 should prevent us from pronouncing a patient out of danger until 
 the period during which dropsy may supervene is passed. To 
 impress the necessity of caution, I may mention that I have 
 seen several cases of scarlatina in young persons and children so 
 mild as not to require confinement to bed, and yet followed about 
 the eighteenth or twentieth day by anasarca ; this usually yields 
 to treatment without much trouble, but in some patients, and 
 without our being able to assign any cause for it, the anasarca 
 increases rapidly, the pulse rises, and in a few days is excessively 
 rapid, from 130 to 150, becoming hourly weaker and weaker, 
 while the heart's action is strong and tumultuous ; the skin is 
 hot, and in many individuals inflammatory symptoms manifest 
 themselves in the head, chest, or belly, and the patient is carried 
 off by internal inflammatory effusion into one or other of these 
 cavities. Other cases are more treacherous, and the approach of 
 danger is not indicated by anything but the rising of the pulse, 
 and the rapid increase of the dropsical effusion, soon to be followed 
 by convulsions that succeed each other until death closes the 
 scene, a termination so much the more unexpected, as these 
 cerebral symptoms have not been preceded by the least head- 
 ache, or any perceptible aftection of the functions of the brain ! 
 
 In addition to the remedies already mentioned, I can speak
 
 SCARLATINA. 407 
 
 with the greatest confidence of the utility of hydriodate of potash 
 in the form of anasarca we are now treating of; and I may add, 
 that I have found the following line of treatment more successful 
 than any other in the malignant forms of scarlatina — local bleed- 
 ing by leeches when necessary, wine and carbonate of ammonia 
 freely given, with camphor mixture. In some cases, attended 
 with intense heat of the skin, the cold aflfusion has given great 
 relief; in others it has failed.
 
 408 
 
 LECTURE XXV. 
 
 INTERMITTENT FEVER. — DISEASES WHICH SIMULATE IT. — THE 
 MALARIOUS FEVER OF AFRICA. 
 
 I PURPOSE devoting to-day's lecture to the consideration of some 
 points connected with intermittent fever, most of which I was 
 the first to ohserve and describe. I will first read for you the 
 notes of a case of intermittent fever reported by Mr. Power : — 
 
 " Mary Gannon, aged 44, was attacked by intermittent fever 
 about the middle of September last. The paroxysms occurred 
 twice every day, one in the morning, the other in the afternoon, for 
 the space of ten days, after which, owing to medical treatment, 
 the evening one disappeared. On the 10th of October she was 
 admitted into the Meath Hospital, and was placed under the 
 care of Dr. Stokes, who prescribed small doses of sulphate of 
 quina, under the use of which the fit became tertian, but soon 
 afterwards returned to the quotidian form. On the 1st of 
 November she became a patient to Dr. Graves, and was put on 
 large doses of the sulphate of quina. On the 7th of the same 
 month the fit again assumed the tertian form, in which state it 
 continued until the 17th, although the dose of quina had been 
 increased to a scruple and a half in the day. She was then 
 blooded to 5xviij., by which the duration of the paroxysm was 
 lessened, and the interval between it and the succeeding one 
 increased by twelve hours. She was again blooded, and the fit 
 become quartan. Venesection was repeated for three times, 
 but without any other sensible efi'ect than a curtailment of the 
 duration of the existing paroxysm. Her strength now became 
 reduced, and she was ordered to take four drops of the liquor 
 arsenicalis in half an ounce of mint water, three times a day. 
 Since she commenced taking the arsenic, the violence of the 
 paroxysms has been gradually subsiding, and strength and appetite 
 arc returning ; at present the fit presents scarcely any other 
 characters than those of a slight shivering."
 
 INTERMITTENT FEVER. 409 
 
 Now, what is the definition of a quartan ague ? According to 
 Cullen, it consists of " paroxysmi si)inles intervallo sejituaginta 
 duarum circiter horarum ; Siccessiomhus pojneridianis,'' that is 
 to say, the attacks must be simihir, there must he an interval of 
 seventy-two hours between them, and the fit is to come on in 
 the afternoon. Let us examine how far the characters of the 
 present case coincide with this definition. Latterly, she had seven 
 attacks with a precise interval of seventy-two hours ; in the next 
 j)lace the attacks were similar ; so far, so good ; but the acces- 
 sions of her paroxysms were in the forenoon and not in the after- 
 noon, for they generally came on about eight o'clockin the morning, 
 and in this respect accommodated themselves to our convenience, 
 for we could be here to witness them. It is very true that we 
 generally find the paroxysm of quotidian in the morning, of 
 tertian in the middle of the day, and of quartan in the evening, 
 and also that one may pass into the other ; but to this I do not 
 attach much importance. Here the disease evidently terminated 
 by becoming quartan. A question arises as to what was the 
 nature of the fever in the commencement ? Was it any 
 variety of quartan ? That is, was it quartan disguised under 
 the type of any other species of intermittent '? In the begin- 
 ning she had two paroxysms every day, constituting what has 
 been termed the quotidiana duplex, a disease which is common 
 enough, though it has not been noticed by Cullen in his Nosology. 
 The nearest approach which the first form of our case makes 
 to the acknowledged quartan of authors, is to the quartana 
 triplex, where we have the fit coming on three times a day, 
 with every fourth paroxysm similar. But you perceive plainly 
 that Gannon's fever, in its first form, is not reconcilable to any 
 known type of quartan ague. 
 
 Now, what was the eff"ect of the remedies employed ? First, 
 to make it assume the form of a simple quotidian, and, as a still 
 further improvement, resolve this into a tertian. Here we have 
 an argument against the supposition of a concealed quartan, for 
 an interval of 48 cannot, by doubling, be converted into an 
 interval of 72. But the eflect of remedies, nevertheless, pro- 
 duced this anti-nosological conversion, for the first bleeding in 
 the cold stage made an addition of 12 hours to the tertian 
 interval ; and a second bleeding added another 12 hours, 
 and then we had the quotidian interval complete. This was
 
 410 CLINICAL MEDICINE. 
 
 indeed a hit-and-hit reform of a double quotidian into a single 
 quartan. 
 
 Let us review the length of the intervals in a series of 
 numbers. First, it was 12 hours for the space of 10 days; next, 
 24 hours for several days ; then, 48 hours for several days ; 
 again, 24 hours for several days; then, 48 for several days ; then, 
 60 for one day ; and, lastly, 72 for seven days. From this, I 
 think we may conclude, that the unit from which we ought to 
 set out in calculating intervals should be 12 hours between the 
 accession of one attack and the accession of the next. This is 
 the atom on which all our computations must be founded, for 
 its multiples include all the varieties of intermittent fever. It 
 would appear that instances where the fit comes on earlier than 
 was expected, or is postponed beyond the customary period, would 
 go to invalidate what I have mentioned. Such cases, however, 
 I look upon as only transition stages to more permanent varieties. 
 
 In many cases of quotidian, it has been observed by nosolo- 
 gists, that every second fit is more severe, and hence they have 
 termed this form the tertiana duplex. The chief argument in 
 support of this opinion of quotidians becoming tertians is that, 
 under the salutary influence of our remedies, they become ter- 
 tians before they cease altogether. In answer to this, it may be 
 observed, first, that this is not always the case ; secondly, when 
 it does take place, it is because the days of the least severe fits are 
 of course those on which they soonest cease, in consequence of the 
 exhibition of bark, or sulphate of quina ; for it often happens that 
 these medicines do not remove the aguish fits entirely and at 
 once, but gradually, and, as it were, by wearing down the 
 paroxysms. Thus, then, a quotidian such as we have described 
 must, if gradually cured, before a complete cure be effected, 
 observe the tertian interval ; but still it is not a true tertian at 
 any period of its duration. 
 
 Hectic fever notoriously has intervals of twelve hours, and 
 it may be observed, that many circumstances corroborate the 
 opinion, that in naming and classifying diseases, it is more 
 consonant with the laws that regulate the diurnal revolutions of 
 the animal economy, to use, as our period, twelve hours, whose 
 multiples give rise to the difierent intervals of agues, than to 
 assume twenty-four hours as the term from which we are to 
 commence our calculations. Thus the state of the pulse,
 
 INTERMITTENT FEVER. 411 
 
 according to the laborious investigations of Nick, have shown that 
 a regular revolution, as to its frequency, takes place every twelve 
 hours, and the same result has been made with regard to the 
 intensity of the respiratory process. We all know that there is 
 a considerable difference between the nervous and calorific powers 
 of the body during the twelve hours we spend in active employ- 
 ment and awake, and those which are chiefly passed in tranquillity 
 and repose. 
 
 As the average period of day and night respectively is twelve 
 hours, in the same manner equivalent spaces of time seem to be 
 destined for the successive and alternating revolutions of the 
 living system. It would be extremely interesting to consider 
 what influence their adoption might have in our calculations 
 concerning the crisis of continued fevers. We would not then 
 count three days and a half, but seven half days ; we would not 
 say seven days, but fourteen half days. If this method were 
 adopted, many of the apparently anomalous critical efi'ects and 
 critical terminations, in continued fevers, would, I have no doubt, 
 become strictly conformable to some regular law of periodicity. 
 To arrive at a knowledge of this law would be of the greatest 
 importance, and would tend much to render our knowledge of 
 fevers more accurate, and our treatment more efficacious. Those 
 who entirely deny the critical period must be either very super- 
 ficial observers or very indifferent practitioners. In private 
 practice, where the precise commencement of the attack can be 
 ascertained, a crisis, or an obvious attempt at a crisis, takes 
 place often on the reputed critical day, occasionally on others ; 
 and if the treatment be judicious, it seldom happens that a fever 
 terminates without either. Within the last year I have seen 
 two cases in which a decided and perfect crisis took place on the 
 forty-second day. In another case the salutary crisis took place 
 on the thirty-fifth day. The first of these cases I saw along 
 with Dr. Stokes ; the second, with Dr. Plant ; the third, with 
 Mr. Rumley. In another case, which I attended with Mr. Kirby, 
 there was an obvious but unsuccessful effort at crisis on the 
 seventh, fourteenth, twenty-first, twenty-eighth, and thirty-fifth 
 days. 
 
 I must admit that I have seen perfect crises on days not reputed 
 critical ; but I am convinced, that if the method of counting 
 by half days and not by days were adopted, the exceptions to
 
 412 CLINICAL 3IEDICINE. 
 
 the occurrence of crisis would be much less numerous. The 
 nature of a crisis has, I think, been never truly explained ; 
 to me it appears evident that all the phenomena which attend 
 this curious change prove that when a continued fever terminates 
 by crisis, it is by being converted into a fever of a new type and 
 shorter duration. A well-marked crisis comes on almost like a 
 fit of the ague ; it is ushered in by great collapse, coldness, and 
 even sometimes by rigor. This is succeeded by a hot fit, and that 
 again by a sweating stage, copious deposition in the urine, &c., 
 and then the patient is found free from fever. Is it not probable, 
 therefore, that the crisis is not merely the termination of the 
 former fever, but a new fever, as it w^ere, superadded to it, for 
 the purpose of exciting a change in the system, attended by such 
 a powerful action of another kind, that the former chain of 
 morbid actions is broken, and the tendency of the new fever to 
 terminate in health is thereby allowed to prevail ? 
 
 To many, I am aware, what I have said may seem fanciful, 
 but to a close and candid observer of nature this h3'pothesis may 
 not appear altogether unfounded. 
 
 I shall not detain you, gentlemen, in making any remarks on 
 the treatment pursued in Gannon's case. You have seen how 
 the sulphate of quina changed the type of the fever, and you 
 observed how completely the liquor arsenicalis succeeded in 
 removing the disease, after other remedies had failed. It is to 
 be recollected, however, that considerable advantage was derived 
 from venesection in the cold stage, and it is probable that this 
 treatment by the lancet was a useful preparation for that by 
 arsenic. It has been supposed that bleeding, during the cold 
 stage of ague, produces a favourable effect, in consequence of its 
 relieving the internal sanguineous congestion. This hypothesis, 
 however, does not appear well founded, for the utility of venesec- 
 tion is by no means confined to those cases of intermittent fever, 
 in which the cold stages are attended with an evident diminution 
 in the external circulation, denoted by a shrunk countenance, 
 cold and pointed nose, and a pale corrugated skin. In such 
 cases it is very reasonable to conclude, that the internal organs 
 must labour under sanguineous congestion, as long as the 
 quantity of blood in the periphery of the body is diminished ; 
 but this obvious deviation from the proper balance of the circula- 
 tion is not observable in every case ; and in that related above,
 
 INTERMITTENT FEVER. 413 
 
 the temperature of the external parts was increased at the very 
 moment that the violence of the rigor was greatest, while at the 
 same time the extremities, face, and general surface of the skin 
 appeared to enjoy a more than usually abundant and active 
 circulation. We must, therefore, refer the benefit derived from 
 the venesection to some other cause, most probably its energetic 
 action on the nervous system ; it is to this we must attribute its 
 effects in stopping the rigor and lengthening the intermissions. 
 
 That the rigor of ague is an affection chiefly depending on the 
 nervous system may be proved by many circumstances, but by 
 none more strongly than by the following fact, quoted from a 
 collection of Notices of Russia, published in the United Service 
 Journal for January, 1833 : — 
 
 " In Kasan these fevers are quotidian or tertian, very rarely 
 quartan, and they differ from the agues of other countries in 
 this respect, that the patient experiences scarcely any shivering, 
 but feels a violent twitching in the spine, which is soon followed 
 by excessive heat and violent headache, during which the pulse 
 beats like a hammer. For this fever the Russian physicians 
 resort to no other remedy but bark." 
 
 The following description of the Russian province, so fertile 
 in ague, is well worthy of your attention, and I shall make no 
 apology for reading it to you : — 
 
 '' The summer in this country is further remarkable, inasmuch 
 as from the end of jMay to the beginning of September no rain 
 falls, and thunderstorms are extremely rare. This phenomenon 
 is doubtless owing to the flatness of the country. For five 
 hundred miles and more around Perm and Kasan, there is not a 
 hill of any consequence, and the whole tract from Kiew to Ural, 
 for the breadth of five hundred miles, may be called a plain, 
 only here and there interrupted by ranges of gentle hills. The 
 extraordinary fertility, especially of the government of Kasan, is 
 occasioned by the inundation of the Wolga, which overflows 
 annually at particular seasons, as regularly as the Nile in Egypt, 
 and converts the whole country, to the distance of ten miles or 
 more from its bed, for five or six weeks, into an immense sea. 
 These inundations of the Wolga, and the other large rivers, 
 Witjatka, the Kama, the Kinel, the Irgis, &c., which discharge 
 themselves into the Wolga, render the countries through which 
 they flow at once lively and fertile. At such seasons you may
 
 414 CLINICAL MEDICINE. 
 
 sail, either for pleasure or upon business, in large two-masted 
 vessels, carrying from six to ten guns, over pastures and corn- 
 fields, to the neighbouring towns, which on this account are all 
 situated upon heights ; and when the waters have withdrawn 
 into their accustomed channels, the ground forsaken by them is 
 covered, often a yard deep, with a fertilizing mud, in which, 
 during the hot season, all vegetables grow rapidly and vigorously 
 as in a hot-house. At the same time pools are left behind in 
 the low grounds, where the water stagnates for several months, 
 becomes putrid, and generates malignant fevers in the months 
 of July and August, in these otherwise healthy countries. The 
 government of Ufa, particularly, is visited about that time by an 
 intermittent fever, which attacks the j^atient every seventh day 
 only, but is so violent that it generally j^roves fatal." 
 
 If this account be correct, and indeed there can be little 
 doubt of its accuracy, a new species of ague must be estab- 
 lished, and to the quotidian, tertian, and quartan must be 
 added a fourth type, whose attacks return every seventh day. 
 
 In Ireland we seldom meet with cases of ague with paroxysms 
 so violent as to endanger the patient's life. I lately saw, how- 
 ever, a case of this nature. I was sent for in a great hurry to 
 visit a gentleman residing in the neighbourhood of Donnybrook ; 
 he had slept well until four o'clock in the morning, when he was 
 awakened by a general feeling of malaise, shortly after which 
 he complained of chilliness, some nausea, and headache. After 
 these symptoms had continued about an hour, his skin became 
 extremely hot, the jiain in the head intense, and drowsiness was 
 complained of, which soon ended in perfect coma, with deep 
 snoring and insensibility ; in fact, he appeared to be labouring 
 under a violent apoplectic fit. He seemed to derive much 
 advantage from bleeding and other remedies, and to my surprise 
 was perfectly well when I visited him in the evening. The day 
 but one after, at the same hour, the very same symptoms re- 
 turned, and were removed by the same remedies. I must 
 confess that I could not explain, in a satisfactory manner, the 
 perfect freedom from all cerebral and paralytic symptoms, after 
 two such violent attacks of apoplexy ; but when a third attack 
 came on, I then saw that it was a case of the tertiana soporosa 
 of nosologists, and I prevented the return of the fits by the 
 immediate exhibition of large doses of sulphate of quina.
 
 INTERMITTENT FEVER. 415 
 
 Let me now direct your attention to the case of a sailor who 
 has been recently discharged. This boy was one of the crew of 
 a vessel which returned lately from the West Indies, and was 
 exposed to great hardship during his voyage. Boys in his 
 situation suffer a great deal of fatigue and rough treatment ; 
 they are the drudges of all on board, and it is impossible to 
 conceive what privations they endure. When the vessels arrive 
 in unhealthy climates, they are generally the first who fall 
 victims to the prevailing malady, and such was the case with 
 this lad, who got yellow fever immediately after his arrival at 
 the West Indies. From this he recovered, but on his way 
 home was attacked with irregular intermittent, which lasted 
 for a considerable time. He had no treatment, and the disease 
 subsided spontaneously, leaving him extremely weak and 
 emaciated. He was, however, obliged to work as usual on 
 his passage, and he arrived in Dublin about three weeks since, 
 debilitated, thin, and with a countenance expressive of long- 
 continued suffering. He had on his admission that peculiar 
 hue of skin which often follows tedious intermittents, and which 
 those who have once seen will always recognize with facility. 
 This colour is to be distinguished from the hue of light 
 jaundice — it is what has been termed a clay colour. In the 
 present instance it was mixed with a faint tinge of jaundice, 
 and on examining the stools we found that they contained 
 scarcely any bile. He had no fever ; his pulse was rather slow 
 and regular ; he complained of lassitude ; his urine was deeply 
 tinged with bile ; and his belly tumefied. On examining him, 
 we found that the abdominal tumefaction did not depend on 
 the presence of fluid in the peritoneum : it was produced by 
 enlargement of the liver and spleen, intestinal congestion, and 
 tympanitis. 
 
 Here was a case of what has been vulgarly termed ague-cake ; 
 that species of congestion and enlargement of the liver and 
 spleen which is apt to accompany the paroxysms of an inter- 
 mittent, and in some cases to remain after the disease has 
 subsided. You are aware that some persons, during the 
 paroxysm of an intermittent, complain of pain in the right 
 hypochondrium, but more frequently in the left, and on ex- 
 amination the liver or spleen is found increased in size. If you 
 take the trouble of reading the experiments which have been
 
 416 CLINICAL MEDICINE. 
 
 made with the view of iUustrating the functions of the liver and 
 spleen, you will have a good idea of the facility with which 
 enlargement of these organs, but particularly of the latter, may 
 take place. 
 
 The spleen undergoes very remarkable changes, even in its 
 natural state, during the process of digestion, and there is a 
 great difference between its size when an animal is fasting, and 
 its size when an animal has taken food. Indeed, it is surprising 
 how rapidly it will become filled with blood, and how quick the 
 transition is from a state of collapse to a state of congestion. 
 It is easy, therefore, to conceive how the spleen may, during 
 the paroxysms of an intermittent, particularly in the cold or 
 congestive stage, become manifestly enlarged. The increase of 
 size, however, never occurs to such an extent in the liver; 
 unlike the spleen, its magnitude remains nearly the same, and 
 its volume does not vary, like that of the spleen, with the time 
 of day or the period of digestion. It is obvious, therefore, 
 a iiriori, that the spleen should be more frequently the seat 
 of congestion than the liver, and that its enlargement should 
 be more distinct and palpable. 
 
 But it is not in the liver or spleen alone that any congestion 
 occurs during an aguish paroxysm ; it may take place in any 
 organ ; and this, in a practical point of view, is worthy of being 
 borne in mind. Thus, in a case which I attended, the patient 
 got intermittent of a tertian tj^pe ; during each paroxysm he 
 had some distress about the chest, and slight cough, but these 
 symptoms disappeared during the intervals. As the disease, 
 however, went on, the fits of coughing and dyspnoea increased, 
 and the sulphate of quina failed in arresting the paroxysms. 
 The pulmonary congestion became gradually more marked and 
 permanent, and no longer disappeared during the intervals ; 
 finally, inflammation of the lungs took place, and the patient 
 died with extensive hepatization. This happened several years 
 ago, when the old notion of connecting the cold stage of ague 
 with debility was universally prevalent, and before the practice 
 of bleeding for the relief of visceral engorgement had been 
 introduced. Subsequently, the practice of bleeding in the 
 cold stage,, as introduced by Dr. Mackintosh, was tried on an 
 extensive scale in the Meath Hospital, and it is a practice which 
 I can stronglv recommend in those cases wbere there is recurring
 
 INTERMITTENT FEVER. 417 
 
 inflammation of some internal organ. It is not a mode of 
 treatment applicable to all cases, and in mild cases, unaccom- 
 panied by extensive congestion of any viscus, it is totally un- 
 necessary ; but where an important organ is threatened, it is 
 a valuable remedy, and has on some occasions cut short the 
 paroxysms altogether, or rendered them much milder and more 
 manageable. 
 
 Sometimes ague is accompanied by symptoms of congestion 
 and inflammation of some internal organ during the paroxysms ; 
 and yet, by giving sulphate of quina, you will succeed in arrest- 
 ing the intermittent and the visceral disease at the same time. 
 I recollect the case of a boy who was under treatment here for 
 ague, and who, during the paroxysms, had severe bronchitis 
 with dyspnoea. The cough did not leave him even during the 
 intervals, but it was much milder ; I was, however, doubtful 
 whether the case would admit of the exhibition of sulphate of 
 quina, from the violence of the pulmonary symptoms during the 
 tits. I determined, after some time, to try the quina, and I 
 found that it stopped both the intermittent and the bronchitis. 
 It is to be observed, however, that in this case the bronchitis 
 was of a chronic character ; and I believe that in all cases of 
 ague, accompanied by visceral derangement, where quina suc- 
 ceeds in curing the disease, the inflammation is either of a 
 trifling description, or is one of a chronic nature. Where the 
 visceral derangement is great, quina will not succeed, and hence 
 it is of great importance, in the treatment of ague, that you 
 should carefully attend to the state of the internal organs. 
 
 There are several forms of disease which simulate intermittent 
 in a very remarkable manner ; and as this may lead to very 
 dangerous errors, it is necessary on all occasions to make a 
 strict inquiry into the origin and history of the complaint. 
 Some forms of hectic assume the intermittent character, and 
 have been frequently mistaken for ordinary ague. Of this I had 
 lately a very striking instance in the case of a lady who came 
 from the county of Limerick, to consult me for what was stated 
 to be an attack of irregular intermittent. She had been con- 
 fined in August ; had been feverish after her accouchement — 
 the consequence, she believed, of exposure to cold — and got a 
 slight cough. This continued, but without any expectoration, 
 for two or three weeks, and then she was attacked with fever of 
 VOL. I. 27
 
 418 CLINICAL MEDICINE. 
 
 an intermittent character, and exhibiting a well-marked tertian 
 type. She began to take quina, but this aggravated the cough 
 very much, without having any effect on the paroxj'sms. Various 
 other remedies were also tried, but their only effect was to render 
 the paroxysms more frequent and irregular. The moment I saw 
 her, I was convinced that she was labouring under some visceral 
 disease. I examined her chest, and found dulness under the 
 right clavicle with tubercular crepitus. Her cough had been 
 dry until she came to Dublin, but now it became suddenly 
 moist, and a distinct gargouillement could -be heard. The 
 apparent intermittent was nothing more than phthisical hectic ; 
 and Dr. Stokes, who was called in, came to the same con- 
 clusion. I recollect having observed something of the same 
 kind in a case which I attended some time ago with Sir Henry 
 Marsh. The patient had well-marked intermittent, and we 
 treated him for it ; but the sulphate of quina, and the other 
 remedies which we employed, had only the effect of converting 
 the fever into remittent. On a sudden, the gentleman, without 
 having made any complaint in the side, or anything indicative 
 of derangement of the liver, became suddenly jaundiced, and 
 sank rapidly. On dissection we found seventeen or eighteen 
 small circumscribed abscesses in the substance of the liver. 
 The intermittent hectic here depended on interstitial inflamma- 
 tion of the liver — a disease which is generally of a latent and 
 incurable character. 
 
 I need not refer here to certain forms of fever which accompany 
 disease of the brain and of the urinary system, and which are 
 remarkable for their intermittent character. There is, however, 
 one form of anomalous intermittent, of which it may be necessary 
 to say something. I allude to that species of ague which seems 
 to be exclusively confined to females of a nervous habit — at least, 
 I have never met with it in any others. Persons of this descrip- 
 tion, after an accouchement, or some acute disease, or in conse- 
 quence of violent mental emotions, will sometimes get into a 
 peculiar state of health, in which they are liable to recurring 
 periodic attacks of fever. Some time since Dr. Stokes called me 
 to see a lady who, shortly after confinement, had got an attack 
 of well-marked tertian. She had, at the regular time, severe 
 rigors, followed by acceleration of pulse, heat of skin, and pro- 
 fuse sweating. When the paroxysm was over, she felt tolerably
 
 INTERMITTENT FEVER. 419 
 
 well, but still there was much excitement of pulse, and the 
 intermissions were anything but perfect. Sulphate of quina had 
 been tried by the accoucheur in attendance, but had failed. On 
 examining the case, I found that the lady was of a decidedly 
 nervous and hysteric habit, and advised the use of nervous and 
 anti-spasmodic medicines. A mixture containing musk, cam- 
 phor, and ammoniated tincture of valerian was prescribed, and 
 the intermittent symptoms rapidly disappeared. 
 
 But to return to the case of this boy. How are we to treat this 
 ague-cake ? The disease has not as yet proceeded so far as to 
 produce ascites ; but if permitted to run on, it would soon cause 
 effasion into the peritoneal cavity. In a case of this kind, a great 
 deal will depend on whether there is any fever present or not. If 
 there is no remarkable excitement of pulse or heat of skin, general 
 antiphlogistic means will be unnecessary, for any local tenderness 
 or irritation can be relieved by local bleeding. In the case before 
 us, there was a slight degree of tenderness, and we applied 
 leeches once with benefit ; but we did not apply them over the 
 abdomen — they were applied to the anus, because it is well 
 known that leeches applied in this situation have a remarkably 
 good effect in removing intestinal congestion, and consequently 
 in relieving hepatic engorgement. Those who have remarked 
 the relief which a flow of blood from piles gives, in cases of 
 hepatic engorgement with dyspepsia, will recognize the value of 
 depletion of this kind, and will imitate the natural mode of relief 
 by art. Hence the use of leeches applied to the anus in cases of 
 intestinal congestion and hepatic or splenic engorgement. There 
 is no necessity here for applying a great number of leeches — 
 three or four every second day will be quite sufficient, and we 
 have found this number answer every necessary purpose. In 
 addition to loCal bleeding and attention to diet, I ordered this 
 lad to take a few grains of blue pill once a day, not with the 
 intention of affecting his system, but merely with the view of 
 keeping up the free action of the bowels. I continued the mer- 
 cui*y only as long as the tenderness of the liver remained ; for 
 experience has shown that, in those cases of ague-cake where 
 there is merely enlargement of the liver without tenderness, 
 mercury is a bad remedy. 
 
 In cases of this kind, where the stage of active congestion is 
 past — where there is no fever — where the tenderness is removed,
 
 420 CLINICAL MEDICINE. 
 
 and nothing but the increased size of the liver remains — how 
 are you to accomplish a cure ? First, by inserting one or two 
 setons over the liver ; and, secondly, by the use of iodine and 
 tonics. The use of setons in cases of this description is well 
 known, and needs no comment. I recollect the case of a lady, 
 who, after several attacks of jaundice, got chronic enlargement of 
 the liver. The right lobe of the liver, which was the portion 
 chiefly affected, extended down towards the crest of the ilium, 
 and was excessively indurated. This state had occurred after 
 the patient had used mercury, and had been copiously salivated. 
 Two setons were inserted over the region of the liver, and these 
 produced rapid diminution of the enlargement, and a perfect 
 cure. 
 
 With respect to tonics, I may observe that they prove extremely 
 useful in chronic enlargement of the liver and spleen. We are 
 in the habit of using, in this hospital, a combination somewhat 
 similar to the celebrated Bengal spleen-powder; it consists of 
 vegetable and mineral tonics combined with a vegetable pur- 
 gative — as, for instance, aloes — and we have seen the best results 
 from its use. With respect to iodine, it is a valuable adjuvant in 
 such cases, particularly where the system has been much deranged, 
 and where mercury would be likely to run down the patient. 
 Here iodine gives vigour to the constitution, and tends in a very 
 remarkable manner to promote the absorption of the morbid 
 products on which the enlargement chiefly depends. 
 
 Before concluding this lecture, I wish to bring before you 
 some singular facts respecting the liability of the human race to 
 be affected with disease. You are aware that certain affections 
 are peculiar to warm climates, and that these affections prove 
 to an extraordinary degree fatal to whites who may come within 
 the operation of the causes by which they are produced. These 
 causes, more especially as regards Africa, are generally believed 
 to be of malarious origin ; just such causes as in colder climates 
 give rise to agues, but in the torrid zone produce a fatal form, 
 not of intermittent, but of remittent fever. How comes it to 
 pass, however, that this peculiar form of fever is almost exclu- 
 sively confined to Africa, occurring on both its western and 
 eastern coasts, while it is not met with off the shores of South 
 America, where the same physical causes, so far as relate to large 
 swamps with quantities of decaying vegetable and animal matters,
 
 INTERMITTENT FEVER. 421 
 
 apparently exist ? Again, in the published accounts of the 
 recent expeditions to Borneo (I especially allude to those of 
 Captain Keppel, in the " Dido," and of Sir Edward Belcher, in the 
 '' Samaraug"), we hear nothing of the crew being attacked with 
 this fever, although they were constantly exposed to malarious 
 emanations in rivers with sw^ampy banks, lined with mangroves, 
 in which there were low tides, and in the self-same latitude as 
 Cape Coast. 
 
 Let us also, for a few moments, contrast the unhealthy con- 
 dition of intertropical Africa with other portions of the same 
 continent. When I come to speak of the pernicious effects of 
 the western coast on our sailors, I shall, in the case of the 
 " Eclair" steamer, give you a very recent illustration of the deadly 
 character of the emanations by which the coast fever is supposed 
 to be originated. I need scarcely say that the same effect is pro- 
 duced, if possible, in a tenfold degree amongst the white dwellers 
 on land in this unhealthy region ; but I cannot forbear reading 
 for you a single sentence from Bathurst, on the mortality of one 
 of our settlements. '" In 1824, there were 346 European 
 soldiers at Sierra Leone, of these 301 died in the rains ; and in 
 1825, of 1,193 there died 621 ; and of 108 young men sent to 
 the Isles de Los, to the north of the colony, 62 died." This 
 deadly character of the climate, moreover, affects the inferior 
 classes of animals as well as man. In Travels in Western 
 Africa in 1845 — 6, by John Duncan, it is stated that at Cape 
 Coast Castle agriculture has made little progress, probably owing 
 to the want of horses, ivhich cannot live more than a few tveeks ; 
 but the native breed of cattle is very handsome, though small, 
 and is not subject to disease. 
 
 Now there is, probably, not a more salubrious climate in the 
 whole world than Southern Africa. All writers on the recent 
 Kaffir war agree that one of its most remarkable features was, 
 the general good health of the troops, notwithstanding the great 
 exertions and hardships to which they were exposed. And in a very 
 interesting paper recently published by Colonel Napier, entitled 
 A Few Months in Southern Africa, 1 find the following singular 
 and interesting observations : — " The most sudden transitions 
 from heat to cold, and vice versa, is a marked peculiarity of this 
 changeful, though, strange to say, most salubrious climate, in 
 which one may, generally speaking, and with equal impunity,
 
 422 CLINICAL MEDICINE. 
 
 sleep under the bush at the mercy of dew and rain, or expose 
 oneself during all hours of the day to the fiery heat of a vertical 
 sun. On the present occasion, a most grilling hot day was 
 succeeded by a night as bitterly cold ; and yet our bivouac 
 produced no bad consequences." 
 
 Again, let us take the Island of Ascension, off the coast of 
 Western Africa, and we find that at the time of Alexander's 
 visit, as narrated in his Western Africa, all the Europeans and 
 Africans were in the strongest health, and the former had florid 
 complexions — a most unusual circumstance within seven degrees 
 of the line. There were 60 Europeans and 40 Africans ; the 
 former sufl"ered no inconvenience in labouring in the sun, for 
 seven or eight hours all the year round, resting in the middle of 
 the day. 
 
 In connexion with this subject, I cannot forbear reading for 
 you the following remarks of Mr. Bynoe, on the climate of 
 Northern Australia ; they are from the second volume of Dis- 
 coveries in Australia, by J. L. Stokes : — "I find, on a reference 
 to the medical journals, as well as to a meteorological table kept 
 by me during a period of six years, on the coast of Australia, 
 and under every variety of climate, that we had no diseases 
 peculiar to that continent, and I am led to believe it a remarkably 
 healthy country. On the north and north-west coasts, where 
 you will find every bight and indentation of land fringed with 
 mangroves, bordering mud-flats, and ledges formed by corallines 
 in every stage of decomposition, with a high temperature, no 
 fevers or dysenteries were engendered. Our ship's company were 
 constantly exposed in boats to all the vicissitudes from wet to 
 dry weather, sleeping in mangrove creeks for many months in 
 succession, pestered by mosquitos during the hours of repose ; yet 
 they still remained very healthy, and the only instance where 
 the climate was at all prejudicial (if such a term can be applied), 
 was in Victoria river, on the north coast, where the heat was at 
 one period very great, and the unavoidable exposure caused two 
 of the crew to be attacked with coup de soldi. Our casualties 
 consisted of two deaths during our stay on the Australian coast ; 
 one from old age, and the other a case of dysentery, contracted 
 at Coepang. 
 
 But to return ; how, I say, can we account for such peculiarity 
 in the climate of inter-tropical Africa ? That it does exist there
 
 INTERMITTENT FEVER. 423 
 
 can be no doubt, although the fact has not, as far as I am aware, 
 been hitherto noticed. It must depend on some chemical or 
 physical cause as yet undiscovered. 
 
 In the absence of any positive knowledge on this subject, are 
 there any means by which the almost uniform fatality of the 
 African fever may be rendered less destructive to mankind ? 
 The only efficient method for so doing, I believe, must be 
 sought for by an investigation into the effects of climate on the 
 human race. 
 
 It is a remarkable and curious fact, that man is the only 
 animal in whom the identity of species is preserved, while the 
 varieties of his physical constitution are so great, that he is 
 enabled, aided by the resources reason and experience suggest, 
 to inhabit every latitude, and multiply in every climate ; but 
 hitherto he has seemed unconscious of the value of the gift 
 thus bestowed by the hand of Nature — and, while history records 
 the sad effects of war in diminishing or destroying these 
 varieties of the human species, we search its pages in vain for 
 any attempt to preserve or increase them ; and yet there can be 
 little doabt that a proper attention to their physical and mental 
 qualities, would soon make known what region of the earth each 
 is peculiarly fitted to inhabit, and what duties calculated to per- 
 form, in extending the empire of civilization. Let, then, the 
 . rulers of nations arrest the hand of destruction — let us have no 
 longer to contemplate such catastrophes as the annihilation of 
 the aboriginal inhabitants of Van Dieman's Laud, and let the 
 voice of reason (not to invoke the holy name of religion) stay the 
 structure of the funeral pile, on which may soon be placed the 
 lifeless corpse of that noble member of the human family, the 
 North American Indian. 
 
 It has been long known that negroes can withstand the action 
 of deleterious exhalations that are fatal to Europeans. A striking 
 instance of this kind must be fresh in the memories of all. In 
 the expedition to the Niger, undertaken by command of the 
 Government in 1841 and 1842, the mortality from fever was so 
 great as entirely to prevent the execution of the intended design, 
 and one of the iron steamers was saved only by the exertions of 
 the surgeon, who acted as engineer, nearly all the other whites 
 on board having perished. Three steamers were employed in 
 this unfortunate enterprise, and their united crews consisted of
 
 424 CLINICAL MEDICINE. 
 
 145 white men and 158 blacks ; ot the former, 130 were attacked 
 with fever in the Niger, and 40 perished ; while, of the blacks, 
 only eleven caught fever, and in them the disease assumed a 
 comparatively mild form, and none died. Of the blacks, 133 
 were entered on the coast of Africa, and consisted of native 
 Africans, chiefly Kroomen, a littoral and seafaring tribe, whose 
 intelligence, nautical skill, and fidelity will hereafter render them 
 most available in the hands of some other civilized nations. Of 
 the 133 natives, the greater number had never been on the 
 waters of the Niger before, and yet not one of them sickened ; 
 the remaining 25 blacks were entered in England, and consisted 
 of men — some natives of the West Indies, some of the United 
 States of America, and one or two from Nova Scotia ; of these, 
 eleven, as I before mentioned, contracted fever, and none died, 
 although every one of them had been in England, and absent for 
 several years from tropical climates. This fact. Dr. M' William 
 observes, proves " that the immunity from fever in warm 
 countries, which is enjoyed by the dark races, is to a certain 
 extent destroyed by a temporary residence in another climate." 
 This is quite true, but let us consider it in another point of view. 
 Ten of the twenty-five blacks entered in England were West 
 Indians, and had never visited the Niger, and yet they either 
 escaped altogether, or had but slight fever ; and two of the 
 twenty-five were born in cold climates. It appears, therefore, 
 that the black man has a physical conformation which fits him 
 to resist better than the white the deleterious fever of tropical 
 climates. 
 
 The same fact is still more strongly proved by the unfortunate 
 results of the fever with which the crew of the '' Eclair " steamer 
 were attacked, when stationed on the coast of Africa in 1845. I 
 need not enter into any particular account of these circumstances, 
 so well known to all ; it is suflicient for my present purpose to 
 state that, as appears from the official documents, out of forty 
 Kroomen on board, not a single individual was attacked with the 
 fever which proved so fatal to nearly every European on board, 
 until after the vessel arrived in England, when five slight fever 
 cases occurred amongst them, but which are ascribed by Sir 
 William Burnett to their being sent on board the " Worcester," 
 a much colder ship than their own. 
 
 Again, it is stated by Major Forbes, in his account of an eleven
 
 INTERMITTENT FEVER. 425 
 
 years' residence in Ceylon, that when the English were occupied 
 in constructing the splendid roads which now traverse that island, 
 some of the localities were found so destructive of human life, 
 that even the native Cingalese labourers fell victims to disease in 
 great numbers, and consequently the undertaking must have been 
 abandoned, had it not been found that our Kaffir soldiers, who 
 acted as pioneers, were comparatively exempt from the effects 
 of the noxious exhalations, and by their labours, therefore, the 
 work was perfected in places where heat and moisture, acting on 
 the accumulated vegetable deposit of this extensive wilderness of 
 wood, gave rise to a miasma fatal to the other races employed by 
 the Government. 
 
 In a lecture which I delivered before the College of Physicians, 
 in 1844, I entered at length into the history of the different 
 rac2S of mankind, as regards their diffusion over the face of the 
 globe, and for further information on this subject I must refer 
 you to that lecture, which was published in The, Dublin Literari/ 
 Journal, of April 1st, 1844. At present, when speaking of 
 ague, I thought that the foregoing observations would prove 
 interesting, as bearing on the malarious origin of disease. But 
 I cannot conclude without expressing my conviction, one which 
 I have arrived at from long consideration given to the subject, 
 that the several original races of mankind were created by the 
 Almighty power, Avith the view of their peculiar adaptation to 
 the different climates of the globe. And I do not know any 
 more interesting or more benevolent subject of inquiry which 
 could engage your minds, than one into the physical circum- 
 stances by which any peculiar variety of the human race is 
 constituted for inhabiting an individual climate.
 
 426 
 
 LECTURE XXVI. 
 
 ON THE LAW WHICH KEGULATES THE RELAPSE-PERIODS OF AGUE. 
 
 I SHALL devote this lecture to the consideration of 'an interesting 
 subject to which I have lately paid much attention, namely, as 
 to whether there is any law which regulates the relapse-periods 
 of ague. 
 
 Having noted with much anxiety and accuracy the course of a 
 quartan ague for twenty-seven months, I constructed a table for 
 the 25urpose of obtaining a connected view of the number and 
 dates of the fits. This table had been made for some time, 
 before I discovered that it contained data which authorize us in 
 concluding that the law regulating the periodicity of agues 
 applies not only to the succession of paroxysms, but is extended 
 to the free intervals between them — in other words, that the 
 same law of periodicity which governs the disease while it 
 occasions fits, continues likewise to preside over its latent move- 
 ments during the interval when no fit occurs ; and thus the 
 true periodic rate is carried on, though, as in a clock from which 
 the striking weight has been removed, the usual signal does not 
 mark the termination of each certain definite portion of time. 
 
 This law, now for the first time brought to light, exhibits a 
 new example of the tenacity with which periodicity clings to a 
 disease, when once firmly impressed on it, and recalls to mind a 
 very similar phenomenon observed with respect to the catamenia, 
 which, having been suppressed for many months, not unfrequently 
 reappear on the very day on which the monthly period would 
 have occurred, had no such suppression taken place. 
 
 The case I am about to detail possesses likewise several 
 features of practical interest, and serves to show that a very 
 obstinate species of ague, accompanied by various complications, 
 may be perfectly cured by the use of quina alone ; and that very 
 large quantities of that powerful medicine may, under such 
 circumstances, be taken not only with impunity but with advan- 
 tage. A boy of good constitution and eleven years of age had
 
 THE RELAPSE-PERIODS OF AGUE. 427 
 
 been at a boarding scliool in Kent, during the spring and 
 summer of 1842, and remained in perfect health all that time. 
 In autumn he was very imprudently allowed to bathe daily in a 
 pond of stagnant water, and he frequently continued in the 
 water for more than an hour. In the November following, 
 feverish symptoms exhibited themselves, and he was several 
 times an inmate of the school infirmary : his disease was 
 considered to be a frequent return of feverish attacks from cold 
 and indigestion ; and accordingly he was treated by confinement 
 and low diet, with mercurial and saline purgatives. Notwith- 
 standing these remedies, the disease frequently recurred, nor 
 was its true nature even suspected by the medical attendant. 
 He arrived in Dublin on the evening of the IGth of December, 
 1842, and the moment I saw him I concluded, from the peculiar 
 tinge of his complexion, that he was affected with ague. He had 
 a slight cough, but in other respects was tolerably well, although 
 fatigued by his journey : he slept well that night. On the 17th 
 of December he made a good breakfast and dinner, but after 
 dinner he sickened : he slept well during the night, and awoke 
 at eight o'clock on the morning of the 18th. He was hot and 
 feverish all day until about eight o'clock in the evening : the 
 paroxysm of ague thus lasting twenty-four hours. He got at 
 four p.m. five grains of sulphate of quina. — 19th. Slept all 
 last night, free from fever ; sulphate of quina repeated. — 20th. 
 No fever: cough much better; third dose of quina. — 21st. He 
 slept well during the night ; he awoke free from the fever, which, 
 however, returned at eleven o'clock a.m. ; the fit lasted eight 
 hours : the quina was repeated. — 22nd. The dose of quina was 
 increased to seven and a-lialf grains, and continued for some 
 days. There was no return of the fever until January the 8th, 
 on which day he had a slight fit. We here remark for the first 
 time, that the paroxysm occurred on the very day on which it 
 would have occurred had it been going on regularly from the 
 21st of December ; for then the days should have been the 24th, 
 27th, 30th, and 2nd, 5th, and 8th of January ; in other words, 
 the periodic time of the disease, while it exhibited no evident 
 paroxysm, was the same as when it did. The quina was resumed 
 on the 8th of January, and seven and a-half grains of it given 
 daily for four days. The disease now disappeared for a time, but 
 on January 21st he had a slight fit ; and it is to be remarked
 
 428 CLINICAL MEDICINE. 
 
 that this does not correspond with the day upon which it should 
 have reappeared, viz., the 20th, had its latent periodic time 
 remained the same, as may be seen in the table. To proceed 
 with this particular part of our subject : — paroxysms occurred on 
 the 21st, 24th, and 27th of January, and then ceased, in 
 consequence of the exhibition of quina, until the 10th of March. 
 Now reference to the table will show that had the disease 
 observed the quartan period, from the 27th of January, it would 
 have reappeared on the 10th of March. Fits occurred on the 
 13th and 16th of March, and then ceased, under the influence of 
 medicine, until the 30th of April, the very day which corresponds 
 with the quartan period, had it gone on regularly from the 16th 
 of March, as may be seen by reference to the table. The fits 
 occurred again on the 3rd and 6th of May, and were then 
 arrested by the use of quina, again to reappear on the 24th of 
 May, the very day the fit was due : but of this more hereafter. 
 We have seen that the fit of the 21st of January was slight, and 
 that on the 24th was severe, commencing at three p.m. The 
 headache was very bad : the fever continued, more or less, to the 
 25th, and his appetite was not restored until the 26th. On the 
 27th, about three p.m. another fit, much less severe : scarcely any 
 headache : less heat of skin, nausea, and restlessness : passed a 
 good night, and was perfectly well at breakfast on the 28th. 
 
 From the 18th of December to the 2nd of January, he took 
 seventy-five grains of quina ; from the 8th to the 12th, thirty 
 grains ; and from the 21st to the 30th, sixty grains ; total 
 amount, 165 grains. The fit did not return on the 30th of 
 January, and he seemed in every respect perfectly well on that 
 day. Medicine was now discontinued. He had not the slightest 
 indication of disease until Friday, March the 10th. The fit was 
 then, however, so slight that I was doubtful concerning the 
 actual occurrence of a relapse, and therefore did not resume the 
 quina, until a very severe aguish paroxysm on the 13th of March 
 removed all doubt upon the subject. It is particularly worthy 
 of notice that the boy exhibited not the slightest feeling or 
 precursory symptom of indisposition, and had a very healthy 
 colour up to the very beginning of the paroxysm on the 10th. This 
 is not usual, nor did it often happen in the case before us ; for, 
 as the disease became more deeply rooted, the return of the fit 
 was invariably preceded, for a few days, by an unhealthy aspect
 
 THE KELAPSE-PERIODS OF AGUE. 429 
 
 and a pale colour. Still the sudden manner in which the a^ue 
 fit sometimes commenced is very remarkable, for I have seen 
 this patient sit down to a meal with a good appetite, and he had 
 scarcely half finished when all at once he felt indisposed, every 
 trace of appetite vanished, and the aguish rigor set in. I particu- 
 larly i-emarked, too, that there was no derangement whatsoever 
 perceptible in his sleep, urine, alvine evacuations, tongue, or the 
 functions of any other organ, during the twenty-four hours that 
 preceded the relapse of the lOtli of March. At later stages of 
 the complaint, this freedom from functional disturbance before 
 the actual fit was not so clear, but, on the contrary, the boy 
 usually felt a little unwell for a day or two before the fit com- 
 menced. 
 
 These facts show us that ague is at first purely periodic, the 
 health being totally unaffected during the interval between the 
 attacks ; but as the disease becomes rooted, as I have said before, 
 in the constitution, the intervals are rendered less purely healthy. 
 On the 14th of March he again began the quina, in daily doses 
 of ten grains. The fit of the 13th had been very severe ; that 
 of the 15th was milder, and, as I already stated, the ague then 
 ceased, not to reappear until April the 30th. From the 14th of 
 March until the 17th he took ten grains of quina daily, and then 
 continued the medicine in gradually increasing doses, until ninety 
 grains had on the whole been taken during this month. The 
 paroxysm of the 30th of April was slight but well marked ; that 
 of the 3rd of May was sudden, and attended from its commence- 
 ment with raving and hallucinations, which were very alarming, 
 and lasted for two hours, until the hot fit was established. This 
 fit was not perfectly solved sooner than sixteen hours, and 
 created so much uneasiness in my mind that I resolved, contrary 
 to my previously formed resolution, to give him quina in order 
 to prevent another attack, or at all events diminish its violence, 
 fearing that the disease, if unchecked, might pass into its worst 
 form, the apoplectic or fchris intermittens 2jerniciosa. Accord- 
 ingly, on the 4th, 5th, and 6th of May he took forty grains of 
 quina, notwithstanding which he had a fit, as I before mentioned, 
 but slight, and without any cerebral symptoms, on the 6th. The 
 following day he went, by Dr. Stokes' advice, to reside in a 
 cottage most favourably situated over the sea, on the high cliffs 
 of the south side of the hill of Howth ; and on the 9th he took,
 
 430 CLINICAL MEDICINE. 
 
 at 2 p.m., a draught containing ten drops of laudanum and 
 twenty of sulphuric ether. He spent his time chiefly in the 
 open air, and his appearance became much more healthy. He 
 remained quite free from the disease, was active, strong, and 
 cheerful, with an excellent appetite and good spirits, and returned 
 to Dublin on the 23rd day of May, having passed seventeen days 
 free from a paroxysm. 
 
 On the 24th, at 4 p.m., he had a slight paroxysm, and on the 
 27th, at the same hour, another, which was well marked hut 
 not severe, for he slept well the whole night, and, though he had 
 but little appetite next morning, he was in every other respect 
 quite well. We were led, probably erroneously, to attribute the 
 comparative mildness of this fit to a draught containing camphor 
 mixed with sweet spirits of nitre and seven drops of laudanum, 
 taken at 1 p.m., and repeated at 3 p.m., the latter followed by 
 a cup of hot coffee. On the 28th of May he again went to 
 Howth, and was directed to take an opiate draught on the 30th 
 as before, and to go to bed at three o'clock, and by means of hot 
 tea to try to prevent the fit. Notwithstanding these measures 
 the fit came on at the usual hour, on the 30tli of May, and, 
 though not of long continuance, was severe, and its commence- 
 ment was accompanied by spectral illusions. Dr. Stokes and I 
 now determined to lay aside medicine and try what the pure air 
 of Howth, aided by fine weather and constant outdoor amuse- 
 ment, would do. The event did not justify our expectations, for 
 he had fits on the 2nd, 5th, 8th, 11th, and 16th of June, and 
 these fits came on with great regularity about 3 p.m., some of 
 them slight and interrupting his amusement only for an hour or 
 two, but others severe, and, though not lasting more than six or 
 eight hours, yet attended with headache, nausea, vomiting, and 
 purging, which affections seemed to relieve the head. As he 
 had eight successive fits, and the disease evinced no inclination 
 to subside spontaneously, we resolved again to try the sulphate 
 of quina, and on the 15th gave him five grains twice, on the 16th 
 three times, and on the 17th twice before 10 o'clock, in order to 
 interrupt the fit ; on the 18th twice, on the 19th three times, 
 and on the 20th twice ; so that he took seventy grains during 
 these six days. The result of this treatment was a milder fit on 
 the 17th, and none on the 20lh. Thus the plan of giving no 
 quina had been tried from the 6th of May to the 15th of June,
 
 THE RELAPSE-PERIODS OF AGUE. 431 
 
 and it is observable that after this uninterrupted series of nine 
 fits, the seventy grains of quina which wore required to stop the 
 fits produced only an interval of eleven free days, from the day 
 the medicine was last exhibited, viz., the 20th of June ; for on 
 the 2nd of July he had a slight but well-marked shadow of a fit, 
 consisting of paleness, collapse, and some headache, short in 
 continuance, and followed by a scarcely perceptible hot fit. We 
 have already seen that where only two fits had been allowed to 
 occur, forty grains produced a free interval of seventeen, and the 
 advantage therefore of immediately giving quina, and as soon as 
 possible arresting the course of the paroxysm, was so obvious, 
 that on the evening of the 2nd of July I gave him five grains of 
 quina, and twenty grains more were given on the 3rd, 4th, and 
 5th, Now the good efi'ects of at once arresting the disease in 
 its progress were made very evident, for these twenty-five grains 
 obtained a clear interval, without fever and without medicine, of 
 fifteen days. 
 
 On the evening of the 20th he was out boating at Kingstown, and 
 came home chilled, as he said, by the breeze ; but as he recovered 
 after tea, and slept very well during the night, we flattered our- 
 selves that it was merely a chill and not the shadow of an ague 
 fit. But on the 23rd he had a decided though not severe fit. 
 He now recommenced quina — five grains on the 23rd, five on 
 the 24th, ten on the 25th, and ten on the 26th, on which day 
 he had a well-marked fit, but not of long continuance, and its 
 commencement was deferred until half-past seven in the evening. 
 On the 27th he took five grains, on the 28th ten gi-ains, and on 
 the 29th ten grains — on that day he had no fit ; so that, between 
 the 23rd and 29th, both days inclusive, he had taken fifty-five 
 grains, which quantity produced a free interval of eleven days. 
 This result forms a striking contrast with the former, and 
 proves that twenty-five grains employed immediately on the ap- 
 pearance of the first fit produce a longer interval than fifty-five 
 grains employed after the second fit had been allowed to come 
 on. I now determined to act on the experience thus gained, and 
 give the medicine the moment the disease reappeared. This it 
 did on the 10th of August, when he had a decided fit, which 
 commenced at half-past five, and seemed to have gone off before 
 nine o'clock, for he slept perfectly well, and was free from fever 
 during the night.
 
 432 CLINICAL MEDICINE. 
 
 lu this case the first paroxysm of some of the series was of 
 long continuance, and embraced portions of two successive days, 
 so as to make it difficult to determine the exact date of the 
 paroxysm. Thus, in December, 1842, the ague fit commenced 
 on the 17th, in the afternoon, and lasted for twenty-four hours, 
 that is until seven o'clock on the evening of the 18th. If we 
 date it from the commencement of this paroxysm, that is, the 
 17th, the next fit should have been on the 20th, whereas it 
 actually occurred on the 21st December ; here, then, the date 
 must be taken from the day on which the fit terminated. An 
 example of the contrary nature occurred on the 9th of March, 
 1844, after a free interval of nearly five months, when a paroxysm 
 of eighteen hours' duration partly occupied the 9th and partly 
 the 10th of March. In this instance the two fits next in order 
 were prevented, but as one occurred on the 18th of March, it is 
 clear that the date must be taken from the day on which the 
 fit began, not from that on which it ended. These two facts, 
 apparently contradictory, taken in conjunction with others of a 
 similar nature observed in this case, prove that when ague com- 
 mences or reappears after a long cessation, it is not always easy 
 at first to determine accurately the dates of the fits. 
 
 He took five grains of quina on the 10th of August, ten on 
 the 11th, ten on the 12th, and five on the 13th, on which day 
 he had no fit. It was now remembered that on the 8th and 9th 
 of August some precursory symptoms had appeared, denoting the 
 approach of the fit, for on those days he complained of consider- 
 able vertigo in the morning after breakfast, particularly on going 
 to stool. The giddiness was very bad on the morning of the 
 11th, but was much diminished on the 12th. Notwithstanding 
 this giddiness he continued the quina, and the vertigo, with its 
 accompanying paleness and slight nausea, disappeared. It was 
 now proved that the occurrence of the morning vertigo might 
 serve to give us one or two days warning of the future fit, and 
 accordingly it was determined to resume the medicine the 
 moment he complained of this vertigo, which he did very much 
 when at stool after breakfast on the 21st of August. He took 
 five grains at mid-day, and five before breakfast on the 22nd. 
 The giddiness was much less. On the 23rd he took five grains 
 in the morning, and had no vertigo after breakfast, and on the 
 24th five grains more were taken, and then, as he appeared quite
 
 THE RELAPSE-PERIODS OF AGUE. 433 
 
 well, the medicine was discontinued ; but was again resumed on 
 the 31st of August, as he complained of some vertigo, and he 
 took five grains daily until the 8th of September, when he was 
 quite free from ague. 
 
 At this period of his treatment I was not aware of the law 
 which governs the return of the ague fit. On looking at the 
 table it was quite evident that the giddiness he complained of on 
 the 21st of August was the precursor of the fit that would have 
 occurred on the 22nd, had not the quina been used ; and again, 
 that the giddiness which recurred on the 31st of August was the 
 first shadow of the fit due on that day ; and which, no doubt, 
 would have made its appearance in full development on the 3rd 
 of September, had not medicine been used. A knowledge of this 
 law will, therefore, prove of the greatest importance in enabling 
 us to guard against the return of the disease ; for, for several 
 weeks after the series of fits has ceased, we can point out to the 
 patient on what days they are liable to reappear ; and, conse- 
 quently, he can upon those days more efi'ectually guard against 
 the occasionally exciting causes of the disease, such as cold, 
 fatigue, &c., and can also more accurately prognosticate his 
 distance from the paroxysm by the greater or lesser degree of 
 health which he feels on the periodic days. As long as they 
 continue as free as the intervening days, the relapse is com- 
 paratively distant. But to return to our history. The disease 
 appeared now much less violent than before, for during the two 
 preceding months the fits had been comparatively slight and of 
 short duration, and much more under the control of medicine. 
 On the 8th of September he went to England. By way of 
 precaution I ordered him to continue the quina in the following 
 manner : he was to take five grains for four consecutive days, 
 and then to omit it altogether for the next six days, at the expi- 
 ration of which the four-day course was to be resumed. Thus 
 twenty grains were given every ten days. This plan of treatment 
 seemed to be attended with much success. For more than two 
 months he had no attack. He gained flesh and improved in 
 looks and spirits, but just as we anticipated the realization of 
 our best hopes, the disease reappeared on the evening of October 
 the 15th, so that from the date of the last attack on the 10th of 
 August, sixty-four days had elapsed without an attack, and by 
 reference to the table it appears that the 15th of October was 
 VOL. I. 28
 
 434 CLINICAL MEDICINE. 
 
 one of the ague days, or rather of the periodic daj's : so that the 
 
 disease suppressed during more that nine weeks had yet, for the 
 
 whole of that time, observed its latent period in the system, and 
 
 reappeared with wonderful regularity on the ague day. As I 
 
 before stated, he had a paroxysm on the 15th of October : it was 
 
 slight, and occurred in the evening : and again tolerably severe 
 
 ones occurred on the 18th and 21st of October at early periods of 
 
 the day : but on the 24th the fit was postponed to seven in the 
 
 evening, and was only a shadow. Between the 16th of October 
 
 and the 28th he took fifty grains of quina. From the benefit 
 
 derived from the four-day course with the sixty-day interval, the 
 
 course of quina was again commenced, and was persevered in for 
 
 nearly five months, during which he enjoyed excellent health 
 
 and was free from every symptom of disease, having taken in 
 
 this period more than 200 grains. However, on the 9th of 
 
 March, his old enemy once more attacked him. The fit was very 
 
 severe, occupying part of the 9th and part of the 10th of March. 
 
 The latter was the day on which it was due, had it returned 
 
 according to the usual period. This can scarcely be considered 
 
 an exception to the usual rule, for when the ague returns after a 
 
 long interval and the fit is severe, occupying the latter half of 
 
 one day and the beginning of another, we have already seen that 
 
 the sequel alone will determine from which of the days we are to 
 
 date : allowing, however, this to be an exception to the general 
 
 rule, our period becomes once more dislocated, and we set out 
 
 anew with a periodic time dated from the 9th of March. This 
 
 periodic time holds true, indicating after an absence of two fits, 
 
 the fit of the 18th of March, and the next fit, which occurred on 
 
 the 11th of Aj)ril, the latter interval consisting of twenty-three 
 
 days between the two fits. There was a fit on the 14th of April, 
 
 another on the 17th, and another on the 20th ; and none then 
 
 occurred until the 2nd of July. According to the new periodic 
 
 time it ought to have occurred on the 1st of July. In this free 
 
 interval of seventy-two days the periodic time failed to indicate 
 
 by one day, or rather by half a day, the reaccession of the disease. 
 
 We must therefore again take a fresh day of departure from the 
 
 2nd of July. Another fit occurred on the 5th of July. No fit 
 
 came on till the 25th of August, that is, there were fifty clear 
 
 days free from the fit, between these two paroxysms ; and the 
 
 latent periodic time came out true. No fit occurred until the 2nd
 
 THE RELAPSE-PERIODS OF AGUE. 
 
 435 
 
 of November, so that there was now a free interval of sixty-eight 
 days : and the latent periodic time was true to a day. Taking 
 date from the 2nd of November, we have next an interval of 
 forty-one clear days, bringing ns to the last fit on the 14th of 
 December, 1844, which coincides with the periodic time. The 
 following is a table of the free intervals which occurred between 
 successive series of fits, showing the respective duration of the 
 intervals which observed the period, and those which did not : — 
 
 Table A. — Free Intervals between successive Series of Fits. 
 
 
 Interval. 
 
 Periodic. 
 
 XoT Periodic. 
 
 
 
 Days Free. 
 
 Days Free. 
 
 1842 
 
 1st 
 2nd 
 
 17 
 
 12 
 
 
 
 
 •3rd 
 
 41 
 
 
 
 
 4th 
 
 44 
 
 
 1813 
 
 
 5th 
 6th 
 7th 
 8th 
 9th 
 
 17 
 14 
 17 
 14 
 65 
 
 
 
 r 
 
 10th 
 
 
 13G 
 
 
 11th 
 
 8 
 
 
 
 
 12th 
 
 23 
 
 
 1844 
 
 \ 
 
 13th 
 14th 
 15th 
 16th 
 
 50 
 68 
 41 
 
 72 
 
 It is worth remarking that all the numbers indicating the free 
 intervals, in which the latent period was observed, consist of 
 multiples of three plus two — the reason is obvious. 
 
 By this it appears that, in thirteen intervals, the latent 
 periodic time was preserved, so as to indicate truly the day on 
 which the disease reappeared ; and that in the remaining three 
 the indication was inaccurate by half a day or more. It is to be 
 noted that two of the failures occurred where the intervals had 
 been very great. We may, therefore, conclude that the law is 
 true of intervals varying from ten to sixty or seventy days ; in 
 much longer intervals it is less certain. During the year 1843 
 twenty-seven fits occurred ; in 1844 but eleven, most of which 
 were in the months of March and April, and some of the latter
 
 436 CLINICAL MEDICINE. 
 
 were among the most violent he experienced. The disease, 
 therefore, did not wear itself out, hut was cured. He has had no 
 fit during the last year, and has remained free from the disease 
 since the 14th of Decemher, 1844, to the present date. 
 
 With respect to the manner in which quina was used, the 
 following observations may be made. At first I gave it in the 
 usual manner, until the particular series of fits ceased ; and then 
 persisted in its use for ten days or a fortnight, gradually decreas- 
 ing the quantity taken. This is the method generally recom- 
 mended by authors, and it is founded on the notion that it is 
 necessary, where the medicine is given in large doses, not to 
 omit its use abruptly, lest the system should feel the loss of this 
 powerful tonic. My experience in this and other cases leads me 
 to doubt the accuracy of the reasoning upon which this treatment 
 is founded, and I am convinced that, in following this rule, we 
 defeat our own object, by accustoming the constitution to the 
 medicinal efi'ects of the quina at a time when the ague fit is 
 absent. The quina is the proper antagonist of the fit, and 
 while the fits require this medicine, it is borne well by the 
 constitution. On the contrary, when the fits are absent, its 
 curative efi'ects appear to be diminished, and the constitution 
 becomes so accustomed to it that, when the disease again requires 
 it, the medicine no longer exerts its anti-aguish influence. We 
 have an analogous example in the case of mercury, of which 
 moderate quantities, judiciously exhibited, are suflicient to cure 
 the venereal disease, provided the mercury is given when 
 venereal symptoms are present, and only in the quantity neces- 
 sary to control these symptoms. If it be given by way of 
 prevention, when these symptoms are not present, or in too 
 great quantity when they are, the system in either case becomes 
 saturated with the mineral, but is not protected from the further 
 ravages of the venereal disease. The second mode of treatment 
 which I adopted was calculated to avoid the inconvenience already 
 pointed out. This method consisted of giving the quina for four 
 successive days, and intermitting it for the six following days, 
 thus embracing the interval comprehended in three fits. By 
 these means it was hoped to keep the system sufficiently under 
 the curative influence of quina while we avoided rendering the 
 constitution too familiar with the medicine ; the six-day interval 
 preventing it from becoming saturated by the quina. This
 
 THE EELAPSE-PERIODS OF AGUE. 437 
 
 method of treatment seems to have been eminently successful, 
 and under its influence the disease abated in violence, the 
 frequency of the attacks decreased, and the long interval of 136 
 days was at last obtained. Finding, however, that though it 
 had broken the violence of the disease it had not extinguished it, 
 I tried another on the third plan, which was to give no quina 
 until a well-marked fit or shadow of a fit occurred, and then at 
 once to use the medicine in large doses, so as to stop the fits 
 as soon as possible. The moment this object was accomplished 
 the medicine was omitted, and was not again given until the 
 paroxysms recurred, when they were similarly treated. This on 
 the whole appears the best method, as it stops the paroxysms 
 speedily, and keeps the medicine in reserve until they reappear. 
 The following table gives a general \'iew of the quantity of quina 
 which this patient took. The quina was prepared by Mr. 
 Donovan, and was of the purest kind. 
 
 On the whole, I conceive the readiest method of giving 
 sulphate of quina to be, to add a dose of the powder to about 
 half an ounce of water at the time it is to be taken ; it can be 
 readily mixed by stirring with a spoon ; and by this means it 
 may be swallowed without the inconvenience which attends the 
 dose when acid is used for the solution of the quina, the action 
 of which might prove injurious to the teeth. 
 
 During the summer of 1843, the young gentleman whoso case 
 has been related had a very delicate and unhealthy appearance, 
 and while he was under the kind superintendence of Dr. Stokes 
 at Howth, evident tumefaction of the spleen had commenced. 
 He is now robust and strong, and has regained his original 
 healthy complexion. 
 
 Table B. 
 
 Sulphate of Quina taken during the Years 1842, 1813, and 1844. 
 1842. 
 Dec. 18. Two draughts, ei 
 
 „ 20. 
 
 Do. 
 
 do 
 
 „ 22. 
 
 Do. 
 
 do 
 
 „ 23. 
 
 Do. 
 
 do 
 
 „ 26. 
 
 Do. 
 
 do 
 
 1843. 
 
 
 
 Jan. 1. 
 
 Do. 
 
 do 
 
 8. 
 
 Do. 
 
 do 
 
 „ 11. 
 
 Do. 
 
 do 
 
 
 
 
 Grains 
 
 ;ontaii 
 do. 
 
 aing gr. 
 gr- 
 
 V. 
 
 v. 
 
 = X. 
 = X. 
 
 do. 
 
 &■•• 
 
 viiss. 
 
 = XV. 
 
 do. 
 
 gr- 
 
 viiss. 
 
 ^= XV. 
 
 do. 
 
 gr- 
 
 viiss. 
 
 = XV. 
 
 do. 
 
 gr. 
 
 V. 
 
 = X. 
 
 do. 
 
 gr. 
 
 viiss. 
 
 = XV, 
 
 do. 
 
 gr. 
 
 viiss. 
 
 = XV.
 
 438 
 
 CLINICAL MEDICINE. 
 
 1843. 
 
 
 
 
 
 Grains. 
 
 Jan. 
 
 21. 
 
 Four dr 
 
 aughts, 
 
 each contain] 
 
 ng gr. viiss. 
 
 = XXX. 
 
 )) 
 
 26. 
 
 Two 
 
 do. 
 
 do. 
 
 gr. viiss. 
 
 = XV. 
 
 )> 
 
 29. 
 
 Four 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XX. 
 
 '> 
 
 31. 
 
 Six 
 
 do. 
 
 do. 
 
 gr. v. 
 
 = XXX. 
 
 -Feb. 
 
 5. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XXX. 
 
 >) 
 
 11. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. iv. 
 
 = xxiv. 
 
 ^ J 
 
 19. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. iii. 
 
 = xviii. 
 
 llarch 13. 
 
 Six 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XXX. 
 
 ,, 
 
 IG. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XXX. 
 
 -,, 
 
 18. 
 
 Four 
 
 do. 
 
 do. 
 
 gr. V. 
 
 ^ XX. 
 
 J) 
 
 22. 
 
 Six 
 
 do. 
 
 do. 
 
 gr. V. 
 
 =: XXX. 
 
 ■> J 
 
 28. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XXX. 
 
 April 
 
 3. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. iv. 
 
 ^= xxiv. 
 
 )> 
 
 8. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. iv. 
 
 = xxiv. 
 
 )) 
 
 15. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. iii. 
 
 = xviii. 
 
 
 21. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. iii. 
 
 = xviii. 
 
 May 
 
 4. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 ^ XXX. 
 
 5) 
 
 6. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XXX. 
 
 June 
 
 15. 
 
 Fifteen 
 
 do. 
 
 do. 
 
 gr. V. 
 
 ^= Ixxv. 
 
 July 
 
 2. 
 
 Two 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = X. 
 
 >) 
 
 3. 
 
 Ten 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = 1. 
 
 ,, 
 
 23. 
 
 Six 
 
 do. 
 
 do. 
 
 gr. x. 
 
 = lx. 
 
 Aug. 
 
 10. 
 
 Seven 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XXXV. 
 
 )i 
 
 21. 
 
 Four 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XX. 
 
 )) 
 
 31. 
 
 Three 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XV. 
 
 Sept. 
 
 5. 
 
 Four 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XX. 
 
 )) 
 
 8. 
 
 Eleven 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lv. 
 
 Oct. 
 
 5. 
 
 Four papers of 
 
 quina, in each gr. v. 
 
 = XX. 
 
 ?? 
 
 17. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XX. 
 
 )) 
 
 18. 
 
 Twelve 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lx. 
 
 )> 
 
 25. 
 
 Six 
 
 do. 
 
 do. 
 
 gr. vi. 
 
 = xxxvi 
 
 Nov. 
 
 2. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 =: XXX. 
 
 Dec. 
 
 1. 
 
 Twelve 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lx. 
 
 )) 
 
 26. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lx. 
 
 1844. 
 
 
 
 
 
 
 Feb. 
 
 5. 
 
 Twelve 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lx. 
 
 i> 
 
 28. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lx. 
 
 March 13. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lx. 
 
 April 
 
 7. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = Ix. 
 
 )j 
 
 15. 
 
 Six 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = XXX. 
 
 >> 
 
 25. 
 
 Twelve 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = k. 
 
 Aug. 
 
 18. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 =:1X. 
 
 Sept. 
 
 4. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = lx. 
 
 Nov. 
 
 7. 
 
 Do. 
 
 do. 
 
 do. 
 
 gr. V. 
 
 = Ix. 
 
 Amounting in the whole to grs. 1,680, 
 equivalent to threr troy ounces and a half; of which he took, in the 
 year 1842, grs. 65 ; in the year 1843, grs. 1,105 ; in the year 1844, 
 grs. 510.
 
 THE RELAPSE-PEKIODS OF AGUE. 
 
 439 
 
 The two tables marked C, represent the fits and intervals during 
 the years 1843 and 1844. D. F., day on which fit occurred. 
 P. T., the periodic time carried on through the free intervals. 
 W. D. marks where the latter falls on the wrong day, i.e., a day 
 on which no fit occurred : a new series here commences in each 
 of the three failures, as I before explained. 
 Table C— 1843.
 
 440 
 
 CLINICAL MEDICINE. 
 
 Table C— 1844. 
 
 
 1 
 
 
 1 
 
 't-i 
 ft 
 
 &» 
 S 
 
 
 t-5 
 
 3 
 < 
 
 a 
 
 m 
 
 1 
 S 
 
 0) 
 
 a 
 
 > 
 o 
 
 !2i 
 
 a 
 
 1 
 
 p. T. 
 
 
 P.T. 1 
 
 
 P.T. 
 
 W.D. 
 
 P.T. 
 
 
 
 
 2 
 
 
 
 P.T. 
 
 P.T. 
 
 
 D.F. 1 
 
 
 D.F. 
 
 p. T. 
 
 3 
 
 
 P.T. 
 
 1 1 
 
 
 1 
 
 P.T. 1 P.T. 
 
 
 4 
 
 P. T. 
 
 
 P. T. 1 1 
 
 P.T. 
 
 
 P.T. 
 
 
 
 5 
 
 
 
 1 P.T. P.T. 
 
 
 D.F. 1 
 
 1 P.T. 
 
 P.T. 
 
 6 
 
 
 P. T. 
 
 
 1 1 1 
 
 P.T. P.T. 
 
 
 7 
 
 P. T. 
 
 
 P.T. 
 
 |p. T. 1 Ip.T. 
 
 
 
 8 
 
 
 
 1 P.T. 
 
 P.T. 
 
 
 P.T. 1 
 
 1 P.T. 
 
 P.T. 
 
 9 
 
 1 P. T. 1 D. F. 1 
 
 
 1 1 
 
 P.T. 
 
 P.T. 
 
 
 10 
 
 P. T. 
 
 1 W.D. 1 
 
 
 P.T. JP. T. 
 
 
 
 
 11 
 
 
 
 1 D.F. 
 
 P.T. 
 
 P.T. 
 
 
 
 P.T. 
 
 P.T. 
 
 12 
 
 
 P.T. P. T. 1 1 
 
 1 
 
 P.T. 
 
 P.T. 
 
 
 13 
 
 P. T. 
 
 
 
 
 P.T. 
 
 P.T. 
 
 
 
 
 14 
 
 
 
 
 D.F, 
 
 P.T. 
 
 
 P.T. 
 
 
 
 P.T. 
 
 D.F, 
 
 15 
 
 
 P.T. 
 
 P.T. 
 
 
 
 
 
 P.T. 
 
 P.T. 
 
 
 16 
 
 P. T. 
 
 
 
 
 
 P.T. 1 
 
 P.T. 
 
 
 
 
 17 
 
 
 
 
 D.F. 
 
 P.T. 
 
 1 P.T. 
 
 
 
 P.T. 
 
 
 18 
 
 
 P.T. 
 
 D.F. 
 
 
 
 
 
 
 P.T. 
 
 P.T. 
 
 
 19 
 
 P. T. 
 
 
 
 
 
 P.T. 
 
 
 P. T. 
 
 
 
 
 20 
 
 
 
 
 D.F. 
 
 P.T. 
 
 
 P.T. 
 
 
 P.T. 
 
 
 21 
 
 
 P.T. 
 
 P.T. 
 
 
 
 
 
 P.T. 
 
 P.T. 
 
 
 22 
 
 P. T. 
 
 
 
 
 
 P.T. 1 
 
 P.T. 
 
 
 
 
 23 
 
 
 
 P.T. 
 
 P.T. 
 
 
 P.T. 
 
 
 P.T. 
 
 
 24 
 
 
 P.T. 
 
 P.T. 
 
 
 
 
 P.T. 
 
 P.T. 
 
 
 25 
 
 P. T. 
 
 
 
 
 P.T. 
 
 
 D.F. 
 
 
 
 
 26 
 
 
 
 P.T. 
 
 P.T. 
 
 
 P.T. 
 
 
 
 P.T. 
 
 
 27 
 
 
 P.T. 
 
 P.T. 
 
 
 
 
 
 P.T. 
 
 P.T, 
 
 
 28 
 
 P. T. 
 
 
 
 
 P.T. 
 
 
 P.T. 
 
 
 
 
 
 29 
 
 
 
 P.T. 
 
 P.T. 
 
 
 P.T. 
 
 
 
 P.T. 
 
 
 30 
 
 
 
 P.T. 
 
 
 
 
 
 P.T. P.T. 1 
 
 
 31 
 
 P.T. 
 
 
 
 
 
 
 
 P.T. 
 
 
 

 
 441 
 
 LECTURE XXVII. 
 
 CHOLERA — ITS ORIGIN AND TEOGRESS. 
 
 While the art of navigation was in its infancy, and communica- 
 tion by land between distant countries unfrequent and insecure, 
 the 'different races and families of mankind who dv/ell far 
 asunder on the earth's surface were necessarily unacquainted 
 with the appearance of new, or the existence of remarkable 
 diseases amongst each other, and, consequently, that department 
 of medical science which may with propriety be termed the 
 Geography of Diseases remained uncultivated. Now, however, 
 we approach to a new era, when the means of intercourse between 
 the most distant nations have been so facilitated by the aid of 
 an improved system of navigation, a commerce almost universal, 
 and the daily increasing efficacy of steam power, that we may 
 indulge in the rational hope of seeing the sciences studied after 
 a new method, which will embrace within the range of observa- 
 tion not merely the phenomena occurring in a single district or 
 country, but those which take place over the whole surface of 
 the globe. 
 
 Already have the enlightened efforts of our own University, 
 and the genius of one of its professors, prompted the rulers of 
 many kingdoms to join in an alliance destined to establish 
 magnetic observatories in distant regions, so as to make the 
 globe of the earth itself a subject of extended experiment ; the 
 philosophers of the new world have combined with those of the 
 old to examine simultaneously meteorological phenomena, and 
 already have the records preserved by observers at sea and land 
 revealed the hitherto mysterious course of storms, and enabled 
 us to map out the extent and direction of the shocks of earth- 
 quakes. When we investigate the physical changes which occur 
 in our planet, we are encouraged to repeat and multiply obser- 
 vations, in the hope of discovering general laws whose appli- 
 cation will enable us to explain the past and predict the future. 
 But the sm-face of the earth abounds with beings in whom
 
 442 CLINICAL MEDICINE. 
 
 the creative powers of life display an order of phenomena more 
 complicated and refined than anything existing in unorganized 
 matter. But for this very reason, and on account of this 
 superiority conferred on organized matter through the agency of 
 vitality, each being thus animated is governed by laws which 
 seem incapable of extension even to other living creatures of 
 the same species ; and consequently we were led to expect an 
 individuality, an insulation among animals, which will prevent 
 them from exhibiting changes occurring simultaneously among 
 great numbers, and capable of being traced to the operation of 
 general laws. 
 
 A closer examination, however, proves that animals and plants 
 are subject to the operation of physical agencies which act upon 
 numbers of individuals at the same time, and thus give rise to 
 great varieties of diseases. Such diseases should be made a 
 special object of study ; many of them are, as it were, fixed, 
 stationary, and confined to certain countries and districts. Thus, 
 the goitre, the tumidum sub Alpihus guttur, has from the earliest 
 times been endemic in the valley of the Rhone and other parts 
 of Switzerland ; modern travellers have observed it in certain 
 parts of South America, and in Kemaon, a subalpine department 
 of Hindostan. Agues, typhus, yellow fever, elephantiasis, beri- 
 beri, Guinea-worm, yaws, Egyptian ophthalmia, are chiefly 
 confined to the inhabitants of certain districts, and, with a host 
 of other complaints, would afi'ord ample materials for the geo- 
 graphy of fixed diseases. 
 
 On the other hand, there are affections of men and animals 
 which travel from nation to nation, and tribe to tribe ; sometimes 
 these moving epidemics progress with such rapidity, that they 
 speedily migrate over the whole earth ; at other times they creep 
 along with a slow and stealthy step, but their journey is continued 
 year after year, until they have travelled round the world. The 
 Asiatic cholera affords an example of the latter class, having 
 been twenty years in compassing the earth ; while influenza, an 
 example of the former, often traverses the same space in a few 
 months. Thus, the epidemic influenza of 1830 — 32 existed in 
 Australia, and was afterwards noticed in the northern hemi- 
 sphere of Moscow, whence in eight mouths it extended to St. 
 Petersburg!!, Warsaw, Frankfort, Paris, London ; three months 
 subsequently it appeared in Italy, and shortly afterwards in
 
 CHOLERA. 443 
 
 Gibraltar. Now it is deserving of attention that this influenza 
 travelled from Moscow to London in eight months, and to the 
 United States of America in seven mouths more, and, allowing 
 something for the inaccuracy of dates, these data give its rate 
 across the Atlantic only a little speedier than across the Con- 
 tinent. 
 
 This forms, as we shall hereafter see, a striking contrast with 
 the progress of cholera from Britain to Quebec, as compared 
 with its march from Moscow to London, and is a fact of 
 considerable weight in arguing whether cholera, like influenza, 
 is propagated by atmospheric influences. 
 
 The influenza of 1833 travelled much more rapidly than 
 that of 1832, for, originating in the north-east, there was but a 
 few days' interval between its appearance in Moscow, Odessa, 
 Alexandria, and Paris ! 
 
 The influenza of 1847, however, appears to have travelled with 
 still greater rapidity. From returns received at the office of the 
 Director General of the Navy, Sir William Burnett, it appears 
 to have prevailed in January and February on the coast of 
 Portugal and south coast of Spain ; in January, February, 
 and March, in Newfoundland and New Zealand ; in February 
 and IMarch at Valparaiso ; in April, on the coast of Syria ; July, 
 August, and September, west coast of Africa south of the equator, 
 and in August in Hong Kong ! 
 
 Influenzas difi'er from each other not merely as to their rate of 
 travelling, but as to the extent of the earth's surface which they 
 affect. Some, as that of 1782, spread from China all over the 
 inhabited parts of Asia, Europe, and America ; while others, as, 
 for instance, the great influenza of 1837, did not reach the new 
 world at all, although it passed the equinoctial line, and w^as 
 severely felt at the Cape of Good Hope and Australia. These 
 facts are alone sufficient to stimulate our curiosity, and ought 
 to direct the attention of philosophers as well as physicians 
 to the study of endemic and epidemic diseases ; nor will their 
 study be destitute of practical benefit, for were the rulers of 
 civilized nations to bring into active operation a number of insti- 
 tutions, which, discharging the functions of medical observatories, 
 should observe and record the appearance and symptoms of 
 epidemics, many curious facts relating to their origin and 
 progress would be soon brought to light, and we might then
 
 444 CLINICAL MEDICINE. 
 
 perhaps be enabled to arrive at a knowledge of some general 
 laws respecting their motions. Thus, we could ascertain 
 whether, as has been asserted, influenza always progresses from 
 east to west, never from west to east ; whether, originating on 
 one side of the equator, it often passes to the other. 
 
 As the means of communication are now-a-days so rapid, 
 it is quite possible to learn the character and the best mode of 
 treating an epidemic disease long before its arrival amongst our- 
 selves ; we knew, for instance, the symptoms and best method 
 of treating the influenza of 1837, several weeks before we 
 experienced its shock, and we had for many years been familiar 
 with the symptoms of cholera before we actually witnessed its 
 baneful effects. I have still by me a manuscript copy of a 
 lecture I gave at the Meath Hospital in 1826 ; in that lecture I 
 actually described, from eastern authors, the symptoms of spas- 
 modic cholera, and prepared the class for its future arrival in 
 Great Britain, a prediction not my own, but derived from that 
 illustrious philosopher and truly excellent man, Dr. Brinkley, 
 then President of the Royal Irish Academy. 
 
 The origin and march of the spasmodic cholera will form the 
 subject of the remarks which I mean to lay before you to-day. 
 In India, or more properly speaking, in Hindostan, the spasmodic 
 cholera is not a new disease ; partial epidemics of it have 
 occurred at difl'erent times since that empire has been familiarly 
 known to the English. These epidemics, however, being almost 
 exclusively confined to the natives, comparatively circumscribed 
 in extent, and limited in duration, did not attract much attention 
 on the part of European writers. 
 
 " In 1762 it prevailed very extensively in Upper Hindostan, 
 destroying, according to Le Begue de Presle, thirty thousand 
 natives and eight hundred Europeans. Dr. Paisley, in a letter 
 from Madras in 1774, states that it was often epidemic, 
 especially among the blacks. M. Sonnerat, in the account of his 
 travels in India, between the years 1774 and 1781, mentions 
 that cholera prevailed on the Coromandol coast, and at one 
 period more particularly assumed an epidemic and malignant 
 character. Curtis, in his work on the diseases of India, and 
 Girdleston, in his essay on the spasmodic afi^ections of that 
 country, speaks of an unusual prevalence of the disease during 
 1781 and 1782. It prevailed in the northern Clears in the early
 
 CHOLERA. 445 
 
 part of 1781, and in the latter end of March it affected at 
 Gangam a division of Bengal troops, consisting of five thousand 
 men, who were proceeding under the command of Colonel Pears 
 of the artillery to join Sir Eyre Coote's army on the coast. Men 
 previously in perfect health dropped down hy dozens, and those 
 even less severely affected were generally dead or past recovery 
 within less than an hour. Above five hundred were admitted 
 into the hospital in one day, and in three days more than half 
 the army were affected. 
 
 "In April, 1783, it broke out at Hurdwar, on the Ganges, a 
 spot held peculiarly sacred by the Hindoos, among a crowd of 
 between one and two millions of persons assembled for the pur- 
 pose of ablution in the holy stream. It is the custom of the 
 pilgrims to repair to the bed of the river, where they pass the 
 night, with little, if any shelter. Very soon after the com- 
 mencement of the ceremonies, the cholera attacked the pilgrims, 
 and in less than eight days is supposed to have cut off twenty 
 thousand of them. The disease was, however, on this occasion 
 so confined in its influence, as not to reach the village of 
 Jawalpore, only seven miles distant."* 
 
 In Europe no such disease as spasmodic cholera had been 
 knowTi ; this assertion, though opposed to some authorities, may 
 be considered as well founded, and indeed I have no doubt of its 
 accuracy. With us spasmodic cholera is an imported disease ; 
 in Hindostan a resident epidemic. What causes combined to 
 convert a malady habitually confined to the Indian peninsula, 
 into a disease which overshadowed the earth, sparing no nation 
 nor language, it would be useless to inquire ; the subject is 
 buried in profound obscurity : in the meantime, let us hope 
 that it will not prove a permanent addition to the nosology of every 
 country, and that it will soon return within its former limits. It 
 was in the spring of 1817 that the cholera of India assumed a 
 new and more powerful character ; it was then it became endowed 
 with properties that rendered its extension steadily progressive 
 over the earth, in spite of all the obstacles interposed by diversity 
 of soil or climate. The disease first assumed the migratory and 
 epidemic form in districts bordering on the Ganges and some of 
 its tributary rivers, at a distance varying from 80 to 150 miles 
 from Calcutta. This took place in the spring and summer, but 
 
 * American Cholera Gazette, p. 3.
 
 446 CLINICAL MEDICINE. 
 
 the date of its commencement is usually referred to the period of 
 its outbreak at Jessore, on the 19th of August, 1817, where the 
 epidemic was first immediately observed and described by Dr. 
 Tyler, who erroneously attributed it to the use of bad rice. 
 Jessore is situated in Gangetic Delta, about 100 miles north-east 
 of Calcutta. The cholera was now observed in general to follow 
 the course of the rivers, and soon arrived at Calcutta, where it 
 commenced its ravages in September, 1817, and continued to 
 rage during nearly the whole of 1818. 
 
 "By the latter end of September the disease w^as prevailing 
 throughout the whole province of Bengal, from the most easterly 
 limits of Purnea, Dinajepore, and Silhet, to the extreme borders 
 of Balasore and Cuttack ; and from the mouth of the Ganges 
 nearly to the confluence of that river with the Jumna, a space of 
 upwards of four hundred miles. Few places escaped the invasion, 
 and the cities of Dacca and Patna, the towns of Balasore, Buris- 
 saul, Ptungpore, and Malda suffered severely. The large and 
 populous city of Mooshedebad, which from extent and local 
 position was apparently favourably circumstanced for the attacks 
 of the epidemic, it is remarkable, escaped with comparatively 
 little loss, while all around was severely scourged. 
 
 " During the autumn of 1817 the disease extended itself to 
 Muzufterpore and beyond the precincts of Bengal, and appeared 
 at Chuprah, and at the cantonment of Gazeepore : its attacks in 
 these places were, however, confined to the towns themselves, or 
 villages in their immediate vicinity ; the principal portion of the 
 adjoining country at this period entirely escaping the disease. 
 Early in November it attacked the grand army, then stationed at 
 Bundelcund, a portion of the Allahabad province. This army 
 had been assembled in anticipation of a Avar with the Pindarees, 
 and the centre division, consisting of ten thousand fighting men 
 and eighty thousand camp followers, was encamped on the banks 
 of the Sinde, under the immediate command of the Marquis of 
 Hastings. Here the cholera exercised its most destructive power. 
 It is uncertain whether it made its first approaches on the sixth, 
 seventh, or eighth of the month. After creeping about, however, 
 in its wonted insidious manner for several days among the camp 
 followers, it seemed all at once to have gained vigour, and burst 
 forth with irresistible violence in every direction, extending through 
 the whole camp before the 14th of the month. Old and young.
 
 CHOLERA. 447 
 
 European and native, fighting men and camp followers, were 
 
 alike subject to its attacks, and all equally sunk in a few hours 
 
 under its pestilential influence. It was a common occurrence for 
 
 sentries to he suddenly seized at their posts, and having been 
 
 carried in, to have two or three successors before the two hours' 
 
 duty was performed. Many of the sick died before reaching the 
 
 hospitals ; and even their comrades, whilst bearing them from 
 
 out-posts to medical aid, sank themselves, suddenly seized with 
 
 the disorder. The mortality at length became so great that 
 
 there was neither time nor hands to carry off the bodies, which 
 
 were thrown into the neighbouring ravines, or hastily committed 
 
 to the earth on the spots where they expired, and even round the 
 
 walls of the officers' tents. In the five days included between 
 
 the 15th and 20th of November, the number of deaths amounted 
 
 to five thousand. The natives, thinking their only safety lay in 
 
 flight, deserted in great numbers ; and the highways and fields 
 
 for many miles round were strewed with the bodies of those who 
 
 had left the camp with the disease upon them, and speedily sank 
 
 under its exhausting influence. The camp being now cumbered 
 
 with the sick, the Marquis of Hastings determined to seek a 
 
 purer air for the recovery of his sick. Although every means 
 
 was put in requisition for their removal, a part was necessarily 
 
 left behind. ' And as many who left the carts, pressed by the 
 
 sudden calls of the disease, were unable to rise again, and 
 
 hundreds dropped down during every subsequent day's advance, 
 
 and covered the roads with dead and dying, the ground of 
 
 encampment and line of march presented the appearance of a 
 
 field of battle, and of the track of an army retreating under every 
 
 circumstance of discomfiture and distress.'* The exact mortality 
 
 could not be ascertained, but it appears that of the fighting men, 
 
 seven hundred and sixty-four fell victims ; and it was estimated 
 
 that about eight thousand camp followers, or one-tenth of the 
 
 whole, were cut off". On arriving at the high and dry banks of 
 
 the Betwah at Erich, the army soon got rid of the pestilence, 
 
 and met with returning health. 
 
 " During December the disease appears to have everywhere 
 abated, and in January of 1818, to have become nearly extinct. 
 Towards the latter end of February it however revived with great 
 force, and before the close of the year the whole peninsula of 
 
 * Bengal Report, pp. 12 — 15.
 
 448 CLINICAL MEDICINE. 
 
 India, from Silhet on tlie east to Bombay on the west, and from 
 Deyrah on tlie north to Cape Comorin on the south, had suffered 
 from its ravages."* 
 
 The ravages of the disease were much facilitated and increased 
 by the superstition of the people, who, in obedience to the 
 Brahmins, collected in prodigious multitudes on pilgrimages to 
 certain favourite shrines, where they prayed for the cessation of 
 what they were taught to believe the cause of the epidemic, viz., 
 a violent and protracted battle between the god and goddess 
 answerable for the tranquillity and happiness of that part of the 
 world. 
 
 During the year 1818 the cholera pursued a threefold route. 
 First, ascending the Ganges and the Jumna, it reached the 
 northern provinces of Hindostan, but was there checked in its 
 progress for several years by the Nepaulese mountains, and 
 finally entirely arrested by the Himalaya range. This is easily 
 accounted for by the thinness of the population of these situa- 
 tions, and the little intercourse which takes place between the 
 mountainous districts and lower regions. Cholera did not in India 
 attain to an elevation beyond six thousand feet above the level 
 of the sea ; in June, 1818, it had reached the range of mountains 
 between Nepaul and Hindostan ; it was at Schaurapoor, many 
 hundred miles to the north-west, in October ; and before the end 
 of the year had ravaged nearly all the numerous cities and 
 villages situated in the vast tract of country watered by the 
 Ganges, the Jumna, and their tributaries. This was one of the 
 most thickly inhabited j)arts of India, and the destruction of life 
 was awful. 
 
 The second route Avas southward along the coast from one sea- 
 port to another, until it reached Madras on the 20th of October, 
 1818. Here at the very onset of the disease, twenty medical 
 men were attacked, of whom thirteen died. 
 
 Sadras, Pondicherry, and the whole Carnatic were affected 
 during the succeeding year ; but even in December, 1818, it had 
 reached Jaffnapatam, the most northern town of Ceylon, having 
 passed thither after travelling along the whole coast of 
 Coromandel. On the 10th of January, 1819, it broke out in 
 Colombo, and produced dreadful devastation on the western coast 
 of Ceylon ; the disease became exhausted there, but at the same 
 
 * American Cholera Gazette, p. 19.
 
 CHOLERA. 449 
 
 moment burst forth witli renewed vigour in Candi, the capital, 
 2,500 feet above the level of the sea. The cholera did not arrive 
 at the east coast of Ceylon until 1820, when it appeared im- 
 ported, as was said, into Trincomalee by the flag-ship "Leander." 
 The epidemic was brought to the western coast of the Indian 
 peninsula, partly by sea round Cape Comorin, and partly by the 
 great overland lines of communication which connect the Presi- 
 dency of Bombay with the Presidencies of Madras and Bengal. 
 
 It first showed itself at Bombay on the 9th of August, 1820, 
 and in that Presidency carried oft' 150,000 persons. 
 
 The third route of cholera in India I have already referred to : 
 it was across the peninsula from the east coast to the west. It 
 came by Nagpoor, Ellishpoor, Aurungabad, Siroor, and Poonah 
 to the Bombay coast, and was introduced either by troops or 
 travellers. 
 
 From Ceylon the disease went to the Mauritius and the Isle of 
 France, whither it was said to have been imported on the 29th 
 of October, 1819. The distance thus traversed at one spring 
 was three thousand miles. Thence it soon passed to the Isle of 
 Bourbon ; and in the year 1820 to the east coast of Africa at 
 Zanguebar. It is remarkable that it never reached the Cape of 
 Good Hope, where the strictest quarantine was observed. 
 
 The following are the dates of its arrival in the subjoined 
 places : — Burmese Empire generally ; Aracan, Ava, 1819 ; 
 Malacca, 1818 ; Sumatra, 1819 ; Java, Batavia (fearful), 1821 ; 
 Madura, Macassar, after Batavia. Amboyna, in Moluccas, 1823. 
 Amboyna was the farthest south-easterly point it attained to. 
 
 The disease visited Borneo and Celebes ; and in 1820 broke out 
 with extraordinary violence in the Philippine Islands, principally 
 at Manilla, where the natives, misled by the idea that they were 
 the victims of poison administered by the Europeans and 
 Chinese, rose en masse, and were not put down until 15,000 lives 
 had been sacrificed in the contest. Similar manifestations of 
 feeling led to some loss of life even in Petersburgh and Paris, 
 when cholera reached these cities. The same suspicions agitated 
 the inhabitants of Europe during the ravages of the black death 
 in the fourteenth century, when the Jews were slain in great 
 numbers as authors of the plague. In Great Britain I am not 
 aware that any such insane popular ideas were manifested when 
 cholera appeared. In Ireland nothing of the sort was displayed ; 
 VOL. I. 29
 
 450 CLINICAL MEDICINE. 
 
 and barbarous, cruel, and uneducated as we are said to be, the 
 visitation was in no country met with greater intrepidity and 
 resignation than in our native land. When a city or town was 
 attacked in Ireland, we never witnessed the flight of the better 
 classes ; there was neither migration into the country nor deser- 
 tion of their poorer fellow-citizens. No ; I record the fact with 
 pride ; every one remained, every one was ready to do his duty 
 and abide in his place until the plague was stayed. In Dublin, 
 and generally throughout Ireland, the members of the medical 
 profession, and the public at large, believed the malady to be 
 contagious, and yet the sick were never abandoned by their friends 
 in private houses, nor in the least neglected in the hospitals. 
 
 In 1819 the cholera appeared in Siam, Bankok, Tonkin, Cochin 
 China, and caused immense loss of life in Cambodia. In 1810 it 
 arrived at Macao, and was said to have been imported by some 
 ships ; thence it travelled to Canton in China, and, coming to 
 Nanking in 1820, penetrated as far as Peking in 1821. In 
 China the disease proved particularly fatal, on account of the 
 denseness of the population of the Celestial Empire. 
 
 So far we have followed the cholera chiefly southward and 
 eastward in the first instance, but afterwards far to the north ; 
 in this part of its course it passed 10° to the south of the line, 
 and then, resuming a northerly direction, went on to Peking, 
 in latitude 40° north. Even this portion of its progress leads 
 forcibly to the conclusion, that it followed the track of commerce, 
 whether by land or sea, and was not dependent for propagation 
 on mere local influence, or climate. There is a jpopular idea 
 current, that its course was tvestward ; such was the case in 
 Europe, hut in most of Asia it tvas eastward. 
 
 I have already said that the Himalaya range opposed the 
 progress of the disease northward from Hindostan, and that the 
 highest altitude it attained to was six thousand feet. With 
 respect to this latter point, I learned from my friend Captain 
 Meredith, of the 13th Regiment, that it broke out in the medical 
 depot at Landour in 1838, for the first time at a height of eight 
 thousand feet above the level of the sea. It is worthy of remark 
 that cholera did not come to New Holland, although it was in 
 several islands, as Borneo and Celebes, to the north of Australia; 
 but it is to be noted that there is little or no communication 
 between them and the settled portions of New Holland.
 
 CHOLERA. 451 
 
 Let us now trace its course westward from Hindostan. The 
 general belief in Persia is, that the disease was brought in ships 
 from Bombay to Mascate, Bender-abassi and Bassorah, in which 
 places it appeared nearly at the same period, in spring, 1821. 
 
 From Bassorah and Bender-abassi the epidemic spread, in a 
 well-defined and marked manner, along the rivers and routes 
 most frequented by commercial travellers. 
 
 Thus from Bassorah it crept up the Euphrates and Tigris ; 
 and in August, 1821, was at Bagdad, where it carried off great 
 numbers of the Persian army then besieging that city. Along 
 the Euphrates it proceeded to the ruins of Babylon, and by the 
 great route of the caravans across the Desert it arrived at Aleppo. 
 Here it did not commit great ravages, and ceased in the follow- 
 ing December ; but afterwards extended to different towns in 
 Asia Minor, as Mosul, Merdin, Darbeker. At Alexandretta, 
 situated on the Gulf of Scanderoon, it did not arrive until 1823. 
 It is strange that cholera did not continue very long in Asia 
 Minor or Syria, and did not at that period penetrate into 
 Egypt. 
 
 From Bender-abassi in Persia cholera travelled along the 
 great mercantile road to Shiaz in August, 1821 ; and thence to 
 Yezd, where it appeared towards the end of September ; but on 
 the approach of winter lay dormant until spring, 1822, when it 
 again showed itself, and spread north-westward, committing the 
 greatest ravages in every town and village situated on the great 
 caravan road. Tauris, Korbia, Ardabil, and the provinces of 
 Kalkhai, Masinderan, and Gilan (on the Caspian), were soon 
 infected. In most of these places it seemed to cease for a time, 
 but reappeared in the middle of 1823 ; and travelling along 
 the Persian seaports of the Caspian, it reached the province of 
 Shirwan, then lately ceded to Russia. Here it ascended the 
 river Cur, and progressed along the high-roads to the fortress of 
 Buku; and on the 21st September, 1823, Astrachan was attacked. 
 In June, 1823, cholera showed itself in the neighbourhood of 
 Laodicea and Antioch (modern names), and then spread in two 
 directions along the coast of the Mediterranean, but disaj^peared 
 again both there and on the coast of the Caspian Sea. 
 
 On the whole, then, the epidemic, from its commencement in 
 1817 till the end of 1823, had travelled over ninety degrees of 
 longitude and sixty-six degrees of latitude, viz., from the Philip-
 
 452 CLINICAL MEDICINE. 
 
 pine Islands to tlie coast of Asia Minor, and from the island of 
 Bourbon to Astracban and to tbe Caspian Sea. 
 
 It is very remarkable tbat cbolera did not come to Europe 
 by way of Asia Minor ; tbis circumstance may perhaps be 
 explained by tbe accident of its not having infected Smyrna, the 
 chief seaport of communication between Asia Minor and Europe, 
 Had Egypt likewise been then attacked by cholera, it is doubtful 
 whether Europe would have been so long spared. Be this as it 
 may^, from the end of 1823 until its outbreak at Orenbourgh in 
 1829, cholera seemed to halt on the very confines of Europe, so 
 that we may consider the years from 1817 to 1823 as constitut- 
 ing the first period in the progress of this epidemic. 
 
 But although the cholera ceased to attract much attention in 
 Europe during the interval which elapsed between 1823 and 1829, 
 yet we are not on that account to conclude that it lay entirely 
 dormant, for we find it continued its ravages in its original seat, 
 India, and extended itself from Asia Minor, Persia, and China 
 through the vast regions of Tartary and Chinese Tartary. 
 
 The thinness of the population in these half desert regions 
 may be the reason why the progress of the disease through them 
 was at once so uncertain and so slow. The want of frequent 
 communication between even neighbouring districts may have 
 baffled for a time the march of the pestilence, and may have 
 occasioned its remarkably slow progress towards the Eussian 
 frontier. Certain it is that this march in Persia, Tartary, 
 Mongolia, and Thibet, countries absolutely destitute of regular 
 roads, formed a striking contrast with its rapid transmission 
 through more populous and highly cultivated countries, or its 
 -still quicker passage from one maritime nation to another, when 
 connected by a constant trade, as from Germany to England, 
 from England to Canada, and from the East Indies to the Isle 
 of France. In the latter cases the epidemic sprung from one 
 country to another ; hut it is remarkable that it never traversed 
 the ocean at a rate exceeding that of ships. 
 
 We next come to the second period of the history of cholera, 
 when it broke out at Orenbourgh in August, 1829, where it raged 
 with great violence, spreading throughout the whole of that 
 Bussian province ; while the disease, after long Hngering in the 
 north of Persia, assumed, in 1829, an increased energy in that 
 kingdom, from whose northern portions it spread along the western
 
 CHOLEKA. 453 
 
 coast of the Caspian, arriving at Salian, and the province of 
 Shirwun in June, 1830, and thus spreading to Baku, Kuba, and 
 Sheki, in Chomath TaHsch, and in the district EHzabethpoL 
 From this the epidemic pursued a twofold route ; the one 
 following the Kura upwards, led to Tiflis, where the mortality 
 reached five thousand : and thence to the Black Sea and the 
 Caspian, until it a second time reached Astrachan, and proved 
 much more fatal in that city than in 18!23 — now counting more 
 than eight thousand victims. 
 
 From Astrachan the progress of the cholera up the Wolga, or 
 Volga, was very remarkable, as it spread from town to town 
 on that river, in the direct route of intercourse and traffic. I 
 may here remark that whenever cholera travels up the highest 
 mountain passes, as in India, or traverses the ocean, as to tha. 
 Isle of Bourbon, or accompanies the caravan across the desert^ 
 as when it arrived at Mecca and Medina, or when it ascends 
 rivers, making the towns on its banks the successive stages. 
 of journey ; in all such cases, cholera, I say, seems regulated 
 by no common physical circumstance, excejJt human trajjic and 
 human intercourse ; for in other things these lines or routes 
 difter remarkably from each other. But, to follow its ascent of ' 
 the Volga : in 1830, in August, it came to Saratow, and shortly 
 after to Kazan, Nijni-Novgorod, Kostroma, Jarislaw, and so on 
 to the circle Tischwin, in the government Novgorod, where it was 
 only 250 versts distant from Petersburgh, and where it attained 
 for that year to its highest northern limit. 
 
 From the country between the Caspian and Black Sea it 
 spread through the Caucasus to the Don, which it ascended,, 
 while it coasted the Black Sea to Cherson and Odessa, in: 
 September and October, 1830. 
 
 The stream of cholera which entered Kussia from the northern 
 provinces of Persia, as it may be seen from the foregoing account, 
 soon formed a junction with that which flowed from Tartary 
 through Orenbourgh. 
 
 In tbe middle of September, 1830, the disease appeared in the 
 government of Moscow, and on the 20th of September in the 
 capital itself, and did not cease until the following March. In 
 Moscow a severe frost and snow set in towards the end of 
 November, without in the least diminishing the diflfusion or the 
 intensity of cholera. Its unabated continuance throughout the
 
 454 CLINICAL MEDICINE. 
 
 whole of a Moscow winter is a fact worthy of attention. In 
 Moscow, according to Jahnichen, there sickened between thirty 
 and forty per cent, of the persons who had hospital duty to 
 perform, including physicians, nurses, &c., while of the whole 
 population not more than three per cent, took the disease. In 
 Dublin, likewise, great numbers of the hospital attendants were 
 affected, and many died ; still more were saved by the timely 
 exhibition of remedies. It is not quite correct to affirm that 
 cholera ceased in Moscow in March, for in the autumn of 1831 
 more than one thousand cases occurred. 
 
 During the winter and spring, 1830 — 1, cholera spread far to 
 the west and south, viz., to Kalusa, Tula, Pultawa, Kiew, Podolia, 
 Bessarabia, Bulgaria, and Silistria, and through the river 
 provinces of the Dnieper, the Bug, and the Dniester. 
 
 In the more northern and eastern governments the disease 
 had ceased, while it continued, though in a milder form, in the 
 provinces Nicolajaw, Crakow, Tauris, and among the Cossacks of 
 the Black Sea. Petersburgh a second time remained untouched, 
 although the disease had arrived at Tischwin, within one hundred 
 miles of it, an immunity to be attributed to the strict precaution- 
 ary measures adopted, and the cordon sanitaire drawn around 
 the capital for the protection of its inhabitants, but not of 
 its emperor, Nicholas, who, it is but just to add, had gone to 
 Moscow the moment he had ascertained the existence of cholera 
 in that city, in order to exert himself in alleviating the sufferings 
 of his subjects. The fear of infection proved no obstacle to the 
 czar, who zealously performed his duty on that trying occasion. 
 
 The war in Poland accelerated the invasion of cholera into 
 that unhappy country, into which the Russian army commenced 
 its march on the 5th of February, 1831, in three columns, of 
 which many battalions came from infected provinces. Thus the 
 governments of Volhynia, Grodno, and Wilna were extensively 
 under the influence of disease in the spring of 1831. During 
 this campaign the Ptussian army lost great numbers by cholera, 
 and Marshal Diebitch himself died at Pultusk, on the 10th of 
 June, 1831, after a few hours illness — a circumstance which gave 
 rise to the unfounded rumour that he was poisoned ; the details 
 of his illness have been published by an eye-witness. Dr. Koch, 
 of the Prussian service. In Warsaw the disease appeared on the 
 14th of April, after the battle of Iganie, where the Poles took
 
 CHOLERA. 455 
 
 many prisoners, who were brought to Warsaw. In Poland the 
 disease advanced and retreated with the infected armies in a 
 striking and remarkable manner. Westwards and southwards 
 from Warsaw it spread rather slowly towards the Prussian con- 
 fines, arriving on the 23rd July at Kozieglow, a little town nine 
 miles south of Czenstochowa, and but two German miles from 
 the frontier of Silesia. 
 
 Northwards the disease had spread in March and April, 
 through Lithuania, to the seaports of the Baltic, particularly 
 Kiga. From Riga the cholera advanced through Courland and 
 Liefland (Livonia). 
 
 Petersburgh was now threatened on every side, for the disease 
 broke out with renewed violence in the European provinces 
 formerly affected, while most of those which had hitherto escaped 
 suffered in their turn. Under these circumstances the metropo- 
 lis, considering the great quantities of goods and passengers who 
 arrive b}' water-carriage from the interior of the country, could 
 not be expected to remain long exempted, although all possible 
 precautions, short of entirely 2)reventing communication with the 
 country, were adopted ; accordingly cholera appeared in Peters- 
 burgh in July, 1831. Very serious disturbances arose in the 
 Russian metropolis among the lower orders, who considered the 
 pestilence as artificially produced for their destruction by secret 
 friends of struggling Poland. These troubles were only appeased 
 by the presence of the emperor, but not before the mob had 
 destroyed the cholera hospital, and murdered one of the physi- 
 cians. During this epidemic seventeen medical men died in 
 Petersburgh, and a great many others were attacked, some 
 slightly, some severely. The hospital nurses, porters, and 
 attendants suffered in a very large proportion, as did a great 
 number of the mob engaged in sacking the cholera hospital. 
 Cholera had already invaded several of the most northern 
 provinces of Russia, and had arrived at Archangel in May, 1831. 
 Archangel is the most northern emporium of commerce in the 
 world, and is the highest latitude attained to by cholera, which 
 in a population of 19,000, destroyed more than 1,200. In 
 the beginning of August cholera arrived at Helsingfor ; and of 
 September, at Abo in Finland. After this, Aland and the 
 neighbouring islands were affected, and so it passed into Sweden. 
 Dantzic, 30th May, 1831 ; Elbing, 11th July ; consequently
 
 456 CLINICAL MEDICINE. 
 
 eleven weeks after its appearance in Dantzic : but there was an 
 interruption, or rather a great diminution, of the intercourse 
 between these towns. From Dantzic the disease radiated in 
 every direction throughout the neighbouring province. Thorn, 
 21st July, 1831 ; Konitz, 22nd August ; Memel, 27th July ; 
 Kdnigsberg, 22nd July — here a formidable cholera insurrection 
 took place. Stettin, 25th August, 1831 ; Berlin, 30th August ; 
 Frankfort on Oder, end of September ; Magdeburgh, 3rd October. 
 From Magdeburgh the disease] spread extensively upwards, 
 along the course of the Elbe. Halle, 20th December, 1831 ; 
 Merseburgh, 1st January, 1832; Breslau,|23rd September, 1831. 
 In the first months of 1832 cholera had nearly disappeared from 
 the German provinces of Prussia. — Deaths, 31,000, Aamburg, 
 7th October, 1831. Mecklenburg, 7th ^October, 1831. Meck- 
 lenburg- Schwerin took most extraordinary precautions, and 
 escaped. 
 
 Saxony, though Prussia and Austria on either side of it were 
 severely visited, adopted strict measures of precaution, and 
 escaped ; the cholera was neither at Leipzic nor Dresden ! 
 Hanover also escaped, with the exception of Liineburgh, 22nd 
 October, 1831. Sachsen-Weimar, Gotha, Anhalt, Hessia, 
 Brunswick, and some other small principalities all escaped, and 
 apparently by the same means, viz., non-intercourse with infected 
 places. 
 
 In some Saxon villages, as Cosing and Edderitz, the disease 
 broke out but did not spread, apparently in consequence of the 
 measures of precaution instantly put in force by the authorities. 
 
 Austria suffered most severely ; Brody (Gallicia), 5th May, 
 1831 ; Limberg, 22nd May ; all over Gallicia in 1831. Died, 
 97,770. 
 
 Cracow seems to have been infected, not from Poland, but 
 from Gallicia. 
 
 Beginning of July, 1831, cholera began in Hungary. In 
 beginning of June, 1831, much popular violence. Spread very 
 rapidly. Pesth, middle of July ; Presburgh, 9th September, 
 1831. 
 
 In Hungary cholera had ceased as an epidemic by the begin- 
 ning of April, 1832, having proved fatal to at least 240,000 
 persons. Vienna, 15th August, 1831 ; Prague, 28th November, 
 1831.
 
 CHOLERA. 457 
 
 Bohemia was widely affected ; but the disease did not spread 
 from Vicuna far either to the south or west, aud accordingly 
 Carinthia, Stiermark, and the Tj'rol escaped, all being protected 
 by the strictest precautionary measures. 
 
 It is worthy of being noted that cholera remained, as it were, 
 stationary and in a suppressed form during the winter of 1831 
 and 1832, in Hungary, Bohemia, and Germany. It did not 
 spread into Saxony, Mecklenburg, Bavaria, aud scarcely into 
 Hanover, although these bordered on infected states, an 
 immunity not to be accounted for by the existence of any natural 
 boundaries, as mountains or rivers, for the limits are mostly 
 conventional between the infected principalities and those which 
 escaped ; many have, therefore, attributed their escape to the 
 precautionary measures taken. It is strange that Leipzic was 
 spared, while Halle suffered so long and so severely ; the situation 
 of the former city appearing to be much more favourable to the 
 development of miasma than that of the latter. 
 
 Moldavia, in spring of 1831. In Jassy the deaths exceeded 
 6,000 out of a population of 27,000. The disease began in June ; 
 and no doubt its diffusion was favoured by the unhealthy position 
 of the town, aud the condensation of a wretched population, 
 chiefly Jews and Gipsies, in its filthy narrow' streets. All the 
 medical men, except three, perished with most of their families. 
 Bucharest, July, 1831 ; Bulgaria, July, 1831 ; Constantinople, 
 July, 1831 ; Adrianople, Gallipoli, Philippopili, September, 
 1831. 
 
 It is to be noted that plague broke out in Constantinople at 
 the same time with cholera ; but while the latter epidemic 
 ceased towards the end of September, the former continued for 
 several mouths longer. Cholera now a second time invaded 
 Asia Minor, and, simultaneously with plague, caused great 
 devastations. Corfu, October, 1831 ; Monastori, in Greece, 
 November, 1831. 
 
 The destruction of religious pilgrims at Mecca was appalling. 
 The place resembled a field of battle, so great were the numbers 
 of the unburied dead ; and at last even the fanaticism of Mussul- 
 mans was forced to yield, and the survivors sought safety in a 
 hasty and tumultuous flight. Three-fourths of the pilgrims are 
 calculated to have perished during the three days they were 
 densely crowded together at Mecca ; and of the fugitives 10,000
 
 468 CLINICAL MEDICINE. 
 
 fell victims on their journey. The Pasha of Egypt now repeated 
 the precautions so successful in 1823, but this time they were 
 taken in vain, because, as is supposed by many, they were not 
 resorted to sufficiently soon ; be this as it may, cholera broke out 
 first at the two quarantine stations, where the pilgrims from 
 Arabia were detained; and in the middle of August, 1831, it 
 appeared in Cairo and Damietta, and towards the end of the 
 month in Alexandria. Egypt lost on the whole 150,000. The 
 cholera ascended the Nile, and was at Luxor, the site of ancient 
 Thebes, by the end of September. 
 
 We next find the cholera visiting England ; it arrived about 
 the 4th of November at Sunderland, a seaport directly opposite 
 to, and commercially connected with Hamburgh. The cholera 
 spread through many towns in the north of England, but did 
 not anywhere rage with very destructive violence, a circumstance 
 attributable perhaps to the more complete separation of families 
 in Great Britain, as compared with our continental neighbours. 
 The existence of the disease was announced on the 27th of 
 January, 1832, in Edinburgh, and on the 10th of February in 
 London. The ravages of the cholera in the metropolis were 
 comparatively insignificant, its victims during the whole epidemic 
 not exceeding 1,500. 
 
 It is exceedingly remarkable, how many of the great towns of 
 England either escaped infection altogether, or were visited by 
 only a trifling outbreak of the disease.* Up to the 24th of June, 
 1832 (that is, during a period of about eight months since 
 its first appearance in Sunderland), the total number of cases 
 throughout Great Britain, inclusive of London, amounted to only 
 14,796, and the deaths to 5,432.t The disease, it is true, 
 continued in many places to linger long after the above date, and 
 reappeared as an epidemic in some places in 1833 and 1834; 
 but still we are quite warranted in concluding that on the whole, 
 in Great Britain and L-eland the cholera did not count 30,000 
 victims. In Ireland, particularly in Dublin and Sligo, the 
 mortality was much greater than in England — an occurrence 
 which may, perhaps, be accounted for by the bad diet of the Irish 
 lower classes, and the crowded state of their dwellings, it being 
 
 * Choleia commenced in Liverpool on the 12 th of May, and in the meantime had 
 vif^ited Hull, York, Leeds, Manchester, and Warrington. 
 f Medical Gazette, vol. x. p. 400.
 
 CHOLERA. 459 
 
 well known that in the worst quarters of the city many families 
 reside on the same floor, and frequently more than one in the 
 same room. "In London," says Dr. Elliotson,* "the greater 
 part of the people are well fed, better fed than in any other part 
 of the world ; they eat more meat, and the flesh is of such 
 quality as is scarcely to be found in any other country. Besides 
 which, they are better clothed and more comfortable ; and instead 
 of trashy wines they have good sound ale and porter, and malt 
 liquor of all kiuds. But in Paris the water the inhabitants 
 drink is very bad ; the people are crowded together, I know not 
 how many families in a house, with little ventilation. The 
 streets are narrow, the houses dirty; and the population live 
 upon what Englishmen consider trash, not roast beef and mutton, 
 but all sorts of dishes made up of bread and vegetables, with a 
 little meat boiled in water to colour it or give it a flavour ; and 
 drink not good beer, but thin wine." 
 
 Certain it is, no matter how we may attempt to account for it, 
 that cholera was much more destructive in Paris than in Loudon, 
 385 deaths having occurred in one day, 8th April, 1832, in the 
 former city. Nothing has puzzled or perplexed the continental 
 physicians more than the comparative immunity from cholera 
 enjoyed by England, notwithstanding their predictions that there 
 its ravages would attain to a maximum, for they contended that 
 in the English towns many circumstances would contribute to 
 render the disease more liable to spread, as, for example, their 
 very dense population, the extreme poverty and bad diet of the 
 lower orders, and the damp, foggy nature of the climate. Now, 
 I believe that the reproaches made by foreigners respecting the 
 extreme penury of the lower orders in England are not well 
 founded, at least comparatively speaking, and with reference to 
 the same class of persons in the continental cities ; and I am 
 persuaded that in English cities the diet of the poor is superior 
 to that of the continental poor. Indeed, foreign physicians have 
 tried their ingenuity to account for the slightness of the ravages 
 of cholera in Great Britain, some attributing the immunity to 
 tea, some to the quantity of meat we consume, and some to the 
 vapours arising from our numerous coal fires ; and each of these 
 hypotheses have been met by objections, for the Chinese, the most 
 national tea-drinkers in the world, were wofully scourged by 
 
 * Medical Gazette, vol. xii. p. 628.
 
 460 CLINICAL MEDICINE. 
 
 cholera ; and the city of Halle, in Germany, the most devastated 
 town of that country, uses nothing but coal for firing. It is 
 to the more substantial nature of English fare, to the superior 
 cleanliness of that nation, and to their living in families separated 
 from each other, that we must attribute their comparative 
 exemption from cholera, an exemption the more remarkable, 
 when we consider that in England commercial and private 
 travelling between town and town is more rapid, and ten times 
 more frequent than on the Continent. 
 
 Cholera first appeared in Paris on the 24th of March, 1832, 
 and it has been argued by those Avho deny the contagious nature 
 of cholera, and its importation from abroad, that in France it 
 broke out suddenly, not on the confines, but in the heart of the 
 kingdom, and consequently that it must have arisen spontaneously 
 in the metropolis. Before we attach much weight to this argu- 
 ment, we must have very strong proofs that the facts are as 
 above stated. Now, it is very remarkable that cholera was 
 officially announced to exist at Calais only eight days after it 
 appeared at Paris : and when Ave recollect how unwilling the 
 authorities in all seaports of hitherto unaffected nations have 
 invariably been to acknowledge the existence of cholera, it is 
 not by any means improbable that cholera may have existed in 
 Calais before it broke out in Paris — a supposition confirmed by 
 the report of Arnaud, Moribaud, and Gendrin, who witnessed 
 in Calais, towards the end of 1831, many very violent cases of 
 cholera resembling the Asiatic ; nay, even after the cholera had 
 manifestly appeared in Calais, many persisted in declaring that 
 its victims died of common enteritis. 
 
 We see cholera introduced probably from England to Calais, 
 and immediately after to Paris, from which it radiated in all 
 directions by slow and varying stages all over the kingdom. The 
 position of Paris, and its daily communication with England, 
 rendered it almost the first prey of the disease in France. Once 
 there, the cholera moved along the different lines of communica- 
 tion in every direction, its route not governed by any of the laws 
 observed by epidemics depending on atmospheric changes ; and 
 its gradual progress from Paris, as a centre, towards all parts 
 of the circumference of France, presenting a course obviously 
 opposed to that of such epidemics. 
 
 From England cholera soon spread to Ireland ; the following
 
 CHOLERA. 
 
 4G1 
 
 dates of its arrival were communicated by Dr. Barker, whose 
 official situation in the Board of Health gave him the best 
 opportunity of ascertaining the progress of the disease : — 
 
 Places. 
 
 Dates of Outbreak of 
 Cholera. 
 
 Dublin 22ncl March, 
 
 Arklow 8th April, 
 
 Banbridge 9th April, 
 
 Cork 12th April, 
 
 Ramelton, County Donegal i 12th April, 
 
 Naas I 13th April, 
 
 1832. 
 
 Belfast 
 
 Warrenpoint 
 
 Stranorlar, County Donegal. 
 
 Tralee 
 
 G al way 
 
 Limerick 
 
 "Waterford 
 
 Wexford 
 
 14th A^pril, 
 17th April, 
 22nd April, 
 28th April, 
 12th May, 
 14th May, 
 1st July, 
 21st August, 
 
 It is worthy of remark that Dublin, Cork, and Belfast were 
 affected about four months before Waterford and Wexford. Now 
 a steamer plies twice a week between Dublin and Cork, and 
 Dublin and Belfast, icJiile tJiere is no direct communication by 
 steam between Dublin and Waterford, or Dublin and Wexford; and 
 consequently it ajjpears probable, from the dates, that Cork and 
 Belfast were infected from Dublin, while Waterford and Vv^exford 
 escaped for many months, not being exposed to infection from 
 this source. At all events, the fact that Waterford and Wexford 
 should have remained so long without the disease is very remark- 
 able, and, if not sufficiently accounted for by their more indirect 
 and less frequent intercourse with Dublin, it may perhaps be 
 explained by their trade with England consisting chiefly of the 
 export of agricultural produce, rather than the interchange of 
 passengers.
 
 462 
 
 LECTUEE XXVIII. 
 
 CONTAGIOUS CHAEACTER OF CHOLERA. — TREATMENT. 
 
 We have hitherto followed the route of cholera in the old world ; 
 we have now to trace it in the new. 
 
 " The disease commenced about the 8th of June, 1832, in 
 Quebec, in boarding-houses and taverns in the Cut de Sac, a 
 low, uncleanly, and ill-ventilated part of the city, crowded with 
 emigrants of the lowest description, with sailors and other 
 persons of irregular habits."* 
 
 Thus we find that cholera appeared in America first at 
 Quebec, just at the season when the spring stream of emigration 
 from England reaches that city. The following account proves 
 that cholera might be thus transmitted : — 
 
 " The following letter from the surgeon of the British barque 
 " Brutus," to the President of the Board of Health of Liverpool,'!' 
 conveys the melancholy intelligence of the cholera having broke 
 out among the passengers eight days after leaving the river 
 Mersey, and which induced the captain to put back. It appears 
 from a statement subjoined to the letter, that between the 27th 
 of May, the period when the first person was attacked, and the 
 loth of June, the day on which the vessel arrived at Liverpool, 
 117 cases had occurred, eighty-one died, and twenty had 
 recovered. 
 
 " ' With the deepest feelings of regret, I have the painful duty 
 to perform of transmitting to you one of the most melancholy 
 and distressing accounts of cholera, which occurred on board the 
 British barque "Brutus," bound for Quebec, from Liverpool, with 
 three hundred and thirty passengers. The first case presented 
 itself on the 25th of May (being the eighth day after we left the 
 river) in a strong, healthy man, thirty-five years of age ; the 
 symptoms were all well marked, the spasms particularly severe ; 
 
 * See the ofBcial Report of the Eoard of Health, Quebec Cholera Gazette, p. 72. 
 I Cholera Gazette.
 
 CHOLERA. 463 
 
 under the usual means of treatment he recovered. The next 
 case was an old woman of sixty, who died in ten hours after the 
 commencement of the attack. The disease continued gradually 
 to increase (notwithstanding every means having heen employed 
 to arrest its progress) until the night of Saturday, the 2nd of 
 June, when we were a good deal tossed ahout by a heavy sea, 
 and dark hazy weather ; it spread to such an alarming extent 
 that on Sunday, most of the ship's crew being attacked, and 
 having lost some of them the week before, we were obliged to 
 bear up again for Liverpool. It is impossible to describe the 
 scene of misery on the 3rd, 4tli, and 5th — people dying in every 
 direction — the greater number of them destitute of the common 
 articles of bed-covering. On the 6th the weather became more 
 favourable, the disease less severe, and the number of new cases 
 diminished, which has since been on the decline. 
 
 '" W. W. Thompson.' " 
 
 On the 10th of June, 1832, it appeared at Montreal, and here, 
 as at Quebec, it immediately assumed the character of a most 
 destructive pestilence. 
 
 The following interesting account* of the route of cholera 
 during the first stages of its progress in North America, is from 
 the pen of S. Jackson, M.D., Secretary to the Consulting Medical 
 Board of Philadelphia. Dr. Jackson is a non-contagionist, as 
 will abundantly appear from his narrative, upon some of the 
 leading facts of which I may hereafter take occasion to make a 
 few observations. It is worthy of remark that the medical men 
 of America have far outstripped their European colleagues in 
 medical statistics. The weekly, monthly, and annual accounts 
 of diseases, deaths, &c., in each of their great cities have been 
 long published systematically and regularly, and that with a 
 degree of accuracy to which we are strangers. Some of the 
 results of this praiseworthy habit appear in Dr. Jackson's 
 account. 
 
 " From the numbers of emigrants who, about this period, had 
 landed at Quebec, and arrived at Montreal from England and 
 Ireland, a first impression was created that they had been the 
 means of transmitting the epidemic across the Atlantic. A more 
 close investigation into the facts connected with the commence- 
 
 * Chokra Gazitte.
 
 464 CLINICAL MEDICINE. 
 
 nient of the disease in these cities served to destroy this suppo- 
 sition. It coukl not be traced to importation. The emigrants 
 and lower classes of the Canadians were attacked simultaneously 
 in both cities. Numbers of the emigrants were in circumstances 
 eminently predisposing them to suffer attacks of the disease, 
 and they and the lower Canadians were precisely the descrij)- 
 tion of persons most obnoxious to the ravages of epidemic 
 cholera, and such as have been universally observed to be its 
 first victims. 
 
 " The lines of communication between the cities of Quebec 
 and Montreal, and the cities of the United States, are by the 
 Richelieu river, Lake Champlain, and the northern canal leading 
 to Troy and Albany ; or by the St. Lawrence to Lake Ontario, 
 to Buffalo, and by the Erie Canal leading to Rochester and 
 Albany. It was confidently expected that the disease would 
 penetrate into the United States from Canada by these routes. 
 Along the first, many cases of the disease did certainly occur 
 in the persons of emigrants, but they terminated without its 
 communication to others. On the contrary, the epidemic mani- 
 fested a decided predilection for the shores of the St. Lawrence, 
 successively attacking the towns and villages along its banks, 
 then following the borders of Lake Ontario until it entered Lake 
 Erie. 
 
 " While attention was directed to the northern and western 
 boundary, supposed to be threatened by the invasion of the 
 disease, it suddenly and most unexpectedly appeared in the city 
 of New York. 
 
 " The first case occurred, it is said, on the 24th of June, when 
 a man, a native citizen, residing at the corner of Gold and 
 Frankfort Streets, was attacked by the disease. Four cases 
 soon succeeded, the location of which was in Cherry Street. The 
 subjects were Irish emigrants, who had arrived in Quebec in the 
 autumn of 1831, and had resided in Albany until the month of 
 May, when they removed to New York. 
 
 " On the 27th of June the disease manifested itself in Belvue 
 Almshouse, distant about three miles from the city. The 
 patient was an aged woman who had not left the house for three 
 years, who had held no communication with the city, and no ad- 
 mission into the ward she occupied had taken place for a month. 
 Several cases immediately ensued in this and the other wards
 
 CHOLERA, 465 
 
 of the house. The epidemic reached its maximum in this 
 establishment on the 11th July, and terminated on the 4th 
 August. 
 
 " In the city of New York the climax of the epidemic arrived 
 on 11th of July, from which period it continued very steadily to 
 decline. 
 
 " The time that elapsed from the outbreaking of the epidemic 
 at Quebec and its appearance at New York is a period of sixteen 
 days, or nineteen at Belvue Almshouse. The distance between 
 the two cities in a direct line is four hundred and fifty miles. 
 
 "It is to be remarked that all the intermediate cities on the 
 seaboard of the province of New Brunswick and Nova Scotia, of 
 the states of Maine, Massachusetts, and Rhode Island, remained 
 entirely exempt from the epidemic ; and even to the present 
 period, except in Providence, Newport, and Boston, no cases 
 have as yet appeared. 
 
 " In this city the epidemic was much more tardy in its 
 progress than it had been in the Canadas or in New York. The 
 first decided case of cholera occurred on Thursday, July 5th. A 
 man of the name of Musgrove, residing in the cellar of a house 
 in Filbert Street, near Schuylkill, Fifth Street, was attacked with 
 symptoms of malignant cholera on that day. This man had 
 but lately been discharged from the New Jersey prison ; he had 
 been affected with diarrhoea for two or three weeks previous to 
 the cholera symptoms. The disease proved fatal on Sunday 
 the 8th. The next case was a black man residing in St. 
 John Street, Northern Liberties, above Callow Hill. He had 
 been employed working on board a ship from England lying at 
 Pratt's Wharf. He was seized with symptoms of malignant 
 cholera the night of Tuesday, July 9th, and died on Friday. 
 This man was perfectly sober in habits ; no premonitory 
 sj'mptoms existed. 
 
 " No other cases presented themselves until Sunday, July 14th, 
 when two females, occupying a room in a dwelling in Coate's 
 Street, were the victims of the pestilence in its most aggravated 
 shape. Both these females were exemplary in their habits of 
 life, but appeared to be infirm in health. The husband of one 
 of these unfortunates had arrived on Saturday, July 7th, from 
 New York, exceedingly alarmed respecting the cholera. He was 
 taken sick the next day, and died on the succeeding Friday. On 
 VOL. I. 30
 
 466 CLINICAL MEDICINE. 
 
 Saturday the widow felt unwell, and without advice took sixteen 
 grains of calomel in the evening. She was soon afterwards 
 seized with vomiting and purging, and in the course of the night 
 she sunk into collapse. She died Sunday night. The mother 
 of the deceased husband on Sunday morning complained of feel- 
 ing unwell, hut without any definite symptoms. Having been 
 up with her daughter-in-law during the night, her uncomfortable 
 feeling was attributed to fatigue. She was then going about the 
 house, and had been out on an errand. She was requested to 
 lie down as a matter of precaution, and a small dose of opium 
 administered to her. This was at eight o'clock in the morning. 
 Dr. Schott, who was in attendance an hour afterwards, went up 
 to her chamber to inquire into her state. He found her lying 
 on the floor; copious dejections of rice-water looking fluid had 
 occurred, and she was in complete collapse : death ensued in the 
 evening. These were the only cases to which the slightest 
 suspicion of communication by contagion could attach ; but 
 on the same day a Frenchwoman, temperate in habits, about 
 fifty years of age, living in Kensington, beyond the close built 
 part of the town, at the head of West Street, was also a 
 victim of the disease. This woman had not been from her 
 dwelling for three weeks ; her house is isolated, being sur- 
 rounded by kitchen-gardens for the supply of the market. She 
 had been aff"ected with diarrhoea since Friday, for which she had 
 dieted, but had taken no medicine. The case proved fatal next 
 day. 
 
 " From this time not more than three or four cases occurred, 
 all scattered in different quarters, particularly Kensington, 
 Northern Liberties, and Southwark, until the 27th and 28th 
 July, when the epidemic fairly set in, and cases continued daily 
 to be developed. The disease attained its height in this city 
 on the 5th, 6th, and 7th of August, since which time it has 
 gradually declined, and appears now to be extinct. 
 
 " Taking the 27th or 28th of July as the proper commence- 
 ment of the epidemic in Philadelphia, there will be a period 
 of twenty-four or twenty-five days intervening between its first 
 appearance in New York and this city. The distance in a direct 
 line is about ninety miles, 
 
 "A comparative view of the population, number of cases, and 
 deaths, in the cities which have been brought under observation,
 
 CHOLEKA. 
 
 4G7 
 
 presents the epidemic in an interesting point, and exhibits in a 
 clear manner the character it assumed in this city. 
 
 Date of Report and Place. 
 
 Popula- 
 tion. 
 
 Cases. 
 
 Deaths. 
 
 Ratio 
 of Cases 
 to Popula- 
 tion. 
 
 Ratio 
 
 of Deaths 
 
 to 
 
 Cases. 
 
 linU 
 1 in 2i 
 1 in 2' 
 
 1 in2i 
 
 Ratio 
 of Deaths to 
 Population. 
 
 Sept. 30— Quebec 
 
 „ 1 — Montreal ... 
 Aug. 22— New York... 
 Sept. 13— Philadelphia 
 
 32,000* 
 
 2s,000t 
 
 140,000§ 
 
 160,000t 
 
 5,783 
 4,385 
 5,547 
 2,314 
 
 3,292t 
 1,853 
 
 2,78211 
 935 
 
 lin 5j 
 1 in 6^ 
 
 1 in 25^ 
 1 in 70 
 
 1 in 10^ 
 1 in 15\ 
 1 in 151 
 
 1 in 173 •,■«;) 
 
 " The results of this table show conclusively, that the causes 
 productive of cholera were less numerous in the city of Phila- 
 delphia than in Quebec, Montreal, or New York, or were so 
 modified as to possess a much less degree of activity. The 
 causes of this result, so favourable to Philadelphia, important in 
 the hygienic history of cholera, and consoling to humanity, as 
 placing this formidable affection to so great an extent under 
 control, it is interesting to investigate. 
 
 " The following are the circumstances which, existing more 
 particularly in Philadelphia, may be regarded as influential in 
 ameliorating the violence of the epidemic cause, circumscribing- 
 its activity, and diminishing its fatality. 
 
 "1. The plan on which the city is built, arranged in hollow 
 squares, separated by wide and paved streets, prevents excessive 
 crowding of the inhabitants, procures free ventilation, and gives 
 facility to the means of cleanliness. It is to be regretted that 
 any deviation has been permitted in the original design of Penn, 
 whose sagacity and foresight has been so amply demonstrated in 
 the circumstances of the late epidemic. 
 
 " 2. The abundant supply of wholesome water, placed at the 
 command of the whole community, affords a healthful beverage, 
 and gives the means of the most complete cleanliness, by wash- 
 ing the dirty gutters of the streets, close alleys, and lanes. 
 
 "3. The well arranged measures of sanitary police, devised 
 
 * " Permanent population, 27,000 ; transient population, 5,000.— Total, 32,000. 
 t " Protestant grounds, 1,244 ; Catholic cathedral, and cholera grounds, to 25th 
 September, 1,574 ; at St. Roch, 470.— Total, 3,292. 
 
 + " Permanent population, 25,000 ; transient population, 3,000.— Total, 28,000. 
 § •' Estimated as remaining by Mr. D. Ijeslic.— Journal of Commerce, August 8Lh. 
 II " Report of the Inspector. 
 Tf " Population within the bill of mortality."
 
 468 CLINICAL MEDICINE. 
 
 and actually carried into effect by the councils of the city, and 
 the boards of commissioners of the district, and the sanitary 
 committees appointed by them, and by the Board of Health. 
 The measures consisted in a thorough investigation into all 
 existing nuisances, and in their immediate abatement ; in a 
 complete system of cleanliness of the city steadily pursued ; in 
 the early establishment of numerous local hospitals, provided 
 with ample medical attendance, nurses, and every means 
 applicable to the treatment of the disease ; and in spreading 
 before the public early information, derived from the consulting 
 medical committees, of the methods — hygienic, dietetic, and 
 medicinal — best adapted for guarding against the attack of the 
 disease, or to arrest the symptoms at its onset. 
 
 "4. A very considerable influence may be attributed to the 
 annunciation made by the mission sent to Canada, immediately 
 on its return, and before the epidemic had commenced its career' 
 in this city, of the different periods of the disease, and especially 
 of the existence, in almost every instance, of premonitory signs' 
 and a preliminary stage, with a description of the symptoms : 
 indicating its existence. This information was communicated toi 
 the public by the sanitary committee through the daily journals - 
 of the city, by handbills liberally distributed, and by j^lacards on 
 the corners of the streets. The Board of Health adopted the 
 same measures, and pursued the same course. In this manner 
 the whole community, before the beginning of the epidemic, was 
 instructed in the most important j)oints in the general knowledge 
 and management of this affection — its commencing period, the 
 premonitory symptoms, its general curability in that state, the 
 necessity of immediate attention and medical advice, and the 
 methods of relief. These facts had been overlooked, and this- 
 attention to the instruction of the public was entirely neglected 
 in Quebec and Montreal, and in New York. From being taken- 
 unprepared by the epidemic earlier than was anticipated, they 
 were not communicated to the public until the measure had been 
 adopted in this city, and when the epidemic there had already 
 attained its maximum of intensity. 
 
 "5. The moral resolution, calmness, and a perfect freedom from 
 alarm and panic generally manifested by our citizens, and inspired 
 by a thorough confidence in the efficacy of the preventive means 
 enforced, in the advantages for salubrity of the city, and in its
 
 CHOLEEA. 469 
 
 medical resources, contributed in no small degree to diminish the 
 number of cases and the intensity of the attacks. No stores were 
 closed on account of the epidemic, and not more citizens loft the 
 city than usually abandon it every summer. A stranger entering 
 our streets, from the busy throng and cheerful aspect of all he 
 met, would never have suspected the existence of an unusual and 
 a desolating scourge. 
 
 " 6. The treatment of the disease generally pursued in the. 
 city, in the preliminary stage, had most probably no small shaie^ 
 in preventing the development of the disease in innumerabl'e-. 
 instances. In the lighter forms, it was limited chiefly to diet, . 
 rest, tranquillizing doses of anodynes, or mild diffusibles,. with 
 occasionally the mildest laxatives or gentle cathartics, conjoined 
 with sinapisms or other rubefacients. The drastic and per- 
 turbating cathartics were seldom if at all prescribed, and the 
 stimulant practice but rarely resorted to. 
 
 " The foregoing circumstances appear to us as those principally 
 instrumental in producing the favourable results attending the 
 epidemic in this city. As such they acquire a high degree of 
 interest, and afford most instructive lessons as regards the 
 measures of municipal and civil regulation connected with sani- 
 tary police. 
 
 '•' In its general features and character, the disease differed in 
 no respect from the many descriptions that have been mad©' since 
 it first attracted attention in Asia, and subsequently hu its- 
 progress through Europe. It will be unnecessary to make the- 
 repetition here; it is, however, important that the fact should be^ 
 signalized, that during the prevalence of the epidemic very few 
 persons in the city were entirely exempt from some derangement 
 or disorder of the digestive functions. It is not probably 
 exaggeration to assert that two-thirds of the population were 
 affected in this manner, which is to be attributed entirely to the 
 epidemic influences. It should also be stated that, in the majority 
 of cases which assumed the decided character of malignant 
 cholera, preliminary symptoms had existed, varying in duration 
 from a few hours to several days. In those rarer instances which 
 were not preceded by any premonitory signs, the subjects were 
 the aged, the intemperate individuals, who had committed some 
 great imprudence in diet, or whose constitution has been en- 
 feebled, and such cases were generally, if not universally, fatal.
 
 470 CLINICAL MEDICINE. 
 
 " The chief mortality of the disease existed in the public 
 institutions. It was much lighter in private practice. The 
 following table exhibits the cases of deaths, as reported in private 
 practice and the public institutions. The reports, however, do 
 not exhibit the results of private practice in as favourable a light 
 as they really were. A considerable number of physicians in 
 the most respectable pra,ctice reported only the cases that proved 
 fatal, or exceedingly severe. They did not return to the Board 
 of Health the lighter cases, which yielded to the operation of 
 remedial measures. The mortality of private practice in the 
 reports appears, in consequence, to have been far greater than it 
 really was. 
 
 *' Table of Cases and Deaths, with Puitio as occurring in private practice, 
 and the pidjlic institutions. 
 
 " Cases. Deaths. ^^f''^ ^^^^^"^ 
 
 to Cases. 
 
 ♦' Private Practice 1,175 ... 270 ... 1 to 4^^ 
 
 "Hospitals 874 ... 342 ... 1 to 2f 
 
 ''Almshouses 174 ... 92 ... 1 to 1^^ 
 
 " Arch Street Prison 80 ... 4G ... 1 to lf| 
 
 " Had the returns of cases in private practice been complete 
 the proportion of cases would have been much greater ; it would 
 have ranged probably as 1 to 70 or 80, or even more. 
 
 "In the hospital practice, the first cases introduced were 
 nearly all fatal. This circumstance is to be accounted for from 
 the universal observation, wherever cholera has prevailed epi- 
 demically, that the worst constitutions were the first to suffer 
 attacks. In the commencement of the epidemic, persons first 
 attacked, unaware of their danger, and the nature of the affec- 
 tion, neglect application for aid, and resist the ofier of hospital 
 assistance until reduced to a hopeless condition. Besides, misled 
 by the authority of the English and Scotch writers, extensive 
 means had been prepared for warming the patients by heated air, 
 steam, and other means. Experience in a short time proved the 
 pernicious effects of this system. The patients succumbed most 
 rapidly under the exhaustion induced by the profuse watery 
 exhalation from the skin caused by this treatment." 
 
 Why the cholera, if an imported disease, should have broken 
 out nearly simultaneously in Quebec and Montreal, is very easily 
 accounted for, since both are the receptacles of British and other 
 foreign emigrants ; on the same principle, we must explain its
 
 CHOLERA. 471 
 
 appearance so soon after at New York, where, no doubt, it arrived 
 by a se])arate importation from Europe — a circumstance which will 
 prevent us from feeling the same surprise with Dr. Jackson, 
 that between Quebec and New York all the intermediate cities 
 on the sea-hoard escaped, at least for a few months. This is 
 analogous to the exemption of Waterford and Wexford, during 
 several months that cholera raged in Dublin and Cork. I gave 
 Dr. Jackson's Report at much length, because it is intended to 
 be conclusive against the theory of contagion ; while it, in my 
 opinion, contains strong internal evidence of a contrary tendency. 
 In the United States cholera spread far and near, as might 
 be expected from the wonderfully rapid and frequent intercourse 
 that takes place all over the Union ; but, except in the condensed 
 population of the chief seaports, its ravages were not great. It 
 is curious to observe how little Philadelphia suffered in compari- 
 son with Montreal, Quebec, or New York ; no doubt because its 
 population is less condensed, and live in families more separated 
 from each other. In making this observation, I do not mean to 
 undervalue the power of predisposing causes, such as poverty, 
 bad diet, intemperance, &c., which prevail more in the latter 
 cities than in Philadelphia. Still, comparing America with those 
 European and Asiatic countries which suffered most, the only 
 constant difference we can discover is, that the separation of fam- 
 ilies is much more complete in the United States than in any other 
 country except England ; and to this difference, consequently, 
 we are justified in referring for an explanation of the remarkable 
 fact, that England and the United States fared better than other 
 countries, notwithstanding their acknowledged superiority above 
 all in the facilities of internal communication. A wish to be 
 brief forces me to conclude the subject of the cholera in North 
 America with the following list of places, and the dates of its 
 arrival in each : — 
 
 Albany , 3rd July, 1832. 
 
 Troy 16th July, ,, 
 
 New Brunswick July, ,, 
 
 Rochester July, ,, 
 
 Baltimore August, ,, 
 
 Washington August, ,, 
 
 Boston August, "^^ ,, 
 
 * I am not certain of the dates of its first appearance, where the day of commence- 
 ment is not mentioned ; but in all the above places the cholera prevailed during the 
 above months.
 
 472 CLINICAL MEDICINE. 
 
 Cholera did not reach South America at all, a fact explicable 
 by the great length of the voyage from the infected countries, 
 which reason also protected the Cape of Good Hope, the West 
 Indies, and New Holland. It is a curious fact, that New 
 Holland, for the same reason, has until lately been free from 
 measles, scarlatina, and hooping cough, although the colony is 
 fifty years old. But now that the intercommunication between it 
 and other parts of the world has become much shorter and more 
 frequent, owing to the rapid spread of steam navigation, it has 
 been visited with all these diseases. 
 
 We must now return to Europe ; and first with respect to 
 Portugal, it appears from the following editorial paragraph in 
 the Medical Gazette,*' that the disease was imported. " The 
 'London Merchant' steamer sailed from England for Oporto, 
 on the 25th December, 1832, and arrived at the mouth of the 
 Douro on the 1st January, 1833, having lost seven persons on 
 her passage by cholera. The troops which she took out with 
 General Solignac landed immediately at Foz, about two miles to 
 the west of Oporto. By a letter from a medical gentleman of 
 that city, which we have lately seen, it appears that the cases of 
 the disease occurred at Foz, on the road to, and in Oporto, before 
 the 15th of January; and we know, from other authorities, that 
 it has since spread to Coimbra on the south, and Vigo on the 
 north." 
 
 Mr. Lardner, a very intelligent surgeon, and formerly a pupil 
 of mine, has written a very interesting paper on the progress of 
 cholera in Portugal. — Lancet, 1834 — 5, p. 314. He is a decided 
 non-contagionist, but his facts seem to me to be strongly 
 corroborative of the doctrine of contagion. Among other 
 admissions, the following is almost conclusive. "Lisbon was 
 not visited by cholera for a considerable time after Aveiro ; which 
 fact may give the contagionist a lift, for, during the siege, there 
 existed no direct communication by water between Oporto and 
 Lisbon. The Miguelite batteries would not allow a ship to enter 
 the Tagus, and Donna Maria's ships kept a strict blockade 
 outside the bar." The epidemic took six months to travel slowly 
 by land from Oporto to Lisbon. Had the communication by sea 
 between these two ports been open, no doubt it would have 
 
 * Vol. xii. p. 123.
 
 CHOLERA. 473 
 
 readied Lisbon sooner : in America how quickly it extended 
 from one seaport to another ! 
 
 It is a remarkable circumstance, and one which ought to have 
 great weight in the discussion respecting the contagiousness of 
 cholera, that cholera has in no recorded instance appeared in any 
 place sooner than the ordinary modes of communication might 
 have hrougJit it from some infected station. Again, it can easily 
 be proved that the rate at ivhich cholera travels varies icitli the 
 rapidity of that communication. A few weeks were sufficient to 
 transport it from the ports of Britain more than three thousand 
 miles across the Atlantic to Canada, while it took six months 
 to creep along the interrupted line of communication between 
 Oporto and Lisbon. 
 
 From the preceding observations it will appear, 1st, that 
 cholera has had no fixed rate of progress ; 2nd, that it has spread 
 in every direction, sometimes northwards, sometimes southwards, 
 and other times east and west, its route being determined not by 
 the points of the compass, but by the great lines of internal and 
 international communication. 
 
 Cholera never got to any of the West Indian Islands, nor 
 to British (formerly Dutch) Guiana, Demerara, nor any of the 
 embouchures of the great South American rivers, Amazon, 
 Orinoco, or La Plata, though the soil and climate, with the 
 immense tracts of inundated and swampy lands, would there seem 
 most favourable to its development. 
 
 In September, 1835 (Lancet, vol. for 1834—5, p. 782), " the 
 cholera had nearly ceased its ravages in the south of France, and 
 took a south and easterly direction along the countries bordering 
 the Mediterranean Sea. It penetrated into Piedmont in spite 
 of the strictest precautions, and prevailed with more or less 
 intensity at Nice, Coni, Livorno, Genoa, Florence." From this 
 extract we do not learn the dates of its arrival at the above 
 places, but they were probably according to their respective 
 distances from France. The kingdom of Naples was not infected 
 until a still later period ; at Naples, probably, September, 1836. 
 It attained the maximum at Naples on the 22nd November, 
 1836 ; Algiers, 14th October, 1837 ; Bona, September, 1837. 
 
 To trace it accurately, its secondary routes and dates of 
 reappearance should be made out ; it would then be found to 
 have returned often on its steps.
 
 474 CLINICAL MEDICINE. 
 
 Thus, in September, 1837, Marseilles was attacked for the third 
 time, while in the same season of the year, 1837, it reappeared 
 also at Berlin, Prague, and Dantzic. 
 
 It is worthy of remark, that cholera began at Naples, which 
 carries on a perpetual commercial intercourse with Marseilles, 
 about a year before it commenced in Eome ! August, 1837. The 
 disease travelled southwards in the north of Italy, setting out 
 from France ; northwards in the south of Italy, starting from 
 Naples. 
 
 Since the year 1838, cholera ceased to be heard of in any part 
 of Europe, if we except an isolated case or two occasionally 
 reported in the medical journals, and which were probably 
 nothing more than aggravated attacks of English cholera ; but 
 in the latter part of 1847 it again made its appearance in the 
 eastern parts of Kussia, from whence, however, owing, I suppose, 
 to the strict precautionary measures which were at once adopted, 
 it has disappeared without spreading farther west. I shall now 
 shortly trace the origin and course of this epidemic, with which 
 we may yet be visited ; for as I have shown you in my last 
 lecture, the epidemic which appeared in Moscow in September, 
 1830, did not reach England until November, 1831. 
 
 " Some time in the early part of 1842,* cholera appeared 
 in the northern parts of Burmah, and, passing in a southerly 
 direction, committed great ravages, and caused great consterna- 
 tion, at Ava and Ameerapoora. After traversing these cities, 
 it passed down towards Rangoon, pursuing the course of the 
 Irrawaddy and its tributaries, and attacking chiefly, according to 
 Burman report, the towns and villages situated on the banks of 
 these rivers. Still pursuing a southerly course, in August it 
 appeared in the Burmese town of Marteban, situated on the 
 junction of three great rivers — the Salween, the Attaran, and 
 the Gyne, and nearly opposite to the British settlement of 
 Moulmein. In September it appeared in Moulmein, and 
 continued to prevail, with greater or less violence, till July, 
 1843, when it disappeared, although an isolated case was 
 occasionally seen during the two following years. Soon after 
 its entrance into Moulmein it was reported to have appeared in 
 the villages to the south, on the banks of the Salween, and on 
 the sea-side, and then, still travelling due south, it reached in 
 
 * Researches, ij'c, by E. A. Parkes, M.D., 1817, p. 158.
 
 CHOLERA. 475 
 
 November the second principal Bnrman town, Tavoy. Tavoy is 
 a place of considerable size, and is situated about one hundred and 
 fifty miles south of Moulmein, on the bank of a broad shallow 
 stream, loaded with debris from the neighbouring mountains. 
 Cholera raged here with great fury for three or four months, and 
 then gradually disappeared. Soon after entering Tavoy it was 
 heard of in the villages round the city, and, travelling south, it 
 showed itself shortly afterwards (some time in January, 1843) in 
 Mergui, the third principal town in the provinces, situated on a 
 small island formed by two branches of the Tenasserim river, 
 opening into the Bay of Bengal, about one hundred and fifty 
 miles to the south of Tavoy." 
 
 It prevailed throughout the Indian provinces at intervals 
 during the next two years, and early in ISio it raged with great 
 violence along the banks of the Indus, and also in Aiighanistan. 
 Thence it spread into Persia, Tartary, Hindostan, and the 
 pachalic of Bagdad. In May, 1846, it broke out with frightful 
 severity at Teheran, carrying off as many as 300 a-day for several 
 weeks, and reducing the population of that town by at least 
 20,000 souls. 
 
 From this town it proceeded in two directions, one south-west 
 in the line of Ispahan, Shiraz, and Bagdad ; and the other north- 
 west to Tabreez. In October some cases occurred at Saliam 
 and Laukeram, frontier Trans-Caucasian towns of Russia. In 
 the south it spread along the Tigris ; and in December it raged 
 with great violence at Mecca, " being supposed to have been con- 
 veyed thither by the pilgrims from Bagdad.'" Early in the year 
 1847, it appeared to the west of the Caucasus, in the Russian 
 army fighting against the Circassians. " By the middle of May 
 it was at Tiflis, and also at Astrachan at the mouth of the Volga; 
 and where it reached its greatest intensity about the end of July. 
 The towns of Kars and Kutais also, lying westward of Erivan 
 and Tiflis, with many of the surrounding villages, were attacked 
 about the same time. In August it broke out at Batoum on the 
 eastern shore of the Black Sea, and soon afterwards at Erzeroum 
 and Trebizonde, to the southward ; reaching the last-named city 
 about the 9th of September. Shortly before this time, it had 
 appeared at Taganrog, Kertsch, Mariopol, and other towns on 
 the Sea of Azoff, and near the mouth of the Don ; subsequently 
 spreading in a northerly direction towards the more inland
 
 476 CLINICAL MEDICINE. 
 
 provinces of Charcow, Kiev, &c. Again were all the most 
 stringent preventative measures found to be utterly ineffectual in 
 arresting, or even in slackening, the progress of the disease. By 
 the Russian official reports in the middle of September, we 
 learned that it was gradually sj)reading more and more into the 
 heart of the empire, by two distinct lines ; one more northerly 
 and along the course of the Volga towards Saratoff, Tamboff, 
 Kasan, Toula, and Moscow; and the other from the north shores 
 of the Black Sea along the lines of the Don and Dnieper, and 
 their numerous branches. The general direction of the epidemic 
 has been north-westward ; and it has been remarked that the 
 route followed in the present year has been very nearly that along 
 which the ' disease-producing something ' travelled in 1831. On 
 the last day of September it appeared at Moscow, and about the 
 same time at Odessa and Perekop, on the north-western shores 
 of the Black Sea, having previously ceased, or nearly so, at 
 Taganrog, Mariopol, and other parts to the eastward. In the 
 middle of October, we are told by official returns that, without 
 counting Georgia, the Caucasus, and the country of the Cossacks 
 of the Black Sea, the disease existed with greater or less severity 
 in sixteen different governments of the Russian empire. At the 
 same time it was announced that it had again broken out in 
 some parts of the north of Persia, as Tabreez, Khoi, &c., and 
 also at Bagdad. 
 
 " In the second week of November the St. Peter shurgh Gazette 
 stated that ' the most western points the cholera has yet reached 
 are the town of Alexandrof in the government of Kherson, and 
 the district of Olgapol in Podolia,' which is not above thirty 
 miles from the Austrian frontier. To the northward it had been 
 travelling from Moscow to Novgorod in the direction of the capi- 
 tal, and also in a course nearly due west to Dwinaberg, at a very 
 little distance from Riga, and within forty miles of the Prussian 
 territory. A letter from Vienna of the 20th ult. announces that 
 some cases had occurred in the circle of Tarnapol in Gallicia." 
 
 This latter extract I have taken from a pamphlet published by 
 Dr. Gavin Milroy of Loudon, which contains an excellent concise 
 history of the cholera epidemic. 
 
 The next account which we have of this epidemic I read from 
 the Russian Cholera Gazette of January 29th, 1848. Dr. 
 Thielmann, writing in it, says: " During the month of December
 
 CHOLERA. 477 
 
 tlie severe colcT so completely arrested the progress of Asiatic 
 cholera, that there was reason to believe it would disappear 
 entirely. It has altogether ceased in the provinces around the 
 Caspian ; and, with the exception of Moscow, Mohilew, and 
 Witepsk, it is no longer met with in any of the great cities or 
 towns of the empire. Even in these and in smaller places the 
 disease has assumed so mild a character, that it appears to be 
 on the point of extinction. 
 
 " Letters from Constantinople, of the 1st January, announce 
 the gradual disappearance of cholera in that city. The epidemic 
 w^as then chiefly confined to the Arsenal; and out of 210 attacked 
 only 58 died. Accounts from Bagdad, of the 7th of Decem- 
 ber, state that the cholera had almost entirely disappeared 
 from Kerkoula and Suleymania. Letters from Mossol, dated 
 the 12th of December, mention that the cholera had ceased in 
 that city, after having killed 300 persons ; and intelligence from 
 Aleppo, of the 18th, states that it has appeared at Beregik, on 
 the banks of the Euphrates, and was causing from ten to fifteen 
 deaths daily." 
 
 Then, as in the previous epidemic, it was, however, only 
 smouldering, to break out ere long with great fury, and probably 
 pursue the same route it did in 1831 — 32 ; for, according to an 
 official account received in the beginning of June of this year 
 (1848), there had been no fewer than three hundred thousand 
 persons attacked, of whom one hundred thousand perished, and 
 the proportion of persons attacked was to the population nearly 
 as great as on the former visitation. Its progress was in all re- 
 spects similar to that of 1832, when it abated on the occurrence 
 of the frost, and reappeared in the spring, and proceeded on- 
 wards. It had declared itself at Nijni-Novgorod and at Moscow. 
 At Moscow there were twelve cases and five deaths between the 
 8th of April and 12th of May; and at Novgorod, twenty-two 
 cases and twelve deaths between the 17th and 24th of April. 
 
 Let me now, before concluding, call your attention to some 
 points in the treatment of this contagious pestilence. When 
 cholera existed in Dublin in the spring of 1832, the modes of 
 treatment principally relied on were, bleeding in violent spasmo- 
 dic cases, emetics of ipecacuanha and mustard, the application of 
 heat externally and internally, stimulants, but, above all, calomel, 
 not in small but in large and frequently repeated doses, either
 
 478 CLINICAL MEDICINE. 
 
 alone or combined with opium. I need not tell you that the 
 mercurial treatment came to us sanctioned by high authority ; it 
 was a remedy to which the experience of Indian practitioners 
 had given a high character, but in our hands, I must say, it 
 proved of very little value. Be this as it may, I must say that 
 I had reason to be dissatisfied with this mode of treatment ; I 
 had tried it myself, and had seen it tried in every way which 
 ingenuity or experience could suggest, but I had seen it fail 
 almost in every instance. 
 
 About the middle of summer the epidemic began to spread 
 fearfully among those who had hitherto been exempt from its 
 attacks ; many j^ersons in respectable life were seized, and my 
 private practice afforded numerous opportunities of becoming 
 practically acquainted with the disease. In several cases to 
 which I was called in, the malady had not advanced to the stage 
 of collapse ; the symptoms of cholera, properly so called, had 
 merely commenced ; the intensity of the disease was still far 
 away, and a fair chance was afforded for the operation of thera- 
 peutic agents. In most instances I tried calomel and all the 
 ordinary remedies with profitless results ; my treatment proved 
 too often ineffectual ; and some persons whose lives I highly 
 valued perished in spite of all my eftbrts, leaving me grieved for 
 their loss, and mortified by my own want of success. I found 
 that I could no longer place any confidence in calomel, and 
 determined in my own mind to give up a remedy which had so 
 signally failed ; it was, however, a question of deep anxiety to 
 me, what I should select instead, or to what article in the Materia 
 Medica I should have recourse, where so many had proved 
 utterly valueless. 
 
 About this time I happened to be called on to attend a case of 
 obstinate diarrhoea with the late Dr. Hunt. The case was an ex- 
 tremely harassing one, and had resisted all the ordinary remedies. 
 I advised the use of acetate of lead and opium in full doses ; 
 this was given, and I had the satisfaction of finding that the 
 diarrhoea soon yielded. Before this period I had received a 
 letter from that able practitioner and excellent man, Dr. Bards- 
 ley of Manchester, directing my attention to the use of acetate 
 of lead in large doses, in that form of diarrhoea which occurs 
 towards the termination of long fevers, that is to say, the 
 diarrhoea which precedes and accompanies inflammation of the
 
 CHOLERA. 479 
 
 glands of the small intestines. I had subsequently, at Sir 
 Patrick Dun's Hospital, several opportunities of witnessing the 
 truth of Dr. Bardsley's remarks. I saw that in many cases 
 during the course of fever, where the patient was low and pros- 
 trated, symptoms of intestinal congestion came on followed by 
 diarrhoea, which many persons thought would end in ulceration 
 of the glands of Peyer ; and I found that in such cases the 
 acetate of lead was the only remedy that could be relied on. I 
 observed, too, that, contrary to the prevailing opinion on the 
 subject, it could be given in large doses with perfect safety. 
 You are aware that Dr. Bardsley has shown that it may be given 
 to children in very considerable doses without any bad effects, and 
 that in adults he has pushed this remedy to the extent of twenty 
 or thirty grains in the day, without any unfavourable consequences. 
 
 With these impressions I came to the resolution of trying the 
 acetate of lead in the next case of cholera which offered a chance 
 of deriving benefit from any kind of treatment. It is known that 
 there are some cases in which the disease at once assumes so 
 frightful a malignity, that the patient is lost from the very moment 
 of his seizure. This hopeless and intractable malignity is not 
 peculiar to cholera; it is seen in fever, scarlatina, croup, measles, 
 and hydrocephalus ; in fact, there are certain forms of all 
 diseases in which the best directed efforts of medical skill not 
 only fail in curing the disease, but even in retarding its progress. 
 But there are cases of cholera where the patient is not struck 
 down at once, where the disease is not developed at once in all its 
 awful intensity, and where time, brief though the space may be, 
 is allowed for the play of therapeutic agencies. It is in such 
 cases the acetate of lead may be given with some prospect of 
 success, and it is by such cases alone, and not by those which 
 are necessarily fatal ab initio, that its value is to be tested. 
 
 Before we proceed further, I may observe that the principle on 
 which the calomel treatment was employed in cholera arose from 
 almost constantly observing that there was a total deticiency of 
 bile in the stools. Soon after the supervention of an attack, the 
 alvine discharges were observed to be white, and without the 
 slightest tinge of bile; and on this very remarkable symptom 
 practitioners dwelt almost exclusively, thinking that the patient's 
 only chance lay in restoring the secretion of the liver. Now it 
 is obvious that the absence of bile in the stools is no more a
 
 480 CLINICAL MEDICINE. 
 
 cause of the disease than is the deficiency of urea in the kidneys, 
 or of serum in the blood. Viewing the disease in this light, 
 it would be just as reasonable to give a diuretic to restore the 
 secretion of the kidneys as to give calomel to produce a flow of 
 bile. The liver ceases to secrete, not only in consequence of the 
 injury done to its vitality by the proximate cause of cholera, 
 whatever that may be, but also from a mechanical cause, 
 namely, from a diminution in its supply of blood. 
 
 It may appear strange that when the same given number of 
 vessels go to the liver and come from it in all times, that the 
 quantity of blood circulating in it should be greater at one time 
 than another. I have not time at present to enter fully into this 
 subject ; but it is a fact admitting of sufficient proof that the 
 quantity of blood circulating in any organ is very much modi- 
 fied by the state of its capillaries. The quantity of blood also 
 which goes to a gland varies according to the peculiar state of 
 that gland, being greater during its period of active secretion 
 than when it is at rest. But in a case of cholera, where the 
 capillary vessels of the intestinal canal from the stomach to the 
 rectum are actively engaged in taking up the serum from the 
 whole mass of blood, and pouring it into the cavity of the diges- 
 tive tube, there is an enormous drainage from the S3^stem, and 
 there must be consequently a deficiency of blood somewhere. 
 Now it would appear that a quantity of blood, sufficient for the 
 purposes of secretion, is abstracted not only from the biliary, but 
 also from the urinary system ; and hence, it appears just as 
 reasonable to give diuretics to restore the urinary secretion as to 
 give calomel to excite the secretion of the liver. It would be, 
 a priori, as original a mode of treatment, and be equally as 
 successful. I have therefore no hesitation in saying, that the 
 calomel treatment has no claim to merit on the ground of theory, 
 and, as far as I have observed of it in this country, it seems to be 
 of no practical value in the treatment of cholera. 
 
 With regard to the quantity of acetate of lead which may be 
 given in this disease, and the mode of administering it, a few 
 words are necessary. I have already stated that when I first 
 tried it, I prescribed it in large doses, fortified by the authority 
 of Dr. Bardsley, and by my own experience of its utility in many 
 cases of diarrhoea. It appears that before I recommended the 
 acetate of lead, it had been used at the Cholera Hospital in
 
 CHOLERA. 481 
 
 Grangegorman Lane. Of tliis I was not aware, until a book was 
 subsequently published by Dr. Cranfield, which I afterwards 
 reviewed in the sixth volume of the Dublin Journal of Medical 
 Science, and I feel that on that occasion I did fair and impar- 
 tial justice to its merits. I certainly did not know that the 
 acetate of lead had been given at the Grangegorman Hospital ; 
 for in the very able report of cholera, as observed at that 
 institution, published by one of its officers, Mr. M'Coy, the 
 treatment relied upon appears to have been the mercurial, and 
 not a word was said of acetate of lead. It had been used there 
 by one physician, but it was given in small doses, insufficient 
 to produce decided effects, and no stress had been laid on its 
 value as a remedy in cholera by the practitioners attached to the 
 hospital. Be this as it may, acetate of lead was not known to the 
 medical men of Dublin and to the practising apothecaries before 
 I recommended it. It had been frequently employed in the form 
 of injection by them ; but no one had given it in large doses by 
 the mouth, or introduced it to the notice of the profession. I 
 believe I can fairly claim the merit, such as it is, of being the 
 first to give it in large and effectual doses. 
 
 The mode in which I administered it was this : a scruple of the 
 acetate of lead, combined with a grain of opium, was divided 
 into twelve pills, and of these one was given every half hour, 
 until the rice water discharges from the stomach and rectum 
 began to diminish. In all cases where medicine promised any 
 chance of relief, this remedy was attended with the very best 
 effects. It gi'adually checked the serous discharges from the 
 bowels, and stopped the vomiting. I need not say of what 
 importance this is : as long as these exhausting discharges con- 
 tinue, as long as the serum of the entire body continues to be 
 drained off bythe intestinal exhalents, what hope can we entertain? 
 What benefit can be expected from calomel and stimulants, when 
 evei-y function of the digestive mucous membrane seems to be 
 totally extinguished, except that of exhalation, and while profuse 
 discharges, occurring every five or ten minutes, are reducing the 
 patient to a state of alarming prostration ? Knowing the inevitable 
 fatality of all cases where these discharges went on unchecked, I 
 was happy at having discovered a remedy which seemed to possess 
 more power in arresting them than any yet devised, and this im- 
 pression was confirmed by the results of subsequent experience. 
 VOL. I. 31
 
 482 CLINICAL MEDICINE. 
 
 That the acetate of lead will succeed where all other astrin- 
 gents fail, was proved by the case of Mr. Parr^ of this hospital, 
 Having got an attack of threatening diarrhoea at a time when 
 cholera was prevailing in Dublin, this gentleman used various 
 kinds of astringents, and took so large a quantity of opiates that 
 he became quite narcotized, but without any relief to his symp- 
 toms. When I saw him, he was as bad as ever, and was 
 beginning to exhibit appearances of collapse. I advised the use 
 of pills composed of acetate of lead and opium, in the proportions 
 already mentioned, and had the satisfaction of finding that before 
 night the diarrhoea had ceased. The pills are to be used one 
 every half hour while the diarrhoea remains unchecked, but as ib 
 begins to diminish, the intervals between each pill may be pro- 
 longed, and in this way the patient may be gradually prepared 
 for leaving off the remedy altogether. I have frequently given 
 in this way as much as forty grains of acetate of lead in twenty- 
 four hours, with great advantage to the patient, and without any 
 bad consequences ensuing. 
 
 It is unnecessary for me to say any more on this subject. If 
 I chose to mention names, I could bring forward the names of 
 many medical men in Dublin, whose lives, I am happy to state, 
 were saved by the use of this remedy. I may, however, observe 
 that this mode of treatment has now become universal here, and 
 that it has almost completely superseded the use of calomel and 
 opium. I will confess that this fact is a source of high grati- 
 fication to me, and I point also with pleasure to the fact that 
 since it became extensively known, as it did during the last 
 invasion of the epidemic, the profession has gained more credit 
 than before, and the number of cures has been proportionally 
 greater. 
 
 I may remark that the most convenient way of making the pills 
 is to add five or six grains of powdered liquorice to the scruple of 
 acetate of lead, and mixing into a mass by means of mucilage of 
 gum-arabic. Year after year, since I first made public the value 
 of this plan of treatment in cholera, I have received the most 
 gratifying letters as to its successful employment from practi- 
 tioners in India. The following observations of Dr. Parkes, who 
 had the opportunity of witnessing two recent outbreaks of cholera 
 in India, in 1843 and 1845, while serving as assistant surgeon 
 in one of H.M. regiments, I look on as most valuable testimony.
 
 CHOLERA. 483 
 
 i quote from his Esscnj on Cholera, to which I have ah-eady re- 
 ferred. At page 207 he says : — 
 
 " Of all the astringents which have been used in cholera, none 
 has appeared to me so efficacious as the one recommended by Dr. 
 Graves, viz., the acetate of lead. It is true that it did not arrest 
 the purging in all cases, but it possessed this great advantage, 
 that, in the form of pill with opium, it did not seem to increase 
 the irritability of the stomach, but rather to allay it. I used to 
 give two or three grains with a quarter of a grain of opium, every 
 half hour for the first two or three hours^ and then every hour 
 for a variable period, according to the intensity of the case. It 
 was often found that the vomiting first ceased, and then the 
 purging ; the algide symptoms were of course unaltered, but, as 
 already said, no remedy yet known possesses any influence over 
 them, and it is the best way to leave them altogether to them- 
 selves, and take the chance of their not advancing to their full 
 extent. The only bad effect I ever noticed after the employ- 
 ment of these large doses of lead was subacute gastritis ; but 
 this is a comparatively trifling afiair, and can generally be 
 overcome by relays of leeches to the epigastrium during the 
 period of reaction." 
 
 Dr. Thom, surgeon of the 86th Regiment, in an account of the 
 cholera as it affected that regiment at Kurrachee in 1846, thus 
 speaks of the combination : — 
 
 " The acetate of lead, in doses of one, two, or three grains, 
 and one-eighth of a grain of acetate of morphia, was employed to 
 stop those profuse watery dejections which continued in some 
 cases after reaction had taken place ; and in this point of view 
 it was a most useful remedy. Of course in those cases where 
 vomiting and purging are the first symptoms, and collapse 
 appears to be their consequence, the early use of this remedy 
 was resorted to, and with very good encouragement." * 
 
 * Medical Times, 1847, vol. xvi. p. 151.
 
 484 
 
 LECTURE XXIX. 
 
 INFLUENZA. 
 
 I ADVERTED in the two last lectures to the subject of influenza, 
 and endeavoured to point out some of the principal features in 
 which epidemics differ, as to their mode of spreading, from 
 diseases which owe their diffusion chiefly to contagion. I stated 
 that contagious disorders were comparatively slow in their 
 progress, attacking different masses of the population in succes- 
 sion, and exhibiting, in general, a tendency to affect distinct 
 classes of the community at different periods. On the other 
 hand, when an epidemic like influenza makes its appearance, 
 everything comes under its influence almost simultaneously, 
 and, like a cloud, it overshadows the whole country in the space 
 of a few Aveeks. Such was the course of the epidemics of 1837 
 and 1847, and so it was with the influenza of 1782, which 
 travelled from the east, and left traces of its ravages in almost 
 every quarter of the globe. 
 
 In the case of epidemics which traverse the whole or nearly 
 the whole extent of the inhabited portion of the earth, it would 
 be a matter of great interest to ascertain the place of their first 
 appearance, or their point of departure. The cholera, as I have 
 already shown you, commenced in Hindostan, and in its route 
 followed the great lines of communication and commerce : its 
 general progress has been north-west : but in Portugal, Spain, 
 and Italy, it has travelled in various directions ; its progress, 
 however, being in general along the great lines of communication 
 leading from the part of the frontier where it first broke out, 
 towards the large towns in the interior. It is probable that 
 influenza pursues some certain and uniform course, independent 
 of the physical circumstances which retarded, accelerated, or 
 stopped the progress of Asiatic cholera. It is likely, too, that its 
 rate of spreading is subject to fewer variations. Cholera took 
 years to accomplish its journey from Hindostan to Britain ; but, 
 once established there, it crossed the Atlantic at a single step.
 
 INFLUENZA. 485 
 
 The march of influenza has not as j-et been mapped out; from 
 the accounts which have reached us in 1837, it seems to have 
 travelled at the same time in very different directions, arriving 
 at Cape Town in January, during mid-summer, and in London 
 in the same month, during mid-winter ; while it is reported to 
 have reached New Holland, and to have raged among our 
 antipodes, two mouths earlier, and in 1847 it pursued the same 
 variable course. 
 
 It is obvious that influenza does not depend upon mere varia- 
 tions of temperature, for we have had many seasons as changeable 
 as the present, without the occurrence of any such epidemic. 
 Besides, influenza is known to be a disease which travels throuirh 
 the most dilferent climates, preserving its peculiar character and 
 identity in all. It is not to be supposed that the same tempera- 
 ture, or the same barometrical and hygrometrical conditions of 
 the atmosphere, prevail here as in Spain, France, Germany, or 
 Sweden ; yet in all these countries the influenza has exhibited a 
 uniformity of character, and an identity of type, proving beyond 
 all doubt that it is one and the same disease. That influenza is 
 not produced by a low temperature is proved by the occurrence of 
 the disease in the month of June, in that of 1762 ; and in the 
 months of May and June, in that of 1782 ; as well as by its 
 appearance at the Cape of Good Hope in the middle of summer, 
 as I have already noticed. In 1837 influenza increased rapidly 
 in this city, while the weather was remarkable for its serenity and 
 agreeable mildness. In London many were led, by a limited 
 view of the subject, to consider its origin as connected Avith the 
 breaking up of the frost and the peculiar state of atmosphere 
 attending a general thaw. Influenza is not influenced in its 
 progress by situation or locality ; it does not creep along the 
 shores, or follow the course of large rivers, or select low marshy 
 districts in preference to drier and more elevated soils. 
 
 From what has been said, it is obvious that influenza does not 
 depend upon vicissitudes of temperature, peculiarities of situation, 
 or supposed moist or dry states of the atmosphere ; neither does 
 it arise from the prevalence of certain winds, for meteorological 
 observation furnishes many instances of the prevalence of such 
 winds without any influenza ; and, on the other hand, it frequently 
 travels against the wind. The same view's are also advocated by 
 the late Dr. Holland ; at page 184 of his " Medical Notes and
 
 486 CLINICAL MEDICINE. 
 
 Reflections," lie says, " It is true that some authors, and in 
 concurrence with common opinion, have attributed these 
 epidemics solely to atmospheric changes and the influence of 
 extraordinary seasons upon the human body. And it must be 
 admitted, on behalf of this opinion, that certain of the seasons 
 during which they have prevailed have been remarkable and ano- 
 malous ; and further, that in common catarrh, arising from obvious 
 causes of atmospheric change, many of the symptoms resemble 
 the lighter and more transient forms of the disorder in question. 
 But there is something manifestly beyond this relation, and 
 independent of it. A disease which has appeared and spread at 
 diff"erent seasons, in the middle of summer as well as in the depth 
 of winter ; which has been found traversing whole continents, 
 continuing this course through many successive months, and 
 often assuming even a definite direction of progress ; which affects 
 contiguous places in difterent degrees and at different times ; 
 which frequently continues in the same place for several weeks 
 or months, under every appreciable variety of atmospheric state ; 
 and which often affects, almost simultaneously, large masses of 
 people living on the same spot, while others in adjoining 
 localities are exempt : such disease cannot be considered as due 
 to any of the known qualities or variations of the atmosphere to 
 which the term weather is applied." 
 
 It is probable that influenza may depend chiefly on telluric 
 influence — upon some agency connected with variations in the 
 physical conditions which operate on the external surface of our 
 planet ; but on this point we can only speak conjecturally, in the 
 present state of our knowledge, and we should not allow our- 
 selves to lapse into mere speculative and fruitless disquisitions. 
 How often the variations to which I have alluded occur, and 
 whether they are subject to any general law remains yet to be 
 determined. Several epidemics of this description have been 
 distinctly recorded in the eighteenth century, viz., in 1708, 1712, 
 1728, 1733, 1743, 1758, 1762, 1767, 1775, 1782, 1788, 1789 ; 
 while in the portion of the nineteenth century already elapsed 
 five influenzas have occurred, viz., in 1803, 1831, 1833, 1837, 
 and 1847. This list is as complete as our medical annals will 
 permit us to make it ; but still we cannot rely on it as including 
 all the epidemics of this nature which have occurred during the 
 last one hundred and forty-seven years. Supposing it correct, it
 
 INFLUENZA. 487 
 
 would indicate the average return of influenza once every ten 
 years. 
 
 In making calculations of this kind, medical writers should 
 always take care not to confound influenza, a disease which 
 spreads rapidly over the whole glohe, regardless of season and 
 climate, with those local catarrhal aftections that occur in all 
 temperate climates almost annually. One thing, at least, is 
 certain with respect to this disease, that it does not arise from 
 exposure to cold, or, as it is termed, from catching cold. This I 
 have repeatedly ohserved. Persons who took the best care of 
 themselves, who always went warmly clothed, and were never 
 exposed to the inclemency of the weather, took the disease just 
 as readily as the half-clad labourer, who had to undergo daily 
 exposure to all the vicissitudes of our changeful climate. But it 
 should be observed that although the attack of influenza in any 
 individual was not necessarily dependent on exposure to cold, yet 
 in many instances it was evident that catching cold determined 
 the immediate access of influenza, or increased its violence when 
 present. 
 
 I have also observed that it seldom attacked persons labouring 
 under acute diseases until the period of convalescence arrived, 
 when their immunity ceased, and they became just as liable to 
 its invasion as others. Thus, patients labouring under typhus 
 escaped as long as the fever continued ; but frequently, on the 
 very day the crisis occurred, and symptoms of returning conva- 
 lescence appeared, they were seized with influenza. This is a 
 Vciry unfortunate circumstance. Just as a patient had struggled 
 through a fever of seventeen, nineteen, or twenty-one days, he 
 was attacked with a new and dangerous malady, which again 
 placed him in a situation of imminent danger. 
 
 You must have observed that influenza does not appear in 
 every individual with the same violence, or exhibit in all 
 symptoms identical in their intensity or duration. As in most 
 other epidemics which afi"ect society at large, the difi'erent 
 constitutions and ages of the individuals, and the different states 
 in which the morbid influence finds them, modify greatly the 
 nature of the attack; so that although a vast number are affected, 
 they suffer in very difi'erent degrees, and the complaint exhibits 
 every variety of shade, from simple cor3"za, or catarrh, requiring no 
 treatment, to catarrhal fever of the worst and most unmanageable
 
 488 CLINICAL MEDICINE. 
 
 description. Many persons laboured under what would be 
 termed a common cold, were it not from the extreme frequency 
 of sucli symptoms, combined with "other circumstances which 
 mark the nature of the disease. The same thing was observed 
 with respect to cholera; few persons, during the prevalence of 
 cholera, escaped without undergoing some form of bowel attack, 
 but the mode and character of such attacks varied very remark- 
 ably. 
 
 Influenza is not by any means so severe or so rapidly fatal a 
 disease as cholera ; but the mortality which it has produced is 
 greater, as it affects almost every person in society, while the 
 ravages of cholera were comparatively limited. Consequently, 
 although the proportion of deaths among a given number of 
 individuals attacked was greater in cholera, the mortality for 
 society at large is much greater in influenza. In Dublin it is 
 extremely difficult to obtain anything like exact statistical details 
 of the comparative mortality at difi'erent periods, for no general 
 registry of deaths is kept in this city. The nearest result to 
 truth that can be determined is from the number of interments 
 in the two chief cemeteries of the city, at Glasnevin and at 
 Harold's Cross. The latter was not long opened when the 
 epidemic prevailed in Ireland in 1837 ; but I obtained the 
 following return from the former, which exhibits the number of 
 interments for the months of January and February, 1837, and 
 for the corresponding months of the previous year. I also give 
 the return for the months before and after the influenza. 
 
 In December, 1836 413 
 
 January, 1837 821 
 
 February, 1837 537 
 
 March, 1837 477 
 
 In December, 
 
 1835.... 
 
 . 355 
 
 January, 
 
 1836... 
 
 . 392 
 
 February, 
 
 1836.... 
 
 . 362 
 
 March, 
 
 1836.... 
 
 . 392 
 
 Total for four months 1,501 2,248 
 
 Increase during Influenza, 747. 
 
 Assuming, then, that in Prospect Cemetery alone about seven 
 hundred persons were buried who died of influenza, and that 
 there were at least three times as many persons buried in the 
 other churchyards of the city and suburbs, we may conclude that 
 in Dublin alone more than four thousand people died of the 
 influenza of 1837, not taking into account the greater number 
 who, although they got over the immediate attack of the epidemic,
 
 INFLUENZA. 489 
 
 sank afterwards under various diseases, of which influenza had 
 laid the foundation. In Paris the same epidemic influenza 
 caused hkewise a great mortahty ; for it appears from a statement 
 in the lievuc Medicale, that the average daily mortality, during 
 the first fifteen days of Fehruary, amounted to one hundred and 
 ten, which is more than double the usual average. This only 
 refers to persons dying in their own houses, and does not include 
 the deaths in the hospitals. Eighteen thousand die in private 
 houses annually in Paris — i.e., on an average, about fifty daily. 
 The rate varies from twenty to seventeen a day, according to the 
 season ; but during the first fifteen days of February it rose from 
 fifty-eight to one hundred and fifty-two in the day. 
 
 I have obtained a similar return to that of 1837, for the 
 months of December, 1847, and January, 1848, being the 
 months in wdiich the late epidemic of influenza prevailed in 
 Dublin ; it is as follows : — 
 
 Prospect Cemetery, Glasnevin. 
 
 1846— November 571 1847— November G97 
 
 December 8G7 December 1,141 
 
 1847— January 756 1848— January 912 
 
 February 700 February 786 
 
 Total for four months 2,894 3,536 
 
 Increase during Influenza, 612. 
 
 This return does not include those who died in the fever sheds 
 and North Union Workhouse, amounting to 215 in the month of 
 December, 1848, alone, and many of which were doubtless cases 
 of influenza ; but, by omitting them, we avoid the increased 
 mortality caused by the epidemic of fever which then raged, and 
 thus obtain a nearer approximation to the truth. 
 
 This return was most kindly furnished to me by Mathias J. 
 O'lvelly, Esq.., the present Secretary of the Cemetery Company. 
 To it I am enabled to add a similar return from Mount Jerome 
 Cemetery, Harold's Cross : very few poor persons are interred in 
 this cemetery. 
 
 In November, 1847 66 
 
 December, 1847 124 
 
 January, 1818 104 
 
 Febrmiry, 1848 72 
 
 Total for four months 332 366 
 
 Increase during Influenza, 34. 
 
 In November, 
 
 1846.... 
 
 . 55 
 
 December, 
 
 1846 ... 
 
 . 113 
 
 January, 
 
 1847.... 
 
 . 90 
 
 February, 
 
 1847.... 
 
 . 74
 
 490 CLINICAL MEDICINE. 
 
 Influenza in 1837 was very fatal where it attacked persons 
 who had been subject to chronic bronchitis, or who had happened 
 to labour under any form of asthmatic affection ; for this, I confess, 
 I was not quite prepared. And when first called to attend 
 asthmatic persons labouring under influenza, I expected that, 
 from being accustomed to periodic attacks of dyspnoea and cough, 
 they would be better qualified to bear the disease, and would 
 continue to exhibit that tenacity of life for which asthmatic 
 persons are so remarkable. The old also suffered considerably; 
 but some very old persons had extremely severe attacks of 
 influenza, and yet escaped. I attended, along with Mr. Maurice 
 Collis, the venerable Judge Day, the cotemporary of Goldsmith, 
 who, at the age of ninety-three, had sufficient strength of consti- 
 tution to shake off a most violent seizure. Two gentlemen, 
 who had fought at the battle of Bunker's Hill, also survived the 
 disease in a severe form ; but generally speaking, it was very 
 fatal among the aged. Influenza was also very fatal among 
 persons who laboured under disease of the heart ; and in this 
 instance age made no difference as to result, for the young 
 and old were equally liable to danger. I have also seen it fatal 
 in cases of deformity of the chest, from curvature of the spine 
 and other causes. The mortality was also very great among 
 persons in advanced life who laboured under tussis senilis : in a 
 word, all persons labouring under pulmonary irritation, or weak- 
 ness, were exposed to very considerable danger. Subsequent 
 experience has proved also, that where influenza left behind an 
 obstinate and irritating cough, and where the constitution had a 
 scrofulous taint, the disease Avas very apt to pass into tubercular 
 phthisis. Among all the families I know, but two escaped 
 the influenza altogether : one consisted of eleven children, 
 besides the parents and servants, and resided in Pill Lane, in 
 the very centre of the city ; the other family consisted of five 
 females, advanced in life, and who lived in one of the fashionable 
 streets. 
 
 Very nearly similar remarks apply to the influenza of 1847, 
 but the depression of the powers of life was, I think, much more 
 marked, while the feverish symptoms were less than in 1837. 
 Consonant with this observation, I remarked that death occurred 
 with symptoms oi parcdysis of the lungs in all the cases which I 
 saw that terminated fatally : this appeared to be the manner in
 
 INFLUENZA. 491 
 
 which the pecuHarly depressing influence of the epidemic was 
 manifested. 
 
 Allow me to digress here for a moment, for the purpose of 
 making one ohservatiou, which a review of several cases of influenza, 
 attended with severe pulmonary symptoms, suggests to me. It is 
 a common error in pathology to confound eftects with causes, and 
 where the cause of a disease is not and probahly cannot be known 
 to fix on some peculiar and leading symptom, and to attribute to it 
 the origin of all the rest. But it is quite illogical to say that one 
 symptom is the cause of another, or that because it has the 
 precedence, it should also have the initiative. I alluded to this 
 error in a former lecture, when speaking on the pathology of 
 scarlatina. It has been over and over again asserted, that the 
 dropsy of scarlatina arises from the previous inflammatory aflec- 
 tioU of the skin, or subcutaneous tissues ; and the same thing 
 has been asserted with regard to the desquamation of the cuticle. 
 But I have brought forward facts and arguments to prove that 
 this opinion is not founded in truth, and that dropsy, as well as 
 desquamation of the cuticle, may take place where there has 
 been no eruption whatever, and not the least trace of cutaneous 
 or subcutaneous inflammation. 
 
 Now, when a person, after exposure to cold, gets pneumonia or 
 bronchitis, followed by anasarca, it is quite a common thing to hear 
 it said that the anasarca had its origin in the pulmonary aflection, 
 and that the effusion of serum depended on obstructed trans- 
 mission of blood through the lung. The same mode of explanation 
 has been applied to disease of the heart as the cause of dropsy. 
 This explanation, however, appears to me inadequate and unsatis- 
 factory. Many cases of influenza were accompanied by extreme 
 congestion of the lungs, and consequently imperfect aeration of 
 the blood ; .and yet I have not in a single instance noticed the 
 occurrence of dropsy as an immediate or remote consequence. 
 Were dropsy dependent on the state of the lung to which I have 
 alluded, it would have shown itself in some cases at least ; and 
 yet I have seen individuals attacked with influenza labouring 
 under orthopnoea and severe pulmonary symptoms for weeks, 
 without observing, in any instance, the slightest anasarca or 
 oedema. In one case, indeed, that I saw, an old gentleman at 
 Eathmines, the feet and legs were much swollen; but this I 
 attributed to his having remained so many days and nights in
 
 492 CLINICAL MEDICINE. 
 
 his chair, unahle to lie down. This has strongly impressed upon 
 my mind the conviction, when dropsy comes on after disease of 
 the lung, that the one is not always the consequence of the other, 
 but that both often result from the same cause, and owe their origin 
 to the same morbid impression on the system. This error has 
 been further confirmed by the results of treatment, practitioners 
 having found that measures adapted to remove congestion of 
 the lung tended also to remove the dropsy ; forgetting here, that 
 where two sj-mptoms closely allied arise together from the same 
 cause, you will be most likely to remove both by those means 
 which are effectual in removing either. The principle which I 
 have here briefly alluded to will apply to many other combina- 
 tions of disease ; it is one of general application and, in my 
 mind, of no ordinary importance. 
 
 The epidemic of 1837 diflfered in many points from that which 
 prevailed about three years previously. The influenza of 1833 — 34 
 was by no means so generally fatal as then, and in 1847. It 
 was characterized, like both, by considerable irritation of the 
 tracheal and bronchial mucous membrane, but not by the severe 
 bronchitis and pnuemonia which have been witnessed in later 
 cases of the epidemic. The former raged in Dublin chiefly 
 during the months of March and April. It came on very sud- 
 denly with rapid pulse, hot skin, great prostration, languor, 
 and excessive sweating ; there were cough, coryza, and not 
 unfrequently vomiting at the commencement. One of the most 
 prominent symptoms, however, was headache, which was exces- 
 sively severe. There was also, cceteris iKirihus, more debility, 
 and the patients did not bear bleeding so well as they did in 
 1837. But the most material point in which they differed was 
 the comparative mortality. The disease in 1834 carried off some 
 very suddenly with cerebral symptoms, and proved fatal to others 
 from oppression of the chest and dyspnoea. Few, however, 
 died who survived for a week after they had been attacked, and 
 the disease rarely left behind it a cough at all approaching 
 in violence and obstinacy to that which in the later epidemics 
 harassed convalescents. On the whole, the fever accompanying 
 the influenza of 1834 was more acute, and set in with more 
 marked depression of the nervous system, and the disease was 
 much less liable to become cbronic. 
 
 It would conduce greatly to the advantage of medical science, if
 
 INFLUENZA. 493 
 
 a brief and accurate history was left to posterity, of the character, 
 symptoms, pathological phenomena, and treatment of every 
 epidemic. Such a record would prove a guide and beacon to 
 the practitioners of future ages — would enable them to draw 
 important comparisons between the existing and the past — and 
 thus arrive at a more fixed and available knowledge of the 
 nature and habits of epidemic complaints. 
 
 There are, I have no doubt, many curious forms of epidemic 
 disease which pass through society either wholly unnoticed, or 
 confounded with others to which they have some slight aftinity. 
 I think I have seen particular forms of scarlatina, measles, small- 
 13o5i, and fever, which have not been accurately noted, although 
 they prevailed as epidemics. If every form of epidemic was 
 noted, and the order of its succession marked, it would remain 
 to be ascertained by posterity whether there may not be what 
 may be termed cycles of epidemics, and whether disease, after 
 having manifested itself in determinate forms, following each 
 other in determinate succession, may not commence again after 
 the lapse of a certain number of years, and pursue the same 
 course. This is not impossible, if we suppose that epidemics 
 are connected with telluric or electrical influences, which are 
 known to observe a periodic course. Were this ascertained, a 
 sort of observatory of epidemics could be easily established in the 
 various civilized states. 
 
 In treating of the nature of influenza, it will be proper to con- 
 sider in the first place the general constitutional symptoms which 
 attend it, and afterwards glance at those w^hich are chiefly of a 
 local description. In some cases of influenza there is little or no 
 fever, as in the last epidemic ; neither does the presence of fever 
 seem essential to the more severe or even fatal cases, although, 
 generally speaking, fever occupied a very prominent position 
 among the group of symptoms by which the disease was charac- 
 terized in 1837. I have seen cases in which there was nothing 
 like regular fever from beginning to end, and yet which terminated 
 fatally. 
 
 I remember treating two patients who had been labouring 
 under orthopnea for ten days, and yet in these patients the skin 
 was cool, the pulse in general soft and very little above the 
 normal standard, and the tongue, though furred, quite moist ; 
 but so great was the distress of respiration, that they were obliged
 
 494 CLINICAL MEDICINE. 
 
 to remain sitting up in bed niglit and day, panting for breath. 
 This, however, was the exception with respect to severe cases in 
 1837, the majority being attended with very considerable fever. In 
 the shght cases the fever was scarcely perceived, or altogether 
 absent ; as was the case with myself and some of my friends. 
 We had coryza, hoarseness, cough, and some degree of pulmon- 
 ary irritation without any fever. At first I thought that fever 
 ■was an essential part of the disease ; but the cases to which I have 
 alluded, and others of a similar kind, have convinced me that this 
 is not the fact — a conviction fully ratified by the late influenza. 
 
 Where the fever appeared it came on with the usual symptoms 
 of pyrexia — namely, sense of chilliness, particularly about the 
 small of the back, without decided rigors, flying pains in the 
 limbs and joints, and headache, generally referred to the situa- 
 tion of the frontal sinus. There were from the commencement 
 great restlessness, jactitation, and more or less insomnia. Sick- 
 ness of the stomach, loss of appetite, and tendency to diarrhoea 
 were also common symptoms. The skin was in general hot, and 
 without any tendency to moisture, although in some cases there 
 were occasional perspirations. These, however, were seldom 
 general or regular, and lasted only for a few hours. The pulse 
 was accelerated and tolerably full, occasionally even hard and 
 wiry. These symptoms were very subject to slight exacerbations 
 and remissions, and seldom continued the same for more than 
 twelve hours together. Where the disease existed for any 
 length of time in a violent form, the tongue usually became furred 
 and loaded, the patient lost all relish for food, and in many cases 
 complained of harassing thirst. 
 
 In severe cases the most prominent symptoms were cough, 
 wheezing, restlessness, dyspnoea, and loss of sleep. The appetite 
 was in general more or less impaired ; but I have seen some 
 severe cases in which it did not fail remarkably for several days ; 
 the restlessness and jactitation attended many cases throughout. 
 You are not, however, to suppose that this always depended 
 on the presence of pain or fever. Tbe headache was not in all 
 severe or distressing ; and I have already stated that the fever 
 was not so general or so violent as one would suppose. The loss 
 of sleep depended upon derangement in the tone of the nervous 
 system, independent of fever ; for I have observed it in numerous 
 patients, in whom scarcely any febrile excitement was observable ;
 
 INFLUENZA. 495 
 
 but when complicated with fever, both react upon and af^gravate 
 each other. The skin, where fever was present, was hot : this 
 heat was interrupted by occasional perspirations, which, however, 
 did not give much relief, or tend to diminish the amount of in- 
 creased temperature. Sometimes the skin was hot, and at the 
 same time bedewed with perspiration during the whole course of 
 the disease ; but this was rather unusual. 
 
 The pulse in influenza is seldom the same throughout ; one 
 time you will find it quick and rather hard ; in six hours after- 
 wards it will be quick and soft ; in six or eight hours more it 
 will appear as if about to fall to the normal standard; and next 
 day you will find it quick and jerking again. These changes are 
 accompanied by corresponding alterations in the temperature and 
 humidity of the skin. But what is most remarkable with regard 
 to the pulse is, that it sometimes becomes full and rather strong 
 and wiry, towards the termination of the disease ; and this you 
 will observe in patients who have been suffering for days, or even 
 weeks. 
 
 I attended, wath the late Mr. Colles, a gentleman in Castle 
 Street, aged 60, of a full habit, and subject to attacks of 
 dyspnoea and cough during winter. This gentleman was attacked 
 with influenza, ushered in and accompanied by severe fever ; and 
 it was observed that as the disease advanced his pulse became 
 fuller and stronger, so that it was thought advisable to bleed 
 him. He was bled with apparent relief, and the blood was exten- 
 sively buffed and cupped. This phenomenon I have observed 
 in every case attended with fever, and indeed in some where no 
 appreciable fever existed. Thus, in a gentleman in Dame Street, 
 who had no fever, and who merely laboured under teazing cough, 
 distress of respiration, and oppression of the chest, the blood on 
 being drawn exhibited very distinct buffing and cupping. The 
 same thing happened in the case of a gentleman in Dominick 
 Street, whom I ordered to be blooded under exactly the same 
 circumstances. 
 
 The gentleman in Castle Street, whom I attended with Mr. 
 Colles, exhibited a very curious state of pulse. In him, as in 
 many others, the pulse was extremely variable as to its strength, 
 being at one time hard and firm, and at another soft and weak. 
 If you were to visit him in the morning, from the feel of the 
 pulse you would be inclined to give him stimulants : if you saw
 
 496 CLINICAL MEDICINE. 
 
 him for the first time ou the evening of the same day, you would 
 think venesection indispensable. This gentleman's state was 
 hopeless ; he laboured under great suffering, dyspnoea, and 
 inability to cough up the viscid mucous secretion, and yet his 
 pulse was both strong and firm. Mr. Colles, whose attention I 
 directed to the state of the pulse, observed, that were he to feel 
 it without seeing the patient, or knowing his previous history, 
 he would be greatly inclined to bleed him immediately. I have 
 adverted in a former lecture to this state of the pulse, as con- 
 nected with irritation of the nervous system rather than with 
 any inflammatory state of the constitution in general ; and, 
 therefore, I shall not now recur to the subject further than to re- 
 mark that I have never observed any disease in which the pulse 
 formed so bad a guide as to the propriety of venesection as in 
 influenza. In some cases venesection was most useful, although 
 the pulse was in every respect natural ; in others it could not be 
 borne even to the smallest amount, although the pulse was hard 
 and wiry. Neither was the state of blood an unerring guide ; 
 for even in those who sank rapidly from the debilitating effects 
 of moderate bleeding, the blood was very much cupped and buffed. 
 " The most important question," says Dr. Holland, " in the 
 treatment in influenza doubtless regards the extent to which 
 antiphlogistic means may be carried, or the fitness of employing 
 them at all. And the point as to bleeding is that which stands 
 foremost here, and has chiefly embarrassed all practitioners. 
 The most general precept on the subject is liable to exceptions ; 
 but collecting what on the whole is safest and most expedient, it 
 must be one which forbids bleeding as an ordinary practice in 
 this disorder. The adynamic type throughout in the greater 
 number of cases ; the singular disproportion in all between the 
 seeming severity of the inflammatory symptoms and their real 
 slightness or nullity ; tlie actual failure of bleeding in mitigating 
 the violent and painful cough which seems most expressly to 
 require it, and the frequent success of remedies precisely the 
 reverse of this ; all show a speciality in the disease to which we 
 must refer more or less directly in every question of practice. 
 Whatever the cause or precise seat of irritation, it is certain that 
 it has rarely the character of true membranous inflammation. 
 In truth, the same reasons which prevent or limit bleeding in 
 hooping-cough apply no less to the peculiar cough and irritation
 
 INFLUENZA. 497 
 
 of the influenza. We have rarely any authority for it iu the 
 state of the pulse, which neither iu strength nor frequency hears 
 relation to these inflammatory symptoms ; while the difficult or 
 painful respiration which often suggests the remedy furnishes 
 evidence against its fitness, by becoming frequently more laborious 
 than before — the efi'ect of larger accumulation in the bronchial 
 cells, and of diminished power." 
 
 I shall now mention the particulars of a very remarkable case 
 which came recently under my notice. I was. called to visit a 
 lady somewhat advanced iu life, but of a good constitution, and 
 labouring under the ordinary form of influenza, with considerable 
 dyspnoea and cough. In the course of eight or nine days her 
 symptoms began to decline ; she got up, and seemed conva- 
 lescent. As the cough and pulmonary irritation still prevailed 
 to a certain extent, it was thought advisable not to allow her to 
 eat meat, but she obtained leave to take some fresh haddock. 
 After dinner her cough becoming more troublesome than before, 
 she had frequent recourse to a stale and rancid cough bottle 
 containing squill and ipecacuanha. During the evening and 
 night she felt her dinner like an undigested load, and her stomach 
 turned. She vomited, and was purged and griped incessantly, 
 until I saw her next day. On the third day the medicines I had 
 ordered moderated the purging, but the nausea and occasional 
 vomiting continued. On the fourth day the purging had entirely 
 ceased, but the sickness of stomach persisted. I sought to appease 
 this by the ordinary means, Avhich failing, I examined her on 
 the following day, and discovered a strangulated hernia. At this 
 time the pulse had scarcely risen above the natural standard. 
 Mr. Cusack operated that night with his usual skill, and all the 
 symptoms depending on incarcerated hernia ceased. But they 
 had scarcely disappeared when the pulmonary symptoms and the 
 copious secretion from the bronchial tubes recurred, and she 
 did not survive this relapse of the influenza more than a few 
 days. 
 
 This is an instructive example of an insidious combination of 
 circumstances very likely to mislead a practitioner ; for as the 
 vomiting was for a day or two accompanied by a looseness of the 
 bowels, the suspicion of hernia would not strike the attention. 
 It is plain that in this case indigestion produced an increased 
 and morbid activity in the motions of the alimentary canal, which 
 VOL. I. 32
 
 498 CLINICAL MEDICINE. 
 
 led to the incarceration of the portion of gut. Up to a certain' 
 moment the symptoms depended merely on one cause ; after that 
 period strangulation took place — an occurrence which could not 
 be easily diagnosed, as vomiting, one of the most striking 
 symptoms, had previously existed. 
 
 When diarrhoea occurs, it is generally at the commencement 
 of the disease ; and it is remarkable that this state is frequently 
 exchanged rather suddenly for one of an opposite character. 
 Thus, when you have succeeded in checking the diarrhoea with 
 chalk mixture and opium, a state of costiveness frequently ensues, 
 requiring the daily use of purgatives and enemata. I have now 
 witnessed several cases in which the moderate use of opiates and 
 astringents brought on constipation, requiring the use of strong 
 purgatives, and enemata thrown up with Read's s,yringe. 
 
 In influenza, as in many other febrile affections, the lungs 
 become considerably engaged ; the disease first attacks the nose 
 and throat, then the larynx and trachea, and finally the ultimate 
 ramifications of the bronchi. There are several other affections 
 which commence in a similar way — as ordinary catarrh, bron- 
 chitis, and measles. In influenza most persons have the nose 
 and throat affected in the beginning ; the inflammation creeps 
 gradually along the lining membrane of the air passages, until it 
 involves the greater part or the whole of the bronchial mucous 
 membrane. The progress of the inflammation is extremely rapid, 
 and in the course of twenty-four or even twelve hours, the lungs 
 become engaged. 
 
 There is, however, much difference as to the extent to which 
 this inflammation proceeds. In many cases it is limited to the 
 nose and throat ; the patients complain of coryza, hoarseness, 
 and slight cough. In others the trachea also is more or less 
 affected, and the cough is more troublesome ; but, generally 
 speaking, the latter as well as the former cases are unattended 
 with fever. The patients eat and drink as usual, go about their 
 ordinary business, and sleep tolerably well at night. This 
 appears to be the general course of the disease when the inflam- 
 mation is limited to the nose, throat, and upper part of the air 
 passages ; when it spreads farther and attacks the first rami- 
 fications of the bronchi, there is some dyspnoea and tightness of 
 chest, the cough is much more troublesome, and the appetite 
 and digestion are somewhat impaired ; but persons in this state,
 
 INFLUENZA. 499 
 
 although resting badly and eating but little, will continue to go 
 about — constantly, however, complaining that they are very ill. 
 ^yhen the smaller divisions and ultimate ramifications of the 
 bronchi are engaged, there are soreness of chest, remarkable 
 dyspnoea, and constant harassing cough ; the headache is also 
 aggravated, the patient loses all inclination for food, sleeps badly 
 at night, and is confined to the bed or house. 
 
 First, then, you have the mucous membrane of the eyes, nose, 
 and throat afi"ected, then the larnyx and trachea, then the larger 
 bronchi, and finally the smaller and more minute ramifications. 
 When the latter state has continued for some time, more or less 
 serious engorgement of the lung takes place, and this adds to 
 the dyspnoea and cough. On applying the stethoscope over the 
 lungs, you will hear at various parts a moist crepitus, indicating 
 the existence of serous infiltration. The smaller bronchial tubes 
 and air vesicles are congested and filled with mucus ; the blood 
 cannot pass freely through the lung, and consequently must be 
 imperfectly aerated ; the secreting and absorbing functions of 
 the lung are deranged ; and hence arises a state in which the 
 pulmonary capillaries become congested, and permit the more 
 fluid part of the blood to exude into the parenchyma of the lung, 
 giving rise to what is termed serous infiltration. 
 
 Something similar to this occurs also in bronchitis, particularly 
 in fever, but we very seldom have hepatization resulting from 
 such causes. In hepatization the capillaries pour out, not serum, 
 but lymph, which glues together the cells of the pulmonary tissue, 
 and forms a dense solid mass. Hence in influenza or bronchitis 
 you seldom have true pneumonic inflammation. You will have 
 extensive and dangerous engorgement, but when you examine 
 the lung after death, you do not find any real solidification, and 
 3^ou can restore the lung almost to its original permeability and 
 buoyancy by squeezing out the infiltrated fluid. Yet I must 
 admit that this is not always the case, and that in influenza, as 
 well as in bronchitis, you may have true pneumonia superadded 
 to the original aff"ection of the lining membrane. This occurred 
 in the case of a lady whom I attended in Capel Street, and who 
 was attacked with influenza shortly before delivery. On the day 
 of her accouchement pneumonia was superadded to the bronchial 
 inflammation, and she died with extensive hepatization of the 
 right lung. This also occurred in the case of a man of middle
 
 600 CLINICAL MEDICINE. 
 
 age, residing in Suffolk Street, who had been labouring for some 
 days under excessive engorgement of the lung. I have also 
 observed the same occurrence in a gentleman whom I attended 
 with the late Mr. Colles in Exchequer Street, and in another 
 case which I saw in Whitefriar Street. 
 
 One of the most singular features in the history of influenza 
 is the extraordinary degree of dyspncea witnessed in most cases 
 where the lung is extensively engaged, but particularly where the 
 patients had been previously subject to pulmonary affections ; 
 and even in many cases where the bronchial mucous membrane 
 is but slightly engaged, the amount of dyspnoea is remarkably 
 great. Indeed it might be said with much truth that the 
 dyspnoea was by no means jDroportioned to the extent of pul- 
 monary inflammation. There was a case in the hospital of a 
 woman labouring under influenza, whose chest sounded clear on 
 percussion, and in whom every part of the lung was permeable, 
 who presented nothing more than a few sonorous rales in the 
 course of the larger bronchial tubes, and yet she was suffering 
 from considerable dyspnoea, and the respirations amounted to 
 forty-six in a minute. We cannot, therefore, attribute the 
 difficulty of breathing to mere bronchitic lesion, for it was not 
 in proportion to this lesion. Another patient admitted into 
 Sir P. Dun's Hospital exhibited a similar train of symptoms. 
 He was a negro sailor, a native of New Brunswick, and was 
 seized with the epidemic a few days after his ship arrived in 
 Dublin ; he was a man of Herculean form and finely developed 
 chest, and in the prime of life. His suffering from dyspnoea 
 was intense ; his chest heaved, he tossed about in bed in a 
 constant state of agitation and restlessness, and yet the respira- 
 tory murmur was everywhere distinctly audible through the 
 lung, and no rale could be heard, except here and there a few 
 bronchitic wheezings. He also laboured under insomnia, and, 
 though he had but little fever, debility was extreme. Indeed 
 his pulse was so weak from the commencement, that I could not 
 venture to treat him antiphlogistically ; and I accordingly ordered 
 extensive vesication over the chest, with the use of wine, stimu- 
 lants, and narcotics. This man subsequently recovered — an 
 event which could scarcely have occurred under the plan of treat- 
 ment adopted, had his dyspnoea depended on mere bronchitis. 
 
 It should be also borne in mind that, in many bad cases of
 
 INFLUENZA. 501 
 
 influenza, the dyspnoea is intermittent, or at least undergoes 
 remarkable exacerbations and remissions at certain hours of the 
 day aud'night. It would appear that the respiratory derangement 
 depends on the same general cause which produces the whole train 
 of symptoms, and that it might exist even where there was no 
 bronchial inflammation at all. It is true that, where the bron- 
 chitis is present, it adds to the distress of respiration, but the 
 dyspnoea appears to be chiefly attributable to some impression 
 made on the vital activity of the lung. That the lungs are 
 endowed with an inherent vitality necessary to the aeration of 
 the blood has been long acknowledged by the Germans, who 
 have described a dyspnoea from paralysis of the lungs ; and this 
 opinion is now generally adopted in Great Britain since the 
 results of the experiments on the eighth pair of nerves have been 
 duly appreciated. We have abundant illustrations of this truth 
 in asthma, in which the greatest dyspnoea is often present, without 
 any appreciable lesion of the lung. And it would be a fortunate 
 circumstance for the patients in influenza if this were not the 
 case ; for we could then treat the afiection of the lung as ordi- 
 nary bronchitis, and should expect to find it amenable to the 
 ordinary remedies. 
 
 You are aware that the mortality in cases of ordinary bron- 
 chitis is extremely small, if we except very young children and 
 persons advanced in life. In adults, when met by prompt and 
 appropriate treatment, it is generally a very manageable disease, 
 and seldom proves fatal, unless combined with other unfavourable 
 conditions. This, however, is not the case in influenza, nor is 
 the pulmonary afiection so easily treated, or the dyspnoea so 
 readily controlled. I saw, some time ago, a fine young woman, 
 servant to a gentleman in Fitzwilliam Street, for whom every- 
 thing had been done which the best and most skilful practice 
 could devise ; but her condition when I saw her was desperate, 
 and she died the following day ; yet her chest sounded well on 
 percussion, and we could hear nothing over the whole lung, 
 except a few sonorous and sibilous rales, and the resjiiratory 
 murmur seemed everywhere nearly as loud as natural. Of course, 
 such a lesion of the nervous influence could not last long without 
 necessarily inducing pulmonary congestion — an inevitable con- 
 sequence of imperfect aeration of the blood. When the eighth 
 pair of nerves is divided, the animal is slowly suffocated ; and,
 
 502 CLINICAL MEDICINE. 
 
 on dissection, the lungs are found engorged, and the bronchial 
 mucous membrane congested and inflamed. May not the affec- 
 tion of these parts in influenza be sometimes induced by lesions 
 of nervous power in the lungs ? 
 
 To the late Dr. George Green, Professor of the practice of 
 Physic to the College of Physicians, I am indebted for the 
 following results of bis very numerous post-mortem examinations 
 in this disease, and I feel great pleasure in being able to give them, 
 as such examinations, at least in this country, are very rare : — 
 
 " The cases which proved fatal at the House of Industry during 
 the late epidemic influenza (1837), occurred principally among 
 the aged inmates of both sexes. I had an opportunity of 
 examining several of these cases, and the following were the 
 principal post-mortem appearances observed. 
 
 " The bronchial mucous membrane w'as found in every case 
 more or less congested and inflamed. The colour varied con- 
 siderably, being in some of a dull red, and in others of a much 
 darker hue. The inflammation, in most cases, was found to 
 occupy both the trachea and the bronchial tubes of both lungs ; 
 in other instances, it was confined to one lung alone. A sanguino- 
 lent frothy mucus occupied the area of the tubes, and increased 
 in quantity as they were traced to their minuter divisions. The 
 parenchymatous tissue of the lung was invariably discoloured, 
 being generally of a dark or violet colour ; its specific gravity 
 was increased, and it did not crepitate, or at least very feebly, 
 when pressed between the fingers. The surface of its section 
 was not rough to the touch, and when pressed in the hand, a 
 quantity of the mucus described above was driven out. In some 
 cases, the postero-inferior portions of one or both lungs were 
 very dark coloured, and the finger could be passed easily through 
 the substance. When the surface thus torn was examined, it 
 did not appear to be granular ; it resembled more a portion of 
 gangrenous lung, except that there was an absence of foetor. 
 This last appearance was found principally in very aged persons. 
 It was rare to find any traces of the second and third stages of 
 ordinary pneumonia in these patients ; but in the young and 
 robust, who were received into the Hardwicke Fever Hospital 
 from the neighbouring streets, these degenerations of the structure 
 of the lung were observed, together with the same inflammation 
 of the bronchial mucous membrane.
 
 INFLUENZA. 503 
 
 " In most of the aged patients, the blood was found dark 
 coloured and fluid in both cavities of the heart, and in every 
 vessel where it was examined. The cases in which fibrinous 
 concretions in the cavities of the heart were found were very few, 
 and these invariably in the young or middle-aged. In the former 
 class of patients, also, the lung occasionally appeared to be oede- 
 matous; and in one or two cases, a considerable effusion of serum 
 had taken place into the pleural cavities. The signs of recent 
 pleuritis were very rare, but old adhesions, as might be expected 
 in such subjects, were very commonly found between the pul- 
 monary and costal pleurae. In one case of a lunatic, who survived 
 the immediate attack of influenza, tubercles appeared to have 
 been rapidly developed in both lungs. In another lunatic, two 
 tubercular cavities were found, in addition to the state of the 
 lung and air-tubes already adverted to. 
 
 " With respect to the nature and duration of the symptoms of 
 those cases which came under my own management, I have little 
 to say in addition to what is already so familiarly known. The 
 physical signs afforded by percussion and auscultation were 
 almost universally as follows : — Dulness, more or less decidedly 
 marked, in the postero-inferior portions of the lungs ; sonorous 
 or some form of bronchial rale throughout the chest, or, what 
 was more common, a mixed sonorous and crepitating rale, or 
 in the latter stages, a muco-crepitating rale. The sputa were 
 seldom rust-coloured or tenacious, but rather resembled those of 
 bronchitis. In many cases, the want of povv^er to excrete them 
 appeared to be the immediate cause of death ; but in others, the 
 morbid cause, whatever it might be, appeared to have affected 
 the entire respiratory and circulating systems, producing great 
 congestion of the venous system, and a state not unlike asphyxia. 
 The latter cases were almost all among the aged inmates of the 
 House of Industry. 
 
 " The appearances of the other viscera were not such as could 
 in any way account for the result, so often speedily fatal ; so 
 that, so far as one could hazard a conjecture, the morbid cause 
 appeared to have made its primary impression on the respiratory 
 mucous surface, thereby interfering with the proper aeration of 
 the blood, and inducing the changes in that fluid and in the 
 structure of the lungs above detailed." 
 
 Such were the appearances observed by Dr. Greene in
 
 504 CLINICAL MEDICINE. 
 
 numerous dissections of persons who died of influenza. They 
 may be relied on as perfectly accurate, for no one was better 
 acquainted with pathological phenomena than Dr. Greene, and 
 consequently no one better able to furnish valuable evidence with 
 respect to the appreciable changes produced by influenza in the 
 pulmonary and other tissues. 
 
 I have already advanced the opinion, that we should not 
 hastily assume that influenza consists essentially in the morbid 
 changes which dissection reveals ; we should examine every side 
 of the question, and consider whether it is not possible that the 
 alterations in the pulmonary tissue may not be, to some extenb 
 at least, the consequences of the disease. Let us consider for a 
 moment the method we pursue in reasoning about the progress 
 and causes of the symptoms in ordinary bronchitis. Here a 
 patient is seized with a pectoral afi'ection, attended with cough, 
 dyspnoea, and more or less fever. We find certain rales, and the 
 expectoration is altered in quality and quantity. Further, observ- 
 ing a number of such cases, we remark that the danger is 
 proportioned to the degree of dyspnoea, and the dyspnoea to the 
 extent and nature of the rales, together with the quantity and 
 quality of the expectoration. To these the general constitutional 
 affection, and the probable results of the disease, have certain 
 definite relations, a knowledge of which is soon obtained by 
 experience. 
 
 But these rales, and this state of the respiration and expecto- 
 ration, we have reason to believe, arise from the presence of 
 bronchial inflammation ; and to this we refer all the symptoms 
 observed. On this supposition, too, we proceed in our treatment, 
 and the result most commonly justifies its correctness ; and we 
 have additional evidence of its truth furnished by post-mortem 
 examinations. Now, in such instances, the chain of inductive 
 evidence is complete, and we feel a conviction that our practice is 
 founded on correct notions of the nature of the disease. But 
 how different is the case when we assume that influenza is 
 caused by bronchial inflammation ! In influenza the dyspnoea is 
 not always proportioned to the bronchitic affection — nay, in some 
 cases we have seen that difficulty of breathing was most urgent 
 in cases where the air entered into all parts of the lung with 
 facility, and where few and unimportant rales existed. Again, 
 although the presence of a copious viscid secretion in the
 
 INFLUENZA. 505 
 
 bronchial tubes was sure to aggravate dyspnoea, yet it often 
 occurred in patients whoso air-passages were very little, or not 
 at all obstructed in this way. The eiiects, too, of remedies, anti- 
 phlogistic, expectorant, and derivative, were very different from 
 what they would have been had the disease depended on a mere 
 bronchitis. I have already stated my conviction, that the poison 
 which produced influenza acted on the nervous system in general, 
 and on the pulmonary nerves in particular, in such a way as to 
 produce symptoms of bronchial irritation and dyspnoea, to which 
 bronchial congestion and inflammation were often superadded. 
 
 In this view of the subject I am not singular, for I find that it 
 has been advocated by Dr. Peyton Blakiston, in a short treatise 
 on influenza as it occurred at Birmingham. He states that his 
 researches have led him to the conclusion "that influenza is an 
 affection of the nervous system, with its concomitant derange- 
 ments in the organs of digestion, circulation, &c., commonly 
 known under the name of nervous fever, accompanied through- 
 out its whole course by irritation of the pulmonary mucous 
 membrane, which not unfrequently amounts to congestion, and 
 even to inflammation." 
 
 This distinction between influenza and feverish cold with 
 bronchitis is, in a practical point of view, of great importance, 
 and should never be lost sight of in the treatment of influenza, 
 for it prevents us from placing our sole confidence in remedies 
 adapted to mere bronchitic inflammation. Thus Dr. Blakiston 
 asserts, and most physicians will agree with him in this point at 
 least, that it was often necessary to have recourse to diffusible 
 stimulants at the commencement, and to administer tonic 
 medicines in an early stage of the disease. 
 
 In some cases, even when dyspnoea exists, the cough is hard 
 and dry, and the expectoration scanty ; in others the expectoration 
 is copious, so as to cause constant efforts to cough it up ; and, 
 indeed, it is melancholy to look at the distress which patients 
 suffer in this respect. You will hear the wheezing of the phlegm 
 in the throat and air-passages before you enter the room, and you 
 will seethe patient exhausted by successive paroxysms of cough, 
 and ineftectual attempts to expectorate. In other cases, where 
 the vitality of the lung is less injured, and the general tone of 
 the system less deranged, the sputa, although copious, are 
 expectorated with considerable facility.
 
 506 CLINICAL MEDICINE. 
 
 The sputa bear consideraLle analogy to those observed in 
 ordinary bronchitis. They consist at first of a greyish mucus ; 
 as the disease proceeds, they exhibit a globular appearance, or 
 assume a puriform character, and do not coalesce. In other cases 
 they are extremely viscid and ropy, like solutions of gum or 
 isinglass. A remarkable fact with respect to the sputa in influ- 
 enza is that they are very seldom mixed with air-bubbles. On 
 mentioning this to some persons attending my class, I was shown 
 some sputa discharged by a patient labouring under influenza, in 
 which there were some air-bubbles ; this, however, is extremely 
 rare. In a lecture which I delivered some time ago, I took occa- 
 sion to allude to the secretions of the bronchial mucous membrane, 
 and stated my conviction that this subject had not received as 
 yet the attention which its acknowledged importance demands. 
 There is one point in particular, of which no adequate explanation 
 has as yet been given — namely, why it is that in some cases of 
 pulmonary inflammation the sputa are filled with air-bubbles, 
 while in other instances there is no appearance of air-bubbles 
 from the beginning to the end of the disease ? 
 
 The presence of air-bubbles in the sputa has been explained 
 by supposing that air becomes incorporated with the mucus, 
 while it is driven up and down in the bronchial tubes during the 
 acts of respiration and coughing ; just as if you shake a solution 
 of soap or any other viscid fluid in a half empty bottle, it becomes 
 impregnated with air-bubbles. There may be some truth in this, 
 but I think it does not sufficiently explain the presence and inti- 
 mate incorporation of air with the sputa in certain afl:ections of 
 the lung ; and it appears to me that we can scarcely understand 
 this, unless we suppose that the air and mucus are secreted 
 together. You are aware that air is secreted by the bronchial 
 mucous membrane, and that in some cases this secretion is 
 morbidly increased, in others morbidly diminished. Now, it is 
 not very unreasonable to suppose that the mucous membrane may 
 secrete air and mucus together in abnormal quantity ; and that 
 this, rather than any mechanical agitation, may be the cause of 
 the intimate combination of air with the expectorated fluids. 
 
 I need scarcely make any observations on the cough in influenza. 
 It is in general very troublesome, particularly at night. Many 
 persons are not much annoyed by it during the day, but at night 
 it becomes very harassing, and prevents them from sleeping.
 
 INFLUENZA. 507 
 
 When severe, it continues both night and clay ; and even when 
 persons have recovered from the fever and dyspnoea, and are able 
 to go about, the cough will continue extremely troublesome : this 
 I have observed in the majority of cases. In this state medicines 
 prove of very little service, and one of the best remedies is to 
 change to a mild country air. Cases of cough, in which I have 
 tried every remedy without success, and which had resisted every 
 form of treatment in the city, yiekled in a few days to the salu- 
 brious influence of change of air. 
 
 In influenza the urine is generally much loaded with lithates, 
 and contains a large quantity of uro-erethrine or purpurine. It 
 is red when voided, deposits a good deal of sediment, and tinges 
 the vessel in which it lies with a jiink film. It bears some 
 resemblance to the urine which accompanies arthritic and gouty 
 affections. In very bad cases, this state of the urine continues 
 up to the period of death. You recollect what I stated with 
 regard to the condition of the blood ; it is generally bufted, even 
 where there is scarcely any febrile excitement in the system, and 
 thus affords a very fallacious indication. The same observation 
 holds good Avith respect to the state of urine and temperature of 
 the skin. I may observe here that the heat of the skin is very 
 variable ; it is sometimes very high, sometimes natural : in fact, 
 like the pulse, it falls and rises in a very remarkable manner, at 
 certain times in the day. 
 
 I have already spoken of the affection of,the mucous membrane 
 of the bowels. I may observe that in some cases of influenza 
 the morbid influence is translated to the brain, and symptoms of 
 delirium or coma supervene. Thus, in two instances that have 
 been communicated to me, the patients fell into a state resem- 
 bling coma during the course of the disease. In three cases 
 witnessed by the late Mr. Swift, the attack of influenza terminated 
 in a train of symptoms bearing a close analogy to delirium 
 tremens, and requiring the use of blisters to the head and nape 
 of the neck, full doses of opium, purgative enemata, wine and 
 the occasional use of mercurials. The patients complained of 
 great headache, noise in the ears, intolerance of light, and more 
 or less sleeplessness from the commencement, along with the 
 usual pulmonary symptoms. After five or six days they became 
 excessively nervous, lost all sleep, had continued subsultus and 
 tremors, and talked very incoherently, particularly at night.
 
 508 CLINICAL MEDICINE. 
 
 During the prevalence of the cerebral symptoms, the pulmonary- 
 affection partially or wholly disappeared, but returned again in 
 some degree after the subsidence of the delirium. All these 
 cases terminated favourably. 
 
 I believe I have already remarked that many persons who have 
 laboured under very severe pulmonary symptoms will struggle 
 through the disease ; and I may mention here, that I have seen 
 persons recover who have suffered from continued orthopnoea 
 for three weeks. Still the mortality, particularly among the 
 aged, is very great ; and I fear that we shall shortly have but 
 few octogenarians to tell the occurrences of the last century. 
 Indeed, the mortality has not been confined exclusively to the 
 aged, for many persons in the vigour of life have sunk 
 under the attack. There have been several deaths among the 
 soldiers in our garrisons, notwithstanding the excellent state of 
 health which our troops enjoy, and the skilful and judicious 
 treatment of our present army surgeons. 
 
 In many individuals influenza has laid the foundation of other 
 and very serious diseases, and this I especially witnessed in the 
 epidemic of 1847. In some, the diseases so produced could be 
 traced to the depressing effect on the nervous system. Thus, 
 Dr. Mulock informs me that in three cases which he attended, 
 relapse from exposure to cold terminated in insanity, which in 
 one of the cases ended fatally. 
 
 It now remains for me to say a few words concerning 
 treatment. First, as to bleeding. A great deal was expected 
 from general bleeding, because the disease was sudden and violent 
 in its onset, and accompanied by symptoms which seemed to 
 require active measures- — such as an inflammatory state of the 
 bronchial mucous membrane, accompanied by quick pulse, hot 
 skin, and high-coloured urine. This led persons to expect much 
 benefit from venesection. The results, however, of its employment 
 are, generally speaking, unsatisfactory. Where venesection was 
 employed promptly and in the beginning of the disease, and 
 where it seemed to be strongly indicated by the buff"ed and cupped 
 state of the blood, even in such cases it has failed to afl'ord any- 
 thing like material or permanent benefit, or to produce a decided 
 amelioration of the existing symptoms. The general impression 
 among practitioners in Dublin seems to be, that bleeding is doubt- 
 ful in its effects, if not altogether improper. I am much inclined
 
 INFLUENZA. 509 
 
 to think that bleedinf)^, unless employed within the first twelve or 
 twenty-four hours, will be likely to do as much, or more, harm 
 than good. Bleeding on the second or third day, except to 
 relieve congestion of the lungs, seems inadmissible. The same 
 observation holds good with reference to other diseases. Thus, 
 in scarlatina, if you happen to be called when the rigor commences, 
 and while the disease is beginning to form, you will sometimes 
 accomplish much good by bleeding your patient; but after eighteen 
 or twenty-four hours, when the disease is fully formed, venesec- 
 tion will not do. On this point I can speak from experience. 
 In scarlatina, the difterence of a few hours renders venesection 
 inapplicable, and even injurious. It is the same thing with 
 respect to influenza ; general bleeding is useful only in the com- 
 mencement ; and where the symptoms seem to demand it, it 
 should be employed at least within the first twenty-four hours. 
 
 Whore I have been fortunate enough to find the disease just 
 commencing, I bleed to the amount of twelve or fourteen ounces, 
 order the patient to remain in bed and take some aperient, followed 
 by the use of nitre. In this Avay, by timely bleeding, aperients, 
 sudorifics, and confinement to bed, the attack generally passes 
 over in two or three days. I could mention many instances of 
 the success of this plan of treatment. In one family I treated all 
 the individuals attacked in this way, and I have done the same 
 thing in many cases of persons somewhat advanced in life. In 
 the case of an old gentleman who was very severely attacked, I 
 succeeded by these means in checking the disease at once. My 
 experience, therefore, is, that bleeding is of service in the very 
 commencement of the disease ; but as it seldom happens that a 
 physician is called in at this period, I would qualify my statement 
 by saying that, as a general measure, bleeding in influenza is 
 seldom admiss-ible. 
 
 "When you are called on to attend cases, you will most gener- 
 ally find that the patients have been ill for two or three days or 
 more ; and then the only mode of abstracting blood, which you 
 can have recourse to with safety, is by leeching. About eight or 
 ten leeches applied over the hollow of the neck, just above the 
 sternum, and allowed to bleed pretty freely, will prove very 
 serviceable ; and if you apply them in the evening, you will often 
 secure to your patient a good night's rest. This plan of leeching 
 n the hollow of the neck, in cases of tracheo-bronchial inflamma-
 
 510 CLINICAL MEDICINE. 
 
 tion, is an excellent one : the leeches are applied at a spot which 
 lies close to the trachea, and particularly to that point to which 
 the irritation accompanying bronchitic affections is chiefly referred. 
 
 By the aid of leeching, the use of aperients if necessary, and 
 confinement to bed, with sudorifics, you will frequently succeed 
 in removing the fever and bronchial inflammation. You will de- 
 rive much benefit, particularly in the early stage of influenza, from 
 tartar emetic and nitre ; but I must say that neither leeching nor 
 tartar emetic and nitre proves as valuable and as efficacious in 
 influenza as in ordinary bronchitis. Some of my friends, who use 
 tartar emetic as a nauseant in the commencement of the disease, 
 inform me that they have derived benefit from its use ; and 
 others have told me that they have used tartar emetic and opium, 
 in the commencement and during the course of the disease, Avith 
 advantage. I have not employed the first of these, but I have 
 the latter, and with favourable results. You may therefore, after 
 using antiphlogistics for a day or two, proceed to the use of opiates 
 in combination with tartar emetic or nitre. In some cases the 
 camphorated tincture of opium will answer very well ; in others, 
 you will find the acetate or muriate of morphia better. A 
 mixture, composed of six ounces of almond emulsion, a drachm 
 of nitre, and half a drachm or more of the liquor muriatis mor- 
 phine, will be found very useful. The muriate of morphia, which 
 possesses many of the valuable properties of opium without its 
 defects, will serve to tranquillize the system and produce sleep 
 — two most important points in a disease like influenza, connected 
 with increased nervous irritability. 
 
 A gentleman on whom I place much reliance tells me that he 
 has treated many bad cases successfully with camphor mixture, 
 tincture of opium, and tartar emetic. I need not mention the 
 various remedies which have been recommended in this disease 
 — as Mindererus's spirit, Hofl'man's anodyne, ipecacuanha alone 
 or combined with extract of conium and blue pill, and many other 
 remedies belonging to the class of diaphoretics or expectorants. 
 They are all more or less serviceable, but they have all the com- 
 mon defect of producing less relief than they usually do in cases 
 where the pulmonary aftection is simple and idiopathic. Towards 
 the end of the disease you find it necessary to give stimulating 
 expectorants and light tonics — as infusion of poly gala senega, 
 infusion of columba, &c.
 
 INFLUENZA. 511 
 
 One word about blisters before I conclude. They are useful in 
 some cases, but in many of tlio severe ones they do little or no 
 good, and only add to tlie patient's sufferings. They do not 
 relieve the pulmonary symptoms, and particularly the dyspna?a, 
 in the manner you would be prepared to expect. I do not know 
 a more remarkable circumstance in the present disease, than the 
 failure of blisters ; and in many cases I do not employ them 
 at all. Fomenting the trachea and chest with very hot water 
 appears to be much more serviceable. This has proved extremely 
 valuable in many cases of this as well as other affections of the 
 air-passages.
 
 512 
 
 LECTUKE XXX. 
 
 THE CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 
 
 In order to acquire a correct and available knowledge of human 
 pathology, and to extend the range and confirm the accuracy of 
 diagnosis, it is of the utmost importance to observe attentively 
 the connexion between the diseases of certain organs or systems 
 of the body. You are aware that some organs, when labouring 
 under disease, are apt, after the disease has continued some time, 
 to implicate other organs, giving rise to various deranged con- 
 ditions, which are developed, sometimes simultaneously, but in 
 general consecutively, and in sequence. I have already pointed 
 out several diseased actions thus associated together, each 
 forming a link in the morbid chain. Now it is of the greatest 
 importance to study each link, and ascertain the nature of its 
 connexion, so as to have a distii'ict conception of the whole. 
 
 Let me first direct your attention to a train of morbid 
 phenomena sometimes observed co-existing with arthritic inflam- 
 mation. A person labouring under inflammation of the joints 
 gets an attack of hepatitis, accompanied by jaundice, and this is 
 followed by urticaria. I have observed this sequence of disease 
 in eight or nine cases. The first was in a gentleman residing in 
 Lower Mount Street, whom I attended with Dr. Cheyne. This 
 gentleman, in consequence of exposure to cold, was attacked with 
 arthritic inflammation and fever. After he had been about ten 
 days ill, he became suddenly jaundiced, and in a day or two 
 afterwards a copious eruption of urticaria appeared over his body 
 and limbs. Exactly the same train of phenomena, and in a 
 similar order of succession, was observed in a man treated in the 
 Meath Hospital in 1832. A short time before this, I had been 
 attending a medical friend in Baggot Street who had been afi'ected 
 in the same way ; and I mentioned to the class, as soon as I 
 perceived the man was jaundiced, that he would most probably 
 get urticaria. I made a similar prediction in a case which
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT OKGANS. 513 
 
 occurred recently in our wards, and it was verified by the event. 
 Now this is not a mere fortuitous occurrence ; the various 
 symptoms must be connected in the relation of cause and ejBfect. 
 It is interesting to bear this in mind, and it is besides of consi- 
 derable importance to the practising physician ; it enables him 
 to predict the appearance and form of disease, and inspires his 
 patient with confidence in his opinions and judgment. 
 
 Since my attention has been drawn to the connexion between 
 these three diseases, I have seen and heard of several other 
 instances in which they appeared thus associated together. A 
 circumstance so remarkable deserves to be studied with more 
 than ordinary interest. Let us, therefore, consider what facts are 
 supplied by physiology and pathology capable of throwing some 
 light upon this hitherto unobserved and uncultivated subject. In 
 the first place, nothing has been longer recognized by physicians, 
 as an established fact, than the intimate sympathy which exists, 
 both in health and disease, between the digestive organs and 
 the skin. Now, acute hepatitis always produces more or less 
 derangement of the stomach and alimentary canal, and we may 
 therefore consider its connexion with urticaria in the same way 
 that we are in the habit of viewing the cases, so frequently 
 observed, in which certain sorts of fish have produced serious 
 symptoms of indigestion followed by nettle rash. The associa- 
 tion between these two diseases is rendered more remarkable by 
 the fact, that when fish taken as food exerts a poisonous efl"ect on 
 the system, it frequentl_y produces not merely violent stomach 
 and bowel complaint, but also inflammation of the joints and 
 rheumatic pains. If I can establish this, you will allow that the 
 connexion between arthritis, disease of the digestive organs, and 
 urticaria can no longer be considered as fortuitous, and depending 
 on the accidental concurrence of causes having no determinate 
 relation ; but must be looked on as owing to and arising from 
 the operation of some fixed law, which regulates and originates 
 this development of morbid actions in, if not a frequent, at least 
 an uniform mode of succession. 
 
 The Otaheitan eel (puhhe pirre rowte) produces, when eaten, a 
 most copious scarlet eruption of the skin — most probably urticaria 
 — and occasions sudden tumefaction of the abdomen, together with 
 swelling of the extremities, hands and feet ; the pain felt in the 
 limbs is so excruciating that the patient becomes quite frantic. 
 VOL. I. 33
 
 514 CLINICAL MEDICINE. 
 
 I may remark here, that this and many other species of fish 
 which act as poisons on the system, give rise very speedily to 
 paralysis of the extremities. You will find in the Edinburgh 
 Medical and Surgical Journal, vol. iv. p. 396, in an excellent 
 review of Dr. Chisholm's work on the poison of fish, an account 
 of the eff"ects produced by eating the Murcena conger, the follow- 
 ing passage : "In the course of the following night they were all 
 seized with violent griping and cholera, together with a peculiar 
 sensation of the lower extremities, attended with violent convulsive 
 twitches, and faintings. They all perceived a brassy taste in 
 the mouth, and a rawness of the oesophagus, as if it had been 
 excoriated. These symptoms continued to afflict the negroes 
 for a fortnight, and thoi terminated in paralysis of the lower 
 extremities. After suffering for several months, they recovered 
 with difficulty." 
 
 WerlhofF, as cited by my friend Dr. Autenrieth in a book * of 
 extraordinary ability and research, gave a case where the Gadus 
 (sglesinus asellus produced a violent affection of the stomach and 
 bowels, together with urticaria. Urticaria, diarrhoea, dysentery, 
 paraplegia, are said, by the same author, to be frequently ob- 
 served in consequence of eating the flesh of the gray snajyj^er. 
 Foster relates a similar train of accidents produced by eating 
 the Sparus pargus (porgee). In short, I could bring forward 
 citation after citation in proof of the truth above advanced ; but 
 I have done, for enough has been already said to establish the 
 point in question. 
 
 Having established the fact that disease of the digestive oi'gans 
 is often intimately associated with urticaria, it remains to prove 
 that a similar connexion exists between hepatitis — the cause of 
 the derangement in the digestive organs in the case before us — 
 and arthritis. Everyone has observed how frequently inflamma- 
 tion of the joints becomes in its course complicated with inflam- 
 matory affections of internal viscera. In general those viscera 
 whose component tissues are most similar to the articular are 
 the organs affected. Hence the heart and pericardium are so 
 often attacked in the course of rheumatic fevers. It sometimes 
 happens, however, although less frequently, that the internal 
 organ attacked has little analogy in point of tissue with the joints. 
 Thus, in rheumatism and in gout, the stomach, the bowels, the 
 
 * Ucber das Gift der Fische : Tubingen, 1833.
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 515 
 
 lungs, or the liver may become engaged ; and of tlieso none, 
 perhaps, so frequently as the liver. We need not be surprised at 
 this, when we consider how intimately the digestive function is 
 connected with arthritic inflammation, which is indeed generally 
 preceded or accompanied by well-marked symptoms of hepatic 
 and stomach complaints. Indeed almost all medicines that 
 aftbrd relief in arthritis are attended with well-marked symptoms 
 of their having acted upon the secretions of the alimentary canal 
 and liver. Thus colchicum seldom diminishes the pain and 
 inflammation of the joints, until it produces copious bilious 
 evacuations. 
 
 There is another sequence of disease, not unfrequently observed, 
 but of which the connexion has not been hitherto noticed by 
 any writer, as far as I can ascertain. About two years since I 
 was consulted by an English gentleman, who had been ill for a 
 considerable time. The history of his case from the commence- 
 ment was this : — Three years previously he had venereal — used 
 and abused mercury, was exposed to cold, and got periostitis. 
 He now got into a bad state of health, used mercury a 
 second time, obtained some relief, and then relapsed again ; 
 finally, after having used mercury three or four times, he was 
 attacked with mercurial cachexy, became weak and emaciated ; 
 the periostitis degenerated into ostitis, producing superficial caries 
 and nodes of a bad character ; he had exfoliation of the bones of 
 the cranium and rupia, and was reduced to a most miserable 
 state. Under my care the symptoms gradually disappeared ; he 
 recovered to all appearance, and even got fat. He then caught 
 cold, and relapsed again. At last his liver became engaged ; he 
 was attacked again with hypertrophy of the liver, ascites, and 
 jaundice, and died soon afterwards. 
 
 Here, then, we have venereal, abuse of mercury, pjriostitic 
 inflammation, abuse of mercury followed by exacerbation of the 
 periostitis and establishment of mercurial cachexy ; and the 
 history of the case is wound up with hypertrophy of the liver. 
 This was the first case in which I had observed this concatenation 
 of diseases ; since that period I have seen a similar train of 
 morbid phenomena twice in private practice and once in hospital. 
 First, we have abuse of mercury, then periostitic inflammation 
 and mercurial cachexy, and the scene is closed by morbid enlarge- 
 ment of the liver. Now I do not look upon this sequence as
 
 516 CLINICAL MEDICINE. 
 
 merely fortuitous. The diseased actions are, I think, related as 
 cause and effect, and each successive condition is consequent on 
 the previous one. 
 
 It may not be amiss to mention here some curious circum- 
 stances observed in the case to which I have just alluded. While 
 this gentleman's liver was enlarging, there was no tenderness 
 of the right hypochondrium on pressure. I have observed the 
 same absence of tenderness in all the cases of this description I 
 have witnessed. The gentleman could bear pressure over the 
 hepatic region without any inconvenience, and yet the liver was 
 so enormously increased in size, that its inferior margin extended 
 almost down to the pelvis. What is equally remarkable, he had 
 no fever, and the tongue was perfectly clean and moist during the 
 whole course of the hepatic affection. In my observations on a 
 case in the fever ward, I remarked a few days since that some 
 persons were too hasty in drawing inferences from the state of the 
 tongue as to the existence of affections of the digestive organs. 
 I shall not touch on this point, however, at present, and shall 
 merely observe that this gentleman's tongae was perfectly clean and 
 moist, notwithstanding the morbid condition and rapid growth 
 of the liver. Another curious circumstance was that during the 
 hepatic affection digestion appeared to go on very well, at least 
 so far as the formation and due expulsion of feces are concerned. 
 The alvine evacuations were regular, and the matter discharged 
 presented the form and consistence of that which is passed by a 
 person in good health. But there was a peculiarity in it to which 
 my attention was first directed by the patient, who was an intelli- 
 gent and observant person. The cylinder of faecal matter was 
 composed of parts differing in colour and appearance : two or 
 three inches consisted of pale clay-coloured substance ; and 
 immediately after this another portion, of about the same length, 
 was observed, presenting the ordinary bilious or brown colour 
 of natural excrement : and then again another mass of clay- 
 coloured matter, without any obvious trace of bile. This ap- 
 pearance I have now frequently witnessed ; and the inference 
 to be drawn from it is this, — that in such forms of hepatic 
 disease the functions of the liver are performed, as it were, 
 intermittently : it secretes bile during a certain period of the 
 digestive process, then stops, and then secretes again. 
 
 This peculiarity is noticed in many diseases of the liver ; and
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 517 
 
 it is important to remark, in attempting to explain the rationale 
 of these hepatic allections, that in no disease of the liver is 
 this symptom more frequently observed than in the scrofulous. 
 Scrofulous disease of the liver is that state in which there is 
 an increase of size in the organ, with induration and imperfect 
 secretion, but without any remarkable tenderness. This condition 
 in children is accompanied by irritability of the digestive organs, 
 fretfulness, emaciation, loss of sleep, and impaired nutrition. 
 The little patient becomes what is termed " pot-bellied," and 
 labours under thirst, debility, and febrile excitement. This has 
 been frequently called remittent fever, and disease of the mes- 
 enteric glands, but in my opinion unjustly. It is only a form of 
 general cachexy connected with the scrofulous diathesis, affecting 
 secretion and nutrition in general, and the digestive and biliary 
 systems in particular. It would be quite wrong to imagine that 
 in this form of disease the liver is the cause of the whole train 
 of morbid phenomena ; it is merely affected in common with 
 other organs, and forms only an individual feature in the group 
 of symptoms. 
 
 Now, in this form of scrofulous cachexy, where you have 
 diarrhoea, emaciation, fever, thirst, and restlessness, the liver is 
 frequently affected in the manner already described; and in the loose 
 stools of such a child you will find one part bilious, another part 
 clay-coloured ; they will be yellow this day, and pale the next, 
 accordingly as the liver secretes bile or suspends its functions. 
 But in this instance, I repeat that the liver is only one of many 
 organs affected by the same general cachexy. Could we ascertain 
 the derangements of other secreting organs with the same facility, 
 it is very probable we should find similar evidences of the morbid 
 influence which pervades the whole system. 
 
 This view of the question shows that you are not to expect to 
 succeed in removing the disease by the use of calomel or any other 
 mercurial preparation. Many of those persons Avhose practice 
 is little better than routine, when called to treat a case of this 
 description first examine or inquire as to the nature of the alvine 
 evacuations, and fixing on the single symptom of deficiency of bile, 
 immediately prescribe calomel to be repeated or continued until the 
 secretion of the liver is established ; but they forget that this state 
 of the biliary system depends on the general state of health, and 
 that the absence of the bile is the consequence and not the cause
 
 518 CLINICAL MEDICINE. 
 
 of the disease. Almost all the organs of the body are affected ; and 
 though calomel may restore the secretion of the liver for a time, 
 it cannot bring back the organ to its natural state, or cure the 
 disease. The malady is to be remedied in a different way : the 
 secretions (and that of the liver among the rest) are to be 
 improved by change of air, bj' an appropriate diet, by exercise, 
 tepid or cold bathing, and the use of those remedies which are 
 adapted to modify or correct that state of the system on which 
 the general derangement depends. 
 
 An observation of such cases has led me to a train of reflection 
 respecting the occurrence of the same order of symptoms in per- 
 sons who have been injured by the abuse of mercury. Many 
 persons Avho get venereal employ mercury injudiciously, and fall 
 into what has been termed mercurial cachexy, in which there is a 
 general unhealthy state of the organs. A patient who has fallen 
 into this state very closely resembles a scrofulous person, and is 
 apt to labour under the same emaciation, impaired nutrition, 
 irritability, feverishness, and the same sort of cutaneous, glandu- 
 lar, and periostitic affections. The chronic mercurial cachexy is 
 very like the scrofulous, and attacks very nearly the same organs 
 and tissues. Hence the difficulty of curing affections of the liver 
 and other organs when they are the result of this depraved habit. 
 This is the key to the explanation of those horrible ravages which 
 we frequently witness in cases of venereal disease complicated 
 with mercurial cachexy — a state of constitution which is closely 
 allied to the scrofulous. You will frequently meet with this 
 consecutive affection of the liver in cases of morbus coxae, where 
 the patient has been labouring for years under ulceration of the 
 joint. The growth of the rest of the body appears checked, the 
 patient is stunted and emaciated, while the liver increases rapidly 
 in size. It was from observing the occurrence of liver disease in 
 persons labouring under the scrofulous cachexy, that my attention 
 was first turned to its occurrence in persons broken down by long 
 or injudicious courses of mercury. 
 
 One word, gentlemen, as to the curability of hepatic affections 
 of this kind. I believe that it is always an unpromising form of 
 disease ; but persons of originally good constitution, and under 
 the age of thirty, will generally escape if treated judiciously, and 
 with proper care and attention. Some months ago I attended, 
 with Sir Henry Marsh, a young gentleman labouring under this
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 519 
 
 affection as a consequence of the abuse of mercury. We found 
 bim greatly emaciated, and bibouring under considerable enlarge- 
 ment of the liver, with commencing ascites. He bad also great 
 determination of blood to the abdomen, diarrhoea, and hemorrhoids. 
 By strict attention to his bowels, a well-regulated diet, change of 
 air, and the use of taraxacum, conium, and hydriodate of potash, 
 he was ultimately cured after an illness of nearly two years, 
 during which the liver had grown to an enoi'mous size. I may 
 state that he is at present in good health, and that the liver is 
 nearly reduced to its natural dimensions : this gentleman's age 
 is about four-and-twenty. 
 
 I observed one circumstance in the progress of this case which 
 is worth noting. He was suddenly attacked with a i^apular form 
 of purpura, accompanied by much tingling and itchiness, and 
 answering to the description given of Purpura urticans. This 
 peculiar eruption was very troublesome at night, and formed 
 several successive crops which altogether lasted a mouth. It 
 occupied the extremities upper and lower, and was very abun- 
 dant on the latter. The gentleman wore a bandage to relieve 
 a varicose state of the veins of the left leg. Now the eruption 
 never appeared in the parts subjected to the pressure of the 
 bandage, although it was very thick immediately below and 
 above these parts. 
 
 I may observe that it is entirely as the result of the cachectic 
 habit, this enlargement of the liver which I have now been speak- 
 ing of is observed. I have assumed this principle as the basis 
 of my argument, and I think it is founded in fact and truth. It 
 is also curious to observe that the same cachectic state which 
 gives rise to emaciation and decay of the body generally occasions 
 hypertrophy of some particular organ. What we most commonly 
 observe in such conditions is general wasting of the system j 
 accompanied by increased morbid nutrition in certain organs. 
 This appears to be the general law. You perceive that in the 
 explanation I have given, I have supposed that enlarged liver is 
 the result of a general cachectic state of the system, and it is of 
 importance to recollect that this state may be brought on by the 
 injudicious exhibition of mercury, or by carrying mercurialization 
 farther than the constitution will bear. In this instance we are 
 compelled to allow that our practice may furnish weapons to be 
 turned against us by the disciples of homeopathy. It cannot,
 
 520 CLINICAL MEDICINE. 
 
 however, be denied that the immoderate use of mercury has been 
 productive of liver disease. The late Mr. Hewson pointed out 
 this to the attention of those who visited the Lock Hospital while 
 under his care. At this period it was the custom to salivate 
 every patient, and keep him under the full mercurial influence 
 for a month or two ; and it frequently happened that, just as the 
 mercurial course was finished, the patient got disease and enlarge- 
 ment of the liver. Were I inclined to theorize, I might perhaps 
 ofi"er some fanciful hypothesis in explanation of this occurrence, 
 and might trace some connexion between the stimulant effects of 
 mercury on the liver, and the subsequent hypertrophy. I shall, 
 however, content myself at present with noticing the fact, and 
 leave the explanation to my juniors, who always explain matters, 
 according to my observation, much more readily than their 
 seniors. 
 
 There are also other diseased states of the system in which we 
 have enlargement and morbid alteration of the liver. I can point 
 out to you four different states of the system in which hypertrophy 
 and disease of the liver form one of the results of the general 
 affection of the system. The next of these to which I shall direct 
 your attention is scarlatina. Those who have attended the wards 
 during the past month have seen examples of this. We have 
 observed during the past week two patients labouring under scar- 
 latina, who got disease of the liver and jaundice. One of the 
 patients, a little boy, was attacked with the disease in an 
 extremely violent form, accompanied by high fever and a very 
 remarkable eruption. In a few hours after the exanthema ap- 
 peared the entire cutaneous surface was dyed of a brilliant red ; 
 in fact, the skin looked as if it had been painted over, and there 
 was not a single spot free. In cases of this kind the violence of 
 the cutaneous inflammation is sufficient to kill, without any other 
 unfavourable complication ; and the patient seldom lives more 
 than three or four days. You observed in this case the whole 
 epidermis peeled off. But what I wish to direct your attention to 
 is, that this boy after two days had evident symptoms of disease 
 and enlargement of the liver. A young man in the same ward had 
 also an attack of scarlatina, but in a milder form. On the third 
 day he likewise got inflammation of the liver, but was cured by 
 general and local antiphlogistic treatment. 
 
 In a previous lecture I have explained to you that scarlatina is
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 521 
 
 one of those diseases in ^Yllicll a train of unfavourable sequelae 
 are apt to remain after the removal of the original complaint. 
 Persons after recovering from the exanthematous fever will some- 
 times get into a bad state of health, and instead of convalescing, 
 become restless and feverish towards evening, have an irritable 
 jerking pulse, hot skin, derangement of the digestive organs, 
 diminished urinary secretion, and finally become dropsical. 
 Now, from observing the supervention of hepatic disease in such 
 cases, both in hospital and private practice, my attention has 
 been directed to the liver; and I never omit making an examina- 
 tion of that organ when called to treat those symptoms which 
 are looked upon as the sequelae of scarlatina. In many of these 
 patients I have found the liver in a state of inflammation of 
 rather a chronic character, and without any of that remarkable 
 pain or tenderness which characterizes acute hepatitis. But still 
 it was inflamed, as proved by the benefit derived from local anti- 
 phlogistic means; and, moreover, its condition appeared to retard 
 and prevent convalescence. 
 
 Not long since a friend of mine, a very intelligent practitioner, 
 who was attending a case of this description, and had tried a 
 variety of remedies without any benefit, was very much surprised 
 when I drew down the bed-clothes and showed him that the liver 
 Avas diseased. He had not thought of the existence of anything 
 like hepatic afl'ection, and was very much surprised that his 
 treatment had proved so ineffectual. By the use of leeches to 
 the right hypochondrium, the employment of mercury, and a 
 proper regulation of diet, the patient was soon relieved, and the 
 fever, thirst, and anasarca quickly disappeared. In cases of this 
 kind the hepatic afi'ectiou is the result of the general inflam- 
 matory diathesis superinduced by scarlatina. You are all aware 
 that nothing is more common after scarlatina than inflammation 
 of various organs. Thus some persons are attacked with pleuritis, 
 some with pneumonia, others with inflammation of the liver. 
 Many persons continue in a valetudinary state after the eruption 
 had declined ; they do not convalesce according to our expecta- 
 tions ; the pulse remains rather quicker than natural ; the bowels 
 are deranged ; the appetite bad ; thirst urgent ; and urine scanty. 
 In many of these cases you will find that there is a species of 
 chronic hepatitis going on, which keeps up the feverishness, and 
 retards convalescence. This is a point of great importance, to
 
 522 CLINICAL MEDICINE. 
 
 which I am the more anxious to draw your attention, because 
 even the latest writers on scarlatina have either entirely omitted 
 or very insufficiently noticed it. 
 
 There is another organ whose morbid affections frequently 
 implicate the liver; I allude here to the heart. I have already 
 spoken of certain cachectic states, in which the liver becomes 
 enlarged and hypertrophied as the result of the general derange- 
 ment of the system. In the present case the hypertrophy and 
 disease of the liver originate in a morbid condition of the heart ; 
 this is a very frequent cause of hepatic derangement. You have 
 an example of it at present in the chronic ward, in the case of 
 a poor man labouring under bronchitis of long standing, with 
 disease of the heart, dropsy, and enlargement of the liver. In 
 cases of this description it is a matter of some difficulty to deter- 
 mine in what organ the morbid sequence commences ; for where 
 many diseases co-exist, it is not easy to ascertain how they are 
 related to each other as cause and effect. I have, however, 
 had several opportunities of observing the progress of the disease 
 from the commencement, and the manner in which the different 
 organs become successively implicated. 
 
 Some time ago there occurred a remarkable example of this 
 form of hepatic affection in a relative of mine, aged 14, who, in 
 consequence of exposure to cold, was attacked with rheumatic 
 inflammation of the joints of a very intense character. Owing to 
 a want of proper care, the disease was allowed to go on unchecked, 
 and metastasis to the pericardium took place. I happened to 
 be out of town at the time, and he had no advice or assistance 
 for nearly twenty-four hours. Pericarditis of a violent character 
 became developed, and it was only by the most energetic treat- 
 ment that he escaped with his life. He had pericarditis with 
 effusion, and all the physical signs and symptoms of carditis. 
 After the acute symptoms were removed, the signs of adhesion 
 of the pericardium, hypertrophy, and partial valvular disease 
 continued ; and for a long time the heart's action was invariably 
 accompanied by a loud bruit de soufflet. These affections were 
 followed by dyspnoea and increased action of the heart. But this 
 was not all. He next got inflammation of the testicle, and 
 finally chronic hepatitis with enlargement. The liver grew to a 
 very considerable size ; it continued to enlarge for about seven 
 mouths ; and altogether he laboured under a chronic form of
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 523 
 
 hepatitis for more tlian a year. At last the disease yielded to 
 treatment, and he recovered completely. 
 
 This you will say was a fortunate termination ; but in young 
 persons the powers of nature often act in a very remarkable 
 manner in remedying or removing disease, and cures are some- 
 times effected in such patients which it would be quite absurd to 
 expect in persons advanced in life. After having laboured under 
 a long train of diseases, and having continued an invalid for 
 neai-ly five years, this young gentleman at last, owing to his 
 j-outh and favourable constitution, surmounted all his maladies, 
 and is at present as strong and healthy as any person I am 
 acquainted with. In this instance the chronic hepatitis was the 
 result of the pericarditis which formed the first link in the chain ; 
 and for the space of a year this young gentleman continued to 
 labour under an affection of the liver, the result of disease 
 commencing in the heart. This is a morbid sequence very 
 frequently observed. You have pericarditis accompanied by 
 inflammation of the lining membrane of the heart, partial disease 
 of the valves, hypertrophy of the muscular substance, and then 
 enlargement and induration of the liver. This is a very common 
 complication, and deserves your most particular attention. 
 When you see a patient whose appearance indicates disease of 
 the heart — who has swelling of the face, dyspnoea, lividity of the 
 lips, and turgescence of the cutaneous vessels — in fact, that 
 2)eculiar expression of countenance which at once informs the 
 practised observer that the patient is labouring under disease of the 
 heart, you should not neglect to inquire after the condition of the 
 liver, for in such cases it is very frequently in a state of chronic 
 disease, I pointed out this circumstance some time since in the 
 case of a late surgeon, Mr. M., and directed the attention of the 
 medical gentlemen engaged in the treatment of the case to the 
 liver, in which no one had suspected the existence of disease. 
 Recollect, therefore, that in many cases of disease of the heart 
 you will also, on examination, find disease of the liver produced, 
 as far as I can judge, in the majority of instances by disease of 
 the heart ; at least, I think I have never seen any case in which the 
 hepatic affection had the initiative, and seemed to have brought 
 on the organic affection of the heart. In Mr. M.'s case and 
 several others which I had an opportunity of watching from the 
 commencement, I have no doubt that the disease of the liver was
 
 524 CLINICAL MEDICINE. 
 
 secondary, and that the morbid sequence commenced with the 
 heart. I am quite convinced that disease of the liver may give 
 rise to a functional derangement of the heart ; for whatever 
 impairs secretion and deranges digestion will give rise to palpita- 
 tions, tendency to syncope, and other j)henomena of functional 
 disease of the heart ; but I have never seen any example of 
 organic disease of the heart as the result of disease of the liver. 
 
 It is of some importance to be aware of this complication ; 
 for in treating the disease of the heart you must also attend to 
 the hepatic affection, because it has a tendency to aggravate and 
 confirm the cardiac symptoms. This affection, however, is not 
 to be looked upon as acute, or even subacute hepatitis. There 
 is scarcely any pain of the side or tenderness present, and the 
 patient is not always jaundiced; it appears to be scarcely any- 
 thing more than congestion, causing hypertrophy and chronic 
 morbid growth. I shall not, however, speak too positively on 
 the subject, as the difference between hypertrophy and inflamma- 
 tion of a low and obscure character cannot be easily determined. 
 I am glad to find that the subject I am now discussing has been 
 taken up by so able an observer as Dr. Bright, who, in the third 
 number of Guys Hospital lleports, p. 605, has made some 
 excellent remarks on the influence of heart disease in producing 
 congestion of the liver. 
 
 There is another disease in which derangement of the liver 
 is a common symptom, and I bring it forward chiefly for the 
 purpose of rendering the subject under discussion more complete, 
 as it is an occurrence well known to the practitioners, and 
 sufficiently dwelt on in medical books. I allude to that affection 
 of the liver which is observed in cases of intermittent fever. 
 Ague frequently produces a powerful determination to internal 
 organs, particularly the liver and spleen, and if treated badly or 
 unsuccessfully, is apt to bring on disease of the liver. The 
 organ becomes congested, hypertrophied, and indurated, and 
 presents a condition somewhat analogous to that which super- 
 venes on disease of the heart, or results from the cachectic state 
 of constitution produced by mercury or scrofula. 
 
 The next form of organic derangement which I shall briefly 
 touch on is that of the spleen. It is of advantage to place 
 cognate affections beside each other for the purpose of compari- 
 son ; by doing so we frequently derive many instructive and
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 525 
 
 useful analogies. Besides, we have had a remarkable case of 
 eulargemeut of the spleen in our wards at the same time we had 
 the cases of hepatic disease to which I have alluded. 
 
 The circumstances under which enlargement of the spleen 
 takes place diifer in many points from those which determine 
 hypertrophy of the liver. We have but few examples of inflam- 
 mation of the spleen, while the cases in which enlargement and 
 congestion of that organ take place are numerous. From the 
 peculiarity of its anatomical structure, the spleen is very apt 
 to become suddenly enlarged. Like the liver, it may become 
 indurated and hypertrophied from intermittent or from some 
 general disease affecting the system, and thus lead to a train of 
 secondary phenomena, the most remarkable of which is dropsy. 
 But there is one peculiar symptom attending enlargement of the 
 spleen, which I have frequently pointed out to the attention of 
 the class as observed at least in two-thirds of the cases, and of 
 which we had an excellent specimen in the patient under treat- 
 ment in the chronic ward. 
 
 The history of this symptom is the more curious as showing 
 a remarkable uniformity in the phenomena of a peculiar disease 
 at very distant periods of time. This is seen by comparing the 
 most recent descriptions of Indian splenitis, as given in an able 
 analysis of Voight's work on the spleen, in the British and 
 Foreign Medical Review, and the description of enlargement and 
 disease of the spleen given by Aret^us. The ancients, it is true, 
 cannot be now considered as authorities to be followed either in 
 pathology or practice ; for they were ignorant of many of the 
 most important facts connected with the healthy and diseased 
 states of the human body. In consequence of their inaccurate 
 anatomical notions, they were unable to appreciate or describe 
 many of those details which now enrich the domain of patho- 
 logical anatomy ; their writings, however, are invaluable in many 
 respects, as containing admirable descriptions of disease which 
 still continue to affect the human body, and as recording certain 
 groups of symptoms which are still associated. A comparison of 
 their descriptions with those of modern times cannot fail to be 
 extremely curious, and may even prove highly instructive ; for if 
 we find that certain internal affections have, from the most remote 
 antiquity to the present period, been generally accompanied by 
 peculiar derangements of distant parts, we are authorized in
 
 526 CLINICAL MEDICINE. 
 
 considering this connexion to be something more than acci- 
 dental, and consequently we may be led to discover relations 
 between organs generally believed to be quite unconnected with 
 each other. 
 
 Thus, some time since I had three patients in succession under 
 my care, who laboured under chronic enlargement of the spleen, 
 who were all affected with a similar sort of cachexy, and had ail 
 the same affection of the skin — namely, superficial ulceration of 
 the legs. This coincidence forcibly arrested my attention, and I 
 was still more struck with the observation on finding that Aretaeus 
 had noticed this very circumstance in his admirable description 
 of splenitis. " If (says he) the spleen does not suppurate, but 
 becomes chronically enlarged, then the patients lose their ap- 
 petite and become cachectic, swollen, and of an unnatural colour, 
 while the surface of the body manifests a disposition to ulcerate, 
 particularly on the legs : the ulcers are hollow, round, livid, 
 sanious, and difiicult to heal." This description agrees precisely 
 with the cases to which I have already referred, and it coincides 
 in a very remarkable manner with the account lately given by 
 Dr. Voight, of chronic disease of the spleen as it occurs in India. 
 He observes that the cachexy connected with the Splenalgia 
 Bengalensis freqently manifests itself by a tendency to ulceration ; 
 the disposition to which is so great, that leech bites and blisters 
 occasionally give rise to foul or phagedenic ulcers, which under 
 certain circumstances, as where the patient has used mercury and 
 is residing in a swampy district, will sometimes run on to a fatal 
 termination. It is also curious that the predisposing causes 
 of the different varieties of chronic enlargement of the spleen, 
 as given by Voight, are exactly the same as those detailed by 
 Aretaeus ; and both writers correspond in their statements as to 
 the age and habits of life of persons most liable to this disease, 
 as well as the nature of the locality and the season of the year 
 most favourable to its production. This agreement between 
 authors separated from each other by so many centuries, and 
 who describe the disease as it occurred in different regions and 
 among different races of mankind, is extremely curious, and 
 exhibits a very remarkable example of the identity of the morbid 
 phenomena produced by the same causes. 
 
 From the observations I have made in this lecture, you must 
 perceive the advantage the physician gains from a knowledge of
 
 CONNEXION BETWEEN DISEASES OF DIFFERENT ORGANS. 5'27 
 
 this connGxion between the diseases of different organs, how 
 much precision it adds to his practice, and what faciHty it gives 
 prognosis. Additional investigations are much wanted on this 
 subject ; but based, as to prove useful they must be, on the 
 accumulation of facts derived from experience, much difBculty 
 lies in the way of their being undertaken.
 
 528 
 
 LECTURE XXXI. 
 
 GOUT. 
 
 I SHALL in tlie present lecture make a few remarks on certain 
 varieties of gout, of which I have recently seen several singular 
 examples, premising some obseiwations on constitutional inflam- 
 mation in general. 
 
 There is no proposition in pathology better established than 
 that there exist several constitutional affections capable of 
 generating and modifying local inflammatory action ; and that 
 local inflammations, depending on a constitutional cause, are 
 subject to very different laws from those which regulate the 
 phenomena of common inflammation. 
 
 Another fact of equal importance in many points of view is, 
 that local inflammations depending on a constitutional cause 
 differ remarkably from each other, and in general present specific 
 characters easily recognized. Thus, local afi'ections arising from 
 scrofula are not likely to be confounded with those depending on 
 gout or rheumatism, and the inflammations produced by syphilis 
 and other animal poisons exhibit peculiarities by which their 
 respective origin and - nature may be satisfactorily ascertained. 
 It must, however, be admitted that, although advanced consider- 
 ably in our knowledge of the phenomena of local disease depend- 
 ing on a constitutional cause, the subject still displays a wide 
 field for investigation, and many points of much importance in 
 pathology and practice require still further investigation. 
 
 Professor Cayol, in his Legons Orales, lias made some obser- 
 vations on this subject well worthy of attention. Speaking of 
 the dependence of local disease on constitutional causes, he says, 
 " II faut necessairement conclure que les degenerations organ- 
 iques ne sont pas cause, mais effet. Et des lors, nous sommes 
 fondes a vous dire, qu'au lieu d'user votre vie a chercher toujours 
 quelles sont les degenerations organiques et les alterations de 
 texture qui 'prodmsent les symptomes des maladies, il serait bien
 
 GOUT. 529 
 
 temps de s'inquieter un pen de savoir ce que produit ces degene- 
 rations elles memes, en etudiant soricusement les caracteres, la 
 marclie, et la tendance des acts vitaux qui les preparent, et qui 
 les ■produiscnt reelment." 
 
 There is one fact connected with local inflammation depending 
 on a constitutional cause not sufficiently noticed, namely, that 
 certain aiTections of this kind are sometimes remarkably fugitive 
 and transient. We are accustomed to regard the process of in- 
 flammation, whether common or specific, as one which generally 
 lasts for some days ; but it occasionally happens, that a peculiar 
 diathesis will give rise to local affections having the characters of 
 inflammation, and which run their course and terminate in the 
 space of a few hours. This observation, which should be borne 
 in mind in the investigation of diseases connected with the 
 general habit, will serve to explain some of the anomalies which 
 strike us occasionally in the study of constitutional maladies. 
 
 The first instance of this kind that came under my notice 
 occurred in the case of a florid healthy-looking boy, aged six 
 years, in whom, on attentive examination, I was led to suspect 
 the existence of a scrofulous taint. At the time I saw him he was 
 subject to a sudden and rapid formation of bumps, or tumors, 
 on various parts of his body — sometimes on his arms, sometimes 
 on his legs, and occasionally on the trunk. These circumscribed 
 tumefactions were accompanied by a feeling of heat and tender- 
 ness, and apparently depended on local congestion, or eff'usion in 
 the subcutaneous cellular tissue. But what was most remarkable 
 in them was, they arose, ran through their course, and terminated 
 in the space of four or five hours ; they were suddenly developed, 
 and disappeared with equal rapidity. In the course of a month, 
 other more permanent inflammations were set up ; scrofulous 
 ophthalmia, glandular swellings, and ulcers supervened ; the 
 joints became affected, and the boy died in about a year and a 
 half, with all the characteristic marks of the scrofulous diathesis. 
 I have detailed this case before, and shall not dwell on it any 
 further at present ; but it is well worthy of notice, in consequence 
 of the very brief duration of the first local symptoms. 
 
 Gout is another disease which occasionally exhibits examples 
 
 of its peculiar inflammation attacking various parts and tissues 
 
 of the body, and that for an extremely short period of time. It 
 
 is well known that persons of a gouty habit are subject to sudden 
 
 VOL. I. 31
 
 630 CLINICAL MEDICINE. 
 
 pains or twitches, which last only for a few minutes, or even 
 seconds. I shall not stop here to consider what may be the 
 nature of these fugitive pains ; I may observe, that certain facts 
 seem to prove that these pains are the result of a momentary 
 congestion. Thus, in various neuralgic affections, and in inflam- 
 matory diseases in which the nerves are considerably engaged, 
 pain is suddenly produced by coughing. If a man labours under 
 neuralgia of the frontal or facial nerves, or if he is affected with 
 sciatica, how are his sufferings increased when he has unfortu- 
 nately at the same time a cough ! Every time he coughs, the 
 affected nerve gives notice that it feels the congestion by a sudden 
 pain. Now, the only way in which coughing can increase a local 
 pain is by favouring local congestion ; that it is capable of doing 
 this is proved by the redness of the face it occasions, as also by 
 the hemorrhage from the nose, or from recent w^ounds, which is 
 so often produced by a fit of coughing. 
 
 As there can be no doubt, then, that a momentary congestion 
 may produce a momentary pain, we may infer that in many 
 instances gouty twitches are owing to some cause which deter- 
 mines an instantaneous congestion of the affected part. Some- 
 times the congestion is more lasting, and the pain is proportion- 
 ally intense and persistent. Thus, the late Mr. Daly, of Henry 
 Street, mentioned to me the case of a gentleman, the lobe of 
 whose ear was sometimes attacked suddenly by gouty congestion, 
 accompanied by agonizing pain, but which never lasted more 
 than a few hours. And I have myself recently suffered from a 
 similar attack in the cartilage of the ear, which did not last 
 longer than an hour, disappearing on the occurrence of gouty 
 pains in the fingers. 
 
 This fact brings to my mind a curious case which some years 
 ago came under the notice of Sir Philip Crampton, Mr. O'Ferral, 
 and myself. A young gentleman of fortune perceived that the 
 pendent lobes or tips of his ears were becoming elongated ; they 
 increased gradually in such a manner that he considered himself 
 disfigured by their unseemly length, and therefore attempted 
 their concealment by allowing his hair to grow in long curls, so 
 as to hide the ears. This gentleman soon afterwards became 
 dropsical and died ; and, on dissection, Mr. O'Ferral found his 
 liver in a state of fatty degeneration. On slitting uj) the 
 elongated portion of the ears, he discovered that their hypertrophy
 
 GOUT. 531 
 
 had been occasioned by the deposition of a large quantity of fat. 
 The subcutaneous adipose tissue and the omentum were likewise 
 much loaded with fat. This observation is of much importance, 
 as teaching us that fatty degeneration may be the consequence of 
 a general tendency in the system to manufacture and deposit fat 
 in the textures of different organs. In this point of view the 
 change of structure in the liver must be regarded as an effect, 
 and not as a cause, of the general derangement of the system 
 and the fatal termination of the case. 
 
 One of the most remarkable instances of fugitive inflammation 
 affecting various parts of the body, which has come under my 
 notice, occurred in the person of a gentleman lately under my 
 care. I shall not go through the whole history of his disease, of 
 which he has favoured me with a very minute account, but shall 
 merely state that he is of a gouty habit, has had an attack of gout 
 in the stomach, and is at present subject to a gouty affection of 
 a very extraordinary character. After labouring for some time 
 under languor and weakness, accompanied by spasms, pain, and 
 sense of weight in the stomach, the pain of the stomach ceases, 
 and his face begins to swell at various points, generally 
 commencing on the forehead, and involving the cheek and eye so 
 as to close up the latter. He first feels as if a small current of 
 air was directed on the face ; then, as it were the fillip of a 
 finger, or the bite of a gnat ; and on looking in the glass, he 
 suddenly perceives a tumor rising on the forehead, which, in 
 the space of half an hour, becomes as large as a pigeon's egg, 
 and, as he expresses it, moves down until it closes the eye. 
 Sometimes it attacks his lips, and other parts of his face, but 
 never affects his nose. These tumors have also appeared on 
 various parts of his body ; and he observes in his letter to me, 
 that he is sometimes led to think that they attack his stomach 
 also. Before and during an attack of the face, which generally 
 occurs on the left side, the discharge from the nostril of the 
 affected side ceases. 
 
 But what is chiefly remarkable in this case is the singular 
 character of the local affection. The tumors arise, run through 
 their course, and disappear in the space of a few hours, and on 
 the following day there is no trace of their existence. Sometimes 
 the lips inside of the mouth, palate, and uvula are attacked, 
 giving rise to a very considerable inconvenience. Were such
 
 532 CLINICAL MEDICINE. 
 
 tumors to occur in the neiglibourliood of the glottis, I need not 
 say that they would he pregnant with danger of no ordinary 
 character. I may observe that this gentleman has derived great 
 benefit from the use of hydriodate of potash, and from decoction 
 of sarsaparilla with nitric acid, and that his health is at present 
 much improved. His case presents a very curious example of 
 transient local inflammation depending on the gouty diathesis. 
 
 Having touched on the subject of anomalous local affections 
 as connected with the gouty habit, I may here refer to a very 
 singular affection of the teeth which I have observed in indi- 
 viduals of a gouty diathesis. The disease I am about to describe, 
 though very singular and remarkable, has not been noticed by 
 practical waiters. A few preliminary remarks on the functions 
 of the dental nerves appear necessary, in order to enable you to 
 form a more exact idea of its nature. 
 
 The teeth are immovably fixed in the jaws, and consequently 
 require no nerves of motion so far as they themselves are con- 
 cerned ; they are on the other hand abundantly supplied with 
 nerves derived from the fifth pair — a nerve of sensation, and 
 their nervous apparatus is developed and expanded within their 
 substance in a manner which shows that nature has bestowed a 
 greater degree of care on this than on any portion of the nerves 
 destined to perform the office of touch. In this respect, they, 
 to a certain extent, approach the affection of the nervous 
 apparatus of the organs of sense properly so called. In truth, 
 no part of the mechanism of the human body seems more 
 admirable than that which thus associates together in function a 
 soft nervous pulp and a solid osseous substance ; and associated 
 together they assuredly are, for the teeth, though encrusted with 
 a coat of enamel as hard as steel, are very delicate organs of 
 touch ; the most minute bodies when hard may be distinctly felt 
 if placed between their edges ; and matters of more yielding 
 texture, as a leaf of paper, or a rose leaf, can be distinguished in 
 the same position. 
 
 The delicacy of touch enjoyed by the teeth has not attracted 
 due notice, nor have its uses been sufficiently dwelt on, for to 
 this sense are owing the ease and precision with which, as 
 instruments, they perform their proper office of cutting, tearing, 
 and grinding the food. It is from the feeling imparted to their 
 edges that we derive instant knowledge of the situation, and
 
 GOUT. 533 
 
 man}' of the physical properties of the morsel, such as its 
 hardness, consistence, shape, size, &c., in consequence of which 
 it is either at once submitted to the action of the teeth, or is 
 removed to be placed in another part of the mouth, and in a 
 more convenient position where teeth of a different shape and 
 form may be brought to bear on it. Without this exquisite 
 sense of feeling, one row of teeth could not act in concert wdth 
 the other ; the incisors and molars in the under could not adapt 
 their cutting and grinding surfaces to those in the upper jaw, nor 
 could certain information be conveyed to the muscles of the 
 lower jaw for the purpose of commanding the consecutive motions 
 they are called on to perform. 
 
 In fact, the teeth are not merely cutting instruments, but are 
 endowed as it were with intelligence ; they are, it is true, assisted 
 in ascertaining the size, portion, hardness, and other physical 
 qualities of the morsel by the tongue and cheeks, but they per- 
 form besides a peculiar function, that of feeling the intimate 
 texture of what is submitted to their immediate operations, 
 thereby warning us instantaneously when the morsel contains 
 anything detrimental to their own substance ; without this sense 
 of touch how soon Avould our teeth be chipped away and worn by 
 minute but hard matters, as grains of sand, which no care can 
 entirely exclude from our food, but which the teeth detect at 
 once when in contact with their edges, and which they refuse at 
 once to act on. In truth the teeth may, in this point of view, 
 be considered as a sort of fingers fixed within the mouth, destined 
 to feel, examine, and adjust the morsel preparatory to placing it 
 in the position most favourable for mastication. 
 
 It is very strange that no example of iiaralysis of the dental 
 nerves Jias as yet been observed. This subject has engaged my 
 attention for several years, and I have been in the habit of in- 
 quiring from all my paralytic patients whether the sensibility of 
 the teeth was lessened ; but in no one instance have I been able 
 to detect anything approaching to the loss of sensation in these 
 organs, an immunity difficult to account for, and I believe unex- 
 ampled, for I am not aware of any other nerve either of sense or 
 of motion which is not occasionally involved in the progress of 
 paralytic affections ; nay, I have been more than once been obliged 
 to direct the removal of teeth in hemiplegic persons in conse- 
 quence of toothache on the paralytic side. This immunity from
 
 534 CLINICAL MEDICINE. 
 
 paralysis, corroborated by the extensive experience of Mr. 
 M' Clean, seems the more surprising, when we recollect how 
 subject the dental nerves are to the opposite affection, or a 
 morbidly increased and exalted state of sensibility constituting 
 the various forms of toothache. 
 
 Some physiologists have been inclined to suppose that the 
 temperature of bodies is judged of by other nerves than those 
 which are the instruments of the sense of touch ; but it appears 
 that if other arguments against this hypothesis are wanting, the 
 instance of the teeth alone would be sufficient, for here most 
 undoubtedly the sense of touch and the discrimination of tempe- 
 ratures are both functions of one and the same nerve, for the 
 teeth possess but one. 
 
 The disease to which I would now direct attention consists in 
 an insuperable desire on the part of the patient to grind his teeth. 
 This desire originates in a disagreeable uneasy sensation in the 
 teeth themselves, and is for the moment alleviated by forcibly 
 grinding them together, but immediately returns when the 
 patient ceases to perform this action, which is therefore continued 
 when the disease is confirmed during the entire day. When 
 asleep the patients no longer grind their teeth, the grinding being 
 in all cases the result of voluntary motion. I have now become 
 acquainted with the cases of four persons so affected, and it is 
 very remarkable that they were all of a confirmed gouty habit. 
 The first person in whom I observed it was my late excellent and 
 esteemed friend the Countess of Egmont, in whom this habit had 
 become so confirmed, that she was impelled to indulge in it 
 continually, for the moment she desisted, the uneasy sensation 
 in the teeth became insupportable, and consequently she was 
 obliged to give up all society for several years before her death. 
 The grinding was in her case strong and forcible, and having 
 been so long continued, at last wore down her teeth to the very 
 sockets. I consulted several of the most eminent surgeons in 
 London on her disease, among the rest Mr. Abernethy, but none 
 were able to suggest any means for its alleviation. She was so 
 thoroughly convinced that some permanent cause of irritation 
 existed in the teeth themselves, that at different times she had 
 several of them drawn in hopes of procuring relief, but they were 
 found to be perfectly sound. 
 
 I was lately consulted by the Rev. Mr. B., likewise of a gouty
 
 GOUT. 635 
 
 habit, and who is driven from general society by precisely the 
 same aftectiou. In him the molar teeth are worn quite flat and 
 smooth, and the incisors and canine teeth have undergone a 
 remarkable change, particularly the former, which being 
 constantly trJtetted by each other, have acquired chisel-shaped 
 edges, and are so sharp that when he inadvertently passes his 
 tongue over them, they make an incised wound like that inflicted 
 by a sharp knife. This gentleman's teeth have the enamel all 
 worn off" the crowns, and consequently their surfaces present a 
 section of the internal or osseous portion of the tooth ; and it is 
 remarkable that in this as well as in the other cases, the internal 
 or nervous cavity of the tooth is never exposed, but appears to 
 be, filled up with bony matter, in proportion as the process of 
 grinding wears away the crown, just as has been observed in the 
 case of old men, such as sailors, who have been in the habit for 
 many years of chewing sea-biscuit. The same phenomenon has 
 been likewise observed in the teeth of skulls supposed to have 
 been Roman, from which it has been inferred that they had 
 generally subsisted on very hard food. 
 
 The third case was that of a young clergyman in the south of 
 Ireland, likewise of a gouty habit, and who was afflicted with tic 
 douloureux of several branches of the fifth pair, and, among the 
 rest, of the dental nerves of the left side ; in him the teeth in 
 the left side only were ground down, and the disease ceased after 
 a continuance of two years. 
 
 The third case I have not seen, but the following particulars 
 have been furnished me by Dr. Battersby : — 
 
 "Henry W., County Meath, aged 60, has suffered from attacks 
 of gout for the last thirty years, which are now so tedious and 
 severe as to confine him to his bed for at least five months 
 annually ; about three years ago he was observed gradually to get 
 a habit of grinding his teeth, which he now does constantly 
 while awake, and so loudly as to be heard in the next room ; he 
 is not conscious of it unless when spoken to, I believe, and his 
 teeth are quite ground down. Two years ago he had an attack 
 of what he called gout in his teeth, and wanted to have them 
 pulled out." 
 
 I have now seen several cases of this kind, and I have observed 
 that they all occurred in persons of the gouty diathesis. The 
 grinding of the teeth continues for years as a daily habit, and
 
 536 CLINICAL MEDICINE. 
 
 produces very remarkable changes in the conformation of these 
 organs, affecting sometimes one side of the jaw, sometimes both ; 
 so that in confirmed cases we frequently find the teeth ground 
 down to the level of the gums. There is not at present the 
 slightest doubt on my mind that the irritable state of the dental 
 nerves which gives rise to this irresistible tendency to grind the 
 teeth, depends chiefly on the existence of gout in the constitution. 
 I may observe, however, that in many persons in whom the teeth 
 are found worn nearly to the gums, there appears to be another 
 cause in operation. Thus, in cases of indigestion, it is not 
 unusual to find the enamel of the teeth partially or considerably 
 worn away long before the natural time ; and in such instances 
 we used formerly to attribute the injury to the generation of 
 acids in the stomach. The researches of Donne and Thomson, 
 however, have shown that the saliva is subject to very remarkable 
 alterations in certain forms of dyspepsia, and that whenever the 
 disease is accompanied by much irritation of the gastric mucous 
 membrane, and derangement of its secreting functions, the saliva 
 becomes extremely acid, and, of course, capable of corroding the 
 enamel of the teeth. The following case has recently come 
 under the notice of Mr. Pakenham, of Henry Street :— 
 
 "A gentleman, aged 45, slightly made, but muscular, and 
 born of healthy parents, was attacked with shivering and loss of 
 power of the right side after a severe wetting. He recovered 
 under appropriate treatment ; but, about a year afterwards, began 
 to observe in himself a tendency to grind his teeth, which 
 gradually increased to such an extent as to prove a nuisance to 
 himself and every one about him. Under these circumstances 
 he consulted an eminent surgeon in Dublin, who applied the 
 actual cautery behind one of his ears, slightly affected his system 
 with mercury, and extracted one of his teeth, — all with consider- 
 able relief, which lasted for about six months. He then became 
 as bad as ever, and applied to another surgeon, who tried iron in 
 every form without success : and subsequently to a third practi- 
 tioner, who used in addition leeching, blistering, postulation with 
 tartar emetic, and various other remedies, but without any 
 favourable result. All this time his medical attendants, so far 
 from suspecting the presence of gout, ridiculed the idea of its 
 existence. 
 
 "About three months ago this gentleman came to Dublin,
 
 GOUT. ' 537 
 
 went to dine at the house of a friend, and, with some others, 
 supped late at uight, and drank some whisk}' punch. Next day 
 he had vomiting, purging, and epigastric tenderness, and on the 
 day after, the ball of his great toe became swollen, hot, and 
 exquisitely painful, leaving no doubt as to the nature of the 
 affection. In this gentleman's case the grinding of the teeth is 
 not constant, but it is always greatest when the stomach is most 
 deranged. The teeth in the under jaw are all sound : three or 
 four of the molars of the upper jaw have been extracted. The 
 four upper incisors are ground nearly half way through to the 
 gum on the one side, while the lower are very little worn. By 
 pressing the tongue against the upper incisors, or by touching a 
 certain point of one particular tooth, he can at any time arrest 
 the tendency to grind, and can suspend it as long as pressure is 
 continued in the manner just described." 
 
 Although I have as yet been unable to discover any mode of 
 alleviating the sufferings of patients affected with this hitherto 
 undescribed disease, I have thought it right to give you the j)re- 
 ceding short account of its chief sj'mptoms, in the hope that 
 others may be induced to publish the results of some successful 
 method of treatment. 
 
 With the view of further illustrating the varieties of gout, I 
 shall detail the following remarkable case, which came recently 
 under my notice. The patient, a gentleman of large fortune, is 
 of a strong and athletic frame, about five and thirty years of age, 
 and a member of a family subject to gout. He was much addicted 
 to field sports, and accustomed, in cold weather, to frequent 
 immersion of his feet in cold water, in pursuit of his favourite 
 amusement, snipe-shooting. The consequence of this exposure 
 has been, that he has been labouring for some time under a 
 neuralgic affection of the lower extremities, which commenced 
 in the feet and ankles, and extended gradually upwards, involving 
 the whole of the lower extremities as far as the hips, and giving 
 rise to sufferings of a very intense character. 
 
 Repeated exposure of the feet to cold seems often to lay the 
 foundation of creeping paralysis. Now in this case there is some 
 danger that the gentleman, were proper measures neglected, may 
 ultimately become paraplegic, or even generally paralytic. I do 
 not bring this case forward as an example of gouty pains gradually 
 advancing from the extremities towards the spine ; for although
 
 538 CLINICAL MEDICINE. 
 
 I strongly incline to the opinion that his complaint is of a gouty 
 nature, and although most of his medical advisers have suspected 
 a gouty complication, still this is by no means a decided point ; 
 but the opinion of his usual attendant, Dr. Little, of Sligo, 
 exactly agrees with mine, as he considers the case to be gouty 
 neuralgia. Be this as it may, his case presents a very interesting 
 specimen of creeping neuralgia, chiefly affecting the cutaneous 
 nerves (nerves exclusively destined to perform the function of 
 sensation), but gradually implicating the nerves of motion in the 
 disease. I shall now proceed to lay before you the details of this 
 case, which have been noted with singular accuracy and ability 
 by the gentleman himself. In a letter to me he observes : — 
 
 "As you wish for a description in writing of the manner in 
 which I am affected, I subjoin every particular I can think of 
 which seems likely to throw Sinj light on the subject. 
 
 "It is now nearly five years since I began to suffer severely 
 from pains in my limbs, which for the last two or three years I 
 have looked upon as neuralgia. About a year previous to that 
 time I had occasional pains in one foot, which increased so as to 
 become violent on one occasion, after a long ride. I had, how- 
 ever, been always in the habit of riding, and considered that 
 exercise to agree particularly well with my health. Indeed, I 
 had found hunting of great use to me when suffering from liver 
 complaint, having had inflammation of the liver twice in my life. 
 It is now fourteen years since I had the last attack of liver 
 disease, and I very seldom have pain in my side ; whenever it 
 occurs, it is generally removed by the use of a little blue pill. 
 
 " When first the pains in my limbs commenced, they were con- 
 fined to my feet ; then, for a long time, extended no higher than 
 my knees ; latterly they had ascended as far as my hips, where, 
 and in the groin, I sometimes experience great suffering. I have 
 had occasional twitches in my arms, and very slightly across the 
 chest. The pain always comes on with sudden violence, which 
 renders it very hard to bear, especially when it attacks me during 
 sleep. I am frequently aware of its approach, from a general 
 feeling of discomfort and depression ; from which, in the begin- 
 ning of my complaint, I used to suffer very much for two or three 
 days before an attack. These paroxysms have, for four years, 
 shown a great tendency to periodicity, recurring generally once 
 every week, commencing on Saturday or Sunday, and sometimes
 
 GOUT. 539 
 
 on Friday, and lasting till Monday. They have twice or thrice 
 lasted for a week together, but sometimes continued only a few 
 hours. 
 
 "'In the commencement I have occasionally been free from 
 them for two or three months together ; and within the last year 
 was free from them, at two difterent periods, for a whole month. 
 "When in pain, I have never experienced the slightest alleviation 
 from, anything, except at times from a full meal with wine, par- 
 ticularly champagne. I have often been unable to remain in 
 bed from the violence of the pain, which is increased by the 
 weight of the bed-clothes, or the slightest touch of anything ; even 
 the air blowing on the part brings on violent torture : at the 
 same time I can bear strong pressure, or even a blow on the 
 parts, without making me worse. The pain appears to be quite 
 on the surface, except that sometimes it appears deeply seated, 
 particularly in the ankle-joint and shin-bone. It is unaccom- 
 panied by any redness or swelling, and flies instantaneously from 
 one limb to the other, rarely occurring in both at the same time. 
 It leaves behind great weakness of the affected limb, so as to 
 oblige me to walk with a stick for some time, and occasionally 
 with two. 
 
 " One very unpleasant consequence of the pains in my limbs is, 
 that I now find I cannot use exercise on horseback, if I leave it 
 off for any time. I have found this and walking at all times 
 conducive to my general health. Indeed I can still walk a good 
 deal, even during an attack, although it is very painful, par- 
 ticularly when setting out. I find it necessary almost constantly 
 to have recourse to aperient medicine — generally rhubarb pill. 
 At times I have had giddiness of my head, and noise in my ears, 
 to a very distressing degree ; and have had recourse to powerful 
 purgatives, and even bleeding, to remove the symptoms, without 
 effect. A medicine, principally nervous, in which gentian was 
 an ingredient, relieved me at one time, after finding the above 
 remedies ineffectual. 
 
 " I have already tried iron, mercury, nitro-muriatic acid, stra- 
 monium, arsenic, and the external use of croton oil, without 
 benefit, except that I felt rather better for a month after the use 
 of these remedies, but no longer, and the pain returned with 
 great violence at the end of that period. The counter-irritation 
 appeared to increase my sufferings. I have also tried anodyne
 
 540 CLINICAL MEDICINE. 
 
 embrocations without effect. Anxiety of mind, or annoyance, 
 often brings on an attack. I even remarked, the other day, that 
 it came on instantaneously, on breaking a tooth whilst eating. 
 On the other hand, excitement, whether from a sudden necessity 
 for exertion, as on occasion of an accident, or anything that 
 gives a pleasing interest and occupation to my mind, such as 
 travelling through an interesting country, seems to keep off, and 
 sometimes even remove an attack." 
 
 The following most interesting account of his own case, which 
 I received from Dr. Mackness, of Hastings, and which I read 
 from his letter, bears much similarity to the foregoing case ; on 
 which account I introduce it here. All the symptoms, however, 
 may, I think, be ascribed to functional derangement of the 
 spinal marrow : — 
 
 " The symptoms in the case of what is here called gouty 
 neuralgia are, in some respects, very similar to what I have 
 myself suffered, and this without any hereditary or constitutional 
 tendency to gout. I am inclined to think that the malady has 
 its origin in slight inflammation or irritation of the spinal cord 
 or its membranes, this state being excited by certain impressions 
 made upon the extremities of the nerves, especially of the lower 
 limbs, and carried along the trunks to the nervous centres, — cold 
 being usually the exciting cause ; but for this to produce the 
 specific effect of which I speak, I believe it necessary that the 
 digestive organs should be in a state of irritation : such was 
 the case with me. I was residing in the country at the earliest 
 commencement of my disease, where the atmosj^here was usually 
 loaded with moisture, arising from a sluggishly flowing river, a 
 short distance from the banks of which my residence stood. I 
 had, in attending to my professional duties, much night work ; 
 riding, perhaps, for several miles on horseback through a foggy 
 atmosphere, and then having to sit for hours in a cold cottage or 
 farm-house, my feet and legs as cold as if they were immersed in 
 ice water. I was very temperate in my habits, but I suffered 
 much from dyspepsia ; at first the pains were slight, and the 
 paroxysms very short, but gradually they became more severe 
 and of longer continuance, generally affecting the lower ex- 
 tremities ; at the same time there was slight loss of power in 
 these limbs, which manifested itself by a little awkwardness 
 of gait, and was more observable to my friends than to myself.
 
 GOUT. 541 
 
 This state of things continued rather increasing in severity for 
 two or three years, at the end of which period my gait became 
 much more unsteady, and I found it difficult to walk in the dark, 
 or Avhere my eyes were not fixed on the road. Bilious attacks, 
 attended with constant sickness and vomitings of bile, with 
 severe pain in the brow and shoulder, then began to visit me at 
 stated intervals, these intervals becoming shorter and shorter, 
 until I rarely passed a month without having had two or three. 
 In the meantime the pain became more severe ; so intense was 
 it at times, that I have as much dreaded any of my family 
 coming within a yard or two of me, for fear that some part of 
 their dress might touch me, and thus excite a paroxysm, as any 
 hydrophobic patient dreads the sight of fluid or any glistening 
 surface. A draught of air was often quite sufficient to excite the 
 paroxysm : what was perhaps worse to bear than even the pain 
 itself, was the constant dread I had during an attack of its coming 
 on. It was not one part only that was affected, but oftentimes 
 the whole of the extremities in turn, yet mostly the lower. I 
 have sometimes tried to point out to my friends the spots which 
 the pain attacked, but so quick were the transitions from one 
 place to another, that although I have tried to touch each part 
 successively, I have always failed in being able to do so sufficiently 
 quickl}'. The cutaneous nerves were often so sensitive, that the 
 slightest touch would produce the most exquisite torture : thus 
 giving an example of the law established by Dr. Marshall Hall, 
 that in proportion as the muscles become less under the control 
 of the will, this irritability becomes increased. This continued 
 strain upon the nervous system produced epileptic fits, which 
 continued for some years, and another affection of the nervous 
 system — spasmodic closure of the glottis — began at this time to 
 show itself, often threatening suffocation. It is very singular that 
 my father was subject to the same affection. At length I gave 
 up my professional duties, after having suffei'ed for four years a 
 mart^'rdom, and went abroad, at first with some benefit, but I 
 afterwards became worse. Having been accustomed to a ver}'- 
 active life, the change to one of complete idleness, although at 
 first useful and pleasant, became after a time intolerable, and 
 produced a state of ennui upon the mind which appeared to keep 
 up the malady. In this state, weak and emaciated as I was, I 
 determined once more to resume my professional avocations, and
 
 542 CLINICAL MEDICINE. 
 
 as I had found by experience that a cokl, damp atmosphere with 
 a claj'ey subsoil was injurious to me, I chose this place for a 
 residence, where I have now resided eight years ; my health and 
 strength gradually improving. The means which I have found 
 most useful in my case have been a simple but nourishing diet, 
 taken only in such quantities as the stomach would bear without 
 a feeling of oppression, moderate exercise not amounting to 
 fatigue, and agreeable occupation of the mind. I do not now 
 suffer often from the disease, and when I do suffer, the attacks are 
 trifling compared to what they formerly were. My firm belief is 
 that I should not suffer at all if my mind was perfectly quiet and 
 pleasantly occupied ; but I have now a large practice, often much 
 bodily and mental fatigue, and sometimes considerable exposure 
 to the weather in long journeys ; and as these are inseparable 
 from the practice of a profession which I love with all my heart, 
 I make up my mind to suffer a little rather than forego it. I 
 have reason to think that the situation of Hastings is peculiarly 
 favourable to my disease. I have never fully recovered the per- 
 fect use of my lower extremities, yet they are much stronger 
 than formerly ; for I used to require a stick to walk with, now I 
 never or rarely use one. I do not, however, walk much, as I 
 find I am soon tired." 
 
 Another singular affection I have lately witnessed in connexion 
 with gout, I may mention here. A lady of a decidedly gouty 
 habit, aged 60, applied to me under the following circum- 
 stances : for the last two months she had become liable to a 
 daily paroxysm, which observed the following course. About 
 three o'clock in the afternoon her nose began to grow hot, and 
 the heat continued for four or five hours, the part becoming first 
 of a bright, and then of a purplish red colour, which spread to 
 the upper portion of her cheeks, and was accompanied by some 
 uneasiness, but no pain, and always subsided about the same 
 hour in the evening. I advised small doses of colchicum to be 
 taken in this case. 
 
 In general, a regular attack of gout in the extremities is 
 preceded by a longer or shorter period of constitutional disturb- 
 ance and dyspepsia. We must not, however, in making the 
 diagnosis between gout and rheumatism, consider this distinction 
 as not liable to exceptions, for I have seen more than one case of 
 hereditary gout, in which the arthritic attacks came on suddenly
 
 GOUT. 543 
 
 •without the slightest precursory derangement of the health, or 
 the operation of any assignable cause. I have as yet seen no 
 instance of a similar nature in acquired gout. 
 
 Another exception to the general rule is also worthy of notice. 
 In general, a lit of the gout is preceded and accompanied by a 
 scanty secretion of turbid high-coloured urine. As the fit goes 
 off, the urine increases in quantity, becomes clearer and paler, 
 and loses its tendency to deposit the lithates and purpurates. 
 Now, in two cases of hereditary gout, I have seen this order 
 reversed, and the approach of the lit announced by a great 
 increase in the secretion of urine, which was quite watery and 
 limpid, and continued so until the violence of the articular 
 inflammation began to decline. The urine then became scanty, 
 and deposited the lateritious and pink sediment in great 
 abundance. 
 
 That the gouty diathesis may excite its specific inflammation 
 in most of the tissues of our organs is a fact generally admitted ; 
 but I regret to state that our knowledge concerning the eflects 
 W'hich it produces in these various tissues is far from being 
 accurate or extensive. Beere, M'Kenzie, Middlemore and 
 others, have done much towards elucidating its eftects on the eye 
 and its appendages ; and we are tolerably well acquainted with 
 its progress in serous, synovial, and fibrous membranes. What 
 changes it produces in the secretions of mucous membranes is a 
 question which has not been studied with an attention commen- 
 surate to its importance. Thus, though all acknowledge the 
 existence of gouty cough or bronchitis, the diagnosis and history 
 of this affection are still very incomplete. This has been 
 acknowledged by Dr. Stokes, who has published by far the best 
 account of bronchitis which has yet appeared.* The eflects of 
 gout on the lining membrane of the urethra and bladder are 
 better known and studied, but I think that much still remains 
 to be done in this as in every other class of inflammatory 
 diseases, where the inflammation depends upon a constitutional 
 taint. 
 
 In my published lectures I have long since expressed an 
 opinion at variance with that generally taught couceruiug the 
 
 * " On the Diac;no?is and Treatment of Diseases of the Chtst," by W. Stokes, M.D. 
 This work places its author among the first medical obs.rvers of the day, and has 
 acquired for him a European fame.
 
 544 CLINICAL MEDICINE. 
 
 bronchitis and pneumonia which accompany pulmonary consump- 
 tion, and I have brought forward strong reasons for beheving 
 that too much importance has been attached, and attention too 
 exclusively devoted, to the tubercles in this disease. Thus, 
 authors talk of tubercular pneumonia, where it would be more 
 correct to designate the affection as scrofulous pneumonia 
 accompanied by tubercles ; they speak of tubercular cavities 
 and abscesses in the lung, in cases where scrofulous cavities and 
 abscesses exist. In fact, I repeat it emphatically, that the 
 essential characteristics of phthisis pulmonalis are derived from 
 scrofula. This it is which converts what would be common into 
 consumptive pneumonia or bronchitis — this it is which so often 
 renders both incurable. 
 
 Tubercles and tubercular infiltration are mere results of 
 nutrition morbidly modified by scrofula ; they are effects, not 
 causes. They often exist without scrofulous inflammation, and 
 the latter may exist without them. It gives me much pleasure 
 to find that these opinions, which I published many years ago, 
 have received ample confirmation from the observations of Dr. 
 Kingston, in a paper read before the Royal Medico-Chirurgical 
 Society of London, and shortly noticed in the Medical Gazette, 
 April 29, 1837. 
 
 In pursuing the subject of my lecture, I shall now turn to the 
 consideration of some phenomena connected with the gouty 
 diathesis, which possess a much deeper interest, and lead to 
 views of far greater importance. I mentioned before that we 
 frequently observe flying pains, or twitches in various parts of 
 the body, arising from a rheumatic or gouty cause ; that in some 
 instances these affections appear to be limited chiefly to the 
 nervous trunks or branches, and that we have thus what may be 
 termed gouty or rheumatic neuralgia. We are familiar with 
 rheumatic or gouty sciatica, and we know that the history 
 and termination of this form of disease often prove it to be 
 inflammation of a specific character, chiefly confined to the trunk 
 of the sciatic nerve. Now, it is not unreasonable to suppose that 
 this specific inflammation of a nervous trunk or branch may, 
 like other inflammations, extend farther, so as to involve parts 
 of more importance to the economy. 
 
 What I wish to draw your attention to is this — that in certain 
 cases, where gout attacks the nerves, giving rise to gouty
 
 GOUT. 545 
 
 congestion or inflammation frequently recurring, and acquiring 
 increased strength and deeper root as it proceeds, the morbid 
 afl"ection may, after years, or even months, run on until it reach 
 the spinal cord, involving a certain portion or portions of that 
 organ, and producing loss of sensation and motion commensurate 
 to the amount of spinal derangement. This is by no means 
 an anomalous occurrence ; it is merely an instance of disease 
 originating in the periphery of the nervous system, passing along 
 the trunk of the aifected nerve with a retrograde motion, and 
 finally reaching the central parts. 
 
 It is too much the custom to look upon paralysis as depending 
 upon original disease of the nervous centres. When I come to 
 speak of paralysis, I expect to be able to prove to you that, very 
 often, disease commencing in the nerves of some particular part 
 or organ may be gradually propagated to the spine, producing 
 all the symptoms which are referable to an original affection of 
 the nervous centres. I shall also bring forward numerous facts 
 in proof of the propagation of disease fi'om the circumference to 
 the centre of the nervous system ; and the pathological deduc- 
 tions to be drawn from these facts seem to me to include all the 
 physiological discoveries made by Miiller and Marshall Hall, 
 concerning what the latter terms the reflex function of the spinal 
 marrow. I shall be able to show you that enteritis, arising 
 suddenly in two young and healthy persons, from indigestion 
 and obstruction caused by an error in diet, was followed in both 
 by well-marked paraplegia. I shall likewise bring before you 
 examples of paraplegia connected with stricture of the urethra, 
 and which were relieved by curing the stricture ; and I shall 
 detail cases of acute and chronic afi'ectious of the uterus and 
 kidneys, which had entailed on the patients, as a remote conse- 
 quence of the original disease, loss of the power of motion in 
 the lower extremities, sometimes partial and curable, sometimes 
 irremediable and complete. 
 
 The cases I am about to relate to you now are most interestincf 
 and valuable, and enable me to carry this principle still farther, 
 by proving that gouty inflammation of the nerves and their neuri- 
 lemma may, in process of time, extend to the spinal marrow and 
 its investments, and give rise to derangements of the latter, 
 terminating in ramollissement and structural degeneration. 
 
 The subject of gouty degeneration of the spinal cord has not 
 VOL. I. 35
 
 546 CLINICAL MEDICINE. 
 
 been alluded to distinctly by any author with whom I am 
 acquainted, and is, as far as I can learn, quite new. The 
 deductions, therefore, which are drawn from my cases must, of 
 course, be subject to such modifications as may be derived from 
 future experience, and must remain to be confirmed by further 
 observation. It has been long known that gout may attack the 
 brain, and the existence of gouty paraplegia is well known by 
 practitioners who have studied attentively the progress of arthritic 
 afiections. Thus, in a case which I witnessed some time back, 
 in consultation with Mr. Kirby, he prognosed the supervention 
 of paraplegia at a time when the indications of its approach could 
 not have been discovered by any observer of less experience and 
 sagacity. 
 
 I have already stated that gouty affections of the brain have 
 long been known, and I am not sure that some of the older 
 authors may not have alluded to gouty affections of the spinal 
 marrow ; but as our knowledge of the peculiar state of the brain 
 and spinal cord, termed ramollissement, is comparatively recent, 
 and not dating with any degree of accuracy earlier than the works 
 of Abercrombie, Eostan, and other modern authors, it is obvious 
 that any observations made by the older writers concerning gouty 
 affections of the nervous centres can have no distinct reference to 
 this lesion. The connexion, therefore, of ramollissement of the 
 spinal cord with gout may be considered now, for the first time, 
 distinctly pointed out. As one of the cases which I am about to 
 detail presented an example of the most extensive ramollissement 
 of the spinal marrow on record, it would, on this account alone, 
 be especially deserving of attention ; but its interest is increased 
 tenfold when placed in juxtaposition with the second case, so 
 as to exhibit in a striking point of view the close resemblance 
 observable in the march or progress of both, as well as the iden- 
 tity of the lesion discovered after death. 
 
 Mr. , residing in the Island of Anglesey, was very much 
 
 addicted to field sports, and, while thus engaged, would occa- 
 sionally remain for a whole day without food. He was also very 
 fond of angling, and has been frequently known to wade up to 
 his waist in water for many hours together, during very cold 
 weather. His general health was good, and his habits were 
 abstemious. In 1825, when about twenty-five years of age, he 
 had fever, attended with inflammation of the joints, and said to
 
 GOUT. 547 
 
 be rheumatic : some pain and stiffness, and an evident enlarge- 
 ment of the knee-joints, remained after the other articular 
 affections had disappeared ; these symptoms, however, yielded 
 in a few months to rest and appropriate treatment. His health 
 also improved greatly, and he had no complaint of any kind 
 whatever until the autumn of 1828, when he had a slight 
 attack of ordinary cholera, after returning from a shooting 
 excursion. 
 
 In the spring of 1832 he was attacked with pain in one foot, 
 supposed to be of a gouty nature. This pain disappeared during 
 a drive of fifteen miles in an open carriage, but a certain degree 
 of tenderness remained, and was always felt, more or less, in the 
 part originally affected. He had a similar attack of pain and 
 tenderness in the same foot in the following autumn. At the 
 time when this attack commenced he was twenty miles from 
 home, and observed that during his journey the pain became 
 diminished as before, and in a few days subsided altogether. In 
 August, 1833, he had a similar, but much more severe attack : 
 the pain was much more violent than before, and both feet v^^ere 
 affected. This, however, did not prevent him from following 
 field sports as usual. He went on horseback to the mountains 
 to shoot grouse ; and to this exercise, and drinking a bottle of 
 wine, he attributed his speedy, or rather sudden recovery from 
 the pain in his feet. 
 
 Hitherto we have seen a naturally strong constitution struggling 
 successfully against exposure to cold, imprudent habits, and a 
 most injudicious method of disturbing, or rather repelling, local 
 inflammation depending on a gouty diathesis. It is not easy to 
 explain how it happened that driving in an open carriage, or 
 riding over the mountains, so effectually cut short the paroxysms 
 of gout in the feet ; but it is enough to know that the fits were 
 suddenly and imprudently arrested, to be prepared for the con- 
 sequences which ensued — viz., an irregular distribution of the 
 gouty effort, and its determination to internal organs. 
 
 In September, 1833 — that is, about a month after the sudden 
 subsidence of the last attack — he was seized with violent colic, 
 accompanied by obstinate constipation. The pain was very 
 severe, but he suffered more from a general feeling of restlessness 
 (a restlessness beyond belief, as he expressed it) than from actual 
 pain. He was also greatly annoyed by singultus, and was jaun-
 
 548 CLINICAL MEDICINE. 
 
 diced after recovering from the attack of colic. In January, 1834, 
 he had another attack of colic, preceded by a fit, the precise 
 nature of which I was unable to ascertain. As these abdominal 
 attacks frequently recurred, I shall give a description of one of 
 them, as communicated to me by Dr. Llewelyn Jones, jun., his 
 attending physician. 
 
 "A dull, wearing, and fixed pain would attack the patient in 
 the region of the colon : this pain was not increased by pressure, 
 and was accompanied by nausea, occasionally by vomiting, and 
 always by obstinate constipation. These symptoms were attended 
 with a most distressing sensation of restlessness and anxiety. 
 They lasted on one occasion for three days and nights before I 
 could get the bowels opened, when they were immediately miti- 
 gated. The pulse was never quickened, and in general remained 
 natural ; but if the attack was prolonged, it became weak. 
 There never was any fever, nor any well-marked indication 
 of inflammation in the abdomen. These attacks were always 
 preceded or followed by a gouty affection of the feet." 
 
 The attacks in the stomach and bowels recurred frequently, 
 and always with the same symptoms, until August, 1835, when 
 a visible tremor of the fingers became observable : during some 
 preceding attacks he used to comjolain of weakness of the wrists 
 and pains in the fingers, particularly the last joints. As the 
 disease progressed, these pains became more intense and exten- 
 sive, and the torture he felt in the hands and arms was beyond 
 description. After August, 1835, he began to lose the use of 
 his arms, the tremors increased, and he began to complain of 
 stifi'ness about the neck, with great restlessness and anxiety. 
 The abdominal attacks came on occasionally, but not so severely 
 as before. The arms became gradually weaker, until the loss of 
 muscular power was complete, and they were greatly emaciated ; 
 but Dr. Jones, who had the patient under his observation until 
 August, 1836, could not detect any evident diminution either in 
 the upper or lower extremities, and the intellectual faculties 
 remained perfectly unimpaired. 
 
 In October, 1835, two months after the state of the upper 
 extremities had indicated the approach of paralysis, the lower 
 extremities became similarly engaged ; they were affected with 
 tremors and weakness, and in the following December the patient 
 had an attack of violent pain, with swelling and increased heat
 
 GOUT. 549 
 
 in the ball of one foot, which was pronounced to be of a distinctly 
 gouty character. After each attack of pain in the feet, as I have 
 been informed by this gentleman's sister, the loss of power in 
 all his limbs increased, and if he gained a little strength in the 
 intervals between these attacks, a recurrence of the paroxysms 
 always made him worse than before. 
 
 In February, 183G, I went to Anglesey to visit this gentleman, 
 and saw him in consultation with Dr. Jones and Dr. Williams, 
 of Denbigh. After a minute examination of the history and 
 symptoms of the case, I declared it to be my opinion that a 
 gouty inflammation had attacked the nerves of the extremities, 
 and had finally extended to the spinal cord and its sheath. I 
 said that at an earlier period of the disease I would have advised 
 salivation by mercury, but as that was inadmissible under the 
 existing circumstances, we should have recourse to other measures. 
 I forgot to state that, from the commencement of the disease, 
 the advice of Sir B. Brodie and other eminent practitioners in 
 London had been obtained by letter. 
 
 It would be useless to detail the various general and local 
 remedies fruitlessly employed in this gentleman's case. He 
 went to Liverpool in August, 1836, for the benefit of further 
 advice ; but finding no relief, returned to Denbigh, where he- 
 died in the ensuing October. For some time before his death 
 he was greatly emaciated, and quite paralytic in all his limbs, but 
 retained his faculties to the last. His body was examined by 
 Dr. Williams, whom I had met in consultation in the preceding 
 February. This gentleman informed me, that the viscera of the 
 thorax and abdomen were healthy and normal, that no derange- 
 ment or lesion of the brain could be detected, but that the spinal 
 cord, opposite to the last cervical and first dorsal vertebrae, was 
 softened to the consistence of thick cream ; the remainder of the 
 cord was also softer than natural, but did not present anything, 
 peculiar in other respects. 
 
 In a letter which I have since received from Mr. Williams, to- 
 whose kindness I am much indebted, he expresses himself with 
 regard to the nature of the patient's disease in a way which con- 
 firms the views I have taken. He observes : — " I once saw Mr. 
 
 in an attack of the gout in the feet, about three years before 
 
 his death. There was much pain, and a decided gouty blush. 
 Exposure in fishing and shooting to a very imprudent degree,
 
 550 CLINICAL MEDICINE. 
 
 while under the influence of these gouty attacks, I have no douht 
 did much to render the disease irregular and erratic." 
 
 The fact that the tremors and loss of power commenced in the 
 arms two months before indications of paralysis of the lower 
 extremities appeared, is sufficient evidence to prove that the 
 spinal marrow was not the point from which the diseased action 
 l^roceeded originally ; for had this been the case, an affection of 
 this organ, sufficiently violent to give rise to paralysis of the 
 upper extremities so gradual in its progress, and so well 
 developed, must long before this period have occasioned paralysis 
 of the legs also. There is a striking analogy between the 
 progress of the tremors and paralytic symptoms in this case and 
 in cases of painter's colic ; and the analogy likewise holds good 
 as to the violent spasmodic affection of the bowels, and the 
 constipation observed in both. It is further worthy of notice, 
 that in painter's colic the nervous affection is accompanied by 
 pain and weakness of the extremities, and ultimately, although 
 long after the commencement of the disease, by spinal tender- 
 ness — a fact which has been already noticed by Dr. Bright. 
 Again, in painter's colic, as in the disease which I have just 
 detailed, the affection of the spinal cord and the consequent 
 paralysis are evidently subsequent to the disease of the peripheral 
 portion of the nerves. 
 
 The next case which I shall now proceed to detail is one of 
 equal interest and importance. A gentleman of robust frame, 
 aged about fifty-five, and having an hereditary predisposition to 
 gout, to which his father had been a martyr, and which had 
 exhibited itself in one of his sons at the early age of thirteen, 
 consulted me on the 7th of June, 1836. Being a man of 
 extensive landed property, he resided chiefly in the country, and 
 was in the habit of using much active employment and exer- 
 cise, but indulged rather freely in the pleasures of the table. 
 After suffering much annoyance from dyspeptic attacks and 
 various premonitory symptoms, he had a regular paroxysm of 
 gout in the spring of 1828 ; he had a similar one in 1830, and 
 another in 1832, each occurring, as before, during the spring 
 season, and remarkably severe. During the year 1832 he had 
 several slight returns of the complaint, and in January, 1833, 
 had an alarming attack of an enteritic character, accompanied by 
 spasms of the stomach and acute pain of the extremities. In the
 
 GOUT. 551 
 
 autumn of 1834 he suffered greatly from a nephritic affection, and 
 got relief after passing a considerable quantity of uric acid gravel. 
 
 In the spring of 1835 he had a fall from his horse, and for 
 some time afterwards complained of pain in the small of the back 
 and around the trunk. He recovered, however, and during the 
 summer and autumn of that year remained pretty well ; but in 
 the last week of December caught cold, which was followed by 
 severe cough, and pains in the chest and feet : the latter were 
 then considered to be the effects of gout. From this period his 
 health, though often apparently restored, was never firm : he 
 became subject to sudden attacks of pain, particularly in the 
 chest, which gave him much uneasiness. On the 3rd of June 
 he consulted a physician in his neighbourhood, to whom he 
 described his ailment as " a slight pain in the right side, which 
 troubled him only a short time before he got up in the morning ; " 
 this he stated he had felt occasionally for two months before. A 
 very careful examination was made over the situation of the liver, 
 the place in which he said he felt pain ; but no tenderness or 
 swelling whatever was detected, nor was there any in the direction 
 of the spinal cord. His pulse was at this time perfectly regular, 
 his bowels natural, and no dyspeptic symptoms existed. He 
 used, by the advice of this physician, tonic and laxative pills 
 and a stimulant embrocation. 
 
 When he consulted me on the 7th of June, 1836, I found 
 him labouring under what appeared to me to be pleurodynia of 
 an intermittent and gouty character. During the day he was 
 perfectly free from pain, but in the evening the pain commenced, 
 and continued with violence until morning. It is unnecessary to 
 detail here the various local and constitutional remedies which I 
 employed in this gentleman's case, but without any favourable 
 result. From the middle of June his symptoms became worse ; 
 during the first part of the night his pains very severe ; towards 
 morning he usually obtained relief by lying on his face, and 
 carefully avoiding all motion. About the latter end of July, the 
 pain, which had been almost constantly felt at the right side, 
 moved to the left, imparting at one time the feeling as if a spear 
 were passing through the diaphragm, and at another resembling 
 the sensation as if these parts were squeezed in a vice. When he 
 was in the horizontal position this pain was accompanied by a 
 sense of weight ; and at times the pain would shoot upwards to
 
 552 CLINICAL MEDICINE. 
 
 the clavicles, producing tenderness of the intercostal spaces. 
 When the diaphragm was free from pain, it most commonly 
 attacked the postero-inferior edges of the scapula, and the dorsal 
 region in its vicinity. 
 
 In August he tried the use of a warm bath, and found 
 temporary relief from the first he took ; he remained too long in 
 the second, which was heated to the temperature of 100, and 
 nearly fainted. He used the warm bath six or eight times, but 
 found no material benefit from it, and could not bear the pain 
 produced by the jolting of his carriage in going thither. About 
 this time there was a visible alteration in his gait and figure ; 
 the left shoulder was elevated, his whole frame attenuated, and 
 his face pale ; he had nearly lost all power of bending the spine, 
 and walked with a peculiar stiffness of gait as if his arms were 
 pinioned. On the morning of the 21st of August he stated that 
 he had suffered great agony during the night, and on its abating, 
 considerable tumefaction was observable under the right ribs. 
 Dyspeptic symptoms now became urgent ; his urine scanty and 
 turbid ; he became melancholy, and his mind was wholly occupied 
 with sad presentiments. At my recommendation he came to 
 town, in order to place himself under my more immediate obser- 
 vation, and to have the benefit of a consultation. 
 
 About the 30th of August he got, to his great joy, an attack 
 of gout in both feet ; while this lasted, which was for about six 
 days, he had complete relief from the agonizing pains in the dia- 
 phragm and chest. The interval of tranquillity was, however, 
 but of brief duration ; the inflammatory affection of the feet 
 suddenly subsided, and the pain attacked the diaphragm with 
 increased intensity. His strength, which had been rapidly failing, 
 now gave way, and he became quite paraplegic. About the 
 10th of September the abdomen became engaged, without any 
 alleviation of the thoracic symptoms, and he began to complain 
 of constipation, tympanitis, and abdominal tenderness. The 
 mucous membrane of the bladder became next affected ; he had 
 retention of urine, with great irritation of the prostate gland, 
 and it was necessary to draw off the water with the catheter 
 several times in the day. This state continued from the 22nd of 
 September to the 10th of November, when the sphincter of the 
 bladder became paralysed, and the urine drained off as fast as it 
 was secreted.
 
 GOUT. 553 
 
 During all this time the urine continued to present the 
 characteristic marks of the lithic acid diathesis in an extreme 
 degree, and contrasted strongly with the secretion furnished by 
 the inflamed mucous membrane of the bladder, which consisted 
 of a greyish or whitish yellow, viscid, and somewhat puriform 
 mucus, containing either a free alkali or an alkaline carbonate. 
 This secretion was extremely adhesive, and hung down in long 
 ropy filaments when the vessel in which it stood was inverted. 
 The nature of this mucus was such as to prevent any reaction 
 from taking place between its own alkali and the acid of the urine. 
 The co-existence of two secretions in the bladder, the one alka- 
 line and the other acid, as observed in this case, is extremely 
 curious. 
 
 In this way the patient's sufferings went on every day in- 
 creasing, and requiring the most extraordinary care to produce 
 any alleviation, a task which was discharged with the most inde- 
 fatigable humanity and attention by Mr. Richardson, to whom 
 I am indebted for most of the details connected with the earlier 
 history of this case. About ten days before his death the 
 extremities, upper as well as lower, and the trunk became quite 
 paralytic ; and from the cervical vertebrae downwards all power 
 of motion and sensation was lost. His voice now became weak 
 and inarticulate, deglutition was greatly impeded, and he finally 
 sank on the 27th of November, 1836. 
 
 It may be necessary to state that at the time the paraplegia 
 was beginning to seize on the extremities, the patient was much 
 annoyed by occasional involuntary jerkings of the weakened 
 limbs. This morbid action of the voluntary muscles continued 
 when all power of voluntary motion had completely ceased. 
 
 This gentleman's body was examined twenty hours after death 
 by Mr. Adams. The body and limbs were greatly emaciated, 
 and there were several sloughing sores on various parts of the 
 body and limbs, particularly over the scapulae, sacrum, and ilium. 
 The brain was perfectly healthy, with the exception of a slight 
 effusion under the arachnoid, and into the fourth ventricle. On 
 opening the spinal canal, which was done with extraordinary 
 care and accuracy, the spinal marrow, from the fourth cervical 
 vertebra down to its dorsal termination, was found converted 
 into a morbid mass, of an ash-grey colour and pulpy consistence. 
 The theca was quite healthy ; but on the first transverse section
 
 554 CLINICAL MEDICINE. 
 
 of it a great quantity of yellow serum flowed out, emptying at 
 the same time the fluid contained in the fourth ventricle of the 
 brain. When the medulla spinalis was slit from above down- 
 wards, various shades of colour were noticed on the surfaces of 
 the sections. Opposite to the third dorsal vertebra a blackish 
 colour prevailed ; and from this downwards a yellowish hue was 
 noticed. Two little tumors, about the size of filberts, were 
 found attached to the crura of the fourth dorsal vertebra ; these, 
 as Mr. Adams remarked, were in all probability merely accidental 
 formations. The bladder was very much thickened in all its 
 coats, and was so contracted that it could not contain more than 
 three ounces ; its internal surface was of a dark green colour 
 approaching to black. The ureters were also thickened, the 
 kidneys enlarged, and their lining membrane of the same dark 
 colour as the bladder. The pelves and infundibula of the kidneys 
 were dilated, and contained a reddish diseased urine, with some 
 puriform matter, the odour of which resembled that of the urine 
 passed during three weeks previous to his death. The other 
 viscera did not present anything worthy of remark. 
 
 In order to understand the nature and progress of a disease 
 like this, which travelled in a retrograde direction along the 
 nerves and their sheaths to the spinal marrow, it may be well to 
 point out some of the more striking phenomena by which it was 
 characterized. In the first place, the long continuance of the 
 pains at one side of the body only is in itself a demonstration 
 that the disease was then situated in the peripheral extremities 
 of the nerves, and not in the spinal marrow, for it has been well 
 observed by Ollivier, that inflammation of the spinal marrow or 
 its sheath can never remain confined to one-half of either for 
 more than a very limited period. Indeed, so narrow is the 
 cavity in which these parts are contained, and so intimate is the 
 connexion of their constituent parts, that it is quite impossible 
 for inflammation to remain more than a few hours, or at most a 
 day or two, confined to either side. 
 
 Some facts connected with disease of the spinal vertebrsB, and 
 the pains accompanying the progress of that disease, may appear 
 to contradict this view of the subject ; for in vertebral caries 
 pains are often felt at one side or in one limb — nay, they often 
 cease or seem intermittent. Now, in order to explain this, we 
 have onlv to recollect that here the inflammation does not com-
 
 GOUT. 555 
 
 menco in the spinal marrow or tbeca, but in the bones, and that 
 the nerves, after their exit from the spinal cord, are affected 
 in all cases before the cord itself. The reason is obvious ; the 
 affection of the nerves is secondary, and solely derived from their 
 proximity to the inflamed bone and investing tissues ; and con- 
 sequently the nerves on one side may be affected, while the 
 corresponding nerves on the other side escape for the time, and 
 until the disease in the bone extends itself to their neighbour- 
 hood also. This view of the subject has not escaped the notice 
 of German pathologists. 
 
 In the case above related, the pains continued in one side for 
 months, and were then suddenly transferred to the other, an 
 occurrence which is quite irreconcilable with the idea of their 
 dependence on primary spinal disease. The well-marked ease 
 the patient experienced when the gout appeared in the feet, and 
 the perfect intermissions of pain which he frequently enjoyed 
 during the earlier stages of the complaint, afford strong evidence 
 that the pains, however violent and excruciating they might have 
 been during the paroxysms, did not depend on an original affec- 
 tion of the spinal cord. Had the fall which this gentleman 
 received, or any other injury, induced inflammation of the spinal 
 cord and subsequent degeneration of structure, the order and 
 course of his symptoms would have been very different, and long 
 intervals of comparative ease would not have intervened between 
 the appearance of the first pains and the subsequent paralysis. 
 
 When paraplegia originates in disease of the spinal cord itself, 
 retention of urine, or irritability of the bladder, often announce 
 the approach of the disease long before the loss of power in the 
 limbs becomes evident ; whereas, in all those cases in which the 
 paralysis creeps from the extremities along the nerves towards 
 the spinal marrow, the bladder is affected only at a late period of 
 the disease, as occurred in the case which I have just detailed. 
 Finally, the remarkable similarity which exists in various points 
 between this case and that of the Welsh gentleman, who had 
 never met with any accident or injury, and in whom a con- 
 siderable degree of ramollissement was observed, leaves no doubt 
 that in both instances the disease commenced with gouty neu- 
 ralgia and inflammation of the nervous extremities and their 
 sheaths, which gradually extended to the central portions of the 
 nervous system, and ultimately involved the spinal cord.
 
 656 CLINICAL MEDICINE. 
 
 It, is of great importance that you should be aware of this 
 termination, and know that in gouty habits the sad results 
 already noticed may be produced : particularly as a knowledge 
 of this fact may lead to the timely adoption of preventive 
 measures. Having experienced the total ineflBcacy of colchicum, 
 hydriodate of potash, strychnia, and all the usual remedies, in 
 relieving or removing this form of disease, I would be strongly 
 inclined to recommend the early insertion of issues over the 
 spine, with prompt and decided mercurialization. The late 
 Mr. Colles has recommended the use of mercury in paraplegia, 
 and cites some cases in support of the utility of the practice. It 
 is to be regretted that he has not given any hints as to the mode 
 of diagnosing the cases likely to be benefited by the mercurial 
 treatment, from those in which mercury would be inadmissible. 
 Hence his recommendation loses much of its value, and cannot 
 serve as a guide to those who have to treat spinal disease con- 
 nected with paralytic symptoms. It appears, however, sufficiently 
 plain that mercury, employed at an early period of the disease, is 
 most likely to prove serviceable where symptoms of paralysis arise 
 from inflammatory affections of the nerves or their neurilemma, 
 or of the spinal cord and its sheath. 
 
 So far at present on the subject of paralysis as connected with 
 the gouty diathesis. I hope to be able in a short time to bring 
 it again before you in a more complete and extended form. 
 
 In the preceding observations we proved that gout often attacks 
 the nerves of the extremities in the first instance, and then 
 pursues a retrograde course until it reaches the spinal marrow. 
 It is an acknowledged character of gout that it wanders from one 
 organ to another, and that it is very uncertain as to the periods 
 and duration of its attacks, sometimes appearing to have ceased 
 altogether, again only to return with redoubled violence. These 
 characters of gout are strikingly displayed in the two cases I have 
 related, where it finally seized on the spinal marrow ; and it is 
 quite possible that what took place towards the fatal terminations 
 of these cases may in other gouty subjects occur at a much 
 earlier period, and without the previous occupation by the disease 
 of the nerves of the extremities ; indeed, there is no reason why 
 gout should not attack the spinal marrow and its investing 
 membranes in the first instance, or in consequence of metastasis. 
 That rheumatism, the disease most closely allied to gout, may
 
 GOUT. 557 
 
 do so has been proved by numerous examples, of which we owe 
 some of the most strildng to Dr. Cophind and Dr. Prichard, 
 for the result of whose researches on this subject I must refer 
 you to the article Chorea in Copland's Dictionary of Practical 
 Medicine, where you will find that rheumatism not unfrequently 
 produces both acute and chronic inflammation of the spinal 
 membranes. These observations I make with the intention of 
 proving that my views concerning gouty aftections of the spinal 
 cord are borne out by analogy, and the experience of others with 
 respect to rheumatism.
 
 558 
 
 LECTUKE XXXII. 
 
 RHEUMATISM. SCIATICA AND LUMBAGO. 
 
 I SHALL commence to-day's lecture, gentlemen, with a few 
 observations on that rheumatic afifection of the joints, to which 
 I shall give the name of arthritic rheumatism. You will meet, 
 in practice, with cases of arthritic rheumatism attended with 
 fever, where, after the violent inflammatory symptoms have 
 subsided, the arthritic inflammation will continue to wander 
 from joint to joint, sometimes almost entirely vanishing, and 
 then again reappearing. You entertain hopes of getting your 
 patient over the disease, and he is indeed better ; but, on your 
 next visit, you find that the pain has fixed itself — suppose in 
 the wrist joint. If such a pain as this should appear while the 
 acute symptoms are present, besides the general remedies you 
 will employ local means of relief; and some persons, as for 
 instance, Dr. Elliotson, would make cold applications to the 
 part : but this I do not approve of, nor would I recommend 
 you to practise it. However, generally speaking, your treatment 
 consists in leeching the afiected part, the internal exhibition of 
 colchicum, &c. 
 
 What I would urge upon your attention is, can you trust to 
 leeches on all occasions, and at every period of the disease ? 
 No ; there is a period when you must blister ; there is a time 
 when stimulant and tonic applications become indispensable. 
 The general treatment of every case of arthritis must close with 
 tonics. First, you pursue the antiphlogistic treatment, next 
 you employ specific remedies, and lastly, you have recourse to 
 tonics ; and so likewise with the local applications. In the 
 beginning, local pain, tenderness, and swelling depend on active 
 inflammation, and yield most readily to leeching. As the 
 disease advances, the number of leeches which each fresh appear- 
 ance of local inflammation requires is comparatively less, and 
 finally, the local afi"ection, on its recurrence in any joint, is of
 
 BHEUMATISM. 559 
 
 such a nature, that leeching is no longer proper, while certain 
 and almost immediate relief may bo obtained from blisterino-. 
 Blisters are better than leeches, not only because they possess 
 the power of removing pain and swelling with more rapidity, 
 but also because they do not leave the part in a weakened state. 
 I tell you that blisters have a powerful effect in removing such 
 pains, and that they may be used in cases of arthritis where they 
 have not been used heretofore. 
 
 There is another practical observation on rheumatism which I 
 made before in the hospital wards. Cases of arthritic rheumatism 
 will come under your notice, in which the pain and fever are, 
 from the beginning, accompanied by sweating, and this sweating 
 is not attended with any relief; the pulse remains quick, the 
 fever persistent, and the pain undiminished. This sweating, be 
 assured, never tends either to diminish fever or relieve pain ; and 
 this is the kind of arthritis which is most apt to terminate in 
 confirmed affections of the joints, and may last for life. From 
 my experience elsewhere, and from the observations I have made 
 in the Hospital for Incurables, I have remarked that most of 
 those persons whose limbs are permanently stiff, or even distorted 
 from rheumatic affections, have been suffering for years under 
 this sweating arthritis. In one of the patients at that institution 
 a curious effect followed this disease. The sweating was general 
 over his body at first, but after some time it declined in the 
 lower extremities, which seemed incapable of sweating any 
 longer. The cuticle over these parts began to exfoliate and 
 become dry and rigid. A still further change took place, and 
 the lower extremities became covered with ichthyosis. He lies in 
 bed on his back in a helpless state, his legs and thighs covered 
 with a horny unyielding cuticle, but his breast and face continue 
 to sweat profusely as before. 
 
 Bear in miiid, therefore, that this form is liable to terminate, 
 as I mentioned before, in incurable arthritis. Some of the 
 senior students may, perhaps, recollect a poor man in the 
 chronic ward of this hospital, who laboured for month after 
 month under this torturing malady. He lay in a corner in this 
 state, and it was a subject of constant regret to everybody to 
 see him in this pitiable condition without any prospect of relief. 
 Practitioners are apt to make a mistake in the treatment of this 
 disease. They find the pulse quick but very seldom strong, and
 
 560 CLINICAL MEDICINE. 
 
 rather forbidding than indicating the abstraction of blood. How 
 are you to treat such cases ? By the use of the lancet. Begin, 
 however, cautiously ; take away, at first, about five or six ounces 
 of blood, and observe what eff"ect this produces. If your patient's 
 pulse is improved, his pain lessened, and the sweating diminished, 
 you are encouraged then to bleed more boldly. Venesection is 
 here our sheet anchor. You have seen how much relief it gave 
 the man above stairs, and what a remarkably buffy coat his 
 blood presented. His sweating was diminished considerably by 
 this means ; and did you remark how I got rid of this symptom 
 entirely ? By giving him minute doses of tartar emetic and 
 opium. He had a mixture composed of half an ounce of the 
 solution of tartarized antimony, and half a drachm of tincture of 
 opium in sixteen ounces of water ; of this he took half an ounce 
 every hour. It is hard to account for this, but it is a fact, that 
 in some cases of chronic sweats, particularly those which attend 
 hectic fever, you can put a stop to them by giving a few grains 
 of Dover's powder at bed-time. 
 
 There is another very remarkable case at present in the house 
 which bears upon the observations I have been now making ; I 
 allude to the patient with sweating arthritis, to whom I drew 
 your attention this morning. This poor man, who is somewhat 
 advanced in life, has been labouring for several months under 
 inflammation of the joints of a rheumatic character, manifesting 
 itself by pain, stiffness, swelling, and probably some slight efl'usion 
 into the synovial membranes. These symptoms were accom- 
 panied by profuse and constant perspirations, with a tendency to 
 diarrhcea — circumstances which caused a manifest deterioration 
 of his health and strength ; he became pale, cachectic, and 
 emaciated. His case has been very tedious and intractable ; he 
 had been a long time in the hospital, and had used all the most 
 appropriate remedies but without any appreciable improvement ; 
 his joints remained stiff, painful, and almost useless ; he was 
 greatly reduced in strength, and entirely confined to his bed. 
 In addition to this, his pulse continued unreduced in frequency, 
 and this is always a bad sign ; cases of rheumatic arthritis, 
 attended with prolonged excitement of the circulation and 
 copious sweating, are generally found to exhibit an intractable 
 chronicity, and too often terminate in rendering the unfortunate 
 patient a cripple for life. 
 
 I
 
 RHEUMATISM. 561 
 
 Now in this case many remedies bad been tried witbout effect, 
 and tbe state of tbe man's constitution, combined with tbe 
 circumstance of bis baving a tendency to bowel compbiint, con- 
 tributed to reduce still furtber tbe scanty list of our remedial 
 agents. Alterative remedies, to afiect tbe general system, were 
 almost entirely out of tbe question, and a vast number of local 
 applications bad proved unsuccessful. It occurred to me bere, 
 tbat some benefit migbt be derived from mercurial ointment, 
 gently rubbed over tbe affected parts, assisting its action by tbe 
 use of rollers applied round tbe joints. Fortunately tbe experi- 
 ment proved successful ; in tbe course of a week or ten days tbe 
 swelling diminisbed considerably, tbe pain is nearly gone, and 
 tbe power of motion is returning. His moutb bas become 
 affected, but tbe relief experienced appears to be proportioned 
 not to tbe influence of mercury on tbe general system, but to its 
 effect on eacb individual joint. As a proof of tbis, I may state 
 tbat tbe man bas been mercurialized before, but witbout any 
 favourable result. 
 
 Here, gentlemen, is an important point for consideration. A 
 patient labours under a certain number of local inflammations, 
 for wbicb mercury is given internally, so as to affect tbe moutb, 
 but witbout any manifest improvement of symptoms ; we after- 
 wards try tbe same remedy in anotber form ; we apply it locally, 
 in tbe sbape of ointment rubbed into tbe skin over tbe diseased 
 parts, and we succeed in giving relief Tbis is a fact deserving 
 of attention. You will perbaps ask me to explain tbis ; I cannot 
 do it ; but I can bring forward many otber analogous examples. 
 If you refer to tbe late Mr. M'Dowel's valuable paper on 
 Erysipelas, published in an early number of tbe Dublin Medical 
 Journal, you will find tbat many cases of tbis affection derived 
 great benefit from tbe use of mercurial ointment ; in fact, mucb 
 more tban tbey could by giving mercury internally. 
 
 In tbe next place, I bave met witb many cases of enteritis 
 and peritonitis wbere tbe disease continued after tbe system 
 became affected by mercury ; and I bave observed tbat tbese 
 cases yielded rapidly to blistering tbe abdomen, and dressing the 
 raw surfaces with mercurial ointment. Sir H. Marsh and I 
 attended a young gentleman lately, who had low fever, accom- 
 panied by a quick but feeble pulse, and great restlessness. 
 About the tenth day his belly became tender and exquisitely 
 VOL. I. 36
 
 562 CLINICAL MEDICINE. 
 
 painful ; he Lad thirst, diarrhcea, and other symptoms of enteric 
 and peritoneal inflammation. Before his illness he had been of 
 rather delicate habit, and had further impaired his health by 
 close study. He was therefore unfit for depletion, and of this 
 we were convinced by the debility which followed the application 
 of a few leeches. Under these circumstances we ordered a large 
 blister to be applied to the abdomen, and the vesicated surface 
 to be dressed with mercurial ointment. This proved eminently 
 successful; the peritonitis, enteric irritation, and fever soon 
 disappeared, and the young gentleman recovered completely. 
 
 The same thing is seen in many cases of pleuritis ; the con- 
 stitutional effect of mercury will fail in removing the affection 
 of the pleura until it is applied locally. I might also refer to 
 instances of common inflammation of the testicle, in which 
 mercurial ointment smeared over the part has been found 
 decidedly beneficial. It is unnecessary for me, however, to 
 multiply examples ; what I have stated gives ample proof of the 
 utility of mercury applied locally. When I was a student, it 
 was the fashion to scout the doctrine that any distinct effect 
 could be produced by the local application of mercury ; our 
 teachers laid it down as an axiom, that, to produce any sensible 
 effect, it was necessary that it should first enter the system 
 through the lymphatics. Thus, when you rub mercurial ointment 
 over the liver to remove hepatic derangement, they said, before 
 it could exert any influence on the liver, it had to pass along 
 the thoracic duct, become mixed with the circulation, and 
 manifest its peculiar action on the whole economy. Hence, in 
 a case of hepatitis or testitis, it was deemed useless to apply 
 mercurial ointment over the liver or testicle, since it had, as 
 they expressed it, to go its round through the whole system, 
 before it could aft'ect either of these organs. 
 
 This reasoning has an appearance of plausibility, but it is 
 contradicted by facts. Numerous examples might be cited to 
 prove that the greatest advantage may be derived from the local 
 application of mercury, independent of any effect produced by it 
 on the general system. How often do we see an incipient bubo 
 dispersed by mercurial frictions, before any constitutional effects 
 occur ? How frequently do we see laryngeal and hepatic inflam- 
 mation relieved by the use of mercurial ointment without 
 salivation ? Do the beneficial effects, which we so often observe
 
 RHEUMATISM. 563 
 
 from the emplastrum ammoniaci cum hydrargyro, depend neces- 
 sarily upon the mouth being affected ? Is the rehef which 
 follows the use of mercurial ointment in erysipelas or testitis 
 unattainable, unless preceded by mercurial action in the whole 
 system ? Indeed, any person who reviews this subject dispas- 
 sionately, must see that the doctrine of a preliminary constitu- 
 tional affection being absolutely necessary, in order to obtain the 
 specific action of mercury on any particular organ, is wholly 
 untenable ; while, on the other hand, there is a host of evidence 
 to prove that, locally applied, it produces a primary and 
 distinct effect, totally independent of its action on the general 
 economy. 
 
 Having spoken now of the utility of mercury in certain cases 
 of rheumatic fever, where the inflammation of the joints will not 
 yield to other means, I have to add that the hydriodate of potash 
 has been found to be a most useful adjunct to mercury, and well 
 calculated for following up and completing the beneficial effects 
 produced by that remedy. In fact, in treating arthritic or rheu- 
 matic fever, when I have reduced the violence of the fever and of 
 the inflammatory affection of the joints by means of bleeding and 
 leeching, followed by tartar emetic or nitre, or both combined, or 
 when, after the antiphlogistic treatment both local and general, 
 I have produced marked alleviation of the patient's sufferings, 
 either by the use of colchicum or by the use of mercury combined 
 with opiates — then, I say, we can employ the hydriodate of potash 
 with the greatest possible advantage, as it quickly dissipates the 
 remaining pain and swelling of the joints, and contributes power- 
 fully to bring the disease to a speedy termination, while at the 
 same time it greatly diminishes the danger of a relapse. I have 
 experienced much comfort and feel much confidence in the treat- 
 ment of rheumatic fever since I adopted this practice ; and it 
 now never happens to me to meet with cases which, in spite 
 of all my efforts, become chronic, and confine the unfortunate 
 sufferers to bed for months. You have observed recently that, in 
 most cases of acute rheumatism affecting the joints, no matter 
 what mode of treatment I adopt in the commencement and 
 during the acme of the disease, I generally complete the cure 
 with the hydriodate of potash, beginning with doses of ten 
 gi-ains, which are quickly augmented to twenty or thirty 
 grains three times a day. It is generally given in decoction
 
 564 CLINICAL MEDICINE. 
 
 of sarsaparilla, to which some preparation of morphia forms a 
 useful addition. 
 
 Having said so much, I shall make but a few observations on 
 another case of rheumatic fever we had lately in hospital. The 
 patient had at first fever and inflammation of the joints ; the 
 fever was removed by appropriate treatment, but the inflamma- 
 tion of the joints continued; the fever set in again, and the 
 arthritic afi'ection increased, and we removed both. He relapsed 
 again, the fever re-appeared, but there was no inflammation of 
 the joints. Here we have a man admitted with rheumatic fever 
 and inflammation of the joints ; we try to cure the disease, and 
 we succeed in removing the fever, but the joints remain inflamed; 
 we remove this also, and congratulate ourselves on a recovery, 
 and we again have fever and arthritic inflammation ; we over- 
 come this ; and again a relapse comes on : but mark the dif- 
 ference ; we have now fever, but the joints are unafi"ected. This 
 is a curious circumstance, and confirms me in an opinion I have 
 entertained for some time, that we may have rheumatic fever 
 without inflammation of the joints. 
 
 Rheumatic fever is usually distinguished by being accompanied 
 wdth pain, swelling, and redness of the joints ; but I have 
 remarked, long since, that this fever presents several other pecu- 
 liarities. We have, as in other fevers, great heat, occasional 
 tendency to sweating, and hard quickened pulse ; we have the 
 urine at first pale, then high-coloured, and the blood buffed. But 
 we have no affection of the sensorial functions, no headache, 
 and, when pain permits, rest ; sleep is not proportionally 
 impaired, the tongue is furred, but the appetite is frequently 
 good, there is no nausea, no disgust at food. These pecu- 
 liarities I have frequently remarked, but it was only lately 
 that I became aware that this species of fever may exist without 
 inflammation of the joints. It is well known, that the affection 
 of the joints may exist without the fever. The combination 
 of these two distinct, but frequently associated, affections, con- 
 stitutes the disease termed rheumatic fever. This explains the 
 reason why we must wait until a certain period, until the 
 fever subsides, before we give tonics. We commence with 
 antiphlogistics, then we employ specifics, such as mercury 
 or colchicum, and afterwards we give tonics. 
 
 The case of Coghlan, who has been for some time an inmate
 
 RHEUMATISM. 5G5 
 
 of our clironic ward, demands a few observations. He was ad- 
 mitted for an attack of arthritis on the 10th of December, 
 and since that period has been subjected to various modes of 
 treatment. You will recollect that on his admission he stated 
 that he had been attacked several times with rheumatic inflam- 
 mation of the joints. Like most persons of his class, he has 
 suifered greatly from repeated fits of illness, brought on by- 
 exposure to the same causes. One of the greatest misfortunes 
 that can fall upon labouring men is a severe attack of rheumatic 
 fever, accompanied by inflammatory aff"ections of the joints ; it 
 not only renders them helpless and useless for a considerable 
 time, but also in some cases leaves them cripples for life, and, in 
 addition, the nature of their employment constantly exposes 
 them to relapses, which at length bring on incurable aff'ections 
 of the joints ; we have, moreover, in this young man's case, a 
 combination not uufrequent in patients of this description, 
 namely, the effects of cold ou the chest as well as on the 
 joints — arthritis combined with inflammation of the bronchial 
 mucous membrane. 
 
 Xow where the arthritic affection is very severe, and accom- 
 panied by high fever, the addition of bronchitis is a great aggra- 
 vation. Every time the patient coughs he feels like one stretched 
 upon the rack ; at every convulsive motion of the chest a severe 
 pang is felt in every joint, and the ordinary rate of suffering is 
 increased to positive agony. A case of this kind is often hard to 
 be managed, even when the disease is recent and the constitution 
 sound ; but when you have to treat a severe attack in a person 
 who has repeatedly laboured under the disease, and whose vigour 
 has been consequently impaired, the difficulty is greatly increased. 
 Here much attention is required on the part of the physician. 
 Where the combination is met with in a primary attack, I am 
 generally disposed to regard both affections as of the same cha- 
 racter, and not requiring any difference of treatment ; I therefore 
 attack the arthritis and the bronchitis with the same remedies, 
 that is to say, venesection, leeches to the affected joints and over 
 the chest, and large doses of nitre and tartar emetic. These 
 remedies, however, are only calculated for the acute stage of a 
 primary attack, and where the patient's strength is unimpaired ; 
 for when the disease is chronic, and debility present, you cannot 
 venture on the use of large doses of tartar emetic and nitre.
 
 566 CLINICAL MEDICINE. 
 
 In such cases much benefit is derived from the use of colchicum, 
 particularly where the patient labours under more or less fever. 
 The following is the form which I am in the habit of using, and 
 from which I have occasionally derived much benefit : — 
 
 R. Misturse Amygdalarum, f^viij. 
 Aceti Colchici, fjss. 
 Acetatis Morphise, gr. i. 
 
 Nitratis Potassae, ^ss. ; Fiat mistura, cujus sumat cochleare 
 unum amplum omni vel secuncla quaque bora. 
 
 In Coghlan's case we tried this mixture, with local applica- 
 tions to the joints and a blister to the chest, but found at the 
 end of some days that there was no visible improvement in the 
 patient. Now, whenever a state of things of this kind occurs, 
 no time should be lost ; for, rely on it, that where colchicum 
 does not afford relief in a short time, and in moderate doses, there 
 is no use in giving it a further trial. You have here to contend 
 with two affections of a very serious character — one capable of 
 rendering your patient a cripple for life, the other threatening him 
 with sufibcation, from an extension of the inflammation into the 
 minute bronchial tubes — an occurrence which is most commonly 
 followed by dangerous congestion of the lung. Under such cir- 
 cumstances, the only treatment you can adopt with a hope of 
 speedy relief and ultimate success, is to lay aside all other 
 remedies, and trust almost exclusively to the use of mercury. 
 In cases of this kind do not hesitate a moment, but mercurialize 
 your patient at once, if his constitution be at all capable of bear- 
 ing it. The treatment which was followed in the case under 
 consideration was this : — we gave the patient ten grains of 
 hydrargyrum cum creta four times a day ; and with the view of 
 relieving pain and the irritation of the bronchial mucous mem- 
 brane, he took one drop of hydrocyanic acid, and ten drops of 
 tincture of hyoscyamus in half an ounce of almond emulsion, 
 three times daily. 
 
 The next affection I shall draw your attention to is chronic 
 rheumatism, of which we have a well-marked instance in the man 
 who lies in the chronic ward immediately under the window. 
 He complains of pain, weakness, and numbness of the lower 
 extremities, for which he used the decoction of sarsaparilla and 
 minute doses of corrosive sublimate, for a fortnight, without
 
 EHEUMATISM. 567 
 
 any obvious improvement in liis sj'mptoms. His complaint is 
 of considerable duration, it being now fifteen weeks since he was 
 first attacked. This, I need not tell you, is a very unpro- 
 mising feature in his case. When rheumatism has continued 
 for three or four months, it becomes a very intractable disease ; 
 indeed, there is scarcely any affection which tasks the ingenuity 
 and tries the patience of a medical man more than chronic 
 rheumatism. In this case, however, we have been so fortunate 
 as to hit on a remedy suited to the complaint ; the man has been 
 rapidly improving within the last fortnight, and is now nearly 
 well. 
 
 You will recollect that, when I undertook the treatment of 
 this case, the patient was free from fever, his general health but 
 little impaired, his pulse tranquil, his appetite good, no remark- 
 able tenderness or redness of the joints — in fact, nothing to 
 indicate the existence of acute local inflammation ; consequently, 
 it would have been useless to have recourse to leeches or blood- 
 letting, or to administer antimonials, nitre, or colchicum. In 
 such cases as this, a different line of practice must be followed ; 
 you must have recourse to stimulant diaphoretics — remedies 
 which will increase the secretion from the skin, at the same 
 time that they exercise a stimulating action on the nervous and 
 capillary systems. Accordingly, we prescribed for this man 
 the following electuary, of which he was to take a teaspoonful 
 three times a day : — Powdered bark 5j, powdered guaiacum 3J, 
 cream of tartar ^j, flowers of sulphur 5ss, powdered ginger 5j, 
 to be made into an electuary with the common syrup used in 
 hospitals. 
 
 The guaiacum not only acts on the nerves, tending to remove 
 chronic pains, but also acts on the skin ; you will find these, and 
 other properties possessed by it, detailed at large in your works 
 on Materia Medica. Whether given in the form of powder or 
 tincture, it often proves an extremely useful remedy in cases of 
 chronic rheumatism, where no symptoms of active local inflam- 
 mation or general fever exist ; where either of these are present, 
 it is inadmissible. Ginger has also a stimulant eftect, although 
 its action is much more limited. It is a favourite domestic 
 remedy, and is very frequentlyprescribed by our rival candidates for 
 therapeutic celebrity — old ladies — in cases of chronic, or, as they 
 term it, cold rheumatism; and I must confess that I have seen
 
 568 CLINICAL MEDICINE. 
 
 some benefit derived from their specific — ginger tea. Witli these 
 we combined sulphur, which exerts a pecuhar stimulant opera- 
 tion on the skin and alimentary canal. Sulphur is an extremely 
 active remedy, and singularly penetrating in its nature, finding 
 its way into many of the secretions and most of the tissues of 
 the body. You will find it in the urine in the form of sulphates, 
 and it is exhaled from the skin and mucous membrane of the 
 bowels in the form of sulphuretted hydrogen. Having said so 
 much respecting sulphur, you will perhaps inquire why I pre- 
 scribed the bark ? It is not easy to give a satisfactory explana- 
 tion- of this ; but we know, from experience, that in cases of 
 rheumatism, after fever and local inflammation are removed, 
 bark and other tonics have been found extremely valuable. The 
 cream of tartar is given with a view of tempering the other 
 stimulant remedies, it being known to possess cooling and aperient 
 properties. The whole form a combination which is similar in 
 its composition to a well known popular remed^^ for rheumatism 
 — the Chelsea pensioner. 
 
 Having thus explained the general tendency of these medicines, 
 and mentioned that they are to be made up into an electuary, it 
 only remains to speak of the effect produced, and the dose or 
 quantity given. I have stated that the ordinary dose is a tea- 
 spoonful three times a day ; this, however, will be too much for 
 some and too little for others. The object in every case should 
 be to keep up a mild but steady action on the bowels, and to 
 procure a full alvine discharge at least once a day. If the dose 
 mentioned already does not answer this purpose, it must be 
 "increased ; if the bowels are too free, it must be diminished. You 
 should never omit making regular inquiries after the state of the 
 bowels, while the patient is using this electuary ; for, if these 
 matters are neglected, the patient will not obtain the full benefit 
 to be derived from it. Besides opening the bowels, this electuary 
 acts on the skin, and frequently causes a rapid disappearance of 
 the disease. I need not say that, in addition to this, I ordered 
 warm baths ; they coincide in effect with the electuary, acting on 
 the skin, and tending to relieve the rheumatic pains. \ 
 
 I shall now conclude with some observations on the treatment 
 of sciatica and lumbago, aJBfections closely allied to rheumatism. 
 In acute and subacute lumbago and sciatica, the most approved 
 treatment consists of antiphlogistic measures, particularly blood-
 
 RHEUMATISM. 569 
 
 letting, general and local, followed by the exhibition of anti- 
 monials and Dover's powder iu proper doses. Cupping the 
 lumbar region (when the operation is skilfully performed) 
 deservedly enjoys a high reputation in lumbago ; and if sciatica 
 is present, the tender parts about the buttock and thigh must 
 likewise be repeatedly cupped. In the latter case, it is requisite 
 to have a very small scarificator, and cups of a corresponding 
 size, so as to enable the operator to follow the track of the 
 sciatic nerve. In Germany they generally use instruments so 
 small, that ten or twelve of the glasses may be placed close 
 to each other, iu a line extending along the painful portion of 
 the nerve, where it lies most superficially in the thigh. This 
 practice deserves more general imitation in this country. 
 
 That popular remedy, a warm bath, often forms a most 
 excellent adjuvant to these measures, and is still more efficacious 
 when preceded by a powerful warm douche. A stream of hot 
 water, played with considerable force against the loins, buttock, 
 and thigh, seems to act not merely by the heat it imparts, but 
 also by the mechanical impulse it exerts, an impulse which may 
 be termed ivater-champooing ; in Dublin such a douche and 
 warm bath may be had at the Northumberland Buildings. The 
 means just enumerated, combined with absolute rest in bed, 
 will succeed in many cases ; in others they will fail, and then 
 this question arises, — What ought we to try next ? In some 
 cases I have followed the example of Dr Percival and Dr. Cheyne, 
 of giving two or three grains of opium in the day, combined 
 with calomel and James's powder, and with much benefit. 
 
 In a case of lumbago and sciatica, which I treated with Mr. 
 White, the disease at first neglected had passed from a chronic 
 to an acute state, and had become painful to the greatest possible 
 degree; in truth, the patient's agony was quite excruciating, 
 and though a man of strong mind and vigorous nerves, the 
 sweat poured down his face from the suffering he endured 
 w^hcnever it was necessary to move himself in bed, or even 
 when the floor of the room was shaken by any person treading 
 heavily. 
 
 As our patient had been repeatedly cupped, and the usual 
 remedies had completely failed, Mr. White proposed a combina- 
 tion of three grains of acetate of morphia, six grains of calomel, 
 and twelve of James's powder, divided into eight portions, one
 
 570 CLINICAL MEDICINE. 
 
 to Lg taken every third hour ; the good effects of this combina- 
 tion were so striking, that I have since had recourse to it 
 repeatedly, and there is no one remedy in which I have greater 
 confidence. Still, however, it is liable to the objection, that it 
 must generally be continued until the gums become tender, or 
 even the mouth slightly sore, an objection not, it is true, of 
 much weight in cases like the preceding, where the disease is 
 very acute, and the patient necessarily confined to his bed ; but 
 which renders this combination quite inapplicable in subacute 
 or chronic attacks, where the sufferer tries to pursue his ordinary 
 avocations, and is necessarily exposed, more or less, to the open 
 air ; to such persons hydriodate of potash will prove most 
 valuable. 
 
 I first became acquainted with the remarkable efficacy of this 
 medicine in lumbago and sciatica under the following circum- 
 stances. In the memorably wet month of July, 1839, I was 
 called out of bed at midnight, to visit a lady in the country, and 
 the vehicle sent to convey me was a hack covered car. The 
 cushions were very damp, and I had not proceeded half a mile 
 before I was attacked with lumbago so severe that I could 
 scarcely walk when I arrived at my patient's residence. Next 
 morning I was better, having perspired much during the night ; 
 but still the pain was troublesome, and as the season continued 
 unusually cold and wet (indeed, it scarcely ever stopped raining 
 from the 8th of July, 1839, to the 19th of February, 1840), and 
 as my duties exposed me much to the weather, and prevented me 
 from giving myself the necessary rest, my lumbago continued to 
 increase again, and in about a month the gluteal and sciatic 
 nerves of the left side became engaged ; I noted particularly, 
 that the pain spread very gradually downwards from the lumbar 
 region, so that it took a week or ten days to arrive at the ham, 
 and still a longer time at the ankle ; I was then quite lame of 
 the left leg, suffered much pain in bed, and had become so 
 helpless, that I had to get my servant to draw on my stockings ; 
 during all this time my general health was perfect ; appetite 
 good ; digestion regular ; and no deviation of the urine from the 
 natural appearance. I mention this, because several of my 
 medical friends advised me to take antibilious aperients, an 
 advice founded on Abernethy's doctrine, that many local affec- 
 tions proceed from stomach derangement.
 
 RHEUMATISM. 571 
 
 I was at last forced to try something for my relief, and had 
 myself cupped, and tried the warm douche and Dover's powder, 
 but without any good effects. I began now to fear that I should 
 be forced to give up all professional business, and confine myself 
 to the house for many weeks in order to go through a mercurial 
 course, combined with proper topical applications, when, happen- 
 ing to meet the late Mr. Ferguson, of Kildare Street, he recom- 
 mended me to try hydriodate of potash, of which he was good 
 enough to send me a drachm dissolved in a pint of decoction of 
 sarsaparilla. I took quarter of this daily, and may literally 
 apply here the common phrase, that I felt each dose do me 
 good ; in truth, the benefit I derived was perceptible hourly, 
 and was so rapid, that in four days all traces of the lumbago 
 were gone, and my lameness had quite ceased. I did not take 
 more than one bottle — one drachm of the hydriodate, but the 
 good effect continued after I had ceased taking it, and in less 
 than a week I was perfectly well. Subsequent experience enables 
 me to recommend this medicine strongly, in subacute and 
 chronic lumbago and sciatica. 
 
 It is right to observe, that the remedy had in my own person 
 to work against various disadvantages, for I neither relaxed 
 from my labours, nor refrained from eating and drinking as 
 usual. This is only another example of the many I have met, 
 which prove how injudicious it often is to seek the cure of local 
 inflammations by means of lowering the whole system. 
 
 In spite of the best directed means, sciatica is very apt to 
 become chronic, and then oil of turpentine, carbonate of iron, 
 arsenic, extract of stramonium, corrosive sublimate, blue pill 
 and iodine internally, blisters to the loins, thigh, and calf of 
 the leg, acupuncture, croton oil frictions, and other stimulating 
 applications must be successively tried. On a former occasion 
 I recommended a combination of opium, with oil of turpentine 
 internally, and when that fails, Dover's powder, combined with 
 sulphate of quina. I am sorry not to have it in my power to 
 lay down any general principle which would enable you to judge 
 in what cases each of these remedies is peculiarly indicated, for 
 experience has not confirmed any of the rules generally relied 
 on, and, therefore, we must content ourselves with treating these 
 diseases empirically. 
 
 Change of climate, and the use of the Bath, Buxton, Harro-
 
 572 CLINICAL MEDICINE. 
 
 gate, and Tunbridge Spa waters, have proved serviceable to 
 many, while others have been obliged to have recourse to the 
 natural hot baths of Bagneres or Bareges. In very obstinate 
 cases, the practice long adopted in the surgical wards of the 
 Meath Hospital, is to apply the actual cautery to five or six spots 
 along the course of the painful nerve. The application ought to 
 be rather severe, so as to produce moderately sized sores, which 
 must be kept open for a fortnight or three weeks by suitable 
 dressings. This is a very painful process, and for several days 
 after the application of the cautery, the patient suffers much, and 
 often thinks the disease to be aggravated ; after some time, 
 however, improvement becomes perceptible ; and, on the whole, 
 I do not think any other remedy is so much to be relied on in 
 very obstinate cases of sciatica. 
 
 An observation made by Dr. Grogan is worth recording here, 
 as it bears on a physiological question. In a patient of his, a 
 young man of robust constitution, who suffered for more than a 
 year much pain from an imperfectly cured sciatica, the affected 
 thigh and calf were much subject to spasmodic pains and 
 muscular twitchings. These sometimes continued night and 
 day, and in consequence of these morbid contractions constantly 
 recurring, the muscular fibres became hypertrophied, and the 
 whole limb became much developed, presenting a more athletic 
 outline, and exceeding its fellow considerably in bulk. This 
 fact, which was pointed out to me by Dr. Grogan, is very 
 remarkable ; for, in general, chronic sciatica induces a flaccid 
 and atrophied state of buttock, thigh, and calf. In the case 
 referred to, the hypertrophy disappeared in less than a month 
 after the actual cautery had been applied. 
 
 As the practical physician ought not to neglect any circum- 
 stance, however trivial it may appear, which bears upon the 
 health of his patients, the following hints should not be regarded 
 as too trifling for notice. Persons subject to lumbago ought, as 
 much as possible, avoid remaining for any length of time in a 
 flexed or stooping position, particularly if exposed to cold ; it is 
 for this reason that lumbago so frequently attacks gentlemen 
 when engaged in the act of shaving. Those who are liable to 
 the disease, therefore, must be careful either to shave while 
 sitting before the glass, or, if standing, let the glass be placed 
 so high that they may stand quite straight. Again, many are
 
 RHEUMATISM. 573 
 
 attacked while drawing on their boots ; this accident may be 
 surely avoided by using boot-hooks, with shanks about fourteen 
 inches long, so that the body and thigh may be nearly in the 
 same line, when the effort to draw on the boot is made. Persons 
 who are in dread of lumbago and sciatica ought always to wear 
 stout drawers, whose waistband should be broad, and consist of 
 a strong, warm, yet elastic material, so as to allow it to be worn 
 very tight without inconvenience.
 
 574 
 
 DISEASES OF THE BRAIN AND NERYOUS SYSTEM. 
 
 LECTUKE XXXIII. 
 
 PATHOLOGY OF NERVOUS DISEASES. 
 
 Befoee I proceed to speak of diseases of the brain and spinal 
 cord, I wish to draw your attention generally to the pathology of 
 nervous diseases. The subject is interesting, and one on which 
 my opinions differ from some of those generally received. The 
 observations I am about to make will involve the consideration 
 of the general principles suited to guide us in the difficult study 
 of nervous affections, rather than the description of any particular 
 disease. In considering the symptoms that accompany diseases 
 of the nerves, pathologists have directed their attention almost 
 exclusively to the nervous centres, and have looked on the brain, 
 cerebellum, and spinal cord as the parts in which the causes of 
 all nervous disorders reside, or in which they originate. If you 
 examine the works of Rostan, Lallemand, Abercrombie, and all 
 those who have written on diseases of the nervous system, you 
 will find that their inquiries consist in searching after the causes 
 of functional changes, either in the cerebrum, cerebellum, or 
 spinal marrow, forgetting that these causes may be also resident 
 in the nervous cords themselves, or their extremities, which I 
 shall call their circumferential parts. 
 
 When we recollect the manner in which the nervous system 
 grows, — when we call to mind the fact that, in the development 
 of that system during the foetal state, the nervous extremities 
 and trunks are formed before any traces of the brain are 
 discernible, we must at once allow it is by no means improbable 
 that these parts may become incapable of discharging their 
 functions in consequence of changes originating in themselves, 
 and not proceeding from the nervous centres. In a word, may
 
 PATHOLOGY OF NERVOUS DISEASES. 575 
 
 not the decay and withering of the nervous tree commence 
 occasionally in its extreme branches ? and may not a blighting 
 influence aflect the latter, while the main trunk remains sound 
 and unharmed ? 
 
 In fact, gentlemen, pathologists have, with respect to diseases 
 of the nervous system, continued an error precisely similar to 
 that which was so long prevalent with regard to diseases of the 
 vascular system ; for it is only lately that, in estimating the 
 forces which influence the circulation in diseased parts, they 
 have begun to appreciate the preponderating influence of the 
 capillary vessels, independently of the heart's action and the 
 vis a tergo. It is only lately that they have recognized the 
 important truth, that diseased vascular action may commence in 
 the circumference. 
 
 I am willing to allow that in most cases of general paralysis 
 the aflection of the muscular system is produced by disease of 
 the nervous centres ; yet I think it is also evident, that an injury 
 of the extremities or circumferential parts of the nerves may 
 cause such a derangement of their functions as to give rise to 
 paralysis. The reason why persons seek for the explanation of 
 paralytic symptoms by referring them to the nervous centres, 
 rather than their peripheral extremities, is because this mode 
 of inference accounts more satisfactorily for the simultaneous 
 aflection of many parts of the system. Thus, if one hemisphere 
 of the brain, or both, or if the cerebellum or spinal cord be pressed 
 or injured, those parts which have a nervous connexion with 
 them will experience a corresponding derangement of function. 
 But if a process of disordered action be set up in one part of the 
 nervous extremities, and this passes on to another part, the 
 translation seems very strange, and you cannot easily comprehend 
 why paralysis of one principal part will produce the same disease 
 in another. 
 
 It has been asked, whether a local paralysis ever can, by spread- 
 ing towards the centre of the nervous system, produce paralysis 
 in another and a distant locality. This is a question we are not in 
 the habit of investigating ; and I think it has never been sulii- 
 ciently or satisfactorily examined, considering its importance in 
 a practical point of view, and the new light which it may throw 
 on many of the most obscure and perplexing forms of disease. I 
 shall endeavour to prove, first, that paralysis (from whatsoever
 
 576 CLINICAL MEDICINE. 
 
 cause it may arise) affecting one portion of the circumferential 
 extremities of the nerves, may also affect other portions of their 
 extremities ; secondly, that pain originating in one situation 
 may produce a similar sensation in distant parts ; and, thirdly, 
 that convulsions resulting from irritation in any part of the ex- 
 tremities of the nervous system may occasion a corresponding 
 train of symptoms in other parts of the body. You perceive, 
 gentlemen, that I have enumerated the three most remarkable 
 symptoms resulting from the disease of the nervous system, 
 namely, paralysis, pain, and convulsions. If I succeed in show- 
 ing that each of these may be produced by causes acting on the 
 extremities of the nervous system at a distance from the part 
 affected, the position I have advanced will be proved. 
 
 A few days ago, happening to call at a gentleman's house, I 
 was told by a young lady that she had wounded the inside of the 
 ring finger with a blunt needle, and that she found in it a con- 
 siderable degree of numbness and loss of sensation. I said to 
 her, " Your little finger is also numb." You are aware these 
 two fingers are supplied by the same branch of the ulnar nerve. 
 Well, the little finger was really numb, as well as the finger 
 next to it, which had been injured. What were the circumstances 
 of the case in this instance ? The side of the ring finger next 
 to the little finger had been wounded with a blunt needle ; the 
 impression made on the nervous extremities of the side of one 
 finger produced numbness not only in that finger, but also the 
 same cause operated backwards, or towards the centre, so as to 
 affect the branch given off to supply the little finger by the ulnar 
 nerve, above the place of the wound. Here is an instance of a 
 cause producing numbness of a particular branch of a nerve, 
 occasioning the same affection in another branch, and giving rise 
 to phenomena identical with those which might arise from an 
 injury of the main branch of the ulnar nerve. This is a plain fact. 
 You have a case of precisely the same paralysis in a poor 
 woman in this hospital, who has been complaining of rheumatic 
 pains in various parts of her body. Before I had been struck 
 by these and other instances of the same kind, I looked for the 
 cause of this paralysis in the trunk ; now I can understand 
 how it may be in the periphery. You recollect I made some 
 observations before on this subject, and mentioned that this numb- 
 ness is frequently remarked in cases of gout and rheumatism,
 
 PATHOLOGY OF NERVOUS DISEASES. 577 
 
 and that this occurrence in old persons often excites apprehensions 
 of approaching paralysis. I have known old gentlemen so alarmed 
 by it, as to seek medical advice ; and as this affection sometimes 
 precedes gout, and sometimes accompanies rheumatic arthritis 
 and phlegmasia dolens, it is a fact worthy of your attention, and 
 one which I would recommend you to hold in memory, though 
 I must confess I am not able to give any explanation of it. I 
 have seen an attack of this peripheral paralysis in a gentleman 
 of gouty habit, and heard him express a great deal of surprise 
 when he was told by Mr. Kirby, his medical attendant, that it 
 would usher in a fit of his complaint. This gentleman, however, 
 after taking some warm stimulant medicine, went to bed, and 
 next morning had a regular attack of gout. 
 
 But to return to our subject. If you make experiments by 
 handling snow, or immersing your hands in freezing mixtures, or 
 any fluid of very low temperature, you find that, after some time, 
 the exposed parts lose first the power of sensation, and after- 
 wards that of motion, and that in this way you produce a com- 
 plete, though temporary, local paralysis. Of this fact you are 
 all aware. But what bears more strongly on the subject in 
 question is that the paralysis, thus induced, is not merely con- 
 fined to the hands and fingers, but also extends to other parts. 
 You not only have the hands and fingers numb, but also lose, 
 in a great degree, the power of flexion and extension, which is 
 seated in the muscles of the fore -arm, and the motions of the 
 wrist-joint are imperfectly performed. Now all this time the 
 muscles of the fore-arm, lying at a considerable depth, and covered 
 by warm clothing, are protected from cold, and yet you perceive 
 they partake in the paralytic ajffection of the exposed parts. Here, 
 then, is another example of the same nature, corroborating our 
 former position, that causes producing loss of power in one part 
 of the extremities of the nervous system may have not merely 
 a local influence, but also travel towards the centre and aff'ect 
 distant parts. 
 
 Speaking of the influence of cold on the system, I have to 
 observe that, from the experiments made on this subject by 
 Hunter, Edwards, Dr. Marshall Hall, and others, some instances 
 of its efi'ects seem very singular. One of the most remarkable 
 is the production of paralysis, which, in most cases, is partial, 
 but is sometimes very general without being followed by death. 
 VOL. I. 37
 
 578 CLINICAL MEDICINE. 
 
 I remember the case of a dog, which lay buried in suow for two 
 days, and was then taken out quite stiff and insensible, and 
 thrown on a dunghill as if dead. After some time the poor animal 
 gave some symptoms of reanimation, and finally recovered. The 
 influence of cold has been alluded to by Dr. Abercrombie, and 
 you will find that he mentions a case of paraplegia, arising from 
 paralysis, brought on by cold, which lasted for eight months. A 
 blast of cold air on one side of the face has been known to cause 
 paralysis and distortion of several months' duration. 
 
 Again you have, as in the case of a man in this hospital, 
 paralysis of the lower extremities from exposing the feet to cold 
 and wet, while employed in bailing out water in a quarry. You 
 may have observed the same thing brought on by similar exposure 
 in fishing or snipe shooting, and that such causes gave rise to 
 paralysis not only in the parts subjected to the influences of 
 diminished temperature and wet, but even extended to the 
 nervous centres, so as to produce decided paraplegia. I was once 
 myself exposed to a very intense degree of cold on board a ship, 
 and observed that the sailors who had been most exposed suffered 
 severely, and did not recover from its effects during the rest of 
 our voyage. In fact, many months will often pass away before 
 the symptoms arising from cold are removed, and you will find 
 that, in addition to the case of paraplegia from cold which lasted 
 eight months. Dr. Abercrombie mentions another in which the 
 paralysis was permanent. 
 
 One of the most remarkable examples of disease of the nervous 
 system commencing in the extremities, and having no connexion 
 with lesions of the brain or spinal marrow, was the curious 
 epidemie de Paris, which occurred in the spring of 1828. 
 Chomel has described this epidemic in the 9th number of the 
 Journal Hcbdomadaire, and having witnessed it myself in the 
 months of July and August of the same year, I can bear testi- 
 mony to the ability and accuracy of his description. It began 
 (frequently in persons of good constitution) with sensations of 
 pricking and severe pain in the integuments of the hands and 
 feet, accompanied by so acute a degree of sensibility, that the 
 patients could not bear these parts to be touched by the bed- 
 clothes. After some time, a few days, or even a few hours, 
 a diminution or even abolition of sensation took place in the 
 affected members, they became incapable of distinguishing the
 
 PATHOLOGY OF NERVOUS DISEASES. 57i) 
 
 shape, texture, or temperature of bodies, the po^Yer of motion 
 decliuetl, and finally they were observed to become altogether 
 paralytic. The injury was not confined to the hands and feet 
 alone, but, advancing with progressive pace, extended over the 
 whole of both extremities. Persons lay in bed powerless and 
 helpless, and continued in this state for weeks and even months. 
 
 Every remedy which the ingenuity of the French practitioners 
 could suggest was tried, and proved inefi"ectual. In some, the 
 stomach and bowels were deranged, and this affection terminated 
 in a bad state of health, and even in death ; in others, the vital 
 organs, cerebral, respiratory, and digestive, were in the same 
 state as before their illness, and their aj)petites were good, but 
 still they remained paralytics. At last, at some period of the 
 disease, motion and sensation gradually returned, and a recovery 
 generally took place, although, in some instances, the paralysis 
 was very capricious, vanishing and again reappearing. 
 
 The French pathologists, you may be sure, searched anxiously 
 in the nervous centres for the cause of this strange disorder, but 
 could find none ; there was no evident lesion, functional or 
 organic, discoverable in the brain, cerebellum, or spinal marrow. 
 Now, here is another remarkable instance of paralysis creeping 
 from the extremities towards the centre ; here is a paralysis 
 affecting all parts of the extremities as completel}' as if it had its 
 origin in the central parts of the nervous system, and can any 
 one, with such palpable evidence before him, hesitate to believe 
 that paralysis, or even hemiplegia, without any lesion of the 
 brain or spinal cord, may arise from disease commencing and 
 originating in the nervous extremities alone ? 
 
 I may observe, en ixissant, that where paralysis simultaneously 
 attacks the arm and leg of the same side, it arises from an 
 impi'essiou on the nervous centres ; but this I think does not 
 hold where the paralysis is creeping, as in the case before me, 
 which has been reported by Mr. Hudson, and was under the care 
 of Dr. Stokes. "The patient, James Moore, was admitted on 
 the 4th of March, labouring under paraplegia, which he attributed 
 to cold and wet. About a month before admission he first per- 
 ceived a stiffness of the great toe of the right foot ; afterwards 
 numbness and coldness of the sole, and then of the \e^ as far 
 as the knee, and dragging of the limb in walking. During the 
 progression of the disease up along the thigh, it commenced in
 
 580 CLINICAL MEDICINE. 
 
 the left foot, and, after a few days, he experienced almost com- 
 plete paralysis of sensation in the right lower extremity, and a 
 lesser degree in the left, accompanied by so much diminution of 
 the power of motion as to render him unable to walk without 
 support. About three weeks after the appearance of paralysis 
 in the lower extremities, the little finger of the right hand was 
 attacked with numbness, which passed successively to the rest, 
 attended with some loss of the sense of touch, and power of 
 grasping objects. He has also had retention of urine, and the 
 bowels were obstinately constipated. There was no tenderness 
 of any part of the spine. He had no pain in the head. His 
 pupils were natural, mind unaffected, pulse, sleep, and appetite 
 also natural." Here, gentlemen, you have an instance of what 
 I would term creeping paralysis, having its origin evidently in 
 an affection of the peripheral extremities of the nerves. 
 
 I may now observe, that I have brought forward instances to 
 prove that direct injury of one part of the nervous system may 
 produce paralysis in another and distant part, but have we not 
 also other instances ? Certain substances, which produce morbid 
 affections on the nervous system, are found to be attended with 
 results analogous to those described. You are all aware that 
 lead frequently brings on paralysis ; that this is caused by the local 
 application of lead, and that the effect of the local application 
 extends chiefly to those parts to which the lead is directly 
 applied. Thus, in painter's colic, the paralysis almost invariably 
 begins in the hands and wrists, preceded, I will allow, in many 
 cases, by symptoms of poisoning of the system, as shown by the 
 tormina and affection of the intestinal canal. Dr. Bright has 
 remarked, that in painter's colic the spine is frequently tender 
 in the cervical region, when the upper, and in the lumbar, when 
 the lower extremities are affected. It has been remarked, that 
 spinal tenderness is often the consequence of disease of the 
 extremities, and not the cause ; so I think it is in painter's colic. 
 
 We found in this hospital a great number of cases in which 
 there was paralysis of the upper extremities, without any spinal 
 tenderness in the commencement ; but when the disease had 
 lasted for some time, the affection seemed to spread towards the 
 spinal column. When this took place, it generally caused an 
 aggravation of the disease ; but it is no less true that we had 
 many instances where it could not be discovered ; and you are
 
 TATHOLOGY OF NERVOUS DISEASES. 581 
 
 not to think that this irritation of the spinal cord should always 
 precede the paralytic affection of the wrist and hand which is 
 observed in painter's colic. You have seen in this hospital two 
 cases of spinal tenderness supervening on peritonitis and acute 
 gastric irritation, and, in fact, in every disease in which the 
 nervous extremities, which are distributed to the parietes or 
 viscera of the abdomen, are engaged, you find almost invariably 
 that, after some time, there will be pain and tenderness of the 
 spinal column as the consequence of these diseases. On the 
 other hand, I grant that as soon as the spine becomes affected, 
 whether the disease be tympanitis, peritonitis, or that swelling of 
 the belly to which the name of hysterical meteorism is applied, 
 there will be certainly an aggravation of the existing symptoms. 
 
 You perceive this conducts us to the solution of the question, 
 how far, in the treatment of chronic complaints, are we to con- 
 sider spinal neuralgia as the cause or consequence of the disease ? 
 Sometimes those troublesome hysterical affections which you are 
 called on to treat are preceded by spinal neuralgia, but in many 
 well-marked cases it is totally absent. I wish to call your 
 attention to this subject, because medical men have been biased 
 to a very considerable extent, by the statements made by Mr. 
 Teale and others, respecting the treatment of various anomalous 
 affections supposed to be connected with irritation in the spinal 
 column. Every female who complains of any kind of abdominal 
 or pectoral symptoms of an obscure nature is examined all over 
 the spine, and if the slightest tenderness be detected, according 
 to the practice generally pursued, you are to leech and blister her 
 back, or to apply tartar emetic ointment. 
 
 I think I have seen injurious effects from this plan of treat- 
 ment. Inquire carefully into the history of the case, and 
 ascertain, if possible, whether it was the central or circum- 
 ferential parts which were first affected, for, in the latter case, 
 you can promise yourselves less from any local application to 
 the spine than in the former ; whereas, in those instances 
 where the disease has travelled from the centre to the circum- 
 ference, you may hope for success from local applications. It 
 is important to recollect, gentlemen, that violent enteritic 
 affections may produce paralysis of the lower extremities. In 
 the case of a young gentleman whose disease arose from obstruc- 
 tion in consequence of eating nuts — and to which I shall advert
 
 582 CLINICAL MEDICINE. 
 
 in a future lecture, violent enteritis and peritonitis arose, and 
 he had two relapses ; from these he recovered with difficulty, 
 but they left him paralytic of his lower extremities. After two 
 months, the paralysis speedily yielded to the application of 
 stimulating liniments. This case Mr. Kirhy and Mr. Cusack 
 saw. In another remarkable case, concerning which I was 
 consulted by Dr. Ireland, a frequently recurring vomiting was 
 in the end followed by paralysis of the lower extremities. 
 
 What I wish to impress upon your attention is, that pain, 
 numbness, spasm, and loss of power from an affection of the 
 circumferential parts of the nerves may commence in these 
 extremities, and be propagated towards the centre, so as to be 
 finally confounded with diseases originating in the central parts 
 themselves. You have seen in the patient, James Moore, 
 hemiplegia, which I am convinced had its origin in the ex- 
 tremities. Have you not also seen, in the cases of peritonitis, 
 gastric irritation, and painter's colic, a consecutive affection 
 of the spine '? Indeed, it frequently happens that pai'alysis, 
 commencing in the nervous extremities, may not only induce 
 disease of the spine, but in time bring on disease of the brain 
 itself. It does not follow that a fatal paralysis affecting the 
 brain should commence in that organ. In Dr. Woolaston's 
 case, are we to account for the occasional partial amaurosis 
 under which he laboured for such a length of time before his 
 ■death, by referring it to disease of the brain ? In consequence 
 of a temporary paralysis of one half of the retina of each side, 
 he saw but the halves of objects, and from this he argued that 
 there was a semi-decussation of the optic nerves. This hap- 
 pened several times, but never remained any length of time, and 
 I do not think that at that period it was proved that any disease 
 existed in the brain. 
 
 Some time back I saw, with Dr. Brereton, a very singular 
 example of defective vision in a wealthy bookseller, who had 
 lost the sight of one eye from accident. This gentleman, one 
 day, in going up a hill near Clonskeagh, remarked that where 
 there was but one man he saw two men, but divided at the 
 middle, as if they were cut by a vertical line into two halves. I 
 questioned him closely on the occurrence, thinking it to be the 
 effect of imagination, but he said this was not the case, and that 
 he was perfectly convinced he saw double. This is but one way
 
 PATHOLOGY OF NERVOUS DISEASES. 583 
 
 of accounting for this optical delusion. It is well known that 
 when vision is much impaired, the power of seeing light often 
 remains, when the eye cannot distinguish any particular object. 
 A partial and temporary paralysis of the retina, in a vertical 
 section, may have given rise to an apparent white line bisecting 
 the object vertically. Again ; in the case of a fine young lady, 
 whom I saw along with Dr. Beatty, amaurosis — acute, sudden, 
 and complete — came on without any headache or cerebral 
 symptoms being complained of. ^Vhen called on to see her, I 
 found her walking about the drawing-room, quite cheerful, and 
 enjoying a good appetite, but perfectly blind. After the lapse 
 of some days, these symptoms were followed by profound coma 
 and death. 
 
 But there are other instances more decidedly corroborative of 
 the positions I have laid down. You all know that if a man 
 gets a blow or cut on the forehead, which wounds or divides the 
 frontal nerve, not only the parts which that nerve supplies 
 become paralytic, but that also the diseased impression thus 
 produced spreads towards the centre, afiects those nerves which 
 anastomose with the frontal, and, by means of the communi- 
 cation formed between the nerves of the eye-ball through the 
 lenticular ganglion, deranges the functions of the optic nerve, 
 and causes amaurosis. Formerly I was in the habit of giving a 
 difierent account of this, and thought that because, in some of 
 the lower classes of animals, as for instance the mole, the fifth 
 nerve, from which the frontal is derived, is the true nerve of 
 vision — those animals having no optic nerve,* I had found an 
 analogy capable of giving an explanation of the fact, that injury 
 of the frontal nerve is sometimes followed by blindness. But 
 this, I am of opinion, cannot be the true mode of accounting for 
 the amaurosis, as I can now readily conceive how injury of any 
 other nerve, having communication with the optic, may spread 
 inwards, and finally derange or destroy its functions. 
 
 * A curious instance of the total absence, or imperfection, of a pair of nerves, is 
 related by the Rev. Mr. Bree, in the Magazine of General History: — "A white cat, 
 of the Persian breed, was kept in his family as a favourite. The animal was a female, 
 quite white, and perfectly deaf. She produced, at various times, many litters of 
 kittens, of which some were quite white, others more or less mottled, tabby, &c. But 
 the extraordinary circumstance is, that of the offspring produced at one and the same 
 birth, such as were, like the mother, entirely white, were, like her, invariably deaf ; 
 while those that had the least speck of colour on their fur as invariably possessed the 
 usual faculty of hearing."
 
 584 CLINICAL MEDICINE. 
 
 You will frequently observe persons in the decline of life, who 
 otherwise enjoy tolerable health, exhibiting, as it were, a slight 
 shade of paralytic affection of the system, fitful and capricious 
 in its appearance and duration, sometimes remarkable on every 
 instance of corporal exertion, sometimes scarcely at all, present- 
 ing at one time a reiteration of successive attacks, and at another 
 time being totally absent for months. Some cases of this kind 
 I have studied for months, and one in particular for years. The 
 gentleman, who was the subject of the latter, complained of 
 barely perceptible weakness and dragging of one of his legs 
 whenever he was tired ; but if he took a glass of wine on coming 
 home, he got quite well, and these symptoms disappeared. 
 Matters went on this way for a considerable length of time, the 
 paralysis being at one time in one leg, and then in the other. 
 At last he got a paralytic stroke, which lasted for some time and 
 then subsided. He next got confirmed paralysis of one side, and 
 soon after this was carried off by an attack on the brain. 
 
 You will often find persons similarly affected with paralytic 
 attacks of the extremities, at first slight and transient, but 
 afterwards increasing in vigour and intensity, until they termi- 
 nate in ramollissement or effusion. Formerly I was of opinion, 
 that this fugitive and shifting paralysis depended upon local 
 congestion in the brain, and others have attributed it to effusion, 
 but this is not the fact. Persons may die after having laboured 
 for some time under hemiplegia, and 3'et no trace of lesion of 
 the cerebral mass be detected : and why ? Because many of 
 them are cases of this creeping paralysis, commencing in the 
 peripheral extremities, and travelling gradually towards the 
 centres of the nervous system. 
 
 It is only on the principle of there being such a disease as 
 local paralysis not induced by lesions of the nervous centres, 
 that we explain the origin and nature of such cases as i^aralysis 
 of the deltoid, concerning which Dr. Elliotson has made so many 
 interesting observations. It is by reference to this hijpothesis 
 alone that ive can account for the following cases, detailed by 
 Dr. Cooke in his admirable work on palsy : — 
 
 " I have lately had an opportunity of seeing a case of 
 anomalous hemiplegia attended with circumstances not less 
 extraordinary than those above described. An officer of high 
 rank in the army, who is now about 60 years of age, was, in the
 
 PATnOLOGY OF NERVOUS DISEASES. 585 
 
 year 1795, affected with a diminution of power in the right hand. 
 This complaint increased, notwithstanding a variety of modes of 
 treatment, till the year 1800, when, after a course of mercury, 
 recommended by Mr. Cline, its further progress was stopped, since 
 which time the disease has remained stationary. The peculiar 
 circumstances of this case are the following : — The muscles of 
 the left arm, from the shoulder to the elbow, are much wasted, 
 and greatly diminished in power ; while the muscles of the fore- 
 arm are not at all lessened in size, and but little in power. The 
 state of the right side is just the reverse, the muscles of the 
 upper arm being of their natural size, and possessing their full 
 power ; whilst those of the fore-arm are very much wasted, and 
 their motion, especially tbat of the fingers, is almost entirely 
 abolished. In all other respects this gentleman appears to be 
 perfectly well. No cause for this disease can be assigned, nor 
 did any method of treatment afford the smallest relief, till the 
 mercurial course was adopted, when the progress of the disorder 
 was arrested in the year above-mentioned. Since that time no 
 attempts to remove the complaint have been made, yet it does 
 not increase. 
 
 " In a late publication by Mous. Keratry, a case of general 
 palsy is related, the circumstances of which are very extra- 
 ordinary. This case is adduced with a view of showing how 
 little residue of animal existence is sufficient for the preserva- 
 tion of the intelligent being. There is now living, he says, in 
 D'Isle et Vilaine, a person who, after having been blind for ten 
 years, lost also the sense of hearing, and in a little time after- 
 w^ards became almost universally paralytic. He was entirely 
 deprived of the use of his arms, legs, thighs, and of the whole 
 exterior surface of the body, with the exception of a part of the 
 face ; but the power of speech, and the functions of respiration, 
 circulation, and digestion remained. Under these deplorable 
 circumstances, however, he is not, says Mons. Keratry, wholly 
 without consolation, for a sort of intercourse is preserved with 
 his family and friends, by means of characters traced on that 
 part which still retains its sensibility, and in this state of un- 
 exampled misery he retains, in some degree, the distinguishing 
 character of man — intelligence." 
 
 I saw, with Sir Philip Ci'ampton, a case of paralysis, in which 
 the mouth was drawn upwards and to one side, accompanied by
 
 586 CLINICAL MEDICINE. 
 
 ptosis of the upper eyelid of the same side, so as to produce very 
 great distortion. Sir Philip Crampton, with his usual decision, 
 said, " Put a blister here and there, here and then there, and 
 you set things to rights," marking out, at the same time, a 
 space over each of the principal trunks of the fifth nerve, which 
 are expanded over the side of the face. It happened exactly as 
 he predicted ; the first blister we applied pulled up the eyelid, 
 the next partially rectified the distortion of the mouth, and the 
 third made it quite straight. Now, the phenomena of this case 
 and its treatment cannot be explained by supposing the paralysis 
 to arise from disease of the brain ; but if, on the other hand, 
 you consider the disease as originating in the nervous extremities 
 themselves, how easy will it be to account for the mode of 
 operation ! 
 
 The paralysis of the insane, first described by Esquirol, and 
 spoken of by Andral in his admirable lectures on monomania, 
 offers another instance of creeping paralysis, of palsy travelling 
 from the circumference towards the centre.* 
 
 This disease is most common in that species of derangement 
 termed idiocy, and it has been remarked, that those whose 
 insanity was caused by venereal excesses, whether males or 
 females, by sexual connexion, or by masturbation, and those in 
 whom it was occasioned by habits of intoxication, were the most 
 liable to this disease. M. Esquirol also believes that it is a 
 peculiar consequence of the abuse of mercury. 
 
 When we recollect that in idiocy there is no vascular excite- 
 ment, no paroxysms of violence, no determination of blood to 
 the head, and no headache, we must allow that this species of 
 paralysis is of most frequent occurrence in that variety of mental 
 alienation which is least likely to be produced by a local disease 
 in the nervous centres, capable of giving rise to a paralj'tic 
 affection of the circumferential parts. When we accurately 
 
 * I think it is quite evident that many of the cases described by Rostan, as examples 
 of creeping palsy, caused by ramollisxement of the brain, should rather be considered 
 as cases of disease spreading from the extremities of the nervous system to the centre. 
 The case of the old woman, named Dassonville, related by Rostan, was clearly of this 
 nature. She had for a year experienced sensations of numbness in the lower extremities, 
 and a slight diminution in their muscular power, so as to cause her gait to resemble a 
 dragging of her legs rather than walking ; during this period, too, her mind was a 
 little impaired and weakened. This series of symptoms was closed by evident inflam- 
 mation of the brain, ending in coma. I cannot but consider Rostan in error when he 
 attributes the former symptoms as produced by the same cause as the latter.
 
 PATHOLOGY OF NERVOUS DISEASES. 587 
 
 examine the march and progress of this paralysis, we find it 
 attended with many circumstances clearly denoting its origin 
 in the nervous extremities, notwithstanding what some French 
 pathologists have asserted to the contrary: — the slow man- 
 ner in which it creeps from one part to another ; the fact 
 that, after the disease has occasioned an almost complete 
 loss of power in the lower extremities, the weakness may, on 
 some days or hours, he less remarkahle or even disappear alto- 
 gether ; so effectually indeed, that if, for experiment, you 
 endeavour to throw the patient down, he will give very powerful 
 resistance. In this circumstance, says Andral emphatically, we 
 find the proof of the absence of any organic lesion. 
 
 Another proof of its not depending on any lesion of the nervous 
 centres is derived from the very extent to which it may arrive ; 
 for, in the third stage of the disease, the paralysis is complete 
 and general, including the four limbs, the tongue, and the volun- 
 tary muscles of the trunk. The involuntary muscles, too, especially 
 those connected with the respiratory movements, become in- 
 fluenced ; in this third and highest degree of the paralysis, 
 convulsive movements may also occur, presenting the strange 
 phenomena of the alternate paralysis, and the complete con- 
 tractility of the same voluntary and involuntary muscles, and of 
 a voluntary muscle, which is perfectly disobedient to the will, 
 being thrown into bizarre and unwonted motion by the involun- 
 tary impulse. This fact, gentlemen, is in itself sufficient to 
 prove the truth of the proposition I have advanced, that a morbid 
 state of the nervous extremities is often unconnected with, and 
 independent of, any central lesion. 
 
 In my own practice, cases of creeping paralysis corroborating 
 this conclusion have occurred. Thus I saw, in consultation with 
 Mr. Colles, a clergyman, all of whose extremities had gradually 
 become affected with the slightest possible degree of paralysis, 
 aff'ecting both the motion and sensation, the latter rather more 
 than the former. The progress of the disease was so irregular and 
 gradual, it is so variable, and has now lasted so long without 
 any further increase in its intensity, that both Mr. Colles and 
 myself have little doubt that the disease is unconnected with 
 any lesion of the brain or spinal marrow. 
 
 In the following interesting case the paralysis is also evidently 
 independent of any alteration in the nervous centres. Dr. Knaggs
 
 588 CLINICAL MEDICINE. 
 
 of Mountratb had a very severe and prolonged attack of the late 
 epidemic fever in the month of March, 1848 ; his life was much 
 endangered, his head being engaged throughout, but he had no 
 apoplectic nor convulsive fit. On recovery he found that he had 
 almost entirely lost sensation in the ring and little fingers of the 
 left hand, but the power of motion was complete : while in the 
 forefinger of the same hand there was paralysis of motion, but 
 sensation was perfect. This state continuing, he came to town 
 a month afterwards to consult me. When I saw him, with Dr. 
 Neligan, the paralysis of sensation and of motion was just as 
 when he first experienced it, but he thought that he had less 
 power in performing any delicate manipulation with the fore- 
 finger, and there was very great atrophy of all the special 
 muscles of this finger, while the other muscles of the hand and 
 arm, including those of the ring and little fingers, were not in 
 the least wasted : thus aifording a beautiful illustration of the 
 intimate connexion ivhich exists between the motive power and 
 nutrition. 
 
 Before concluding this summary of my views on some points 
 connected with the Pathology of the Nervous System, which I 
 published for the first time many years since, and of the truth of 
 which subsequent experience has fully convinced me, I cannot 
 avoid expressing my surprise that Dr. Todd — in his admirable 
 essay on the Pathology of the Nervous System, published in the 
 Cyclopcedia of Anatomy — has not noticed my observations, 
 although it is evident from the following paragraph among 
 others that he has arrived at the same conclusion : — " I shall 
 here cite various facts in addition to those already adduced, 
 which unequivocally demonstrate that a power exists in the cord 
 of exciting movements in parts which receive nerves from it, by 
 changes occurring in its substance, which may arise there from 
 some modification of its nutrition developed in the cord itself, 
 or he excited by a stimulus brought to act upon it by afferent or 
 sensitive nerves.^'
 
 589 
 
 LECTURE XXXIV. 
 
 APOPLEXY. — PATHOLOGY OF CEREBEAL DISEASES. 
 
 Gentlemen, — Two persons labouring under severe cerebral 
 disease, admitted lately into the same ward, presented a striking 
 contrast between the symptoms by which each respectively was 
 accompanied ; in fact, so completely did these cases differ in 
 their duration and history, that they scarcely resembled each 
 other in anything but their fatal termination ; and it was conse- 
 quently expected by all who had watched their progress during 
 life, that an examination of the brain would detect lesions of 
 that organ as different in their nature as had been the symptoms 
 which they had occasioned. 
 
 Such, I confess, was my own opinion, and such was the 
 opinion of many others who have no little experience in pathology. 
 The result, however, differed widely from our expectations, and 
 is therefore well worthy of your attention. 
 
 As this result is in direct opposition to our preconceived 
 opinions concerning the origin and causes of some of the most 
 serious derangements of the cerebro-spinal functions, I must 
 trespass on your patience while I lay before you the particulars 
 of these cases, and the lesions observed on dissection ; after 
 which we shall compare them together, and consider what 
 pathological and practical inferences may be drawn from them. 
 I am more anxious to draw your attention to this subject, 
 because many late writers on diseases of the brain affect an 
 accuracy of diagnosis which I have found unattainable in my 
 practice. Numerous cases, it is true, are cited by each of these 
 authors, and are so arranged and classified that the conclusions 
 seem to be arrived at by a perfectly fair induction, and of course 
 command our assent on the strongest grounds, the evidence of 
 facts. It is to be feared, however, that these facts have been 
 too frequently warped to suit preconceived pathological arrange- 
 ments, apparently founded on the basis of morbid anatomy ; and
 
 590 CLINICAL MEDICINE. 
 
 I am inclined to think that a more unbiassed observer will find 
 little cause to join the ranks of those who claim for this depart- 
 ment of medical science a degree of accuracy almost equal to that 
 which the unrivalled discoveries of Laennec have enabled us to 
 attain in the diagnosis of pectoral affections. To prevent the 
 suspicion of having accommodated the history of these cases to 
 any opinion of my own, I shall read them out from the case- 
 book. 
 
 Patrick Kearney, aged forty, admitted October 6th. — Has 
 always enjoyed good health, with the exception of being subject 
 occasionally to ill-conditioned ulcers. Three months ago, after 
 having been subject to very violent vertigo for some time, he was 
 attacked by slight hemiplegia of the left side, from which he 
 recovered in three days. The vertigo, however, continued, and in 
 walking he consequently frequently staggered, and sometimes fell, 
 but did not become insensible ; and on such occasions he was able 
 immediately to rise from the ground without assistance. Three 
 weeks ago he again lost the use of his left side in the evening, 
 and says that this attack was not preceded by headache. His 
 left arm has lost the power of motion, but not of sensation. 
 The fore-arm is flexed on the arm, the fingers on the hand, while 
 the latter is bent towards the fore-arm. Extension of these parts 
 could not be effected, even by the application of considerable 
 force, and every such attempt appeared to give him pain. This 
 flexed state seemed to arise from a permanent tonic spasm 
 affecting the flexor muscles of these parts ; and it is remarkable 
 that it continued even when the patient was asleep. He has 
 occasionally great trembling in this limb, but no pain. The 
 left lower extremity is less engaged ; there is no flexure, and 
 but little trembling. Pulse 92, full and soft ; other functions 
 natural. 
 
 His disease underwent no material alteration until eleven 
 o'clock in the forenoon of the 15th October, when his respiration 
 became suddenly stertorous, and his eyes fixed. The stertor 
 increased, and in about ten minutes he became quite comatose, 
 having lost all power of sense and motion, and his limbs were 
 stiff. This fit lasted about half an hour, and on its subsiding 
 he recovered his consciousness perfectly, but his voice was very 
 obscure, and his articulation difficult. His whole frame, too, 
 continued to be acritated by a nervous restlessness and tremor.
 
 APOPLEXY. 591 
 
 In the evening be had another fit, which was not so severe as 
 that of the morning. During the night he did not sleep a 
 moment, but constantly cried aloud, so as to disturb the other 
 patients, and was perpetually agitated and restless, making 
 frequent attempts to leave his bed. At eight a.m. on the 16tb, 
 the hemiplegia was observed to be increased, while the tonic con- 
 traction had extended to the left lower extremity. During the 
 visit, a continued shivering affected him generally, but it seemed 
 greater on the affected side. This rigor soon subsided. Although 
 so agitated and restless, and although he was constantly crying 
 out in an incoherent manner, as if from pain, yet when spoken 
 to he answered in a perfectly rational manner, and said he had 
 no pain in the head, nor did he lose his intellect or speech until 
 the very moment of his death, which took place about noon on 
 the same day. During the time which intervened between the 
 first fit and his death, the pulse and heat of skin are noticed to 
 have continued as before. 
 
 Examination of the bodij 18 hours after death. — Cadaveric 
 stiffness inconsiderable ; contraction of the left leg resolved, that 
 of left arm remains with considerable stiffness. The vessels of 
 the scalp contained but little blood, but on opening the cranium 
 the sinuses of the dura mater were found much distended by 
 fluid black blood. The vessels of the pia mater exhibited an 
 intense congestion, being everywhere distended with dark- 
 coloured blood. No blood was extravasated on the up2)er surface 
 of the brain, neither was there anywhere a trace of sub-arachnoid 
 serous eftusion, or of puriform matter, coagulable lymph, &c. 
 At the base of the brain a stratum of extravasated blood, in 
 some parts very thin, but in other places two or three lines in 
 thickness, was found at both sides of the pons, and occupying 
 all the space between it and the commissure of the optic 
 nerves ; coagulated blood also existed in the fourth ventricle, 
 and, passing by the iter, it so exactly occupied the third, and 
 both lateral ventricles, that when extracted the coagula appeared 
 like casts of these cavities. It is to be observed, howevei-, that 
 the blood so effused into these cavities by no means considerably 
 distended them. 
 
 A pretty accurate account of its quantity in all may be formed 
 from the fact, that in each of the lateral ventricles the coagulum 
 in size and shape resembled a leech of the ordinary size, when
 
 592 CLINICAL MEDICINE. 
 
 about half filled by sucking. No rupture of tlie basilar or other 
 arteries could be found ; but, on examining the structure of 
 these and the neighbouring arteries, forming the circle of Willis, 
 the following diseased state of their parietes was detected. The 
 thickness of the arterial tunics was increased, and the three 
 coats were separated from each other by areolar tissue, loose 
 and friable in its texture ; in fact, the connexion between these 
 coats was but trifling, and with a little care, the middle or 
 elastic tunic could be drawn out from between the others in the 
 form of a hollow cylinder. Between the middle and internal 
 tunics were several patches of white opaque matter, but as yet 
 no ossific deposition. A most minute and careful examination 
 of the brain, cerebellum, medulla oblongata, and about one 
 inch of the cervical spinal marrow, was next made, but not the 
 least morbid alteration — not the least change in consistence or 
 colour — or, indeed, in any other particular from the healthy 
 state, could be anywhere detected. Thoracic and abdominal 
 viscera healthy. 
 
 Before I make any remarks on this curious case, I shall read 
 you the particulars observed during the illness of Joseph 
 Murphy. 
 
 This young man, aged 18 years, was admitted on the 5th of 
 November. He was a shoemaker's apprentice, and had, until 
 the commencement of his present illness, four weeks ago, always 
 enjoyed good health, with the exception of an incontinence of 
 urine, which he attributed to the cruelty of his master, who only 
 permitted him to leave his work at certain times, in consequence 
 of which he was unable to relieve his bladder as often as nature 
 required. About a month before his admission, having been 
 much exposed to damp and cold air, he observed his abdomen 
 to swell, and become painful on motion, particularly on stooping. 
 Within the last eight days these symptoms have been much 
 increased ; purging has supervened, and he has been attacked 
 by an acute pain in the left hypochondrium, and such a degree 
 of debility that he is compelled to abandon his occupation. 
 
 November 6th. — Abdomen considerably swollen ; the swelling 
 appeared to be rather the consequence of a tympanitic distention 
 of the intestines than of dropsical effusion ; no part of the 
 abdomen was tender on pressure except the region of the spleen, 
 which was obviously much enlarged. He described himself as
 
 APOPLEXY. 593 
 
 affected with a pain wliicb shot across the epigastrium from 
 one hypochondrium to the other, and rendered stooping at his 
 work extremely distressing. The patient was considerably 
 emaciated ; appetite good ; some thirst ; tongue red and dry ; 
 bowels free, two or three stools being passed daily ; no tenesmus ; 
 involuntary discharge of urine ; no pain or tenderness in the 
 region of the bladder ; pulse 120 ; sleeps well ; has no pain in 
 the head; no derangement whatever of cerebral or respiratory 
 functions ; his eyes are suffused, but not weak or sore. Twenty 
 leeches were applied to the epigastrium, and he was put on low 
 diet. 
 
 November 7th. — Nurse states that he continued without any 
 alteration in his symptoms until yesterday evening after supper, 
 when, becoming very drowsy, he went to bed, and fell into what 
 she thought was a natural sleep. This morning, however, she 
 became alarmed at finding that she could not awake him. He 
 is now lying in a state of deep coma, and constantly tosses his 
 head from side to side on the pillow ; the eyes are suffused ; the 
 pupils dilated, and totally insensible to light ; there is slight 
 strabismus of the right eye. Skin warm ; pulse 120, hard, 
 and somewhat full ; a rale is audible in the trachea. A vein 
 was immediately opened, but when about three ounces of blood 
 had been taken, the pulse became very weak, and he appeared 
 so sunk that no more blood was drawn. The pulse shortly after 
 regained its strength, and the tracheal rale ceased. An injection 
 of several pints of warm water was carefully administered by 
 means of Read's syringe, and brought away an enormous quantity 
 of hardened feces. In two hours a turpentine injection was 
 ordered. In the meantime his head had been shaved, and was 
 kept constantly wet with towels dipped in cold water, while the 
 actual cautery was applied to the nape of the neck, and a scruple 
 of calomel was given, to be followed in the course of the day by 
 a draught containing castor oil and spirits of turpentine, for the 
 purpose of removing or diminishing the tympanitic state of the 
 belly, which still persisted. None of these measures afforded 
 him the least relief. The draught was no sooner swallowed than 
 it was rejected, and the application of the cautery roused him 
 but for a few minutes, after which he again became comatose. 
 In the evening he bad a severe fit of screaming ; his pulse rose 
 to 140, was somewhat full and hard ; and his death, which took 
 VOL. I. 38
 
 594 CLINICAL MEDICINE. 
 
 place about nine o'clock that evening, about twenty-six hours 
 from the first appearance of the cerebral SYmptoms, was preceded 
 by two or three slight convulsive fits. 
 
 Dissection 12 hours after death. — Head : — There was no 
 congestion of the vessels of the scalp ; on removing the cal- 
 varium, the sinuses of the dura mater were found gorged with 
 black blood, mixed with small quantities of fibrine deprived of 
 colouring matter. No fluid was found between the visceral layer 
 of the arachnoid membrane and the convex surface of the brain, 
 and not more than a teaspoonful at its base. The pia mater was 
 excessively congested, its larger veins gorged with black blood, 
 and their smaller branches, similarly distended, formed numerous 
 ramifications over that membrane. In the ventricles of the 
 brain was a small quantity of serous fluid, and a little in the 
 third ventricle, but the quantity of serum so efi'used was too 
 inconsiderable to be considered as a morbid j^roduct. The sub- 
 stance of the brain and cerebellum was perfectly healthy in 
 every respect. In both this and the preceding case the brain, 
 when cut, exhibited numerous red points, but not more than are 
 frequently seen on the section of a perfectly healthy brain. 
 
 Thorax : — Nothing remarkable, except a considerable engorge- 
 ment of the posterior portion of both lungs, owing partially to 
 cadaveric gravitation, and partially to the effect of gravitation 
 during the long agony preceding death. This, from affording a 
 crepitating rale before death, and from its rendering the pendent 
 portions of the lung impervious to the air, Laennec has termed 
 the pneumonia of the dying, a term by no means applicable, for 
 pneumonia renders the pulmonary tissue impervious, in conse- 
 quence of an exaltation of the vital powers of the afiected part; 
 whereas, in the impervious pulmonary tissue just spoken of, this 
 state arises from a decrease, a gradual cessation of the vital 
 powers, which permits the vessels to allow the blood, in 
 obedience to physical laws, to accumulate in the most depending 
 part. 
 
 Abdomen : — The large intestines were flaccid and empty, and 
 lay concealed beneath the stomach and small intestines, both of 
 which were excessively distended with air, and presented on their 
 serous surfaces the appearance of intense venous congestion ; the 
 veins, everywhere gorged with dark blood, were injected with 
 this fluid to their ultimate ramifications. There was a consider-
 
 APOPLEXY. 595 
 
 able congestive redness in the mucous membrane of the stomach, 
 and that of the small intestines was throughout their whole 
 extent of a slate colour, evidently produced by its state of 
 sanguineous engorgement during Hfe; the most pendent portions 
 of the intestinal loops were red, and still more congested, in 
 consequence oi iwst-mortem gravitation. 
 
 Having thus put you in possession of the symptoms and post- 
 mortem appearances observed in these two cases, I shall now, 
 gentlemen, proceed to compare them together, and afterwards 
 examine them with reference to the opinions expressed by writers 
 on diseases of the brain. 
 
 In the first place, no two cases could possibly differ from 
 each other more than these in their duration, general history, 
 and individual S3'mptoms. In one, coma suddenly supervened 
 without any previous warning, and persisted until death, 
 accompanied by dilatation of the pupils, and insensibility of the 
 retina to light. Here the derangement in the sensorial functions 
 was quite unexpected, and there were neither hemiplegia, tonic 
 spasms, rigors, nor successive fits of convulsions, which were the 
 very symptoms that in the other case constituted the chief 
 features of the disease. In the other case, too, were absent the 
 uninterrupted state of coma, the contraction of the pupils, and 
 the insensibility to light. The state of mind in each was 
 strikingly difierent ; in the one, being as it were annihilated 
 from the very commencement, while the other patient answered 
 questions rationally to the last. In the old man the cerebral 
 affection had subsisted for several months ; in the young man 
 it had proved fatal in twenty-four hours. 
 
 Having formed a general comparison between the symj^toms 
 of these two cases, can we, in the lesions observed in the exam- 
 ination of the brain, detect the causes of the numerous and 
 strildng differences just enumerated ? Most certainly not, for the 
 morbid appearances were exactly the same in both, if we except 
 the blood effused on the base and in the ventricles of the old man's 
 brain. Arguing from the generally received ideas concerning 
 the effects of such an effusion of blood, its detection in these 
 situations would undoubtedly lead the morbid anatomist to 
 conclude — had the bodies of both these patients been presented 
 to him for examination — that the man in whose brain this 
 effusion had occurred must during life have been much more
 
 596 CLINICAL MEDICINE. 
 
 likely than the other to present such symptoms as permanent 
 coma, dilatation of the pupils, insensibility of the retina to 
 light, &c. In fact, it is quite obvious that the post-mortem 
 appearances would mislead him, and that the history of the 
 cases thus formed would be extremely incorrect — symptoms 
 being attributed to one which had only been displaj'ed 
 by the other. I do not mean to assert that morbid 
 anatomists have not long ago observed that coma, dilatation of 
 the pupils, &c., may occur without effusion, or that effusion may 
 exist without having occasioned these very symptoms. Still, 
 however, it cannot be denied that the cerebral mass and mem- 
 branes being found in every other respect in exactly the same 
 state in the two cases, an effusion of blood on the base and 
 in the ventricle of one being superadded to the appearances 
 observed in the other would be considered as constituting an 
 important difference, increasing the probability of the occurrence 
 of coma, &c., during the life of that patient. The cases just 
 related exhibit striking exceptions to the justice of such a mode 
 of argument. 
 
 Let us next, gentlemen, compare these cases with the opinions 
 recorded by authors concerning the lesions connected with certain 
 symptoms. 
 
 No proposition seems more universally allowed by those who 
 profess to reduce cerebral diseases to a classification depending 
 on evident alterations of structure, than that paralysis of one 
 side of the body always arises from a local affection of the 
 opposite hemisphere of the brain. This affection may either 
 consist of an effusion of blood, a ramollissement, or the pressure 
 arising from a tumor, &c. ; but in all cases it is assumed that 
 hemiplegia must be attended with and caused by some such 
 local and evident alteration. On the other hand, general 
 paralysis, affecting alike both sides of the body, is caused, 
 according to most authors, by a general derangement of the 
 cerebral circulation usually called congestion, and believed to act 
 equally on both hemispheres. The latter species of paralysis 
 may arise suddenly, and may be as suddenly relieved, as it ceases 
 when, by means of venesection, we succeed in removing the 
 congestion that produced it. 
 
 An unbiassed attention to facts will, I think, prevent us 
 from giving our assent to either of these propositions. In the
 
 APOPLEXY. 597 
 
 first place, we often, in dissecting the brains of hemiplegic 
 patients, find both hemispheres, so far as evident alteration of 
 structure, affected exactly in the same way. This was remark- 
 ably the case in Kearney ; there was no alteration in one hemi- 
 sphere which did not exist in the other, and yet this man had 
 complete paralysis of one side. It is in vain to assert that some 
 alteration of structure existed, but escaped our notice, unless it 
 were microscopic, for both myself and those who assisted in the 
 dissection were too familiar with diseased appearances, and too 
 careful in conducting the examination, to allow any diflcrence in 
 one hemisphere as compared with the other to escape notice. In 
 the next place, it is by no means an unfrequeut occurrence to 
 meet with patients who, being suddenly attacked with symptoms 
 of general determination of blood to the head — such as head- 
 ache, tinnitus aurium, vertigo, are rendered for the time more or 
 less completely hemiplegic, and yet recover in the course of a 
 few minutes or hours the use of the affected side so suddenly and 
 so perfectly, as to preclude the idea of local lesion such as could 
 be detected by the scalpel of the anatomist. Of this I have 
 seen several instances both in hospital and private practice, and 
 which I cannot reconcile with the doctrines laid down by Rostan, 
 Lallemand, and other authors. 
 
 To quote one of the many examples I myself have seen : — 
 A man named Thomas Lynch was admitted into Sir Patrick 
 Dun's Hospital, afllicted with symptoms indicative of cerebral 
 disease. During his residence in fclie hospital he sufiered four 
 or five attacks of hemiplegia, in every respect complete, and 
 depriving him of the use of his speech. Some of these attacks 
 lasted only fifteen minutes, while the longest continued about an 
 hour and a half: they ceased as suddenly as they commenced, 
 and left no traces of hemiplegia behind them. 
 
 The circumstances of this case evidently prevent us from 
 assigning each attack to a separate effusion of blood ; for were 
 it owing to this cause, it would be impossible to account at 
 once for the sudden appearance and as sudden cessation of so 
 extensive and complete a paralysis. 
 
 Again, I have carefully watched the progress of several cases, 
 which after months and years have finally terminated in hemi- 
 plegia, the supervention of which I had anticipated from the 
 patients having remarked to me, that although otherwise in good
 
 598 CLINICAL MEDICINE. 
 
 health, they had more than once observed, when fatigued by 
 exercise, that they felt a degree of weakness in one leg, the 
 motion of which, so long as this feeling continued, they described 
 as slightly approximating to the dragging of a half-paralysed ex- 
 tremity. In some this feeling was accompanied by a scarcely 
 observable thickness of speech, and a certain confusion of mind, 
 all of which subsided shortly on their taking rest. These persons 
 usually complained at the same time of numbness in some part 
 of the afiected extremity, and which numbness not unfrequently 
 was the sole symptom of these transient warnings. The remark 
 already made with regard to Lynch's case applies more strongly 
 here ; and since the hemiplegia, when it did supervene, always 
 affected the side in which these premonitory symptoms had been 
 felt, we can scarcely avoid attributing both to the operation of 
 causes the same in nature but differing in degree. 
 
 Many, I am aware, would account for the transient attacks by 
 supposing that each was preceded by a very small effusion of 
 blood in the opposite hemisphere of the brain, and that the 
 final complete hemiplegia was owing to a similar but more copious 
 effusion. I am ready to admit the truth of this explanation in 
 those cases where there have been several distinct attacks of 
 paralysis, differing in intensity, all affecting the same side, and 
 all lasting several days, or even weeks, and then gradually 
 disappearing. Instances of this kind are frequent, and in such 
 it is not unusual to find traces of those successive extravasations 
 of blood which had caused the series of paralytic attacks ; but 
 the comparatively longer duration, and the gradual cessation of 
 such attacks, sufficiently distinguish them from the affections 
 above spoken of, and which are too sudden in their disappearance 
 to admit of a similar explanation. 
 
 The manner in which the arteries of the brain communicate 
 together renders it more difficult to conceive how local determin- 
 ations of blood could occur in this organ. Still, however, such 
 an occurrence is by no means impossible ; and did it take place, 
 it would account for the phenomena observed. Thus, were the 
 right side of the brain to become congested, a sudden attack 
 of hemiplegia of the left side of the body would be produced 
 suddenly, and would as suddenly subside on the removal of that 
 congestion. When the congestion is violent, and affects the 
 whole hemisphere, the paralysis will affect the whole of the
 
 APOPLEXY. 599 
 
 opposite side, and ^yill be intense ; when, on the contrary, the 
 congestion is inconsiderable, or else confined to particular portions 
 of a single hemisphere, the paralysis will be in proportion less 
 severe and less extensive. This explanation* does not appear to 
 be inconsistent with the laws known to regulate the circulating 
 system in other organs, for it is by no means unusual for the 
 parts deriving their blood from one common artery to display 
 occasionally very difiercnt degrees of sanguineous congestion, 
 a circumstance only explicable on what appears a very tenable 
 hypothesis — an active participation on the part of the smaller 
 vessels and capillaries in the process by which every part of the 
 body is supplied with blood. 
 
 Another mode of explaining the occurrence of such attacks 
 as I have described, is to suppose that they arise from a mere 
 functional derangement, more or less intense, of the whole or 
 a portion of one cerebral hemisphere. This ex]>lanation would 
 certainly account for the sudden appearance and cessation, as 
 well as for the short duration of such paralytic affections ; but 
 I do not feel inclined to adopt it, because they are invariably 
 accompanied by other symptoms denoting determination to the 
 head ; and also because sooner or later they usually terminate 
 in actual extravasation of blood in the side of the brain opposite 
 to the side of the body aflected by these transitory attacks. 
 Whatever mode of explaining the occurrence of these latter be 
 adopted, it is important, gentlemen, to recollect that whenever 
 they are observed, the medical attendant must be on his guard 
 — must warn the patient's friends of his future danger, and must 
 endeavour, by the most suitable means, to avert the tendency to 
 cerebral congestion, and its consequence, extravasation. It is to 
 be regretted that the latter is too often inevitable ; such cases, in 
 persons past the prime of life, being usually attended with an 
 alteration in the texture of the arteries of the brain disposing 
 them to rupture. 
 
 The state of these vessels in Kearney was worthy of attention, 
 as the existence of three coats or tunics, which some have denied, 
 to the cerebral arteries was here demonstrated. Another symptom 
 
 * Rostan has advanced this explanation under the head of " Congestion cerc'brale 
 locale " ; but he does not attempt to accoupt for the manner in which these local 
 affections are produced, nor does he sufficiently dwell on them as the frequent pre- 
 cursors of paralysis from extravasation on the side of the brain most prone to these 
 local congestions.
 
 600 CLINICAL MEDICINE. 
 
 — tonic spasms of the affected side — formed one of the most 
 remarkable features of this poor man's disease, and combined 
 with the hemiplegia, seemed to furnish indisputable evidence of 
 some local affection of the opposite side of the brain, and yet 
 none such was detected ; the congestion of the pia mater was 
 intense on both sides, although somewhat greater on the side 
 opposite to the paralysis. The difference, however, was incon- 
 siderable, and might have been occasioned by the position of the 
 head shortly before or after death. I do not say it was so^ for 
 the position was not observed, but I mention this exj)lanation to 
 impress on your minds how trifling was that difference. Here, 
 then, is a second instance of an affection permanently confined to 
 one side of the body, without any lesion to account for it being 
 found in the opposite side of the brain, — a fact at variance with 
 the testimony of several systematic writers. 
 
 The tonic spasm of the paralysed extremities requires notice 
 in another point of view, as constituting one of the chief 
 symptoms characteristic of ramollissement, or at least that state 
 of brain which finally ends in softening. The absence of any 
 local cerebral affection in Kearney, in whom this operation had 
 been during life so remarkably developed, is conclusive in proving 
 that even its most extreme degree may be excited by some other 
 cause. The same remark applies to the headache, the tingling, 
 and the spastic pains of the affected limbs, the paralysis, and in 
 fact to each of the whole group of symptoms which are said, when 
 combined with the tonic spasm, to constitute indubitable evi- 
 dence of ramollissement. I do not deny that, when associated 
 together in the order described by Lallemand and Eostan, tliey 
 afford very strong evidence of that lesion; but this I will assert, 
 that I have met with several cases in which, after a careful com- 
 parison of the symptoms with the descriptions of these authors, 
 I was induced to make the diagnosis of ramollissement with con- 
 siderable confidence, and yet, as the result proved, erroneously. 
 Had such mistakes occurred in my own practice only, I might 
 possibly have believed that I had not rightly understood these 
 celebrated pathologists, but I have witnessed similar errors 
 committed by others so often, that I am rather inclined to doubt 
 the general applicability and correctness of the rules laid down 
 for recognizing this lesion. 
 
 Let it not be imagined, however, that I wish to throw doubts
 
 APOPLEXY. 601 
 
 upon the beneficial influence of morbid anatomy on the diagnosis 
 and treatment of diseases of the brain ; far be from me any such 
 intention ; my object in making these observations is not to 
 retard, but to advance, the progress of morbid anatomy, by 
 pointing out the errors of some generally received opinions, and 
 thus opening the way for a renewed and unprejudiced examina- 
 tion of the subject. It may, indeed, be a priori expected, that 
 of all organs the cerebro-spinal system must give rise to the 
 greatest number of diseases which, without much impropriety of 
 expression, may be termed functional, being of such a nature as 
 to be unaccompanied by sensible changes in the matter of the 
 diseased tissue, and consequently not entering within the pro- 
 vince of morbid anatomy. We all know that tetanus may be 
 artificially produced by irritation of the spinal cord, and conse- 
 quently that inflammation reaching that part often occasions this 
 disease. So far we obtain from morbid anatomy useful know- 
 ledge concerning the nature and treatment of certain cases of 
 tetanus ; but do we advance or retard the progress of this 
 department of medicine, by asserting that inflammation of the 
 spinal cord exists in every case of tetanus ? So it is with those 
 who, aJBfecting to account for all cerebral diseases by lesions 
 observed after death, have excited expectations in the student, 
 which not being in every case fulfilled, he is tempted in disgust 
 to abandon all further investigations on the subject. 
 
 No other organ of the body, in the healthy discharge of its 
 functions, presents such opposite states as the brain during the 
 period of being awake and asleep, and yet we may reasonably 
 doubt whether these states are accompanied by any physical 
 change in the brain or its appendages, of sufficient magnitude 
 to be within the cognizance of our senses. 
 
 Can we perceive any physical alteration in the cerebro-spinal 
 system of an animal suddenly killed by prussic acid, or by 
 violent concussion ? and yet both these undoubtedly act on the 
 nervous system. 
 
 Nothing proves in a more convincing manner that morbid 
 anatomy cannot be expected to reveal the nature of all cerebral 
 diseases, as has been too implicitly taught by many French 
 pathologists, than its being totally incapable of suggesting or 
 explaining the action of some of our most useful remedies. 
 Thus, what are the physical conditions of the brain in delirium
 
 602 CLINICAL MEDICINE. 
 
 which indicate, if known, the exhibition of opium ? or, in other 
 words, why does this medicine act so much more beneficially 
 in delirnnn tremens than in other species of delirium ? What 
 physical change does the nervous mass undergo in cJiorea Sancti 
 Viti, which would lead us to expect such decided advantage from 
 the carbonate of iron ? What alteration of nervous structure 
 would induce us to try the effects of arsenic in certain cases of 
 neuralgia, or of strychnia in paralysis from lead ? Would the 
 inspection of the brain of a person labouring under sea-sickness of 
 itself be sufficient to prove that the only certain method of check- 
 ing this vomiting is to replace the patient on terra firma ? All 
 these considerations, gentlemen, leave no doubt on my mind 
 that the ancients were not so wrong as Kostan and others would 
 have us believe, in thinking that many nervous diseases were 
 unattended with appreciable organic changes in the nerves, or 
 nervous centres. 
 
 The object of morbid anatomy, therefore, should be not to 
 explain the causes of cerebral diseases, but to investigate and 
 ascertain in what number of such diseases we may with con- 
 fidence refer the origin of the symptom to evident lesions. I 
 fear much that modern authors have not sufficiently attended 
 to this distinction, and, consequently, have most injudiciously 
 endeavoured to establish systems, embracing all the various 
 diseases of the brain and spinal marrow, on the basis of morbid 
 anatomy, a mode of proceeding injurious to the latter science, 
 and little calculated to promote the interests of practical medicine. 
 If other proofs of the truth of this assertion were wanting, I 
 might appeal to the almost endless opinions lately published 
 concerning the physical alterations of the brain supposed to 
 produce insanity and its attendant diseases ; opinions ap- 
 parently supported by numerous dissections, but really too 
 often resting upon the supposed existence of morbid appearances 
 which are sought for with such avidity that they are always 
 found f 
 
 The following case is another good example of the truth of the 
 doctrine I have been now trying to enforce. It was one in which 
 very long-continued epilepsy existed without any appreciable 
 lesion of the brain or spinal marrow. Mr. A. B., the subject of 
 the case, was visited during his long illness by a great many 
 medical men ; among the rest by Mr. Colles, Sir P. Crampton,
 
 APOPLEXY. G03 
 
 Mr. Smyly, Dr. Lees, and myself. He died on the 27th 
 December, 1839, aged thirty years. 
 
 He had been a very fine, robust, and intelligent boy until he 
 was nine years old, when he unfortunately got possession of 
 five or six hard, unripe pears, and devoured them greedily : in 
 a few hours he became thirsty, and drank a large quantity of 
 buttermilk ; in the course of the evening he fell into a state 
 of insensibility, during which he was convulsed ; a physician of 
 great experience and judgment from Kilkenny was called in, who 
 opened the temporal artery immediately on seeing the patient, 
 and employed the usual means resorted to on such occasions ; 
 notwithstanding this, the insensibility continued, and in about 
 seven hours it was observed that a hard tumor could be felt 
 distinctly in the epigastric region. This induced the suspicion 
 of the presence of some undigested substance, and a strong 
 purgative enema was therefore administered ; its eftect was most 
 satisfactory, for after the discharge of some copious stools the 
 tumor subsided, and the boy recovered his senses. The injury 
 inflicted on the cerebral system by this violent shock mani- 
 fested itself soon after in the recurrence of the fit, and from that 
 time forth he was subject to epileptic attacks. They annually 
 became more frequent and more severe, but the vigour of his 
 intellect was not impaired until after the disease had continued six 
 years, when his mental faculties displayed a manifest dulness, 
 and in the course of a few years more he gradually lapsed into 
 idiocy, with however occasional gleams of reason, particularly on 
 subjects connected with religion. 
 
 He now remained entirely in the house, and for many years 
 had several epileptic fits daily ; the convulsive stage did not 
 usually last more than three or four minutes, but the coma 
 often continued nearly an hour. The disorder generally 
 exhibited a manifestly increased severity twice a year, when the 
 fits would return about ten times daily, and with more than 
 ordinary \dolence; after such a paroxysm had lasted about a 
 week, it invariably terminated ip outrageous madness, the 
 appearance of which was a sure sign that the paroxysm, so far as 
 regarded the fits, was over; this madness was of the most violent 
 and noisy description, and required restraint ; when it had 
 subsided, as it usually did in about three days, he relapsed into 
 his ordinary state with a few and comparatively slight fits daily.
 
 604 CLINICAL MEDICINE. 
 
 Such was the course of the disease for sixteen years, during 
 which he was most tenderly and assiduously nursed. I ought to 
 have mentioned that a Eiudden and copious bleeding from the 
 nose often took place when a fit came on ; the breathing was 
 invariably violent, irregular, and heaving for eight or ten minutes 
 after the convulsions had ceased, but then gradually became 
 tranquil, and so continued for the remainder of the comatose 
 stage. During the last five years of this gentleman's life the fits 
 became gradually less violent, but never ceased ; for several years 
 before his death he remained free from the attacks of madness. 
 
 In 1833, he became subject to diarrhoea, which recurred 
 frequently, was difficult to stop, and seemed to have induced a 
 most depraved appetite ; in fact, at certain times he would 
 swallow everything he could lay hold of, paper, coals, cork, lead, 
 glass (after due mastication), boxes of family pills, straw, bits of 
 books, &c., &c., from none of which did he seem to sustain any 
 •permanent injury. These fits of depraved appetite used to come 
 on at irregular intervals ; about 1833 he began to fall away in 
 flesh, and for the last few years was pale, haggard, and emaciated. 
 His sleep was, however, sound, and his appetite usually normal. 
 About two months before his death the bowel complaint returned 
 with more than its usual violence, and soon weakened him so 
 much, that for the first time from the commencement of his ill- 
 ness he was confined to bed, and everything failed to check the 
 diarrhoea, which finally proved fatal, exhibiting during its pro- 
 gress the usual symptoms of chronic inflammation succeeded by 
 ulceration of the mucous membrane of the intestines. 
 
 While the diarrhoea was on him, and indeed all through his 
 illness (except perhaps during the convulsions), his pulse was 
 perfectly natural, sloio, and soft, and so continued to within two 
 days of his decease. The respiration (with the exception formerly 
 noted) was always perfectly natural ; never in the least short or 
 •hurried, and he never had a cough until two nights before he 
 died, when he had a violent fit of coughing which lasted a quarter 
 of an hour, and was apparently stopped by a dose of hartshorn 
 in water ; the same happened on the following night. He was 
 never observed on any occasion to expectorate, and never had a 
 vestige of wheezing in his chest ; in fact, he was to all appearance 
 so free from the least suspicion of pectoral complaint, that neither 
 I nor any one else had examined his chest for many years. It
 
 APOPLEXY. G05 
 
 is true that ever since the first epileptic seizure be frequently 
 complained of what he termed pain in his heart, and nineteen 
 years ago he was blistered for it by Dr. Ryan, of Kilkenny. This 
 pain, referred invariably to the left side, used often to go away 
 for considerable intervals, and was consequently believed to arise 
 from a straining produced by the violence of the convulsions ; 
 during the last year of his life this pain was very constantly 
 complained of. About three years ago I saw him for jaundice, 
 which lasted about three weeks, and disappeared without 
 medicine ; I could not, at the time, make out the cause of the 
 jaundice ; he had no pain, no fever, no hepatitis. 
 
 The preceding history of my patient's case is imperfect, but 
 as far as it goes its accuracy may be relied on. I am particularly 
 anxious to impress this on your minds before I relate the result 
 of the j)ost-mortem examination, which was conducted under the 
 most favourable circumstances, and at the express wish of the 
 family of the deceased, by Dr. Lees and Mr. Quinan, in the 
 presence of myself and Mr. Smyly ; we had the advantage of a 
 well-aired and admirably lighted room, and during the dissection 
 the morning sun shone brightly on each organ in succession 
 as we examined it ; I mention these facts, lest any one should 
 hereafter attempt to explain away the extraordinary discrepancy 
 which this case exhibited between the symptoms observed during 
 life and the morbid appearances discovered after death ; the 
 dissection was slowly and carefully conducted, and occupied five 
 hours. 
 
 The following account will prove that, except ulceration of the 
 bowels, we found nothing we expected, and many things totally 
 unexpected. 
 
 Post-mortem examination of Mr. A. B. tivenijj-four liours 
 after death. — Body emaciated to an extreme degree : the scalp, 
 cranium, dura mater, arachnoid, pia mater, together with the 
 cortical and medullary substance of both cerebrum and cere- 
 bellum, all perfectly healthy ; a very small quantity of transparent 
 serum was found in the ventricles ; there was no notable sub- 
 arachnoid effusion. The spinal marrow and its investments were 
 quite normal. 
 
 The x>leiLra pulmonalis of the right side was everywhere inti- 
 mately adherent to the ribs ; the right lung itself was rendered 
 quite solid by tahercles, which occupied its whole structure, and
 
 606 CLINICAL MEDICINE. 
 
 presented themselves in every stage of development, but no 
 tubercular cavities could be detected ; many crude tubercles 
 were scattered through the otherwise healthy tissue of the lung. 
 
 The mucous membrane of the lower third of the ilium, of the 
 caecum, and colon was thickened, highly vascular, and extensively 
 ulcerated. The liver healthy, gall bladder thickened, not larger 
 than a walnut, and entirely filled with a gall-stone. 
 
 This case, to which I shall again refer in my lectures on 
 phthisis, as an example of the latent form that disease sometimes 
 assumes, is in many respects worthy of notice ; in the first place, 
 we have here an example of a very violent form of epilepsy 
 lasting for twenty-one years, giving rise to fatuity, and yet the 
 most minute examination failed to detect the least trace of 
 organic lesion in the cerebro spinal system. That so formidable 
 an affection of the brain could continue for so many years, pro- 
 ducing a daily recurrence of convulsions, a frequent return of 
 violent mania, and a thorough dilapidation of the intellect, — 
 that such an aifection could continue, without the occurrence of 
 any observable changes of structure, is truly surprising, and 
 militates strongly against the doctrine on which I have already 
 commented, of many modern pathologists, who seek to explain 
 every derangement of cerebral function by the lesion found on 
 dissection. I fully agree in opinion with those who maintain 
 that epilepsy, mania, insanity, and fatuity may arise without 
 being caused by appreciable changes of structure in the brain or 
 elsewhere. 
 
 In fine, without detracting from the true value of morbid 
 anatomy, these facts — with many others already published by 
 various authors — prove that the attempt to connect symptoms 
 with diseased alterations of structure is attended with many 
 difficulties, and is often impracticable.
 
 607 
 
 LECTURE XXXV. 
 
 DELIRIUM TREMENS. — CHOREA. — EPILEPSY. 
 
 Let me first, gentlemen, direct 5^our attention to the case of a 
 man above stairs, \Ybo liad such a compHcation of affections that 
 it is quite impossible to give his disease a name. He is, in fact, 
 a kind of synopsis of the phlegmasitie. You have seen him in 
 one of the upper wards, a careless, idle, drunken vagabond, but 
 possessed of a constitution naturally good. He had within the 
 last few days delirium tremens, he had herpetic eruption on the 
 face, he had violent bronchitis, severe pneumonia, inflammation 
 of the mucous membrane of the stomach and bowels, inflamma- 
 tion and enlargement of the liver. Here was a complication 
 of diseases extremely hard to treat. Such a complication 
 exemplifies the advantage to be derived from general treatment. 
 From an attentive consideration of the manner in which they 
 arose, we were enabled to treat in a proper manner, and overcome 
 these diseases. 
 
 In the first place, this man was a person of intemperate 
 habits ; he had walked about the city for two days and two 
 nights in a state of drunkenness, exposed to rain and cold. The 
 inflammations by which he was attacked set in simultaneously, 
 or, at least, we cannot ascertain their date. In the meantime, 
 in consequence of the feverish state of the system, he naturally 
 got delirium tremens. Now I need scarcely remind you that if 
 a man of intemperate habits gets any shock of the nervous 
 system, he is likely to get delirium tremens. Here w^as a case 
 to require accurate powders of diagnosis ; it might have been the 
 delirium of fever, or of gastritis, or of bronchitis, or of drinking. 
 You are aware that gastritis, and fever, and bronchitis will give 
 rise to delirium, and that it may attend typhus without inflam- 
 mation of the brain or engorgement of the vascular system ; but 
 in this man's case, when we connected the disease with his 
 habits of intemperance, and looked to the history of the case,
 
 608 CLINICAL MEDICINE. 
 
 and observed that there was nothing about the head to account 
 for his symptoms, and from his answering rationally when asked 
 a question, we were convinced that it was delirium tremens. 
 
 You know that there are instances of delirium from bronchitis, 
 and it is an old opinion that this arises from the blood passing 
 to the brain in a state not sufficiently aerated, and the same 
 thing is adduced as the cause of pain in the head. But you 
 know that in cholera, where the blood is scarcely aerated at all, 
 there is very little pain in the head, and the intellect remains 
 unaffected. Some late experiments, as those of Edwards, Dr. 
 Marshall Hall, and those which have been made in Edinburgh 
 by Dr. Knox, seem to oppose this theory of the noxious influence 
 of blood not properly aerated. I think that it arises rather from 
 engorgement, as in such cases the face is generally congested 
 and the lips purple, and that this affection originates rather in 
 congestion than in a venous state of the blood sent to the brain. 
 The reason which induces me to speak of this influence of venous 
 blood is because there are certain cases of paralysis from the 
 action of cold on the lower extremities, which may produce a 
 permanent asphyxia of the parts affected. I knew a man whose 
 fingers remained of a blue colour for five months, except when he 
 put them into warm water. 
 
 To return to the case of "William Fox. With respect to the 
 herpetic eruption, it is not necessary that I should say much, 
 except that you will most commonly find it combined with 
 a feverish state of the system, which is said to be pro- 
 duced by cold. I shall also pass over his other diseases, and 
 proceed to a more important point — the mode of treatment to 
 be pursued. Here we had a number of co-existing diseases, 
 varying in their seat and character, presenting a complexity of 
 indications, and requiring a nice adaptation of remedial means. 
 Fortunately everything but the delirium tremens depended on 
 inflammation : they were all inflammatory diseases. This gave 
 us an opportunity of employing the antijihlogistic plan of treat- 
 ment, and we adopted it. Tartar emetic could not be given, in 
 consequence of the state of his stomach and bowels ; and its 
 utility, so far as hepatitis was concerned, was extremely doubtful. 
 It might have been prescribed for the delirium tremens with 
 some prospect of advantage, for the delirium tremens here was 
 accompanied by a degree of vascular excitement, for which
 
 DELIRIUM THEMENS. 009 
 
 bleeding cannot be safely employed without depressing the system; 
 and opium is contra-indicated from its tendency to increase con- 
 gestion : and, therefore, as the safest means of combating the 
 disease, you have recourse to tartar emetic. 
 
 You begin with the tartar emetic ; you then add a little 
 opium, and thus go on gradually increasing the latter until you 
 cease to give the former, and use opium alone. Opium, if given 
 in the beginning, will increase the congestion and bring on 
 subarachnoid effusion. I treated a case of delirium tremens in 
 this way too boldly, and the man died with subarachnoid effusion ; 
 it was a lesson to me, and I would advise you to profit by my 
 experience. Where you have congestion with this delirium, 
 bleed or leech ; and if you are doubtful of the issue of blood- 
 letting, or convinced that it is dangerous, give tartar emetic with 
 or without opium, according to circumstances. In the present 
 instance there were other affections, namely, the pneumonia and 
 bronchitis, which called for the use of the lancet. We bled this 
 man, therefore, as far as his strength would allow, and applied 
 leeches to the epigastrium. He then got calomel in large doses 
 without opium, in such a manner as to bring him rapidly under 
 its influence. The manner in which 'I prescribed it is that 
 which is practised by most physicians and surgeons in the East 
 Indies. I put about a scruple of calomel on the tongue, and 
 let the patient swallow it without any liquid, or wash it down 
 with a little cold water. 
 
 The next case I shall call your attention to is that of a man 
 named Keddy, aged 27 ; he was a workman in the porter brewery 
 of the Messrs. Guinness, and was in the habit of consuming 
 daily large quantities of their famous XX porter, besides whisky. 
 Three weeks before admission he was attacked with rheumatism 
 in all the large joints, which, when we saw him, were swollen, 
 red, and painful ; the fingers of both hands Avere semiflexed, and 
 he could not bear them to be touched ; his countenance was 
 dejected, and expressive of intense suffering ; pulse 72, weak 
 but regular ; heart's action normal ; profuse sweating ; inability 
 to move in bed ; insomnia ; loss of appetite and thirst. He was 
 bled and put on the use of calomel and opium ; the quantity of 
 opium taken daily was/oi<r grains. 
 
 The next day, twenty-first, pericarditis was detected. There 
 was nothing remarkable in the signs ; the mercury and opium 
 VOL. I. 39
 
 610 CLINICAL MEDICINE. 
 
 were continued; cupping over the heart followed hy blisters 
 directed, and on the twenty-fifth salivation set in ; the cardiac 
 symptoms subsided, and the inflammation of the joints greatly 
 disappeared. The quantity of calomel was diminished from 
 twelve grains daily, combined with four grains of opium, to three 
 of the former with one -fourth of the latter every second day. 
 On the twenty-sixth the rheumatism appeared much relieved, 
 and the pulse was 88, soft, and regular, yet there was something 
 unusual about his appearance ; his countenance was excited and 
 his eyes bright, and on inquiry we ascertained that he had slept 
 none during the night, and that he had raved the whole time, 
 occasionally shouting and singing. On the twenty- seventh he 
 was much worse, he lay quite prostrated on the bed, the upper 
 part of the body was covered with a profuse perspiration, he had 
 twitching of all the muscles of the face, subsultus, and tremor 
 of lower limbs ; he slept none, but raved all night, and about 
 3 o'clock a.m. got out of bed, and endeavoured to break through 
 a door into the adjoining ward. His tongue was dry and unsteady 
 when protruded ; he answered questions, however, rationally, 
 and said he had no headache; pulse 116, very weak. 
 
 He was now ordered one grain of opium in the form of a pill 
 every fourth hour, and four ounces of wine in the day. 
 
 On the twenty-eighth the report states that he fell asleep 
 after the third pill (about 11 o'clock), and did not waken for six or 
 seven hours, when he again commenced shouting and singing, 
 but soon became quiet, and at 8 o'clock the following day the 
 tremors had greatly diminished ; his countenance was vastly 
 improved, skin cool, tongue steady when protruded, but dry and 
 furred, and his intellect restored. It was found necessary to 
 increase the wine from four to sixteen ounces since the twenty- 
 sixth. 
 
 On the twenty-eighth all the symptoms of delirium tremens 
 had vanished ; he was free from headache, his skin cool, 
 tongue moist, and no thirst, and tbe pains in the joints nearly 
 gone. 
 
 The wine and opium were now diminished gradually, and in 
 ten days after he was discharged perfectly cured. 
 
 The complication of delirium tremens with acute rheumatism 
 is not by any means common ; and it is remarkable that in this 
 case the first symptoms of the afi"ection manifested themselves
 
 CHOREA. 611 
 
 the day after the quantity of opium was diminished. Can we 
 explain this by supposing that the opium acted as a stimulant, 
 and that being stopped suddenly, it produced the same train 
 of symptoms that usually follow the leaving off of any strong 
 stimulant that had previously been largely indulged in ? 
 
 The explanation may seem at first plausible, but we know 
 from experience that when opium acts hcncficiaUy as a remedial 
 agent, it seldom produces any of the bad consequences that 
 follow its exhibition in a healthy state of the body, an illustration 
 of which this case affords : for we find that it neither occasioned 
 headache, heat of skin, furred tongue^ thirst, contracted pupil, 
 nor acceleration of the pulse. We must, therefore, look upon 
 the circumstance as a mere coincidence, and we can easily 
 comprehend how delirium tremens might occur in a patient of 
 intemperate habits during the course of a painful illness, by 
 which he was much reduced and worn down. 
 
 Let me call your attention to some points connected with the 
 treatment of chorea. In general chorea is a disease yielding 
 to treatment with sufiicient ease, but examples occur now and 
 then requiring great assiduity and patience, and some which 
 even bafile all attempts at cure. The best treatise I know on 
 the subject is contained in the article Chorea, in Copland's 
 Dictionary of Practical Medicine. 
 
 The following case was seen by Mr. Mulock, Sir Philip 
 Crampton, Sir Henry Marsh, and myself, and exhibits in a 
 striking point of view the dilficulties the physician has to contend 
 with in the treatment of the aggravated form of chorea, as well as 
 the inefficiency of some of the best reputed medicines and the 
 striking utility of others. The young lady was attacked on the 
 17th April with the first symptoms of chorea, affecting one side 
 of the body only. In the course of twenty-four hours the peculiar 
 motions of chorea had extended to all her limbs, and became 
 hourly worse. For the first few days of her illness she could 
 walk, although unsteadily, but she soon lost this power altogether, 
 so strong and uncontrollable did the involuntary motions of her 
 legs become. At the same time, she became incapable of raising 
 her arms and hands, as they were perpetually jerking about in 
 every direction. Indeed the rapidity with which the disease pro- 
 gressed was remarkable, for in the course of a week from its first
 
 612 OLINICAL MEDICINE. 
 
 beginning it had assumed a degree of intensity and violence 
 whicli had no parallel in the experience either of Sir Philip 
 Crampton, Mr. Colles, or Sir Henry Marsh. 
 
 When at its height the disease presented a truly appalling 
 spectacle ; every part of the system of voluntary muscles seemed 
 to be affected ; all the directing influence of volition had ceased, 
 and the muscles everywhere were agitated by sudden, violent, 
 and jerking motions, which constantly and forcibly changed the 
 position of her limbs, throwing her into attitudes the most varied, 
 and succeeding each other with extraordinary rapidity. Her 
 arms were indeed thrown about with such force, that it became 
 necessary to cover with blankets and soft padding the sides of the 
 sofa on which she lay, and in spite of this and other precautions 
 her limbs were soon covered with bruises. Her state was truly 
 pitiable ; one or two persons were constantly engaged in pre- 
 venting her from rolling off her couch ; now and then she sat up 
 suddenly, made an involuntary effort to assume the erect position, 
 and as suddenly flung herself down ; meanwhile her limbs were 
 flexed, extended, thrown backwards and forwards with unceasing 
 rapidity. At one moment her hand would be struck against her 
 head, and at the next be passed behind the back. It was almost 
 impossible to keep her covered with clothes, for the constant 
 motion of the limbs often tossed the sheets, blankets, and quilts 
 off together, and not unfrequently even stripped her of her 
 stockings. 
 
 At the height of her illness the motions of her limbs and body 
 were quite extraordinary, and appeared to be such as could be 
 only performed by a person whose very bones were pliant and 
 flexible. She soon lost all power of articulation, and during 
 a period of three weeks she was not able to put out her tongue, 
 or speak a single word. The muscles of deglutition became 
 engaged in the disease, but the muscular system of resj)iration, 
 circulation, and digestion was unaffected throughout the disease ; 
 hence her breathing and pulse were natural, and her digestion 
 and alvine evacuations regular. A continuance of muscular 
 exertion, so violent although involuntary, could not fail rapidly 
 to exhaust the system, and accordingly she lost her flesh daily, and 
 before the middle of May, that is in four weeks, her emaciation 
 had become extreme. Her countenance was sunk, her pulse 
 weak, the whole surface of the body was excoriated from the
 
 CHOREA. G13 
 
 friction unavoidably produced by the constant movement of both 
 trunk and extremities. 
 
 This rendered all attempts to act on the disease through the 
 medium of the skin quite hopeless. Leeches, plasters, blisters, 
 liniments could not be applied ; it was even impossible to ad- 
 minister a lavement. During sleep, and during sleep only, had 
 she respite from the muscular labours ; then she lay quiet. The 
 liquor of the muriate of morphia proved very serviceable indeed 
 in procuring sleep, and did not appear to produce headache, 
 constipation, or any other inconvenience. I should, however, 
 remark that her intellect was unaffected, and her head quite free 
 from pain except for a few days previously to the occurrence of 
 epistaxis in the beginning of the attack. Her appetite continued 
 good throughout. The following brief sketch of this case has 
 been given me by Mr. Mulock, of Charlemont Street : — 
 
 " S. W., aged 15, was affected with influenza in the beginning 
 of April, and relieved in a few days ; she continued well until the 
 17th, when she had a slight hysteric illness, with tossing of the 
 left hand and arm. Dr. Graves saw her on the morning of the 
 18th ; the disease was then manifestly an attack of chorea ; the 
 menses had appeared about two months previously, but not after- 
 wards : Dr. Graves ordered aloetic pills combined with calomel 
 at night, and a brisk saline aperient in the morning. She 
 appeared to amend for a few days in her general health, but the 
 tossing of the limbs, &c., increased ; he then directed aloetic 
 mixture with iron ; I should mention that the pulse was natural, 
 and tongue not loaded. After taking these draughts for two 
 days the countenance flushed, and she had a slight hemorrhage 
 from the nose ; Dr. Graves left off the draughts, and ordered 
 vegetable jellies, without either meat or wine. 
 
 " Sir Philip Crampton saw her at this time in consultation; 
 he said the only case he had latterly was relieved by oil of 
 turpentine, given in decoction of aloes : she took two of these 
 draughts, but they produced so much excitement, we were 
 obliged to give them up ; the tongue became also swollen, and 
 there was great difficulty in swallowing, indeed a person was 
 obliged to eat before her to enable her by imitation to do so. 
 Both sides were now affected ; liquids passed out of the side of 
 the mouth ; it was impossible to give medicine either by enema 
 or in pills. Dr. Colles was called in consultation ; he ordered
 
 614 CLINICAL MEDICINE. 
 
 carbonate of iron and rhubarb in the electuary : it could not be 
 taken, though often tried. Dr. Graves then considered that 
 medicine ordered in the form of a lozenge could be swallowed ; 
 he thought the liquor arsenicalis in that form would be useful ; 
 this was tried for two days and appeared to be of service, with 
 twenty-five drops of the solution of muriate of morphia, and four 
 drops of the oil of peppermint on sugar at night ; the only time 
 jactitation of the limbs, &c,, stopped was when sleep was procured. 
 " The prescription for the lozenge was : — 
 
 R. Liquoris Arsenicalis, gtts, xviij. 
 Pulveris Gummi Arabici, 5ss. 
 Saccbari albi, gr. xxv. 
 Misce et fiat secundum artem massa. 
 Divide in partes sex a^quales ; sumat unam ter in die. 
 
 " The disease now appeared to be hysteria combined with 
 chorea, as there were constant sobbing, heaving of the chest, and 
 other hysteric symptoms, along w'itli incessant tossing of the 
 head, limbs, &c., and twisting of the eyes and mouth. She 
 continued the liquor arsenicalis with muriate of morphia for three 
 days ; she had some rest, but when not under the influence of 
 the morj)hia the disease appeared unaltered. Sir Henry Marsh 
 saw her in consultation on the 16th of May, and ordered quina 
 with extract of stramonium, and tepid salt-water shower baths 
 three times a day ; these were obliged to be given while lying on 
 a hair mattress : and to continue the anodyne at night. After 
 taking Ig grains of stramonium, dilatation of the pupils took 
 place, and it was thought prudent to leave off the medicine for 
 some hours ; the tossing of the limbs, &c., and difficulty of 
 swallowing gradually abated. 
 
 " The form for the stramonium lozenges was : — 
 
 R. Sulphatis QuinpB, gr. viij. 
 Extracti Stramonii, gr. i^. 
 Pulveris Glycyrrliizaj, gr. xv. 
 Tberiacai quantum sufficit. 
 ri<at massa, et divide in partes quatuor. Sumat unam quater in die. 
 
 " The entire skin, previous to using the baths on the shoulders, 
 sides, and cheeks, &c., was in such a state of irritation from the 
 constant friction as to require to be constantly washed with Eau 
 de Cologne.
 
 CHOREA. 615 
 
 " lOtli. — The uneasiness was much lessened; the bath was 
 of much service ; her diet from the 14th was generous, as 
 emaciation was extreme from the trifling sleep and constant 
 motion ; she has now taken the lozenges for eight days, and 
 continues to improve ; she can also take the bath sitting in an 
 oval tub, which has been lined with wool and covered over with 
 coarse cloth to prevent her hurting herself : the stramonium 
 after the second day did not appear to affect the pupils." 
 
 In this case the failure of all remedies until we tried the 
 shower bath and the combination of sulphate of quina and 
 extract of stramonium, recommended by Sir Henry Marsh, was 
 not more remarkable than the rapid improvement which took 
 l^lace after the new plan had been adopted ; indeed, at the time 
 I speak of, I considered her case as nearly hopeless, and believed 
 that a few days would close the scene of her sufferings. 
 
 The shower bath was used at first warm, and then tepid. Its 
 aj)2'>lication was very difficult ; the plan pursued was to place the 
 patient on a large mattress covered with a blanket, where she 
 was held by an assistant destined unavoidably to enjoy the bath 
 along with her : other servants, mounted on chairs, then poured 
 the water from several large watering pots, held high, on the 
 patient beneath ; when this was done, she was taken into 
 another room, well dried, and then covered. 
 
 This operation, however troublesome, was perseveringly re- 
 peated three times daily ; as she improved, the application of 
 the shower bath was attended with less flooding of the apart- 
 ment, as she could then be placed in a large stuffed tub to 
 receive the affusion. From a careful observation of the effect 
 of the remedies, I am inclined to attribute the improvement 
 more to the shower bath than to the sulphate of quina or 
 stramonium, although the effects of the latter on the system 
 must have been powerful, for in a few hours after commencing 
 its use her pupils were dilated to a maximum. Be this as it 
 may, this combination of remedies produced a change the most 
 astonishing, and she regained flesh, colour, strength, and com- 
 mand of her muscles so rapidly, that now but a slight vestige of 
 the complaint remains. 
 
 The powerful effects of water, whether hot, tepid, or cold, 
 poured on the naked skin, may be illustrated by many facts ; 
 but it is not easv to determine whether those eflects are owing
 
 616 CLINICAL MEDICINE. 
 
 to the impression made on the sensation of the cutaneous nerves 
 by the temperature of the fluid, or to the force with which it is 
 applied to the surface. Both probably concur in making affusion 
 of water so effectual a remedy : by means of cold affusion, 
 hysterical fits and convulsive disease are frequently checked, and 
 persons narcotized by opium or prussic acid are most speedily 
 awakened. Water applied to the surface, whether in a con- 
 tinued and forcible stream, as a douche, or in the usual manner 
 by means of the shower bath, frequently produces much benefit 
 in diseases, general and local, acute and chronic. The case I 
 have just related affords an additional example of the beneficial 
 employment of this remedy. 
 
 Since this case occurred, I was induced by the reported bene- 
 ficial effects of sulphate of zinc in certain spasmodic diseases, 
 whether of an hysterical or of a truly epileptic nature, to try its 
 efficacy in chorea, and I can assert with confidence that no other 
 single remedy is so generally useful. In several severe cases it 
 has, without the aid of any other medicine, cured the patient 
 speedily and perfectly. In one case, which I saw with Mr. 
 Barker, it failed altogether, and so did everything we tried except • 
 opium ; which, however, was only useful in so far that it pro- 
 cured sleep at night, without which the patient, a boy of thirteen, 
 must have been speedily worn out, so violent and continued were 
 the spasmodic motions of the affected limbs. In the case referred 
 to, time gradually brought about recovery. The sulphate of 
 zinc may be given simply dissolved in rose-water, in half-grain 
 doses, repeated often in the day. When tolerance of the salt on 
 the part of the stomach is obtained, it will be often borne to the 
 amount of ten or fifteen grains in the day ; but we must also 
 study its effects, and use the smallest quantity that will ensure 
 a cure. 
 
 Authors who have written on the subject of chorea agree in 
 stating that it very seldom persists after puberty. " We see 
 little of it," says Dr. Blackmore, "in adults, yet it will some- 
 times continue for the whole life." It appears plain, from this 
 observation, that Dr. Blackmore had never witnessed the first 
 access of chorea at an advanced age, and consequently I think it 
 right to mention that Dr. Ireland consulted me formerly respect- 
 ing the late Mr. Dyas, a respectable apothecary residing in 
 Castle Street, who, when seventy years old, was attacked by
 
 EPILEPSY. 617 
 
 chorea in as complicated a form as I ever saw. The disease 
 was very severe, and lasted many months. Thus do diseases 
 of the nervous system, like the waning intellect, affect a second 
 childhood ! 
 
 The following, another instance of chorea occurring for the 
 first time in advanced life, was communicated to me hy Dr. 
 Patton, of Tandragee : — 
 
 "The patient is a woman aged 50; four years since, her 
 hushand left her, and two or three of her children removed 
 from this country to Scotland. She became much depressed 
 in spirits, and fretted a good deal ; she then had startings in 
 her sleep and annoyance from flatulence, then the chorea came 
 on at the end of a year, and continued, at first being severe, but 
 with intermissions, during which she felt in better spirits. The 
 approach of the attack was ushered in after each intermission, by 
 lowness of spirits and sighing ; the motions during the night 
 and startings in sleep were not severe, but never left her com- 
 pletely. The disease has now (July, 1847) continued three 
 years ; the violent attacks never occur at present, but slight 
 ones, which are always aggraA'ated when the moon is cJiaiifiing, 
 or when she has suftered fatigue or anxiety. She has never 
 been epileptic or had a convulsion, is active for her time of 
 life, and has a very healthy aspect. The catamenia ceased ten 
 years since." 
 
 I have just now mentioned the good effects of sulphate of zinc 
 in convulsive diseases ; the following case is a good example of 
 the benefit it sometimes produces in epilepsy : — T. A,, set. 39, 
 unmarried, of full habit, liable for years to bilious attacks, and 
 suffering occasionally from hemorrhoids, which bleed at times — 
 after labouring for several months under dyspepsia — about the 
 end of September, 1843, being more than usually fatigued by 
 continued mental and bodily exertion, was seized with a fit, in 
 which he fell from his chair insensible, but was after a little 
 while able to get up and go to his bed unassisted. Ho was again 
 seized about the end of November in the morning whilst dressing, 
 the fit continuing from about five to eight minutes, not preceded 
 by any unpleasant feelings, nor followed by any bad consequences. 
 About the middle of December, same year, he was seized with 
 another fit of the same kind, but of longer duration and severer
 
 618 CLINICAL MEDICINE. 
 
 character, in which the tongue was injured by the teeth; this fit 
 was followed by great muscular soreness and lassitude, much 
 depression of spirits, nervous anxiety, irritability of temper, and 
 disinclination to pursue usual avocations, from the mind be- 
 coming easily fatigued and confused. In this paroxysm, as in 
 two or three succeeding, there was frothing from the mouth, 
 stertorous breathing, with rigidity of the muscular system, fol- 
 lowed towards the termination by occasional twitchings of right 
 hand and arm. In none was there from the first to the present 
 any inclination to sleep towards the termination of the fit or 
 afterwards, and in some time, on taxing the memory, every 
 occurrence up to the moment of seizure, and from its termina- 
 tion, could be distinctly remembered. In general, the fits are 
 immediately preceded by foolish, unconnected ideas, some mut- 
 tering, a sense of suffocation, and sometimes a scream, and in 
 some, but not all, there is seminal emission. 
 
 There was no treatment adopted till this period, when, in the 
 last attack, from twelve to sixteen ounces of blood were taken 
 from the arm. On consulting a medical man some time early 
 in February, 1844, he was ordered gamboge pill with calomel, 
 occasionally followed by black draught, five grains of assafostida 
 twice daily, to use the shower-bath, and to relieve the mind as 
 much as possible from business. After continuing this plan, 
 which had the effect of regulating the bowels and lessening in 
 some degree nervous irritabilit}^ without otherwise causing any 
 great change in symptoms, until June, 1844 — the attacks 
 becoming if anything more frequent but less severe — he 
 left home to try what change of air and variety would do ; 
 this he found of use, as the fits became less frequent as well as 
 less severe. 
 
 At this time, while in London some time in the end of July, 
 1844, he was advised to be cupped occasionally from the nape of 
 the neck if any fulness of head was experienced ; which was done 
 four times, to about six or eight ounces each operation : to take 
 four ounces of infusion of quassia twice daily, to act on the 
 bowels when necessary, with the same jiill as before used, to take 
 as much walking exercise as possible, to leave off eating vege- 
 tables, to live on animal food and bread, and not to take more 
 than two glasses of wine or half a glass of brandy and water at 
 and after dinner. He followed this plan till September, 1844 ;
 
 EPILEPSY. 619 
 
 it had the effect of giving tone to the stomach and bowels ; the 
 nervous system graduall}^ gaining strength, with a longer inter- 
 mission than any before. 
 
 T>ut he was again seized with a severe fit in September, 1844, 
 after which he was ordered to take sulphate of zinc made into 
 pill with extract of gentian, and to increase the quantity as much 
 as possible ; to continue the exercise so as to reduce cor- 
 pulency, and after a time to alternate the zinc with the sulphate 
 of quina, regulating the dose of it as of the former. He began 
 the zinc in September, 1844, in three-grain doses three times 
 a-day, and increased it to ten ; at the end of twelve weeks, 
 during which time it was regularly taken, he left off its use and 
 began the quina, taking it in much the same doses, and alter- 
 nating them occasionally, but taking the sulphate of zinc as the 
 ]3rincipal remedy till March, 1845. 
 
 This treatment had the effect of prolonging the next inter- 
 mission till about the middle of November, at which time he had 
 a slight attack. About that time the spasmodic action of the 
 hand and arm (before described as occurring in the fit) now 
 appeared during the intermissions at irregular times, often twice 
 or thrice in the day, at others not for days together, and increased 
 so much that it was not under the control of the will, being often 
 obliged to grasp anything within reach ; it also affected the 
 right leg, not so powerfully however, and preceded by an un- 
 pleasant kind of shock, felt for the first time, passing through 
 the whole system, and continuing severe till about July, 1845, 
 from which time it began to lessen in severity and frequency, 
 but recurs occasionally to the present. From about the second 
 or third attack of the disease to the present, there is at uncertain 
 periods, often twice, sometimes thrice a-day, again not perhaps 
 for two or three days, a kind of oblivious state experienced for a 
 minute or so, then going off Avithout any particular results : this 
 continues up to the present. 
 
 From the last attack, which occurred in November, 1844, he 
 had a longer interval than any since the commencement of the 
 disease ; but after using zinc and quina, as I before stated, for 
 about six months, he got tired of them, and left off their use. 
 They had the effect of prolonging the intervals, and in some 
 measure lessening the fits. For some time before the zinc was 
 left ofi" there was felt a kind of metallic state of mouth, evidently
 
 620 CLINICAL MEDICINE. 
 
 indicating that the system was saturated with the remedy. The 
 paroxysms have continued from the date of the last, reported in 
 November, 1844, to the present (the last occurring 27th 
 January, 1846) at uncertain intervals, ranging from three to 
 five, eight, and sometimes twelve or fifteen weeks, and with 
 varied degrees of severity. 
 
 The following are the dates of the attacks in this case, ex- 
 tending over a period of three years ; from them you will see the 
 effects of the sulphate of zinc in prolonging the intervals between 
 the fits : — 1843, September 26th, November 25th, December 18th; 
 1844, February 5th, until September 3rd, when he commenced 
 to take the zinc, he had five fits ; and from this time until 
 February, 1846, a period of eighteen months, he had but nine 
 fits, or one every second month, while previously he had one 
 every month. 
 
 In another case in which I was consulted by Dr. Taylor, of 
 Bailieborough, I gave the sulphate of zinc in much larger doses, 
 but without any evident advantage. I mention it to you chiefly 
 as showing the quantity of this medicine that may be given 
 without producing any injurious effects. According to Dr. Taylor's 
 report, I recommended him on August 5th, 1845, to begin the 
 treatment of the case, that of a young lady, by administering 
 " one grain of the sulphate of zinc four times a-day for three 
 days, then one grain to be added to each dose at the end of every 
 three days, until eight grains were taken at a dose four times 
 a-day. This course having been strictly attended to, she was able 
 at the end of the month to take eight grains four times in the 
 day. During this month she had four fits. About this time 
 she complained of sickness of stomach immediately after taking 
 the medicine, but by omitting one dose daily for one or two days 
 she was able to take the full quantity. From the 8th of September 
 to the 22ud of October she was occasionally able to take forty grains 
 a-day, and had eleven fits, the majority of them of more than or- 
 dinary severity. Previous to this time I wrote to Dr. Graves on the 
 subject, and by his advice continued the medicine at the same 
 rate until about the 23rd of November, when I received a letter 
 from him in which he stated that he thought it would be inju- 
 dicious to persevere longer in the use of the medicine, and that 
 he would advise the quantity to be diminished two grains daily 
 for a fortnight, when she should be put on the use of valerian,
 
 EPILEPSY. 621 
 
 camphor, and aromatic spirit of ammonia, in doses sufficient 
 to conntcract the general marasmus of the system which then 
 prevailed to a very considerable extent." 
 
 It is right that I should mention to you here that the pre- 
 parations of zinc, when their use has been long continued, have 
 been described as producing general marasmus ; you should 
 therefore be careful not to continue their administration too long ; 
 it is evident that in the case I have been now speaking of, this 
 effect was beginning to be produced, I therefore stopped the use 
 of the sulphate gradually. 
 
 Before concluding, I wish to lay before you the particulars of 
 another case of epilepsy derived from the patient's own account, 
 a gentleman of the highest talent and most accurate observation. 
 It is an example of epilepsy depending on injury to the bones of 
 the cranium, but not occurring for some years after the accident 
 by which the injury was produced. The following was his state- 
 ment on consulting me : — "About twenty-five years since, driving 
 out with my servant in a gig, I suddenly lost my speech, and was 
 conscious of it for a short time, making signs to him to drive home, 
 and then became insensible for twenty minutes or half an hour, 
 as I was told. After this I had repeated attacks of the same 
 kind. Having suffered previously from intense headache and 
 intolerance of light, I came to Dublin for advice, and consulted 
 the most eminent physicians of the day, with little advantage, 
 for a fortnight or three weeks, when, on going one day to meet 
 them, I observed that a swelling and tenderness had appeared on 
 the top of the head. This was immediately examined, and I then 
 recollected, and told them that three or four years before I had 
 been riding rapidly along the road, and my horse had suddenly 
 fallen, cutting its head and not the knees, that my hat was cut 
 and dinged, and on rising on my feet I felt dizzy and confused, 
 from which I soon recovered. The swelling was then opened 
 with caustic, and after some time portions of diseased bone came 
 away. Before I came up to Dublin a seton had been tried in the 
 neck, but with little advantage — this seems to be the commence- 
 ment of my disease. 
 
 " It is at varied intervals that loss of speech and insensibility 
 have since occurred, sometimes after years, at others three or 
 four months, but only once or twice so soon — and then only the 
 bewildered feel, unable to articulate or to write (which I have
 
 622 CLINICAL MEDICINE. 
 
 attempted), without the insensible state accompanying or suc- 
 ceeding — and in every instance relieved by the discharge of wind 
 from the stomach ; indeed, I would suggest that indigestion or 
 gouty tendency producing flatulence may in some measure excite 
 these attacks. Subject to uneasiness in the stomach, and 
 anxious hurried sensation and feeling of distention, with a noise 
 of wind passing from side to side about the region of the navel 
 on exerting the muscles, I have felt relief from chewing a bit of 
 ginger and swallowing it, wind immediately coming away. All 
 these annoyances generally vanish for some time after an attack 
 of gout, which I have had occasionally in the feet at intervals 
 of twelve or fifteen months. Warm baths or warm water to 
 the feet always bring on faintishness, a feverish feel, and want of 
 rest ; my appetite is perfectly good, and I walk four or five miles 
 v^'ithout any fatigue, as my general allowance of exercise ; at least 
 one mile before breakfast ; the bowels at times are confined, and 
 rest disturbed by dreams and sudden awaking, in fact ' night- 
 mare,' and then the stomach continues uneasy till wind is 
 expelled. 
 
 " The last attack of insensibility came on after I had gone 
 to sleep, and I doubt whether I should have been conscious of 
 its extent had I been alone ; the following day I found one eye 
 blackened, and a black mark or bruise on the thigh near the hip- 
 joint. I cried out on the attack commencing, as I am informed 
 — this was the 28th or 29th of Januarys and my bowels had been 
 very irregular, with pain and uneasiness low down, griping and 
 flatulence to a considerable extent. After this attack I felt little 
 worse, if at all, on the following days — the tongue had been a 
 little bitten at one side, and there was rather a stifl' and cramped 
 feel in the legs. The opening whence the bone came in the 
 head is kept open as an issue, with a bean, and sometimes 
 becomes inflamed and painful, and may perhaps aggravate the 
 stomach uneasiness, but the application of lunar caustic relieves 
 this in general. Before the headache commenced, sea-bathing 
 and swimming agreed particularly well, but any application of 
 cold water (except to the head) now disagrees, but I use it daily 
 to the head and neck by sponging before dressing the issue."
 
 623 
 
 LECTURE XXXVI. 
 
 PARALYSIS. 
 
 Having recently met with some very interesting and remark- 
 able cases of impairment of the muscular functions of the lower 
 extremities, I am anxious to ofter a few observations on paraplegia, 
 particularly while the subject is still fresh in my mind : you are 
 aware that by paraplegia is meant that species of paralysis in 
 which the lower extremities are affected — a paralysis frequently 
 embracing loss of motion and loss of sensation in the lower ex- 
 tremities, accompanied, in many instances, Avith derangement of 
 the muscular power of the bladder and rectum. Now, I wish 
 you clearly to understand that it is not my intention to describe 
 the symptoms, or discuss the causes, of those species of paraplegia 
 which are well ascertained, and of Avhich you will find satisfactory 
 descriptions in your books ; under this head may be classed all 
 those cases which are produced by disease of the spinal marrow, 
 its membranes, the vertebrie or their ligaments, and diseases 
 directly affecting the great nerves which supply the lower ex- 
 tremities. All these matters have been sufficiently studied, 
 and require no additional observations from me ; my object is to 
 elucidate some of the obscurer varieties of paraplegia. I have in 
 the last lecture but two touched on this topic, but I have since 
 met with many cases, and made inquiries which tend still 
 further to illustrate the subject. Within this last month, I have 
 had an opportunity of witnessing a very striking illustration of 
 the fact, that injury affecting one branch of a nerve will be 
 propagated by a retrograde action, so as to affect another and 
 more distant branch. A young gentleman, distinguished for 
 the extent of his classical and mathematical acquirements, and 
 who had just succeeded in obtaining the senior moderatorship 
 (analogous to the ivraivilership of the English universities) 
 swallowed a small but angular piece of chicken-bone. It lodged 
 low down in the oesophagus, and was not pushed, by means of
 
 624 CLINICAL MEDICINE. 
 
 a probang, into tlie stomach until after the lapse of more than 
 an hour. Considerable inflammation of the pharynx, oesophagus, 
 and surrounding tissues was the consequence ; on the third day 
 of his illness he got a violent, long-continued, and ague-like 
 rigor, which terminated in a profuse perspiration, and ushered 
 in a well-marked inflammation of the neck of the bladder. 
 
 We also find that impressions affecting the frontal branches 
 of the fifth nerve may, by a reflex action, operate on the retina so 
 as to cause blindness. Here the morbid action travels from the 
 circumference towards the centre, and is again reflected towards 
 the circumference so as to affect a separate and distinct part. Ol 
 this I lately saw a curious and instructive example. A medical 
 student travelling through Wales on the outside of the mail, was 
 exposed for many hours to a keen north-easterly wind blowing 
 directly in his face. When he arrived at the end of his journey, 
 he found that his vision was impaired, and that everything 
 seemed as if he was looking through a gauze veil. There was 
 no headache, no symptom of indigestion, to account for this 
 evidently slight degree of amaurosis, and yet he was recommended 
 to use cupping to the nape of the neck, and strong purgatives. 
 When he consulted me, which he did in the course of a few days 
 afterwards, I at once saw that there was something unusual in the 
 case ; and, after a careful examination, I at length elicited from 
 him the fact of his having been exposed to the influence of the 
 cold wind. It was now apparent that the retina suffered in 
 consequence of an impression made on the facial branches of the 
 fifth pair. The cure was effected not by a treatment directed to 
 relieve cerebral congestion, but by stimulation of the skin of the 
 face, forehead, temples, &c. 
 
 It is, however, unnecessary to multiply examples to prove the 
 truth of the proposition, that disease may commence in one 
 portion of the nervous extremities, and be propagated towards 
 the centre, and hence, by a reflex action, to other and distant 
 parts. Bearing this in mind, we can explain why it is that 
 disease commencing in one part of the system may produce 
 morbid action in another and distant part ; and it certainly 
 appears strange that, with so many striking examples before 
 them, pathologists should have so long overlooked this cause 
 when seeking to explain the nature of many forms of paralysis. 
 If certain irritations of the nervous extremities in one part of
 
 PARALYSIS. 625 
 
 the body are capable of giving rise to a derangement in the whole 
 system of voluntary muscles ; if a local affection may become the 
 cause of exalting and rendering irregular the functions of every 
 muscle in the body; then, surely, it is not difficult to conceive 
 that a cause, local as the former, and tending not to exalt but to 
 depress the motor function of the muscles, may likewise affect 
 not merely the nerves and muscles of the part, but also those of 
 the whole body, or of distant organs, giving rise to paralysis. 
 
 Now, pathologists have long recognized the fact that general 
 muscular excitement and spasm may arise from the operation 
 of a local irritation. A man gets a contused wound on his 
 thumb, or one of his fingers, and some superficial nerves are 
 injured. In the course of a few days he begins to feel a degree 
 of stiffness about the lower jaw and muscles of the neck, accom- 
 panied by a sense of constriction about the diaphragm. This 
 increases gradually, all the muscles are thrown into a state of 
 fixed spasm, and he gets tetanus. Here a few trifling branches 
 of the digital nerves are injured, the morbid action is conveyed 
 from them along the nerves of the arm to the spinal cord and 
 brain, and is thence by a reflex action propagated all over the 
 body. A wound in the finger causes a morbid action in its 
 nerves, and it has been acknowledged by pathologists, that this, 
 by acting on the brain and spinal cord, may give rise to a general 
 morbid action of the muscular system. This being the case, 
 there is nothing improbable in supposing that a cause affecting 
 any portion of the branches of the nervous tree, and which pro- 
 duces effects of a paralytic nature, may likewise react backwards 
 towards the nervous centres, and thence by a reflex progress may 
 extend its influence to distant parts of the circumference. 
 
 To give another instance : how often do we see irritation 
 commencing in the intestinal mucous membrane propagated back- 
 wards towards the brain ? Take the familiar example of in- 
 testinal worms. A child labours under worms ; here the irritation 
 of the digestive mucous surface, whether it be produced by the 
 worms or by the indigestion which accompanies them, is propa- 
 gated from the stomach and bowels to the brain, and thence 
 reflected to the voluntary muscles, causing general convulsions. 
 
 Dr. Stokes details the following case in his lectures: — "A 
 young woman was admitted into one of the surgical wards of the 
 Meath Hospital, for some injury of a trivial nature. While in 
 VOL, I. 40
 
 626 CLINICAL MEDICINE. 
 
 the hospital she got feverish symptoms, which were treated with 
 purgatives consisting of calomel, jalap, and the black bottle, a 
 remedy which deserves the name of coffin hottle, perhaps better 
 than the pectoral mixture so liberally dealt out in our dis- 
 pensaries as a cure for all cases of pulmonary disease. She was 
 violently purged, the symptoms of fever subsided, and she was 
 discharged. A few days afterwards her mother applied to have 
 her re-admitted, and she was brought in again, and placed in 
 one of the medical wards. Her state on admission was as 
 follows : — she had fever, pain in the head, violent contractions 
 in the fingers, and alternate contraction and extension of the 
 wrist and fore-arm. These muscular spasms were so great, that 
 the strongest man could scarcely control the motions of the left 
 fore-arm. In addition to these symptoms she had slight thirst, 
 some diarrhoea, but no abdominal tenderness. On this occasion 
 a double plan of treatment was pursued, the therapeutic means 
 being directed to the head, in consequence of the marked 
 symptoms of local disease of the brain, and to the belly from 
 the circumstance of abdominal derangement observed in this 
 and her former illness. 
 
 " She died shortly afterwards with violent spasms of the head 
 and fore-arm ; and as she presented all the ordinary symptoms 
 of a local inflammation of the opposite side of the brain, we 
 naturally looked there first for the seat of the disease. After a 
 careful examination, however, no perceptible trace of disease 
 could be found in the substance of the brain, which appeared 
 all throughout remarkably healthy. She had all the symptoms 
 which, according to Serres and Foville, would indicate disease of 
 the optic thalamus or posterior lobe of the opposite side ; yet we 
 could not find any lesion Avhatever of its substance, after the 
 most careful examination. But on opening the abdomen we 
 found evident marks of disease ; the lower tJiird of the ileum, 
 for the length of six or ei<jht inches, was one unbroken sheet of 
 recent ulcerations.'" This case, gentlemen, j'ou will perceive 
 just now, bears very strongly on the subject of paraplegia arising 
 from enteritis. 
 
 Again, how often do we see convulsions brought on in the 
 same Avay by cutaneous irritation ! A child gets an attack of 
 fever accompanied by general irritability and restlessness. 
 During the course of the disease the lungs become afi"ected, and
 
 PARALYSIS. 62.7 
 
 the medical attendant applies a large blister, which is left on for 
 several hours. Next day the symptoms of nervous irritation 
 become more violent ; the child is perfectly restless, or if it 
 dozes for a moment, awakes screaming, and is finally attacked 
 with general convulsions. Many other examples could be 
 brought to support this view of the question, and prove that 
 morbidly increased action of the whole muscular system may be 
 excited by a cause acting merely on some insulated portion of 
 the nervous extremities. 
 
 I think, therefore, that I am borne out by analogies, strikingly 
 exhibited by numberless examples, in asserting that the circum- 
 ference of the nervous system has been too much neglected by 
 pathologists in their explanations of the nature and causes of 
 paralytic affections. I have given before instances of pains 
 commencing in particular parts of the body, and travelling 
 back towards the spine, so as to give rise to an affection of 
 that organ which has been too generally looked upon as th& 
 result of idiopathic disease. How often does this happen in 
 hysteria ! How often does it occur that the organ primarily^ 
 engaged in hysterical cases becomes during the attacks acutely 
 painful, and as the disease proceeds, the pain travels back 
 towards the spine, until at length the spinal cord itself 
 becomes affected, and we find acute pain and tenderness over 
 some portion of its track ! I am fully persuaded that many 
 modern authors who have ascribed the phenomena of hysteria 
 and other affections to spinal irritation, have been too hasty and 
 indiscriminate in their explanations. In the majority of cases 
 you will find hysteric patients complain at first, not of pain in 
 any part of the spinal cord, but in the right side in the situation 
 of the liver, and in the region of the heart or stomach, or in the 
 head, or the pelvic region. At this period there is seldom any 
 tenderness over the spinal cord ; but as the disease goes on, the 
 irritation which existed in some of the situations to which I 
 have referred is extended to the spine, and pain and tenderness 
 are now felt over some of the spinous processes of the vertebra. 
 When this has taken place, then the spinal irritation thus 
 produced becomes itself a new cause of disease, from which as a 
 centre the morbid influence is propagated to other organs. The 
 profession owes much to Teale, Griffin, and other writers, who 
 have pointed out the importance of attending to this spinal
 
 628 CLINICAL MEDICINE. 
 
 tenderness in cases of hysteria, &c. Still, however, like all 
 those who have been employed in investigating a new subject, 
 they have, perhaps, generalized too hastily, and have in many 
 cases regarded this spinal tenderness as a cause, when it should 
 have been merely considered as a consequence. 
 
 Having now endeavoured to explain some of the general 
 principles which should guide us in the investigation of nervous 
 diseases, I shall relate some cases of paraplegia, which, though 
 diflering in their origin as to the organ inflamed, will strike you 
 as exhibiting a close analogy to those published by Mr. Stanley. 
 
 In November, 1832, I attended with Mr. Kirby and Mr. 
 Cusack a young gentleman aged fourteen, who was residing at 
 a boarding school in the vicinity of Dublin, and whose case I 
 before cursorily referred to. He had eaten a large quantity of 
 nuts on the eve of Allhallows, and had in consequence obstruc- 
 tion of the bowels, attended with sense of weight and pain of 
 the stomach, nausea, loss of appetite, and obstinate constipation. 
 Active purgatives of different kinds were employed without efi"ect, 
 and the obstruction was only removed by the use of repeated 
 enemata, thrown up with Read's syringe, introduced as far into 
 the cavity of the intestine as the circumstances of the case 
 permitted. To these means, assisted by leeching and stuping, 
 the constipation yielded : but its removal was followed by 
 symptoms of enteric inflammation, embracing not one but all 
 the coats of the intestine — the mucous, the muscular, and 
 certainly the peritoneal. The occurrence of a new and violent 
 disease greatly impeded his cure ; we had a long and anxious 
 attendance, and the young gentleman escaped with great 
 difficulty. However, the enteric symptoms at last gave way, 
 convalescence became manifestly established, the patient was 
 able to sit up in his bed, and as his strength and appetite were 
 rapidly returning, he was informed that he might get up. On 
 attempting to leave his bed, it was found that he had lost the 
 power of using his lower extremities — in fact, he had become 
 paraplegic. He had perfect power over his arms and trunk, 
 but the lower extremities were quite useless. The paralysis, 
 however, was entirely limited to the muscles ; there was no 
 diminution of sensibility in the limbs ; no numbness, pain, or 
 sensation of formication ; and the muscular functions of the 
 bladder and rectum were apparently uninjured.
 
 PARALYSIS. 629 
 
 Before I enter on this explanation of the case, permit me to 
 recite the following : — I was called to visit a lady residing in the 
 neighbourhood of Merrion Square who was said to be labouring 
 under symptoms of dyspepsia. She had a sense of weight about 
 the stomach, nausea, tendency to vomit, epigastric and hypo- 
 chondriac tenderness — the latter situated on the right side, but 
 no fever nor excitement of the circulation. In the course of two 
 or three days she became slightly jaundiced, and it was evident 
 that the latent cause of her disease was in all probability a 
 gastro-duodenitis, terminating in an affection of the liver. It is 
 sufficient to say that this lady's symptoms went on, and that the 
 diseased action gradually extended to the whole intestinal tube,, 
 liver, and peritoneum. Her bowels became tympanitic, her- 
 belly extremely tender on pressure, she got low fever, with quick, 
 pulse and great restlessness, and was saved with difhculty by 
 the repeated application of leeches and the use of calomel, sO' as.. 
 to affect the mouth. She became convalescent; but with the 
 return of health it was found that she had lost the power of 
 using her lower extremities, and she continued paraplegic for a 
 long time. 
 
 In the case of the young gentleman already detailed, you will 
 recollect that the paralysis was entirely limited to the muscular 
 functions of the lower limbs, and that there was no derangement 
 of sensation, no lesion of the muscular powers of the rectum or 
 bladder. The same thing occurred in this case. There was in 
 the beginning no impairment of sensibility, and the power over 
 the rectum and bladder was uninjured. Soon afterwards, how- 
 ever, she complained of pains in the loins and bowels, and the 
 muscular functions of the bladder became deranged. Indeed,., 
 the case was then unfavourable ; it had resisted the ordinary 
 remedies, and threatened to become one of confirmed paraplegia, 
 but she began to improve in about six months, and eventually 
 recovered completely. It is to be observed that in this lady the 
 loss of power was much more complete than in the young gentle- 
 man before referred to ; his paraplegia was by no means perfect, 
 and yielded to the employment of stimulating frictions to the 
 extremities, combined with a cautious use of internal stimulants 
 and tonics. In neither of these cases was the loss of muscular 
 power so great as to deprive the patients of the use of their 
 legs while lying in bed. They could then be raised, flexed, and
 
 630 CLINICAL MEDICINE. 
 
 extended witli apparent ease and strength ; and yet, when the 
 patient attempted to stand up or walk, he was totally unable 
 to do either, his legs sinking under him ; and even when sup- 
 ported by a person on each side so as to take the greater part 
 of the weight of the body off the limbs, he was still unable to 
 advance one foot before another. I cannot understand why so 
 great a difference should exist between the muscular force of the 
 legs in the one position and in the other. 
 
 Here, you perceive, we have more or less complete loss of 
 power of the lower extremities supervening on inflammation of the 
 gastro-intestinal mucous surface. Of this I have now witnessed 
 several examj)les. How are we to account for this ? In what 
 way does paraplegia arise from inflammation of the bowels ? 
 
 The mode in which I would explain this phenomenon is as 
 follows : — The impression made by inflammatory derangement 
 on the nervous filaments distributed to the mucous coat of the 
 intestines is propagated to the spinal cord, and from this reacts 
 on the muscular functions of the lower extremities. It is true 
 that the intestines, and most of the abdominal organs, are 
 almost exclusively supplied with nerves from the great sym- 
 pathetic ; but you are to recollect that these communicate by 
 numerous branches with the spinal nerves, and that, conse- 
 quently, morbid imjiressions made on their extremities may be 
 rapidly and extensively propagated to the spinal cord, and from 
 thence by a reflex action to the muscular nerves of the lower 
 extremities. When I first met with cases of paraplegia after 
 inflammation of the bowels, or fever with gastro-enteric symp- 
 toms, I thought that owing to some peculiarity in the case, the 
 great lumbar nerves had become implicated in the disease ; that 
 there was an actual inflammatory state of the neurilemma, accom- 
 panied by thickening and effusion, which, by compressing the 
 nervous matter, gave rise to the paraplegic symptoms. A more 
 extensive view of the subject, however, has convinced me that 
 this is not the fact ; for, if it were, the aftection of the nerves 
 would naturally be attended with acute pains shooting in the 
 direction of their course — for, as far as my experience goes, in 
 every instance of inflammation attacking the neurilemma, intense 
 pain is felt in the parts to which the branches of the affected 
 nerve are distributed. 
 
 Again, though this explanation might apply to cases in which
 
 PAEALYSIS. G31 
 
 the inflammation was general — as where enteric is combined 
 with peritoneal inflammation — it would not apply to those cases 
 in which the inflammator}-- action is localized. Thus, in Mr. 
 Stanley's cases, the paraplegia supervened on inflammation 
 principally limited to the kidneys. In seven cases detailed in 
 Mr. Stanley's paper,* we find paralytic symptoms produced, 
 not by any derangement commencing in the brain or spinal 
 cord, but in consequence of an irritation having its seat and 
 origin in the kidneys ; and yet in the majority of his patients, 
 the paraplegia was as complete as if it had been produced by 
 idiopathic disease of the cord or its investments. What was 
 equally remarkable, many of these cases were accompanied by 
 spinal tenderness ; so that the most experienced practitioners, 
 on a review of the symptoms, were inclined to look upon them 
 as cases of disease affecting the vertebrae, or the spinal cord and 
 its sheath. Yet on dissection there was no caries of the bones ; 
 no destruction of ligaments ; no remarkable vascularity, soften- 
 ing, or suppuration of the spinal cord ; no inflammation of its 
 membranes, or eflusion in its sheath. In almost all, the morbid 
 phenomena were confined to the kidneys ; there were depositions 
 of pus dispersed through their substance, and the mucous lining 
 of the iufundibula, ureters, and bladder was thickened and 
 vascular. The formation of purulent matter was not, however, 
 connected with the paraplegia, further than as being, like it, 
 produced by the same cause — inflammation of the kidney. In 
 one case the paraplegia was very complete, and the inflammation 
 of the kidney had not advanced to the stage of suppuration. 
 
 There can be little doubt that others have frequently noticed 
 the occurrence of paraplegia after inflammation of the bowels, 
 although no- author has as yet written upon the subject. It is 
 well to be acquainted with the occasional occurrence of so un- 
 toward and obstinate a sequela of enteric inflammation, in order 
 that we may watch attentively the state of the lower extremities 
 immediately after the inflammation of the bowels has been sub- 
 dued. As the patient in such cases has no pains in his limbs, 
 and is not conscious of any loss of power until he attempts to 
 stand up ; and as this attempt is not usually made for many 
 days after the subsidence of the inflammation of the bowels, in 
 consequence of the great debility which the disease and the 
 
 * Medico- Chirurgical Transactions, vol. xviii. p. 2G0,
 
 632 CLINICAL MEDICINE. 
 
 active treatment necessarily resorted to produce ; this variety of 
 paraplegia is very liable to be overlooked in its commencement, 
 and is thus neglected at the very period when treatment is most 
 likely to prove beneficial. 
 
 The foregoing observations have no doubt excited a suspicion 
 in the minds of some of you, that the paralysis so often observed 
 to follow painter's colic may be derived from a reaction of the 
 nervous system of the bowels on that muscular system in general. 
 Dr. Bright, indeed, has asserted that inflammation of the spinal 
 marrow or sheath, as denoted by spinal tenderness, always pre- 
 cedes the paralysis produced by lead. It often does, but by no 
 means constantly ; for I have pointed out to you several cases 
 in this hospital in which not the slightest vestige of spinal 
 tenderness could be detected, either before the commencement 
 or during the progress of the paralysis which so often follows 
 painter's colic. I am not inclined to adopt the supposition that 
 the paralysis in such cases is merely secondary, and the result 
 of the intestinal irritation. I think it much more probable that 
 it depends on the poisonous effects of the lead acting directly 
 on the nervous system. The same observation applies to the 
 paralysis which so often occurs as a result of large doses of 
 arsenic. Orfila has remarked that some of the dogs he experi- 
 mented on, and which narrowly escaped dying in consequence 
 of large doses of arsenic, became, when they recovered from 
 the immediate effects of the poison, permanently paraplegic. I 
 look upon this paralysis as a direct consequence of the dele- 
 terious action of the arsenic on the nervous system, and not as 
 the result of the gastro-enteritis it invariably produces. The 
 fact, however, is well worthy of attention, that both arsenic and 
 lead produce intestinal irritation in the first instance, and loss 
 of muscular poAver in the second. A knowledge of this fact will 
 prepare us for understanding the connexion which appears to 
 exist between intestinal irritation and paralysis. 
 
 In a lecture published by Dr. Stokes, in the London Medical 
 and Surgical Journal, he makes the following observations : — 
 " Here, then, we have well-marked paraplegia, without any per- 
 ceptible organic change in the spinal cord or its investments, but 
 presenting distinct traces of disease in the kidneys. This leads 
 me to observe the very close connexion which exists between the 
 kidneys and spinal cord — a connexion which has been long recog-
 
 PARALYSIS. 633 
 
 nized by medical practitioners, but only in a limited point of view ; 
 for, though they were of opinion that disease of the kidneys 
 and a discharge of ammoniacal urine were the results of spinal 
 disease, they never seem to have reflected that the reverse of this 
 might happen. It seems, however, now to be almost completely 
 estabhshed, that disease of the kidneys may produce symptoms 
 Avhich are referable to disease of the spine. Medical men have 
 been too much in the habit of looking at this matter only in one 
 point of view. They know that disease of the spine will produce 
 disease of the kidneys, and here they stop ; but it has been 
 shown that the reverse of this may happen, and that renal dis- 
 ease may produce very remarkable lesions in the functions of the 
 spine. Of this very curious occurrence we have many analogies 
 in pathology. Thus, for instance, in several cases of cerebral 
 disease, but particularly in hydrocephalus, we have vomiting ; 
 here we have functional disease of the stomach depending on 
 disease of the brain. Take the reverse of this, — observe the 
 delirium which attends a case of gastro-enteritis ; here you have 
 the functions of the brain deranged in a most remarkable 
 manner, and this produced by sympathy with an inflamed 
 mucous membrane. The truth is, that in the spine and kidney, 
 as well as in various parts of the body, we may have two organs 
 so closely connected in sympathy, that disease of the one will 
 bring on serious functional lesion of the other." 
 
 It will be seen that these observations coincide in many 
 points with the principles I have laid down in my lecture on the 
 subject of nervous pathology. On this point Mr. Stanley makes 
 the following remarks : — " In reflecting on the phenomena of the 
 first series of cases which have been detailed in this paper, it 
 might be thought improbable that irritation, commencing in the 
 kidney or in the bladder, should be propagated through sentient 
 nerves to the spinal cord, and that the impression should thence 
 be transmitted through both the motive and sentient spinal 
 nerves to the limbs — here occasioning an impairment both of 
 sensation and the power of motion. Some illustration of this 
 subject seems to be furnished by the researches of experimental 
 physiology. If in an animal, ' a few seconds after it has been 
 deprived of life, the spinal cord be then divided in the middle of 
 the neck, and again in the middle of the back, upon irritating a 
 sentient organ connected with either isolated segment, muscular
 
 634 CLINICAL MEDICINE. 
 
 action is produced— that is to say, a sentient organ is excited — 
 and an irritation is propagated through the sentient nerve to the 
 isolated segment of the spinal marrow, where it gives rise to 
 some change which is followed by an impulse along the voluntary 
 nerves to the muscles of the part.'* In the instances which 
 have been adduced, irritation, commencing in the nerves of 
 an internal organ — the kidne}' — -has been transmitted through 
 the spinal cord to the motive and sentient nerves of the lower 
 extremities ; but the same phenomena may occur in an opposite 
 order, as in the case of a compound fracture or other severe 
 injury of the lower extremity, followed by retention of urine 
 from irritation arising in the anterior crural and ischiatic nerves, 
 and communicated through the lumbar and sacral plexuses of 
 spinal nerves to the nerves of the bladder. Extending these 
 views to cases of neuralgia where there is no visible derangement 
 of structure or other local cause of excitement, it will always be 
 difficult to determine whether the source of irritation be in the 
 affected nerves, or in the central portion of the nervous system 
 whence they are derived." 
 
 You will perceive that this explanation, as far as it goes, 
 though not in the same words, is in meaning the same as that 
 which I have given, with this exception — that it is only corollary 
 of the general principles Avhich I had laid down in my lectures 
 on the pathology of the nervous system. Long before the publi- 
 cation of Mr. Stanley's paper, I had established the proposition that 
 impressions made upon any portion of the nervous extremities 
 may be proj)agated towards their centres, and thence by a reflex 
 action transmitted to the nerves of other and distant parts, so 
 as to give rise to morbid phenomena analogous to those which 
 are j^roduced by disease originating in the central parts them- 
 selves. Applying this principle to the subject of paraplegia, 
 we shall find that, independently of cerebral or spinal disease, 
 it may arise from a variety of causes, each referable to lesions 
 commencing in distinct and isolated portions of the nervous 
 extremities. 
 
 Thus, in Mr. Stanley's cases, the exciting cause seems to have 
 originated in the urinary system ; in the case which I have 
 detailed, where it supervened on inflammation of the bowels, 
 it commenced in the digestive — and it appears from a com- 
 
 * Outlines of Human Fhysiology , by H. Mayo.
 
 r.vRALYsis. 635 
 
 munication made to Mr. Stanley by Mr. Hunt, of Dartmouth, 
 that the same thing may result from irritation existing in the 
 uterine— system. Mv. Hunt alludes to several cases of disease 
 of the uterus being followed by such loss of power in the lower 
 limbs, that the patients were entirely confined to bed ; adding 
 that there was no change of structure in the parts to which the 
 symptoms referred, as the source of irritation. In addition to 
 these, I shall in my next lecture bring forward several cases to 
 prove that a similar loss of power may be produced by the action 
 of cold on the lower extremities. Indeed, the number of cases 
 which I have recently met with, where paraplegia was evidently 
 brought on by exposing the lower extremities to cold and wet, has 
 very strongly directed my attention to this form of the disease ; 
 and I trust I shall be able, at our meeting, to communicate some 
 very interesting matter on the subject.
 
 636 
 
 LECTURE XXXYII. 
 
 PAKALYSIS. 
 
 I SHALL commence this lecture by reading the following case, 
 bearing on the subject we were last engaged considering, for 
 which I am indebted to the kindness of Dr. Hutton : — 
 
 "' Eichard M'Nab, a sailor, aged thirty-eight, was admitted 
 into the Richmond Hospital on the 16th of January, 1835, and 
 placed under Dr. Hutton's care. His previous history was 
 briefly as follows : — In the summer of 1826 he strained his back 
 in leaping, and was confined to bed in consequence of the 
 accident, but recovered in about twelve days. Shortly after- 
 wards he contracted gonorrhoea, which was attended with hernia 
 humoralis ; this yielded to repeated local bleeding, but a gleet 
 remained, and this, after continuing for some time, disappeared 
 under the use of sea-bathing. He then enjoyed good health, 
 with the exception of occasional slight pain in the lumbar region, 
 until October, 1830, when, being much exposed to cold and wet 
 during a long and fatiguing voyage, he got an attack of piles, 
 for which he was under medical treatment for seven months. 
 During the continuance of this affection he first observed a 
 frequency in micturition, but had no retention or sensible 
 obstruction of urine. 
 
 " After recovering from the hemorrhoidal attack, he enjoyed 
 good health until September, 1834, when, coming from Cadiz to 
 the port of Dublin, in a very leaky vessel, he suffered greatly 
 from cold, wet, and fatigue — being almost constantly engaged at 
 the pumps, which could not be left for ten minutes at a time. 
 In addition to this, being deprived of his usual allowance of 
 spirits for thirty-two days, he found himself, on his arrival in 
 Dublin, in a very weak state. He rested from his occupation 
 for a fortnight after discharging his cargo, and states that during 
 this time he drank from four to six glasses of whisky daily. He 
 then went on board the "Elizabeth," of London, as chief mate, but
 
 PARALYSIS. 637 
 
 after eight or nine days his back and lower extremities became 
 affected with pain and weakness, which increased to such a 
 degree that he was obhged to give up his occupation on the 
 thirteenth day. He states that, during the time his back and 
 legs were getting weak, he was obliged to pass water about three 
 times in an hour, which he did with pain and tenesmus. On 
 the 1st of January the pain of his back was very severe, and he 
 lost the use of his limbs, but not completely, for he could support 
 himself, and even walked a little with the aid of two sticks. 
 
 " At the time of his admission he appeared somewhat broken 
 down in his general health ; he was pale, emaciated, and laboured 
 under derangement of his digestive organs. He suffered from 
 occasional chills, succeeded by heats and sweating, which occurred 
 at irregular periods ; he also laboured under incontinence of 
 urine and dysuria, and the stream of urine was much dimin- 
 ished : weakness and loss of power in his lower extremities, as 
 reported. 
 
 " His treatment was as follows : — First, cupping over the 
 loins, then moxae in the same situation ; attention to his digestive 
 organs ; diluents and opiates for the urethral symptoms. On 
 the 26th of the same month, a very close stricture was found 
 to exist in the membranous portion of the urethra. A small 
 catgut bougie of double length was introduced, so that one half 
 of it projected from the meatus ; over this was slided a small 
 gum-elastic catheter of ordinary length, and open at each end, 
 until it traversed the stricture and reached the bladder ; the 
 catgut bougie was then withdrawn, and the gum-elastic catheter 
 secured. A little constitutional disturbance followed, but soon 
 subsided, and in a few days gum-elastic catheters of a much 
 increased size were introduced with facility. 
 
 " A very remarkable amendment took -place in his hack and 
 lower extremities, in a very few days after the first introduction 
 of the instrument ; in fact, it was almost sudden. Warm baths, 
 friction to his limbs, &c., completed his cure. He was discharged 
 on the 25th of February, at which time the power of his lower 
 limbs was perfectly restored, and the symptoms affecting the 
 urinary system had disappeared." 
 
 You at once perceive the extreme importance of this case ; it 
 bears directly on the question I was speaking of, and proves that 
 urethral irritation may, as well as inflammation of the kidneys.
 
 638 CLINICAL MEDICINE. 
 
 give rise to paraplegia ; and it affords another striking illustration 
 of the general proposition which I have laid down. 
 
 In the next class of cases we have to consider, the cause of the 
 paraplegia is extremely obscure — I mean those cases in which 
 the paraplegia occurs during the course of fever. Here the other 
 sufferings of the patient, and his general debility, attract our 
 notice so exclusively, that the paralysis entirely escapes notice 
 until convalescence is established — until, in fact, the patient 
 wishes to support himself on his legs. He then finds, much to 
 his surprise, that his limbs collapse under him, and that he has 
 little or no power over them ; this appears to him the more 
 extraordinary, on account of his having recovered a good deal 
 of strength in his upper extremities. Thus, a Miss F. was 
 attacked with fever whiJe on a visit to a friend in Dublin. She 
 was attended by Mr. Carmichael. Her fever was protracted and 
 severe, and exhibited, during its progress, well marked symptoms 
 of gastro-intestinal irritation and congestion, viz., tympanitis, 
 epigastric and abdominal tenderness, &c. When her conva- 
 lescence was established, her attendants found, to their great 
 alarm, that she had no power in her legs. She complained of 
 coldness and numbness in the lower extremities. This lady 
 gradually recovered the use of her legs, but not until moxge 
 without number had been applied along the course of the spinal 
 column. The cure lasted about a year. No evidence could at 
 any time be detected, indicating disease of the spinal bones or 
 ligaments. Mr. Carmichael has seen several cases of paraplegia 
 following the remittent gastric fever of children, totally uncon- 
 nected with spinal disease. Such an occurrence is most usual in 
 children of a scrofulous temperament, and it is seldom, very 
 seldom, remedied either by time or medicine. 
 
 Two explanations suggest themselves as capable of accounting 
 for the paraplegia after fever. The first rests upon the frequency 
 of the occurrence of violent pain in the small of the back in the 
 commencement of this disease. This pain in the back is often 
 excruciating, and generally accompanied by proportionally violent 
 pains in the lower extremities. I am quite as anxious to relieve 
 the pain in the back in the beginning of the fever, as I am to 
 remove headache ; one is almost as serious as the other, for the 
 vital importance of the spinal marrow in the economy is scarcely 
 less than that of the brain.
 
 TARALYSIS. 639 
 
 In roferciice to this point of practice, I have been in the habit 
 of usiuf^ the expression — in order to fix the attention of my 
 pupils — that such a patient has not any pain in his head, hut he 
 has f/otten his headache in the small of his hack. Now, when 
 headache is the prominent feature of the first stage of fever how 
 few will omit bleeding, leeching, cupping, cold or hot applica- 
 tions, &c. When, on the contrary, the lumbar spinal marrow is 
 the seat of the congestion, how generally do practitioners neglect 
 the application of topical bleeding, and other appropriate remedies. 
 Were such neglect of less frequent occurrence, it is probable that 
 paraplegia after fever would not be met with so often. Some 
 may be inclined to look for the source of the paraplegia which 
 follows fever in the irritation of the gastro-iutestinal mucous 
 surface, propagated by a reflex progress to the spinal marrow. It 
 is not easy to decide between these two explanations, but I con- 
 fess myself more inclined to adopt the former than the latter. 
 
 I shall now proceed to lay before you some facts and cases 
 illustrating the nature of another form of paraplegia, a form of 
 extreme interest, from the circumstance of its being hitherto 
 but little understood, and not mentioned by any writer I am 
 acquainted with, as well as from the peculiar nature of its 
 origin and the frequency of its occurrence. I have, within a 
 comparatively short period of time, met with several instances 
 of this aflection, and have some cases of it at present under 
 treatment. 
 
 Before I enter on this part of the subject, I may be allowed to 
 remark that, in some cases, loss of the power of motion in a limb 
 can evidently be traced to the operation of a cause whose action 
 is confined altogether to the surface. Thus, in the case of a 
 woman in Sir Patrick Dun's Hospital, erysipelas occupied the 
 calf and inside of the right leg, and occasioned some inflamma- 
 tion and tenderness along the chain of lymphatics extending to 
 the groin, where one of the inguinal glands was slightly enlarged 
 and painful. The erysipelas yielded to the employment of local 
 and general remedies ; but, for several days, and particularly 
 while the disease was at its acme, she was altogether destitute of 
 any power of motion in the affected limb ; she could neither bend 
 the leg on the thigh, nor could she raise the whole limb. This 
 aff'ection must have been produced by a reflex action propagated 
 from the cutaneous branches to the larger muscular nerves. It
 
 640 CLINICAL MEDICINE. 
 
 is evident that the muscles wliicli move the leg on the thigh 
 could have been affected only in this way, for they lay far above 
 the part in which the erysipelatous inflammation existed. It is 
 in the same way that we are to account for the paralysis observed 
 in cases of phlegmasia dolens. 
 
 Sometimes the reverse of this happens, and a single limb 
 becomes paralysed, on account of an injury done to one of its 
 principal nerves by the application of sudden violence, or of 
 pressure long continued. Thus, a case was related to the late 
 Dr. Brennan and myself, in which a robust gentleman having 
 been much fatigued during the day, fell asleep after dinner, his 
 head resting on his arms, which were crossed on the table. In 
 consequence of some unfortunate awkwardness in his position, 
 one of the ulnar nerves was compressed during the time he slept, 
 and on awakening, his fore-arm and hand were completely power- 
 less. Many remedies were tried in this case without success, 
 and the paralysis continued until the day of his death, which 
 occurred several j'ears afterwards. A lady not long since was 
 tripped up in walking across the floor, and fell with considerable 
 force. The parts which sustained the principal shock were the 
 left hip and trochanter. From the moment of the accident, she 
 lost all power in the left lower extremity, which remained per- 
 manently paralytic. Fracture or dislocation was suspected at 
 first, but a minute and careful examination showed that the 
 suspicion was groundless. No injury of the spine could be 
 detected, and she had no numbness, pain, or formication in the 
 afiected limb. After a month she was j^laced under the care of 
 Mr. Kirby, who used every topical application likely to prove 
 useful, but without the slightest benefit. She returned to the 
 country, where she died shortly afterwards, quite unexpectedly, 
 in the bloom of life, and without the occurrence of a single 
 symptom indicative of approaching danger. No autopsy was 
 permitted. 
 
 I shall now, with the view of illustrating the form of paraplegia 
 to which I have alluded, read the following very remarkable case, 
 which I had an opportunity of tracing through all its stages, and 
 which made a very considerable impression on me at the time. 
 The history is chiefly derived from notes furnished by the patient 
 himself before he became too weak to write ; what relates to the 
 latter stages of his complaint is taken from my own case-book.
 
 PAEALYSIS. 641 
 
 Mr. B., aged twenty-three, was remarkably strong and healthy, 
 though of a spare habit. He was able to take a great deal of 
 exercise, capable of enduring much fatigue, and passionately 
 fond of hunting, fishing, and shooting, particularly the latter ; 
 and, in pursuit of his favourite amusements, frequently exposed 
 himself to wet feet during his excursions through bog lands, and 
 when wading in the water. These habits, however, he laid aside 
 after the occurrence of the first attack of his illness, which hap- 
 pened in 1829. He had for many years been of a costive habit, 
 his bowels being frequently confined for a week at a time, but did 
 not experience any sensible bad effects from this circumstance, 
 and never took any aperient medicine. 
 
 Since the first attack in January, 1829, this state ceased, and 
 his bowels became ever afterwards inclined to looseness, which 
 always increased before the appearance of one of the attacks, 
 accompanied by griping, nausea, and inclination to vomit. Each 
 attack was generally preceded by a copious secretion of insipid 
 watery fluid in the mouth, and then the characteristic symptoms 
 of his disease commenced. These consisted in obstinate and 
 protracted nausea and vomiting ; he first threw up whatever 
 happened to be on his stomach at the time, and afterwards every- 
 thing he swallowed, whether solid or liquid. The matter ejected 
 was at first acid and afterwards bitter, varying in colour from 
 mucous to bilious, but being generally of a greenish and occa- 
 sionally of a bluish tinge. The greenish fluid annoyed him 
 much, from its extreme bitterness, and the quantity thrown up 
 in the course of a day varied from three to four quarts of fluid. 
 He complained also of pain, referred to the stomach or lower part 
 of the chest, which continued throughout the attack, being most 
 acute at its commencement ; for the last year this sensation had 
 passed into a feeling of painful constriction, which he described 
 as a "contracted feeling of his inside," and compared it to some- 
 thing like the effects of a cord drawn tightly, so as to compress 
 or strangulate his body exactly along the outline occupied by the 
 insertions of the diaphragm. During the prevalence of the attack 
 he had profuse perspirations, particularly towards the termination 
 of each paroxysm. 
 
 The duration of the first attack did not exceed four or five 
 days, after which he became quite well, and continued so for six 
 or seven months, when his symptoms suddenly returned. He 
 VOL. I. 41
 
 642 CLINICAL MEDICINE. 
 
 began to reject everything from his stomach as before ; but 
 in the course of a few clays the vomiting disappeared, and 
 for a considerable interval he had no return of his com- 
 plaint. In the year 1830 he had three attacks of a similar 
 description ; from these he recovered also completely, and 
 without remarking any diminution of power in his lower 
 extremities. In 1831, however, the disease began to assume a 
 more serious aspect ; the paroxysms became much increased in 
 severity, lasted longer, and recurred at shorter intervals. For 
 one of these attacks he took mercury, and was salivated. In 
 1832, his symptoms became still more violent, and the duration 
 of the paroxysms more protracted. He had one in March, a 
 second in May, and a third in June, each of which was accom- 
 panied by some numbness and loss of power in the lower 
 extremities ; this, however, was slight, and disappeared altogether 
 as the vomiting subsided. About this time he noticed that his 
 urine was scanty, and deposited more sediment than usual. He 
 also complained of being very apt to catch cold whenever he 
 got out of bed, and stated that he suffered occasionally from 
 severe twitches and pains in his legs, thighs, arms, and other 
 parts of his body, which were generally succeeded and carried 
 off by profuse perspirations. 
 
 In August, 1832, he had a violent attack, which lasted nearly 
 a month. The vomiting was incessant, continuing night and 
 day, and he suffered severely from the feeling of painful con- 
 striction already described. On getting up after this attack, his 
 legs suddenly failed him, and he dropped down on the floor 
 quite powerless. The paralysis did not now disappear during 
 the intervals, although it grew somewhat better after each fit of 
 vomiting had ceased ; indeed he used to improve in his walking 
 after the paroxysm had entirely disappeared ; and, aided by two 
 sticks, supported himself so as to give some hopes of a recovery, 
 until a recurrence of his attack reduced him again to a state of 
 almost total paraplegia. His legs now began to waste sensibly, 
 and he noticed that they had lost their feeling, and were remark- 
 ably cold. He also complained of severe twitches of pain in 
 various parts of his body, accompanied by profuse night sweats, 
 and turbid, scanty urine. 
 
 For some months before his death he was comi)letely paraplegic, 
 and continued to be attacked with violent fits of vomiting. ThQ
 
 TARALYSIS, 643 
 
 vomiting went on night and day, and lie was unable to retain 
 the mildest and most soothing substances for a moment on his 
 stomach. Sir Philip Crampton and Dr, Ireland attended him 
 with me, and we had recourse to everything we could think of 
 to allay the irritability of his stomach, but in vain. After con- 
 tinuing to resist obstinately every form of treatment for five or 
 six days and nights, the vomiting would suddenly cease, the 
 gentleman would exclaim, "Now I am well," and he could 
 then eat, with perfect impunity, substances which would prove 
 irritating and indigestible to many stomachs. This was one 
 of the most singular circumstances I ever witnessed. The 
 transition from a state of deadly nausea and obstinate retching 
 to a sharp feeling of hunger used to occur quite suddenly. One 
 hour he was the most miserable object you could behold, racked 
 with painful constrictions across the epigastrium, alternately 
 bathed with cold perspiration, and rejecting everything from his 
 stomach, the next found him eating with a voracious appetite 
 whatever he could lay hold of, and digesting everything with 
 apparent facility. 
 
 It may be observed that as the disease in this case proceeded, 
 the intervals between the attacks diminished, while the paroxysms 
 increased in duration. For the last two years they continued 
 only for four or five days, and appeared at intervals of six or 
 seven months ; latterly they used to last for eight or ten days, 
 and returned every third or fourth week. During the paroxysm 
 the only thing which he took was a little cold water with some 
 brandy and a few drops of laudanum, which remained longer on 
 his stomach than anything else, and enabled him to enjoy a few 
 minutes' sleep. He never complained of any headache, and his 
 intellect was remarkably clear, and his memory good. 
 
 No trace of organic disease could be detected in the abdominal 
 viscera, and there was not the slightest tenderness over any part 
 of the spine. He also retained to the last a complete power 
 over the bladder and rectum. 
 
 At length his system began to give way ; long confinement to 
 bed and the frequent recurrence of these exhausting attacks 
 completely wore him out, and he sank the 30th September, 
 1833. A post-mortem examination was allowed by his friends, 
 and we scrutinized every part of his system with the most 
 anxious care. The brain, cerebellum, spinal cord, and their
 
 644 CLINICAL MEDICINE. 
 
 investing membranes were carefully inspected ; we examined the 
 large nervous trunks that supply the lower extremities, inspected 
 the viscera of the thorax, and searched for evidences of disease 
 in the stomach and intestinal tube ; we could find none. There 
 was no lesion of the brain or spinal cord, no thickening or 
 vascularity of membranes, the large nerves exhibited their 
 normal condition, the stomach was perfectly healthy, the in- 
 testinal canal was natural, the liver and other glandular viscera 
 of the abdomen without any trace of appreciable derangement. 
 
 Here, then, was a case of perfect paraplegia (I say perfect, for 
 he had lost all power of his lower extremities for more than two 
 months before his death), which may be fairly termed functional, 
 inasmuch as there was no lesion of any part of the nervous 
 centres to explain the phenomena present. How, then, are we 
 to account for them ? The first symptoms were undoubtedly 
 those of abdominal irritation, as manifested by the tendency to 
 diarrhoea in an originally costive habit, accompanied by violent 
 paroxysms of vomiting which recurred at distant intervals. Are 
 we to attribute this diseased condition of the stomach and 
 bowels, which, from the remarkable periodicity of its occurrence, 
 was evidently functional, to irritation, congestion, or inflamma- 
 tion of the brain or spinal marrow ? From the data we are in 
 possession of, it appears that this question must be answered in 
 the negative. There was no headache, heat of scalp, throbbing 
 of the temporal arteries, or other sign of determination to the 
 head, of congestion or inflammation of the brain, either before 
 or during the attacks. The patient's intellect was all throughout 
 remarkably clear, and his memory good. 
 
 Again, if we look for the origin of the disease in the spinal cord 
 or its investments, we can find nothing to assist in explaining 
 the phenomena. There was no pain in any portion of the spinal 
 cord, and at no period of his illness could we detect any tender- 
 ness over the spinous processes. The history of the case seems 
 to prove that whatever was the cause which operated on the 
 nerves of the stomach and intestines, it gradually extended the 
 sphere of its morbid influence to the spinal cord, and, through 
 it, implicated the nerves of the lower extremities. The case is 
 in many respects highly interesting, and well worthy of the 
 attention of the pathological inquirer. The dissection was 
 conducted in the presence of Dr. Ireland and myself, and by
 
 PARALYSIS. 645 
 
 Mr. Harris. It was not made in a hurried or careless manner, 
 each organ was carefully examined, and the process occupied at 
 least four hours. 
 
 The next case to which I shall call your attention was in the 
 Meath Hospital under the care of Dr. Stokes. 
 
 A robust, middle-aged man was admitted into the chronic 
 ward of the Meath Hospital, labouring under paraplegia. He 
 stated that he was generally employed as a boatman about the 
 the river and port, was frequently exposed to cold and wet, 
 particularly in his lower extremities, and that he was in the 
 habit of drinking freely. He had enjoyed good health until 
 about seven weeks before his admission, when he was seized 
 with numbness of the feet and legs, which, after continuing for 
 three or four days, was followed by tingling pains running along 
 the course of the nerves. He then remarked that the power of 
 his lower extremities was much diminished, and this gradually 
 increased, so as to prevent him from walking or even standing 
 without support. His bowels became obstinately costive, and 
 about a month after the commencement of his attack, he per- 
 ceived that his urine was discharged in smaller quantity than 
 usual, and that he was much more frequently called on to pass 
 it than before. He also mentioned that he had gonorrhosa 
 about six months before, and that he had used balsam of 
 copaiba and injections. 
 
 Some time after this he said he noticed some white matter 
 passing with the urine, but did not pay any particular attention 
 to it, as it gave him no inconvenience. His appetite was tolerably 
 good, and he had no headache nor any symptom of determination 
 of blood to the brain. He denied having received any injury of 
 the back, and there was no tenderness over the spinous processes 
 of the vertebrae. He had no pain in the spine, either before or 
 since the occurrence of his illness, nor was there any symptom 
 of inflammation of the substance or membranes of the spinal 
 cord. When admitted, he had considerable diminution of sen- 
 sation and complete loss of motion in one of the lower ex- 
 tremities ; in the other he still retained some power. He had 
 also retention of urine, requiring the daily use of the catheter. 
 
 The treatment was as follows : — He was placed on one of 
 Dr. Arnott's hj'drostatic beds, as there was a great tendency 
 to stripping over the hips and sacrum, a purgative pill was
 
 646 CLINICAL MEDICINE. 
 
 administered two or three times a day to remove the costiveness, 
 and he was ordered to he cupped over the loins. The latter was 
 done in consequence of his complaining of some tenderness on 
 pressure in the situation of the kidneys. His symptoms, how- 
 ever, went on without any improvement, and he died about a 
 month after his admission. 
 
 On dissection, the following phenomena were observed : — 
 The kidneys, which were first examined, appeared rather soft and 
 of a yellowish colour, but there was no vascularity, suppuration, 
 nor other change of structure. The ureters were somewhat dis- 
 tended, but presented no other trace of disease. The bladder 
 was contracted, its muscular coat thickened, and its mucous 
 membrane very vascular. There was no affection of the prostate. 
 On examining the spinal cord. Dr. Stokes observed that he 
 thought the cauda equina appeared to be slightly softened, but 
 remarked that from its appearance he could not state that it was 
 actually diseased. The rest of the spinal cord appeared healthy 
 and normal ; there was no vascularity, effusion, nor softening. 
 External to the sheath of the cord there was a small, flattened, 
 oval body, about the size of half a very small hazel-nut, and of a 
 consistence intermediate between lymph and fat. Around this 
 there was some slight degree of vascularity. Dr. Stokes observed 
 that, from the small size of this body, and the peculiarity of its 
 texture, he entertained strong doubts as to its having any in- 
 fluence in the production of the symptoms noticed during life. 
 He remarked, although it might have been originally the product 
 of inflammation, and have existed in the form of an efi'usion of 
 lymph, still the circumstance of its conversion into a fatty sub- 
 stance proved that it must have existed for a very considerable 
 time, and the smallness of its size, as well as the obscurity of its 
 ^origin, did not by any means satisfactorily explain the occurrence 
 of paraplegic symptoms. 
 
 The last case in connexion with this subject, which I have to 
 lay before you, appears to be analogous in its mode of origin to 
 the former : — A gentleman of strong constitution, and extremely 
 fond of field sports, particularly fishing and shooting, exposed him- 
 self repeatedly to wet feet at a time when he was labouring under 
 the efiects of a long mercurial course. Taking large quantities of 
 blue pill, and exposing the lower extremities to wet at the same 
 time, are circumstances which have an obvious tendency to pro-
 
 PARALYSIS. 647 
 
 duce disease, and it is not to be wondered if tins j:^entleman 
 became the victim of bis want of caution. He got numbness and 
 weakness in bis legs, which he at first attributed to fatigue and 
 over-exertion ; but, as the disease went on, he became more and 
 more powerless, and finally applied to me respecting his illness. 
 
 On examination, I found that he had no pain in the back, nor 
 tenderness on pressure ; nothing, in fact, to indicate any original 
 affection of the spinal cord. The functions of the brain also were 
 natural, and there was nothing about him to lead me to suspect 
 cerebral disease. He had, however, considerable impairment of 
 the muscular functions of the lower extremities, and could not 
 walk without the aid of crutches, or some person to support him. 
 Jn treating this case, I looked upon it as an instance of imperfect 
 paraplegia, in which the paralysis apparently rose from im- 
 pressions made upon the sentient extremities of the nerves of 
 the legs and feet, at a time when these nerves were particularly 
 liable to be deranged in their functions from the previous use 
 of mercury. I therefore had recourse to remedies directly applied 
 to the extremities of those nerves, and fortunately succeeded in 
 restoring this gentleman to the use of his limbs. The cure, how- 
 ever, was not perfect, for a very notable degree of weakness still 
 remains. 
 
 Of this form of paraplegia, I have now witnessed many 
 instances. In most cases I was induced to think that it arose 
 from impressions made by cold and wet on the lower extremities. 
 It is most commonly observed in young gentlemen who are 
 addicted to fishing and shooting, and who in pursuit of their 
 amusements get wet feet repeatedly, from walking over boggy 
 grounds, or wading in the water. It is also observed in labourers 
 whose employment obliges them to stand in water for many hours 
 together, as in draining, pump- sinking, and other similar 
 occupations. In all cases it assumes the creeping form, and 
 generally appears at first in one limb, and afterwards in the other. 
 There is, however, considerable variety in the rate of its progress ; 
 in some cases the patients become almost completely paraplegic 
 in a few weeks from the commencement of the disease ; in others 
 it will go on for months, and even years, before the power of the 
 lower extremities is completely destroyed. 
 
 Where its progress is slow, it makes its approach in an in- 
 sidious manner, and is at first scarcely noticed by the patient.
 
 648 CLINICAL MEDICINE. 
 
 Its latency is here further favoured by the absence of pain, 
 numbness, or formication ; for it is only at the most advanced 
 stages of such cases that derangement or diminution of sensation 
 is noticed. It is only when making some unusual exertion, as 
 in going up stairs or ascending a hill, that the patient finds a 
 more than ordinary degree of weakness in the lower extremities. 
 The first symptom which generally attracts his attention is an 
 incapability of Avalkiug as far as he has been accustomed, but 
 this is attributed to some temporary weakness, or is considered 
 to be the result of previous fatigue. As the disease progresses, 
 walking up an ascent becomes a matter of some difficulty, there 
 is a shuffling motion of the legs, and the patient is apt to stumble 
 from slight obstructions. Gradually the loss of power becomes 
 more manifest, it excites the attention and surprise of the 
 patient, and he finds that he is no longer able to walk without 
 the aid of a stick or some person to lean on. The paralysis is, 
 however, seldom complete ; with the help of crutches the patient 
 continues to hobble about, and it is only in bad cases, and at an 
 advanced period of the disease, that he becomes paraplegic. The 
 paralysis is never so sudden nor so complete in this form of 
 paraplegia, as it is in cases of disease of the spinal cord, or 
 scrofulous ulceration of the bones and ligaments. 
 
 In other cases, however, the paraplegia, though evidently of 
 the same origin, and having the same creeping character, 
 advances with much more rapidity ; and the patient may, in a 
 few weeks from the commencement of the attack, experience a 
 very considerable diminution of power in the lower extremities. 
 In such cases it will be generally found that one limb is much 
 more affected than the other, the loss of power being most com- 
 plete in the limb which was first engaged. 
 
 With respect to sensation, it appears to be aftected as well as 
 motion. In the slow and chronic form of this species of para- 
 plegia, it does not attract the attention of the patient so quickly 
 as the derangement of muscular power; it is generally some 
 time before he notices any diminution of sensation, and then 
 accidentally. In the more advanced stage, however, this 
 becomes manifest, and is accompanied by a feeling of cold in 
 the lower limbs, which seldom extends higher than the knees. 
 In the more rapid and acute form, the derangement of sensation 
 is much more obvious, and is generally the first symptom noticed
 
 PARALYSIS. 649 
 
 by the patient. There is at first a feeling of numbness, which 
 commences in the toes or feet, and extends up the hmb ; this, • 
 in the course of a few days, is followed by formication and ting- 
 ling pains in the course of the nerves, and then loss of power 
 and diminished sensation. TJicrc is, lioivever, in both these 
 forms of parapleriia, much less impairment of sensation tha)i (f 
 motion, and the loss of sensation is never so complete as in para- 
 plegia from disease of the spine. 
 
 There is one curious symptom occasionally observed in this 
 disease, w^hich is that, before the appearance of any decided 
 symptoms of loss of power in the lower extremity, irritation of 
 the lower part of the digestive tube takes place ; the rectum 
 becomes morbidly excited ; the patient complains of tenesmus, 
 and thinks he is about to have an attack of piles. This was 
 the first symptom observed in one of the cases I attended ; the 
 patient complained so much, that we were induced to examine 
 the state of the rectum, but could not find anything to account 
 for the morbid excitement. The same observations apply to the 
 bladder, with this exception, that the morbid irritability of this 
 organ occurs occasionally after the disease is confirmed and has 
 made considerable progress. On the whole, however, affections 
 of the bladder and rectum are rare in this form of paraplegia ; 
 and it is only at the advanced stages that we sometimes meet 
 with that derangement in the muscular powers of the bladder 
 and rectum, which occurs so frequently, and at such an early 
 period, in the paraplegia from spinal disease. 
 
 In cases of paraplegia from disease of the spinal cord or its 
 investments, it has been observed that the urine becomes altered 
 in its qualit}', and assumes an ammoniacal odour. I have not 
 observed this occurrence in the forms of paraplegia that I have 
 detailed. The urine is turbid, scanty, and voided oftener than 
 usual ; but I cannot say that I have seen it in any case decidedly 
 ammoniacal, even in the advanced stages of the disease, and 
 where the patient was completely bedridden. Should future 
 observations prove that this diagnostic mark is constant, it may 
 be of some value in distinguishing this from other forms of 
 paraplegia. 
 
 In these cases there is scarcely anything which would lead us 
 to fix on the spine as the seat and organ of the disease ; neither 
 can we find anything in the brain with which we can connect the
 
 650 CLINICAL MEDICINE. 
 
 paraplegic symptoms. There is no pain of the head or of the 
 spine, very seldom any tenderness, the patients are in the full 
 vigour of intellect, and all the organs of sense in their normal 
 condition. The functions of respiration and circulation are 
 uuafiected ; and it was remarked in the first case which I have 
 detailed, that there was no change in the pulse, either during the 
 fits of vomiting or the intervals of ease. The appetite also is 
 generally good ; but, in almost every instance I have met with, 
 there has been remarkably obstinate constipation. 
 
 With respect to the prognosis and treatment of this form of 
 paraplegia, I have but little to say. The prognosis is generally 
 unfavourable, particularly where the disease has lasted for some 
 time, and is accompanied by morbid irritation, or loss of power 
 in the bladder or rectum. It is also bad in proportion to the 
 slowness with which it has come on, and the absence of pain or 
 formication of the lower extremities. With respect to treat- 
 ment, I may observe that I have never seen any benefit derived 
 from applications to the spine. The application of blisters or 
 issues over the back or loins does not appear to be productive of 
 the least good effect ; of the latter I can speak positively from 
 experience. They are an enduring source of annoyance to the 
 patient, and never produce the least amelioration of symptoms. 
 
 I am in the habit of applying my local remedies to the legs 
 and thighs, selecting those parts in which the greatest cutaneous 
 sensibility exists. What I generally do is to keep up a suc- 
 cession of blisters along the inside of the legs, and over the 
 anterior and inner parts of the thighs. The practice of medicine 
 furnishes many proofs of the utility of stimulant applications 
 to the nervous branches, in case of disease affecting the larger 
 trunks. Thus, in sciatica, a blister applied over the ham or calf 
 of the leg, w^here many of the ultimate ramifications of that 
 nerve are superficial, will frequently produce a much more 
 decided effect than Avhen applied over the origin of the nerve 
 itself. Liniments of a stimulating kind, and blisters repeatedly 
 applied, are the local means on which I chiefly rely in the treat- 
 ment of this form of paraplegia. After some time I commence 
 with the use of strychnia, and continue it until some sensible 
 effect on the system is produced, when I omit its further use, and 
 have recourse to the exhibition of sulphur. These are the two 
 internal remedies from which I have derived most benefit. I
 
 r.mALYsrs. 651 
 
 have in siicli cases seen very good effects from a perseverance in 
 the use of the sulphur electuary. Much also will be accomplished 
 by the external use of sulphur, in the form of baths, and hence 
 cases of paraplegia of this kind might be materially benefited by 
 the internal and external use of the waters of Lucan, Harro- 
 gate, Baden, Bareges, &c. With respect to the use of mercury, 
 it appears to be decidedly injurious. I have seen it given in 
 three cases ; in all it did much more harm than good.
 
 652 
 
 LECTUEE XXXVIII. 
 
 bell's paralysis. — STAMMERING. — VARIOUS NEURALGIC AFFEC- 
 TIONS. — INFANTILE CONVULSIONS. — MYELITIS. 
 
 I PURPOSE to devote this lecture, gentlemen, to the consideration 
 of some other affections of the nervous system,*of which I have 
 not yet spoken ; and first, as to the prognosis to be derived from 
 affections of the portio dura of the seventh pair of nerves. 
 
 Sir Charles Bell and Herbert Mayo were the first who distinctly 
 enumerated the symptoms attendant on paralysis of the portio 
 dura, and drew the attention of medical men to the fact that 
 this paralysis of the face, now popularly termed '' Bell's paralysis," 
 may often exist independently of cerebral disease ; and, con- 
 sequently, practitioners in general consider this affection as 
 dependent upon some impression made upon the nerve itself, or 
 its extremities, and unattended with danger. This view of the 
 subject is, generally speaking, correct, but still it is liable to the 
 following important exceptions : I have seen two cases of seizure, 
 evidently apoplectic, in which the only paralysis that followed the 
 seizure was seated in the muscles supplied by the portio dura. 
 This paralysis yielded in both patients, in the course of ten days 
 or a fortnight, to appropriate general treatment, with a succession 
 of small blisters applied behind the ear, over the orbit and to the 
 cheek. It is difficult to conceive how any cerebral affection can 
 give rise to a paralysis limited to a part supplied by a single 
 portion of the nervous system ; but still such an occurrence 
 occasionally takes place, not only in the part specified, but in 
 the tongue and in the upper extremity. Nor is this isolation of 
 the paralytic affection in such cases always decisive of a favour- 
 able termination ; for usually, in the progress of time, another 
 apoplectic seizure occurs, giving rise to general hemiplegia ; the 
 physician must therefore determine the degree of danger attend- 
 ing Bell's paralysis, and other insulated paralytic affections, not 
 by the extent of the parts engaged, but by the cause which has 
 given rise to them.
 
 bell's paralysis. 653 
 
 In almost all the cases of Bell's paralysis heretofore published, 
 the cause has heeu local and external, and therefore this paralysis 
 is usually considered to indicate no deep-seated or dangerous 
 lesion. That it is not always so, however, the instances brought 
 forward by Abercrombie and Mr. John Hamilton distinctly 
 prove ; for in both the disease arose from destruction of the 
 portio dura, occasioned by caries of the petrous portion of the 
 temporal bone, necessarily fatal. The followhig case is similar, 
 and is peculiarly instructive, as proving that caries of the petrous 
 portion may exist in a very chronic form combined with otorrhoea, 
 and may not give rise to any urgent symptoms affecting the 
 general health, until long after the portio dura has been 
 destroyed, and Bell's paralysis been produced. 
 
 From an attentive consideration of the history of the following 
 case, it would appear that the disease first destroyed the mem- 
 brana tympani, the internal ear, the ossicula, the portio dura 
 of the seventh pair within the aqueduct of Fallopius, together 
 with a good deal of the petrous portion of the temporal bone 
 on that side which looks towards the tympanum. During this 
 stage Bell's paralysis was produced, and profuse otorrhoea existed 
 without any cerebral disturbance. But as the disease ate its way 
 inwards, until it perforated the dura mater, the matter formed 
 found a readier exit into the cavity of the arachnoid, and an 
 entirely new set of symptoms commenced, denoting cerebral and 
 spinal disturbance. The cessation or diminution of the flow of 
 matter from the external ear at this point of time cannot therefore 
 be considered as the result of a vicarious suppuration set up in 
 parts more deeply situated, but must be regarded as the simple 
 result of the fact, that the progress of the disease had formed a 
 new opening internally, into which the matter found a readier vent. 
 
 A boy about ten years old was admitted into the Meath 
 Hospital, labouring under general dropsy. He appeared of a 
 scrofulous habit, and was much worn down by long-continued 
 diarrhoea. Under appropriate treatment his symptoms gradually 
 but slowly disappeared, and he was restored to comparative health. 
 "We now observed that the right side of the face was affected with 
 paralysis, and on examination found that he had been subject to 
 a discharge from the right ear for seven years previously. The 
 paralysed cheek presented the phenomena usually observed in 
 "Bell's paralysis." He was attacked soon after with acute pain
 
 654 CLINICAL MEDICINE. 
 
 in the ear, and in the left side of the head ; a fortnight after, 
 convulsions set in ; the pain moved from the side to the back of 
 the head, then to the hack of neck, and ultimately extended the 
 whole way down the spine, and about this period the otorrhoea 
 diminished. A few days before death he was attacked with 
 spasms resemhling those of tetanus, and the surface of the body 
 became exquisitely tender to the touch. He never had any loss 
 of motion, and to the last his intellect was perfect. From the 
 period when the pain set in to that of his death, the convulsions 
 returned about six times. 
 
 Post-mortem. — The portio dura was dissected on the face, and 
 found healthy ; the nerve was also healthy from its origin at the 
 base of the brain to its entrance at the meatus auditorius ; 
 immediately above this opening the dura mater was of a greenish 
 colour, detached from the bone as if by fluid, and perforated by a 
 round hole large enough to admit a small crow quill. On divid- 
 ing this part of the membrane, the space between it and the bone 
 was occupied by a thick, greenish, and oflensive jjus, and the 
 opening in the dura mater was observed to lie exactly opposite 
 the foramen in the petrous portion of the temporal bone called 
 the aqueductus vestibuli ; this opening was much enlarged, and 
 the bone around it was in a carious condition. The nerves at 
 the base of the brain were bathed in this thick green pus, but 
 the organ itself was everywhere healthy, and free from any excess 
 of vascularity. The arachnoid was nowhere thickened or opaque, 
 and the pia mater not more injected than natural ; the ventricles 
 were not distended. Our attention was next directed to the 
 state of the spinal cord ; the theca vertebralis was much distended 
 by the same kind of matter, which flowed abundantly from any 
 accidental puncture of the membrane. The matter was contained 
 in the sac of the arachnoid, which membrane was quite healthy, 
 and presented its usual glistening appearance, no thickening or 
 opacity observable in any part of its extent ; the pia mater was 
 also free from disease ; all the attachments of the ligamentum 
 dentatnm remained unbroken. The spinal marrow, on being slit 
 up, presented no trace of disease ; the roots of all the nerves 
 from the base of the brain to the cauda equina were bathed in 
 pus, the presence of which fluid on the surface of the brain and 
 spinal marrow had no doubt irritated these organs, and occasioned 
 the tetanic symptoms and the cutaneous tenderness.
 
 bell's paralysis. G55 
 
 Mr. MacDoniiell, my clinical clerk, traced the portio dura 
 through the aqueduct of Fallopius ; about a quarter of an inch 
 from its entrance, the nerve was completely divided ; the petrous 
 portion of the bone was extensively destroyed, and presented a 
 more shell ; the membrana tympani and all the internal ear 
 were destroyed. 
 
 The following case contrasts in an interesting way with the 
 former, exhibiting the vitality of the parts supplied by the portio 
 dura, aft'ected exactly in an opposite manner ; for the muscles 
 that in the one were paralysed, were in the other subject to a 
 spasmodic action which lasted for several months, and during 
 the period of its greatest intensity returned about every fourth 
 second. I am not aware that this disease had been hitherto 
 described, and therefore am authorized to give it a name ; and, 
 accordingly, in honour of the great man to whom we owe such 
 extensive discoveries on the physiology and pathology of the 
 nervous system, and who has more particularly thrown such 
 light on the affections of the portio dura, I propose calling it 
 " BelVs spasms of the portio diiraJ" 
 
 A woman named Quinn, aged 40, of spare habit, was admitted 
 into the Meath Hospital, June, 1841. She stated that her com- 
 plaint commenced four years and a half before, in the following 
 w\ay : — " The lower eyelid of the right eye became affected with 
 spasmodic twitches, producing a kind of winking ; and other 
 muscles of the face which receive branches from the portio dura, 
 and which it is unnecessary to enumerate, became affected in a 
 similar manner by degrees. This disease was unpreceded by pain 
 in the head, ear, or any part of the face. Her general health was 
 good. On admission, all the muscles of the face supplied with 
 the seventh nerve were affected by spasmodic contractions, occur- 
 ring many times during a minute. The angle of the mouth and 
 ala nasi of the right side were pulled towards the ear ; the lower 
 eyelid closed in a peculiar manner, producing a rather ludicrous 
 kind of winking. It w\as also observed that the platysma myoides 
 participated in each spasmodic contraction, and its fibres were 
 seen throwing themselves out strongly in relief, in well-marked 
 bundles. She also complained that the os hyoides was some- 
 times pulled towards the right ear. These phenomena occurred 
 also during sleep, and were greatly exaggerated by any kind of 
 excitement. She complained of constant noise in the right ear
 
 656 CLINICAL MEDICINE. 
 
 without any pain ; but the sense of hearing was quite unimpaired. 
 No diminution of sensation, or alteration of the temperature of 
 the affected side. Her health was good. 
 
 The phenomena presented in this case were all owing to some 
 unknown affection of the portio dura. The only muscles engaged 
 were those receiving branches from that nerve. We know that, 
 on quitting the stylo-mastoid foramen, the portio dura sends a 
 branch to the stylo-hyoid muscle and another to the digastric, 
 both which muscles being connected with the os hyoides, will, 
 of course, when affected by spasms, drag that bone towards the 
 ear of the same side. In the substance of the parotid gland the 
 nerve divides into two large branches ; one ascends on the face, 
 called the tempore- facial ; the other, the cervico-facial, assists 
 the former in supplying the muscles of the face and chin, and 
 also sends some remarkahhj long hrancJtes to the platysma myoides 
 muscles, and the other superficial muscles of the neck. Can we 
 explain the constant noise in the ear, unaccomimnied by pain or 
 loss of hearing, by a similar spasmodic action of those small 
 muscles of the internal ear which receive branches from the 
 portio dura, by which a muscular bruit was produced, the intensity 
 of which may have been greatly exaggerated by its vicinity to the 
 organ of hearing. 
 
 Let me next call your attention to neuralgic affection of the 
 larynx. The first case which I shall speak of occurred in a young 
 lady originally of vigorous constitution, but latterly suffering from 
 menstrual irregularity and hysteria. The laryngeal affection had 
 been considered to be inflammatory in the country, and had been 
 treated with purgatives, leeches, blisters, antimonials, and finally 
 mercurialization. No relief had been obtained, and she came to 
 Dublin, where she was placed under my care, and that of Sir 
 Henry Marsh and Mr. Barker. The pain had become almost con- 
 stant when we first saw her, but was by no means violent, except 
 now and then, when it used to become suddenly aggravated. 
 These paroxysms of pain could not, properly speaking, be called 
 violent ; they were, however, distressing, and amounted to a most 
 annoying feeling of distress about the whole region of the larynx. 
 There was no external tenderness, and the internal fauces were 
 healthy. We considered it to be a hysterical nervous affection. 
 This neuralgia was chiefly remarkable for a change of tone and
 
 NEURALGIC AFFECTIONS OF THE LARYNX. 657 
 
 weakness in the voice, which invariably attended the paroxysms, 
 showing that the rima (jlottidis and the chorda vocales wore the 
 parts chiefly implicated. "We must suppose, therefore, that the 
 pain was derived from the branches of the superior laryngeal 
 nerve, which Dr. Reid has proved to be chiefly sensitive. 
 
 The alteration of voice which accompanied the paroxysms of 
 pain must be considered as a proof that a superior laryngeal 
 nerve has some influence on the motions of the vocal organ ; 
 unless, indeed, we adopt the supposition that the affection 
 extended likewise to the inferior laryngeal nerve. The facts of 
 the case contain nothing decisively confirming or negativing 
 either hypothesis. 
 
 We first gave large doses of carbonate of iron, which had the 
 effect of rendering the attacks periodic. Every morning, at 
 ten o'clock to the viinutc, the paroxysm commenced. The dose 
 of iron was now increased, afterwards sulphate of quina, and 
 finally arsenic was employed, but without any corresponding 
 improvement. The degree of suff"ering became, indeed, less 
 severe, and its duration less protracted, but it appeared extremely 
 doubtful whether the improvement was not owing more to time 
 than to medicine. Under these circumstances we thought it 
 prudent to desist from all active treatment, and we recommended 
 change of air, scenery, and the use of chalybeate mineral waters. 
 
 This case aftbrds a striking example of the curious fact, that 
 medicine administered for the purpose of relieving a disease more 
 or less fluctuating or remittent in its character, will sometimes 
 render it strictly periodic, with marked paroxysms and free 
 intervals. Having produced so striking an eflect Avith our 
 remedies, we are apt to calculate with confidence on still further 
 improvement, and we increase the doses of tonics with boldness 
 and full of hope ; disappointment, however, here awaits us, for 
 no tonic will be found capable of affecting any further alteration 
 or shortening of the fit. In such cases we cannot be too much 
 on our guard, lest we injure the constitution by too frequent 
 attempts to procure a diminution of suffering. 
 
 Loss of speech arises sometimes from lesions of apparently 
 a very trifling character. A person may totally lose his speech 
 without any previous existing or premonitory symptoms indica- 
 tive of nervous lesion — without having experienced any sensation 
 of pain or vertigo, any noise in the ears, any indications of deter- 
 voL. I. 42
 
 658 CLINICAL MEDICINE. 
 
 mination to the head — in fact, without anything to show that 
 the aphonia was connected with any particular state of the brain. 
 Thus, a barrister whom I attended with Dr. Beatty, was walking 
 up and down the hall of the Four Courts waiting for a case to 
 come on, and chatting with one friend and another ; as the hall 
 was rather crowded and hot, he went out into the area of the 
 courts for the sake of the air, and had not remained there more 
 than ten minutes, when an old friend from the country came up 
 and spoke to him. He Avas pleased to see his friend, and wished 
 to inquire about his family, when he found to his great surprise 
 that he could not utter a single audible sound ; he had com- 
 pletely lost his voice. He recovered the use of his tongue in 
 about three weeks, but not completely, for some slowness of 
 speech remained. When loss of speech was first perceived, his 
 friend brought him home in a carriage ; and during the day he 
 had several attacks of vertigo, and afterwards hemiplegia. For 
 several hours, however, before distortion of the face or any of the 
 usual symptoms of paralysis had commenced, the only existing 
 symptom was loss of speech. This gentleman died of apoplexy 
 in about two months. 
 
 In many cases of paralysis you will find that although the 
 patients have lost the power of utterance, yet the motions of the 
 tongue appear to be nowise deranged. In the majority of cases 
 it can be shortened, elongated, raised, depressed, or moved from 
 side to side, with as much apparent facility as in a state of 
 health ; and yet the voice is in some instances very much 
 impaired, in others totally lost. In such cases it would appear 
 that the defect lies in the glottis, which forms and modulates the 
 voice, and not in the tongue or lips, which divide and articulate 
 it. Indeed this is evident to any one who observes the interrupted 
 and spasmodic efforts which paralytic persons make when speak- 
 ing ; they are in fact all stutterers. 
 
 A young gentleman of delicate constitution, and who is now 
 about sixteen years of age, continued to enjoy tolerably good 
 health up to his sixth year. When about six years of age he 
 went to bed one night in health, and without any unusual symp- 
 tom ; but on getting up in the morning it was observed that he 
 had lost his speech, and was unable to articulate a single word. 
 Jlis family became alarmed, and sent for a physician immedi- 
 ately ; the boy got some internal medicine and a stimulant
 
 NEURALGIC AFFECTIONS OF THE LARYNX. G59 
 
 gargle, and recovered Lis speecli iii a few days, without the 
 occurrence of any symptom of laryngeal inflammation or cerebral 
 disease. But what was remarkable in the case was this : the boy, 
 who up to this period had spoken well and distinctly, now got a 
 terrible stutter. 
 
 This resisted all kinds of treatment, and for ten years he con- 
 tinued to stammer in the most distressing way, and was so 
 annoyed by it himself, that when a boy he used to stamp on the 
 ground with vexation whenever he failed in uttering what he 
 wished to express. In the month of May last he got an attack 
 of chronic laryngitis of a scrofulous character, and evidently the 
 precursor of phthisis. Dr. Stokes and I have examined him, 
 and we feel convinced that tubercular deposition is going on in 
 the lungs. But what is most curious in the case is this : after 
 he got the laryngitis, a very peculiar change took place ; the 
 laryngeal inflammation modified the tone of his voice so as to 
 make it a little husky, hut tJte stammering has completely ceased. 
 
 You are aware that stammering has been explained aS' 
 depending on spasm of the muscles which are employed in 
 modifying the column of air as it rushes through the narrow 
 aperture of the glottis. At certain times, and under a variety of 
 circumstances, those fine muscular organs become spasmodically 
 aftected, the vocal chords no longer undergo the same steady and 
 exact tension and relaxation, and speech becomes interrupted in 
 consequence of frequently recurring closure of the glottis. 
 
 In the case to which I have referred, inflammation taking 
 place in the mucous membrane covering these delicate muscular 
 fibres, you can conceive that either the thickening of the mucous- 
 membrane, or the alteration in the state of its vitality, may have- 
 so modified the disposition of the parts, that they become- 
 incapable or indisposed to undergo those rapid contractions 
 necessary to produce stammering, by inducing closure of the 
 glottis at the moment that its aperture ought to remain open. 
 The case itself, however, is an extremely curious one, and I do 
 not believe that there is any similar one on record. Everything 
 which bears on the cure of so important a disease as stammering, 
 even though it be accidentiil, and not the result of medical care 
 and ingenuity, is of great value, inasmuch as it tends to place 
 the causes of the disease in a clearer light. In this point of 
 view I look upon the case as one of very great interest.
 
 660 CLINICAL MEDICINE. 
 
 There is one curious fact with reference to stammering which 
 I do not think has heen hefore noticed, namely, that women very 
 rarely stammer. In a family of my acquaintance, this defect 
 of the speech has been hereditary among the males for three 
 generations, but the females have in no single instance been so 
 affected. 
 
 With respect to the cure of stammering, I have recently dis- 
 covered a method by which the most inveterate stutterer may be 
 enabled to obtain utterance for his words with tolerable fluency. 
 It is simply by compelling him to direct his attention to some 
 object, so as to remove it from the effort he makes to speak. 
 Thus, I direct him to hold a rule or bit of a stick in his right hand, 
 and with it to strike the forefinger of the left in regular time with 
 the words he is uttering ; the eye must be fixed, and all the atten- 
 tion directed to the finger he is striking, and the time must be 
 strictly kept with the syllables. This method I have tried in 
 several instances with complete success, and Dr. Neligan informs 
 me that since I first mentioned it to him, he has found it com- 
 pletely effectual in numerous cases. Although, of course, when 
 thus employed, this plan can only be regarded as a means of 
 affording temporary relief, I have no doubt that if it were per- 
 severingly followed out with young persons who stammer, both 
 in reading and speaking, it would cure them permanently of 
 this unpleasant affliction. Its efficacy would seem to prove 
 that stammering is altogether a nervous affection. 
 
 With reference to neuralgia, we find that it attacks various 
 parts of the body, and amongst others the mammae. — An 
 unmarried lady, residing in the neighbourhood of Dublin, con- 
 sulted me in July, 1829, for this affection. She was of the 
 sanguineous habit, robust, and otherwise healthy. The disease 
 had lasted two years with various degrees of violence ; the 
 breasts being at times nearly free from pain, but generally they 
 were very troublesome. During the paroxysms, which often 
 lasted several days, and sometimes considerably longer, the 
 mammffi, which in this lady were full and large, became extremely 
 painful and tender, but were neither tumefied, hard, nor red. 
 The intervals between the paroxysms were marked not only by 
 a total cessation, but by a gradual diminution of pain. At no 
 period had there been any spinal tenderness. One breast was
 
 NEUKALGIA. 661 
 
 not more afl'ectecl tliau the other, and the axillary glands were 
 not swollen. She had consulted several practitioners, had taken 
 much medicine, and made use of many topical applications, with- 
 out relief. Leeches had been repeatedly applied, but their bites 
 had invariably caused excruciating pain, and the bleeding they 
 occasioned was not followed by the least relief. 
 
 I at first tried stupes, narcotic liniments, and plasters, with 
 warm salt-water baths, but these measures were unattended with 
 the least improvement. The absence of complete intermissions, 
 and of well-marked paroxysms, prevented me, during several 
 weeks, from perceiving the true neuralgic nature of this pain ; 
 at last this view of the subject occurred to me. I tried the 
 carbonate of iron with marked benefit. The disease has since 
 frequently recurred, but its violence has always been lessened by 
 the carbonate of iron. Sea bathing she likewise finds useful. I 
 may here observe that in those cases of neuralgia in which car- 
 bonate of iron proves useful, I never found it necessary to raise 
 the dose beyond one drachm three times a day. Indeed, a larger 
 dose than half a drachm is seldom required. This statement of 
 my experience I consider necessary to counteract the impression 
 made on the minds of students by a perusal of some of the 
 London periodicals, where enormous doses of carbonate of iron 
 are recommended by Dr. Elliotson. 
 
 I have examined this subject in a practical point of view with 
 great attention, and think that what is true concerning carbonate 
 of iron applies also to most tonic medicines. In fact, we may 
 consider it as a general rule that tonics are rarely indicated where 
 moderate doses do not efiect the desired purpose. This applies 
 more particularly to the stronger tonics, such as the salts of iron, 
 of arsenic, and quina. I can scarcely conceive a case possible in 
 which a judicious physician will find it necessary, for instance, to 
 give more than ten grains of sulphate of quina in a day, and yet 
 much larger doses are not unusual here and elsewhere. When- 
 ever the symptoms supposed to call for such a treatment resist 
 moderate doses of sulphate of quina, we ought to pause, and reflect 
 whether another plan of treatment ought not to be adopted. 
 
 There are two states of the system attended frequently with 
 well-marked rigors, febrile paroxysms, and intermissions closely 
 resembling ague ; I mean internal suppuration, and local 
 inflammation without suppuration. Practical physicians are fully
 
 662 CLINICAL MEDICINE. 
 
 aware of this circumstance : hut there is another condition of 
 the system in ichich synq^toms simulating ague arise, totally 
 uncon7iected tcith inflammation, and of which I have seen two 
 remarkable examples. They both occurred in females. One, a 
 lady of a nervous temperament, in about a fortnight after her 
 confinement was affected with well-marked symptoms of quotidian 
 ague, which grew worse and more violent during the exhibition 
 of very large doses of sulphate of quina, but she rapidly got rid 
 of her complaint when, at my suggestion, camphor, aromatic 
 spirit of ammonia, &c., were substituted in its place. In another 
 lady, symptoms of tertian, and afterwards of double tertian, had 
 continued for many weeks, and had reduced the patient extremely ; 
 sulphate of quina, arsenic, and opium had successively received 
 a fair trial, but in vain. The disease, however, finally yielded to 
 the exhibition of difiusible stimulants, used in combination with 
 antacids. 
 
 I cannot point out how such cases are to be distinguished from 
 ague, except it be by the failure of the sulphate of quina. From 
 local inflammations and suppuration they may in general be 
 distinguished with facility. I may here observe that in a 
 gentleman treated by Sir Henry Marsh and myself, violent 
 symptoms of ague depended on the presence of a number of very 
 small abscesses in the liver. Here sulphate of quina given in 
 lavements caused a cessation of the rigors, but did not diminish 
 the other sym])toms of fever ; on the contrary, had it been perse- 
 vered in, the intermittent would have been evidently converted 
 into a continued fever. 
 
 The influence of sulphate of quina in preventing rigors, even 
 where it cannot remove the cause of constitutional irritation, 
 is well illustrated by its effects where the symptoms depend on 
 stricture of the urethra ; and ought to be recollected by every 
 practitioner, lest he be misled occasionally by this partial im- 
 provement into an injudicious continuance of the medicine. 
 "Where sulphate of quina is intended to act as a tonic, I am 
 persuaded that the dose should never exceed a grain three times 
 a day, and generally even smaller quantities are sufficient ; when 
 a combination of tonic and purgative medicines is required, all 
 our intentions may be answered by a combination of sulphate of 
 quina in proper quantity, with the compound extract of colocynth, 
 or the aloetic pill with myrrh.
 
 CASES SIMULITING TIC DOULOUREUX. 663 
 
 Neuvalifia of the testicle is not a very common form of disease, 
 but it requires notice, as it gives rise to excruciating agouy, and 
 constitutes one dtf the most painful affections that can bo imagined. 
 I have seen two examples of it within the last 3'ear ; the first was 
 a young gentleman of highly irritable nerves, who had studied 
 hard and dissipated much ; in him the paroxysms of pain did 
 not observe any very marked period, but returned daily at un- 
 certain intervals, which grew shorter and shorter, until at last he 
 had scared}^ any respite day or night. There was no fever, and 
 not the slightest appearance of local congestion or inflammation. 
 When attacked with a paroxysm the patient would throw himself 
 on the floor, and roll about in the greatest agony, covered with a 
 cold perspiration. This case yielded to large doses of carbonate 
 of iron freshly prepared, and frequent inunction of the testicle 
 and cord with belladonna ointment. The second case of neuralgia 
 of the testicle occurred in a gentleman who laboured under 
 neuralgic pains, decidedly of a gouty nature. In him the pain 
 of the cord and testicles used to come on every afternoon about 
 four o'clock, and continue for several hours. The pain, though 
 considerable, did not approach the degree of agony experienced 
 in the first case. It was at times, however, so severe as to 
 compel him to groan aloud. This neuralgia of the testicle 
 disappeared after a few days, and was replaced by a violent gouty 
 pain in the loins and right hypochondrium. The latter yielded 
 to the usual local treatment and the use of colchicum internally. 
 
 A man was admitted into the chronic ward a few days ago, 
 who cannot separate the lower from the upper jaw to the distance 
 of more than two lines. What are the cases in which we find 
 this immobility of the lower jaw ? Most commonly in tetanus 
 or locked-jaw; but here this cannot be the case, for the man 
 has no sign indicative of a tetanic affection, no rigidity of the 
 muscles of the neck ; his countenance is very difi"erent from that 
 of a tetanic patient, and he has not been exposed to any of the 
 ordinary exciting causes of that disease. But, leaving all con- 
 sideration of the nature of the disease out of the question, what 
 is it that prevents him from moving his lower jaw ? It must 
 depend on one of two causes ; either the muscles wdiich perform 
 the motions of the lower jaw are stiff, rigid, and incapable of 
 motion, or else there is some disease of the articulation which
 
 664 CLINICAL MEDICINE. 
 
 obstructs the motion of the bone. This proposition is universally- 
 true of all articulations, that when they become impeded or 
 completely obstructed in their motions, the derangement arises 
 from some abnormal condition of the muscles, or of the bones 
 and ligaments which form the joint. 
 
 In this case we find that, in addition to being unable to 
 perform the proper motions of the lower jaw, the patient has 
 intense pain, darting from the angle of the jaw towards the 
 temple, the ear, and the side of the neck. This pain is of an 
 extremely violent character, so as to resemble tic douloureux, 
 and the resemblance is still further increased by its being more 
 or less intermittent. Now, on inquiry into the history of this 
 case, we find that the patient had some time ago laboured under 
 toothache, for which he had the last molar tooth but one of the 
 upper jaw extracted, and that immediately afterwards he was 
 seized with violent pain in the part, and found that he could no 
 longer move his lower jaw as usual. I have seen many cases of 
 this kind, in which a painful or carious tooth, or an injury done 
 to the gum or jaw, has been followed by violent darting pain 
 in the nerves of the face, simulating in many particulars tic 
 douloureux. 
 
 I remember being sent for to Middleton, near Cork, some 
 time since, to see a young lady of delicate constitution, whose 
 health was materially deranged from what was said to be an 
 attack of tic douloureux. She had been under the care of many 
 practitioners, and had used very large doses of the carbonate of 
 iron and sulphate of quina, and at the time I visited her was 
 taking arsenic. The first thing I did on my arrival was to 
 examine her teeth. On close inspection, I observed that on the 
 crown of one of the upper molar teeth there was a spot which 
 appeared to be decayed, and found on inquiry that she had 
 frequently suffered from pain in this spot when she drank any 
 cold liquid. I had the tooth drawn, and soon afterwards the pain 
 completely ceased. Yet in this case the pain was not only of an 
 intense character, preventing sleep and wearing out her strength, 
 but it had its intermissions, and was aggravated at particular 
 hours of the day. 
 
 Another instance of the same kind came under my notice 
 about twelve months ago. A young lady was brought to me by 
 a medical friend of hers to have my advice for an attack of tic
 
 CASES SIMULATING TIC DOULOUREUX. 665 
 
 douloureux. She had been attended by this gentleman with 
 great care, and no mode of relief left untried, for her sufferings 
 were intense, and she had constant exacerbations of pain. I 
 asked him were her teeth sound, or had she any disease of the 
 gum or jaw ? He said not, and that he was sure of this, for he 
 had examined her teeth over and over again. On opening her 
 mouth, however, I thought I saw some unsoundness in one of 
 the teeth, and recommended her to go to Mr. M'Clean and get it 
 drawn. She did so, and the pain quickly disappeared. 
 
 I could also give you many cases in which an injury done to 
 some of the branches of the dental nerve has given rise to 
 symptoms closely resembling those of tic douloureux. One of 
 the most curious circumstances connected with such cases is, 
 that the pain is always of a more or less intermittent character. 
 The same thing is observed in that form of headache which 
 arises from irritation of the brain, produced by spiculae of bone 
 growing from the internal table of the skull. In a case which 
 occurred some time back at the Meath Hospital, where several 
 spicule, some of them more than a quarter of an inch in length, 
 were pressing on the brain, the headache was of a distinctly 
 intermittent character. This remarkable periodicity of exacer- 
 bation, in cases where the operation of the exciting cause 
 continues still the same, seems to be peculiar to the nervous 
 system. 
 
 In many cases considerable derangement of the facial nerves 
 is found to follow an injury done to some branch of the dental 
 nerve in drawing a tooth. When the bone has been injured by 
 the force used in extracting the tooth, it frequently happens that, 
 if the injury be not quickly repaired, and the parts healed up, 
 symptoms resembling those of tic douloureux or rheumatic 
 neuralgia w'ill supervene, and give the patient a great deal of 
 annoyance. Such was the origin of the mischief in the case 
 before us ; the man received an injury of the upper jaw in 
 drawing a tooth which is not as yet healed, as you may perceive 
 by introducing a probe between the separated portions of gum, 
 when you will find it grate against the rough surface of the bone. 
 In addition to this, there are considerable tenderness of the gum 
 and swelling of the neighbouring parts, which have extended to 
 the muscles, their sheaths, and finally to the articulation of the 
 lower jaw. You can satisfy yourselves of this by examining the
 
 666 CLINICAL MEDICINE. 
 
 parts and striking the lower jaw, so as to press it suddenly 
 upwards and backwards into the glenoid cavity, just in the same 
 way as you press the tliigh bone against the acetabulum wlien 
 you wish to ascertain whether there is inflammation of the hip 
 joint. The motion of the lower jaw is here prevented by inflam- 
 mation, extending from the upper jaw, so as to involve its 
 ligaments and the neighbouring muscular sheaths. 
 
 There are other causes also which may be attended with the 
 same diminution of motion in the joint. Thus, a man may get 
 an attack of rheumatism in the scalp, which may extend to the 
 temporal muscles, and prevent him from being able to depress 
 his lower jaw ; and I have known cases in which this condition 
 of the temporal muscle has given rise to suspicions of the 
 existence of trismus. When you examine the articulation you 
 find nothing amiss, but when you come to press on the temporal 
 muscle, above the zygoma, the patient complains of pain and 
 tenderness. The irritation produced by rheumatic inflammation 
 gives rise to a fixed rigid state of the muscle, and hence the 
 patient cannot open his mouth. This form of disease I have 
 described long since in a paper published in the Dublin Hospital 
 Reports. It can be relieved with great ease by applying leeches 
 to the temple, and ordering the patient to rub over the part a 
 small portion of mercurial ointment with extract of belladonna, 
 two or three times a da.y. The same state of the temporal 
 muscle is sometimes observed as resulting from an extension of 
 inflammation, in case of a wound of the scalp in its vicinity. 
 
 In the case before us, almost everything will depend on the 
 process which nature may adopt with respect to the injury of 
 the maxillary bone. If the bone throws up healthy granulations, 
 and the inflammatory process ceases, the aflection of the nerves, 
 as well as of the muscles and joint, will quickly subside. All we 
 can do under the circumstances is to apply leeches over the side 
 of the face, and order the man to rub in mercurial ointment ; 
 everything, however, will depend on the turn the disease of the 
 bone may take. 
 
 Let me next call your attention shortly to infantile convulsions, 
 more especially those which attack children at the ages of two, 
 four, and six months, and to the utility of oil of turpentine in 
 their treatment.
 
 INFANTILE CONVULSIONS. 007 
 
 When we consider the convulsive afi'ections of the infantile 
 j)ei'iod, we find that they may arise from a variety of causes. In 
 the first place, they may be produced by the process of dentition. 
 Some persons seem to think this impossible ; but it is not only 
 possible, but true : for teething is capable of exciting a very 
 great degree of irritation in the system. We also observe that 
 an irritable state of the brain, accompanied by a hydrocephalic 
 tendency, will produce convulsions ; but in very many instances, 
 particularly in children of the ages mentioned above, they proceed 
 from intestinal irritation. Of those forms which spring from the 
 irritation of dentition, or of cerebral excitement, I do not intend 
 to speak, as, on these matters, the standard medical works 
 furnish abundant information. I shall restrict myself, therefore, 
 to some observations on those convulsions which depend on 
 intestinal irritation. 
 
 As such convulsions frequently arise from causes which affect 
 digestion, and produce a change in the mode of nutrition, they 
 appear very soon after birth. The animal which but a short 
 time before was nourished by the placenta, is now supported by 
 ingesta; and hence, from this sudden change, if there be any 
 source of irritation existing in the system of the child, or in the 
 nature of its food, an unhealthy state of bowels rapidly ensues. 
 To the consequences of this aft'ection, manifesting itself so soon 
 after birth, nurses have given the name nine-daij convulsions. 
 Again, when another change is made, and the nurse's milk is 
 left off, children are also liable to convulsive fits, and these are 
 the convulsions of ablactation. In fact, at any period during the 
 first year infants are very apt to get convulsions from various 
 causes. If the mother uses an improper kind of food or drink, or 
 gets into- a bad state of health, or be strongly affected by mental 
 emotion, the quality of the milk will be suddenly changed.* 
 Under all these circumstances, or if the child be over-fed — a 
 very common fault — the bowels get out of order, the whole 
 intestinal canal is thrown into a state of irritation, and convul- 
 sive fits succeed. 
 
 It is necessary to be more explicit on this subject. When you 
 are called to treat a case of infantile convulsions, bear in mind 
 
 * The custom adopted by some of keeping the child at the breast for a year or a 
 year and a-half is both unnatural and injurious. Every child should be weaned whea 
 nine months old.
 
 668 CLINICAL MEDICINE. 
 
 that they very frequently arise, particularly during the first six 
 months, from the cause before mentioned, and this should, 
 therefore, claim at once your attentive consideration. I remember 
 the time when it was the common practice to treat every case of 
 convulsions as if it were an hydrocephalic attack, and when 
 antiphlogistics, calomel, and cutaneous irritation were the indis- 
 criminate means employed in combating every form of this 
 disease. If a child happened to get a convulsive fit, it was 
 immediately said, here is inflammation or congestion of the 
 brain ; and leeches were applied in successive relays, calomel 
 given in large doses, egg-shells, crabs' eyes, magnesia, and other 
 absorbents administered, and the unfortunate infant cruelly 
 tortured by the repeated application of blisters to the scalp. I 
 have seen cases where this blistering was carried to such an 
 extent, that the child had not a place to rest its head upon. 
 
 It is to Dr. Gooch we owe the valuable discovery that there is 
 in children a state of heaviness of head and torpor, accompanied 
 by a tendency to convulsions, in which depletion cannot be 
 emploj^ed, and where narcotics and even stimulants may be used 
 with advantage. Dr. Locock asserts that convulsions of this 
 nature may be recognized by the depressed state of the fontanelle, 
 an assertion which I have not verified. With respect to leeching, 
 I have to remark that a single leech to an infant is equal to a 
 bleeding in an adult ; and yet how often have we seen children 
 leeched and leeched, until, becoming pale and exsanguineous, 
 they sink as much from loss of blood as from the efiects of 
 disease. 
 
 With respect to the causes and periods of indigestion in 
 children, I have already spoken. There is one point more which I 
 wish you to hold in memory. Milk is a compound fluid, a beautiful 
 emulsion furnished by the hands of nature, in which sugar, oil, 
 and curd are blended with a certain proportion of water. Now, 
 when a compound fluid such as milk enters the stomach, and 
 is submitted to the process of digestion, those parts which are 
 soluble in water are absorbed, and those which are not become 
 first coagulated, and afterwards undergo resolution in the gastric 
 juice. Thus, while the water and sugar are absorbed, the curd 
 of the milk is separated from it by coagulation, and forms a 
 solid substance which is acted on by the stomach, and becomes 
 dissolved by the agency of the gastric juice, and in this way
 
 INFANTILE CONVULSIONS. 669 
 
 contributes to mitrition. Not a particle of the milk, however, 
 ought to enter the duodenum until it has passed through the 
 usual process of digestion. As the first step to the accomplish- 
 ment of this is the coagulation of the curd, this occurrence takes 
 place with extraordinary rapidity : and it is a sign of health if 
 the milk be thrown up in this state immediately after it has been 
 sucked. The rennets of young animals give striking evidence 
 of this power. But if it should happen that the stomach does 
 not act properly, and the curd remains undissolved, what is the 
 consequence ? The curd passes into the alimentary canal in a 
 condition different from that in which nature intended it should, 
 and consequently produces intestinal irritation. None of the 
 purgatives given to children are attended with half so much 
 griping as this substance. 
 
 This explains the phenomena which in such cases present 
 themselves to our observation. The child becomes griped, 
 irritable, and feverish, his tongue is loaded and white, he gets 
 restless, and now and then utters a shrill scream. In this way 
 the disease may go on for a considerable time ; as the child is 
 dropping asleep, he starts suddenly, and screams out, bends 
 himself in the form of an arch, and throws his head back as 
 in opisthotonos. I have seen children in this state for a week. 
 The physician or nurse gives castor oil or some other piirgative, 
 and a great quantity of the curds are passed, and surprise the 
 child's relatives. On examining the discharge, you find it con- 
 sisting of lumps of different sizes, covered imperfectly with bile, 
 and having a burnt appearance ; on breaking them up, you 
 perceive them to be white internally, and consisting of indigested 
 curd. You remove them by purgative medicine, and the child 
 gets well. 
 
 Now, we all can do this ; it is clearly laid down in books : you 
 are told to examine the egesta, and give purging medicine where 
 it is necessary. But there is one fact which has not been 
 noticed. When you have treated the child in this way, and the 
 attack has been cured, if the child is very strong when put to 
 the breast again, he may go on well, and you have no further 
 trouble ; but if he is weakly, or of an irritable habit, when he is 
 brought back to the suck again, or spoon-fed with milk, the same 
 process of imperfect indigestion takes place, and he gets another 
 fit. The physician is again called in, and repeats the purgative,
 
 670 CLINICAL MEDICINE. 
 
 and the child gets better a second time ; and in this way the 
 physician goes on giving medicine, and the mother giving milk, 
 and everybody wonders at seeing what a quantity of foul stuff 
 passes from the bowels. How are you to avoid this ? By 
 making the infant abstain from milk in any shape for twenty-four 
 hours, sometimes for the space of two, or even three days. It is 
 incredible how small a 2:)ortion of milk, even in the most diluted 
 state, will keep up this disease, acting like a species of poison on 
 the intestinal mucous surface. You know that animal poisons, 
 such as the variolous or vaccine virus, will affect the system even 
 when applied in a state of extreme dilution, and you can there- 
 fore conceive that a small portion of milk will operate in this 
 manner. 
 
 I attended a case of this disease some time ago ; the child 
 had a relapse, and, on being called in again, I asked the mother 
 whether she had given it any milk, and she told me scarcely any. 
 I am always suspicious when I hear the word scarcelj/ used ; 
 and, on requesting to see the kind of food she had been adminis- 
 tering, she handed me a bowl of barley-water, with the usual 
 proportion of milk and sugar in it : it is in this way that we see 
 the disease prolonged week after week by the prejudices of the 
 nurse and the ignorance of the physician. Well, if you forbid 
 milk altogether, what will you give the child ? Let him take 
 chicken-broth, barley-water, thin panado, veal-broth, or whey. 
 How long are you to continue this ? The number of days will 
 depend on the power which the child possesses of regaining the 
 proper tone of the stomach ; some children will have the stomach 
 out of order to-day and well to-morrow, and the length of time 
 you are to keep up this diet will vary considerably. 
 
 When you are called, therefore, to a case of convulsions, 
 inquire into the history of its symptoms, the nature of the alvine 
 evacuations, and the quality and quantity of your patient's food ; 
 and, if you find that before the attack the child's bowels have 
 been in a bad state, that they have been for some weeks inclined 
 to be loose, or that the stools are, at the time, similar in colour 
 and consistence to what I have described (though, by the bye, you 
 are often told that everything is quite right when it is not the 
 case), you will then be able to judge properly of the nature of 
 the case, and, by giving aperient medicines, you will probably 
 not only cure the disease, but also prevent a return of the convul-
 
 INFANTILE CONVULSIONS. G71 
 
 sions. Sometimes, llo^Yevcr, the convulsive fits will remain after 
 the irritating sordes have heen removed by purgative medicines. 
 Absorbents are next made trial of. These have a very beneficial 
 influence in many cases ; they can do no harm, and where acid 
 is present (and this occurs in the stomachs of children to a 
 greater extent than in those of adults), prove mildly purgative. 
 
 But if the convulsions continue, what else will you prescribe ? 
 I remember attending, not long since, an infant about three or 
 four months old, who had been for some time under treatment 
 for convulsions. Leeches had been applied to the epigastrium ; 
 it got calomel, castor oil, and hydrargyrum cum cretA, absorbents, 
 aperient and foetid enema ta, and blisters to the vertex and 
 stomach. Still the convulsions went on. Well, what did I do ? 
 I prescribed the following mixture : — 
 
 R. Olei Terebinthinaj, 3J. 
 Olei Ricini, 5iv. 
 Syrupi Papavcris albi, 
 Mucilaginis gummi Arabic!, 
 Aqua) focniculi, aa, 5ij. Misce. 
 
 Of this mixture, when well shaken, exactly 5j. was to be given 
 every third hour, and what was the result ? It operated on the 
 bowels, and produced a copious discharge of urine, a marked 
 improvement took place, and towards evening the convulsions 
 entirely ceased. 
 
 Dr. Brereton informs me that he has, in similar cases, after 
 the bowels were evacuated, succeeded in preventing a recurrence 
 of the convulsions by means of the following mixture, suited to a 
 child six months old : — 
 
 R. Olei Anisi, gtts. iv. 
 Sacchari Albi, gr. x. 
 Intime misceantur et adde, 
 Aqua), sij. 
 Pulveris Rhei, gr. x. 
 Carbonatis Magnesifc, 3j. 
 Tincturae Opii, gits, iv. 
 Spiritus Ammonia) fuetidi, gtts. x. 
 Sumat cochleare unum medium tcrtia qu.iqne hora. 
 
 It is to be observed that much caution is necessary in giving
 
 672 CLINICAL MEDICINE. 
 
 such combinations containing opium to infants, but there is a 
 period when depletion ceases to be useful, that a mixture like 
 this will prove the most effectual means of curing convulsions. 
 In such cases of convulsions, in addition to the use of purgative 
 medicine, prescribing the mother's milk, and giving oil of 
 turpentine, you may, during the first twenty-four hours, while 
 the child is strong, order a warm bath, applying at the same 
 time a sponge dipped in cold water to the head ; or, if the child 
 is weak, incline its head over the side of the cradle, and use the 
 cold sponge, and you will find that it will diminish the fit. 
 
 Before concluding, let me say a few words on inflammation of 
 the spinal marrow. This disease is closely connected with the 
 subject of neuralgia. Myelitis is so liable to be confounded with 
 a great variety of painful affections, that every ascertained case of 
 inflammation of the spinal marrow ought to be recorded for the 
 purpose of rendering more perfect a department of pathology 
 already diligently but not completely cultivated. A young 
 married woman was admitted into the Meath Hospital on the 
 12th of September, 1838. She was healthy until the period of 
 marriage, soon after which her husband commenced a system of 
 ill-usage, comprising beating, kicking, throwing down stairs, &c., 
 &c. He was frequently drunk, and occasioned her every species 
 of grief. No wonder that a life like this should have reduced 
 our patient to the truly miserable condition she was in. She 
 had been injured so often, that it was difficult to say to what 
 particular act of violence her present malady ought to be referred. 
 She is much emaciated, respirations hurried, and pulse very 
 quick. Has no headache, but complains much of agonizing 
 pains in the loins, aggravated by pressure of the lumbar spinous 
 processes, extending round the abdomen, and downwards to the 
 hips and thighs. Tbere is no pectoral affection, and her tongue, 
 state of stomach, and general appearance are not those of a 
 person labouring under fever. She writhes in the bed from the 
 violence of the pains ; she does not sleep night or day, and 
 disturbs the other patients by her cries. 
 
 Blood was drawn by cupping from the loins ; leeches were 
 applied, and Dover's powder administered. Her extreme emacia- 
 tion prevented us from adopting either more active depletion by 
 the lancet, or the use of calomel. In short, we sought to relieve,
 
 INFLAMMATION OF THE SPINAL MARROW. 673 
 
 uot to cure, for her death appeared iuevitable. Blisters we could 
 not apply on account of the great emaciation. On the 15th we 
 found that she had been screeching all night, and constantly 
 wanting extract of opium, which was ordered her as a palliative. 
 On the 16th she complained that the sense of feeling was leaving 
 her thighs, and she died on the 18th, five days after admission. 
 On dissection we found all the viscera healthy; there was extreme 
 atrophy of the intestines, especially the colon and caecum ; so it 
 is probable that starvation was among her afflictions. The lower 
 portion of the spinal marrow and the cauda equina exhibited an 
 excessive vascularity and redness, but no exudation of lymph. 
 Each nervous fasciculus of the cauda exhibited a vein on its 
 posterior surface distended with blood ; and the remaining 
 portion of each fasciculus displayed great arterial vascularity. 
 
 END OF VOL. I.
 
 rrinteii by Jas. Teiscott & Son, 
 Suffolk Lane, Citj-. 
 
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