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 THE LIBRARY 
 
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 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 PRESENTED BY 
 
 PROF. CHARLES A. KOFOID AND 
 
 MRS. PRUDENCE W. KOEOID 
 
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DISEASE IN INDIA 
 
LONDON 
 
 PRINTED BY SPOTTISWOODE AND CO. 
 
 NEW-STREET 3QUABE 
 
CLINICAL RESEARCHES 
 
 DISEASE IN INDIA 
 
 CHARLES MOREHEAD, M.D. 
 
 FELLOW OF THE ROYAL COLLEGE OP PHYSICIANS : PRINCIPAL OF GRANT MEDICAL COLLEGE : PROFESSOR OF THE 
 
 PRINCIPLES AND PRACTICE OF MEDICINE ADD OF CLINICAL MEDICINE : SURGEON TO THE JAMSETJEE 
 
 JEJEEBHOT HOSPITAL, AND FQRMERLY ASSISTANT-SURGEON TO THE EUROPEAN 
 
 GENERAL HOSPITAL, AT EOJIBAY 
 
 SECOND EDITION 
 
 LONDON 
 
 LONGMAN, GEEEN, LONGMAN, AND EOBEETS 
 
 1860 
 
Digitized by the Internet Archive 
 
 in 2008 with funding from 
 
 Microsoft Corporation 
 
 http://www.archive.org/details/clinicalresearchOOmorerich 
 
fit 
 
 6 1 
 
 TO 
 
 JOHN M C LENNAN, M.D. 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LATE PHYSICIAN-GENERAL 
 
 OF THE ARMY, AND MEMBER OF THE BOARD OF EDUCATION, 
 
 OF THE PRESIDENCY OF BOMBAY, 
 
 CONSPICUOUS THROUGHOUT A LENGTHENED PERIOD OF TUBLIC SERVICE 
 
 FOR PROFESSIONAL ATTAINMENTS, ADMINISTRATIVE ABILITY, 
 
 AND GENEROUS PHILANTHROPY, 
 
 COMMEMORATED, ON HIS DEPARTURE FROM INDIA, 
 
 BY THE UNITED TESTIMONY OF THE GOVERNMENT AND ALL CLASSES OF 
 
 THE COMMUNITY, 
 
 THIS WORK IS DEDICATED, 
 
 WITH THE ADMIRATION AND REGARD WHICH LONG FRIENDSHIP 
 HAS INSPIRED. 
 
 
PREFACE 
 
 TO 
 
 THE SECOND EDITION. 
 
 The haste inseparable from the circumstances in which this work 
 was originally prepared and published, led to numerous defects of 
 arrangement and execution, which I have endeavoured to amend 
 in the present edition. While the size of the book has been 
 much reduced by the adoption of a smaller type, a more careful 
 selection of cases, and a thorough revision of the text, — full use has 
 been made of three years' additional experience in India, partly as 
 Professor of Clinical Medicine, and partly as Superintending 
 Surgeon of the Poona division of the Bombay army. 
 
 My matured opinions on the therapeutic value of quinine and 
 of arsenic, and on the best methods of using these medicines in 
 malarious fevers, have been explained. The occasional occurrence 
 of Typhoid — Enteric — fever in India has been acknowledged ; and 
 chapters on Sun-Stroke and on the Hill Sanitaria of the Deccan 
 have been added. 
 
 London, Augiist, 1S60. 
 
PREFACE 
 
 THE FIRST EDITION. 
 
 The desire which I have long entertained of contributing to the 
 resources of practical medicine in India, has been realised at the 
 present time, in obedience to the wishes of the Honourable Court 
 of Directors of the East India Company, originating in the following 
 minute, which was submitted on the loth May, 1854, by Dr. Mc- 
 Lennan, Physician-General of the Bombay Army, to his colleagues 
 in the Board of Education, approved by them and by the Govern- 
 ment of Bombay : — 
 
 MINUTE. 
 
 " I now beg to submit to my colleagues the proposition to which I lately adverted, 
 when treating of the approaching departure of Dr. Morehead on sick leave. My own 
 impression was. that in all probability eighteen months would be necessary for the 
 purpose of recruiting his health ; but in consideration of the special nature of the leave 
 applied for, the Medical Board restricted their recommendation to a period about which 
 there could be no doubt, and, therefore, mentioned twelve months only as the time 
 deemed requisite for his restoration to health and efficiency. 
 
 "I would now submit, that the Board of Education make a suggestion to Govern- 
 ment, in view to its transmission to the Honourable Court of Directors, that at the 
 end of that period Dr. Morehead be requested to occupy himself in advancing the 
 cause of Indian Medical Education by the preparation of a work on the Diseases of 
 India, calcidated, not only for the Students educated in Indian Medical Colleges and 
 for Indian Graduates, but also for Medical Commissioned Officers of the Honourable 
 Company's Service on first arrival in India, and till such time as they have acquired 
 that experience which years of service alone supply. The period necessary to 
 bring out such a work, with the materials already accumulated by Dr. Morehead, 
 would probably not exceed another year, and thus the whole term of absence, both on 
 account of health and duty, would not exceed that for which leave within the limits 
 on the old Furlough Rules has hitherto been given. 
 
 •' It may be well that I shoxdd say something of the grounds on which I venture to 
 
X PREFACE TO FIRST EDITION. 
 
 make this recommendation, and here I would say that Dr. Morehead's experience 
 has been varied and extensive. On first arrival in India he served for two years with 
 European, and for as many years with native troops, at different stations. He was 
 then for two years in charge of the sanatory station of Mahableshwur ; — thereafter, 
 for more than six years, resident Assistant Surgeon of the European General Hospital, 
 Bombay — an institution in which the inmates are of very varied circumstances as to 
 habits, position in life, nature of duties, and length of residence in India, &c. In that 
 hospital are accommodated the newly arrived European and the old servant of many 
 years' Indian residence — the seamen of the Royal, Indian, and Mercantile navies — 
 the soldiers of all arms and both services, Queen's and Company's — the townsman — 
 mechanic — clerk — male and female — adult and child — from most classes of life, 
 and many stations in the interior. The opportunity for seeing variety of disease, 
 therefore, under great diversity of circumstance, is considerable. 
 
 "Dr. Morehcad was likewise for six years Surgeon of the Bj-culla Schools. In parts 
 of 1843 and 1844 he was in Sinde, and had an opportunity of observing the state of 
 health of Europeans and Natives after the sickly season of 1843. 
 
 " He has been for nearly nine years Surgeon of the Jamsetjee Jejeebhoy Hospital, 
 and for six years has been engaged in teaching Medicine and Clinical Medicine in the 
 Grant Medical College ; and the records of the Clinical Wards have been carefully 
 preserved during the whole of this period. 
 
 "He has been twelve years Secretary to the Medical and Physical Society, during 
 which time there has been afforded him by the Medical Board the opportunity of 
 becoming acquainted with the tenor of the medical reports and cases from all parts 
 of the Presidency. 
 
 "In 1833, and again in 1853, Dr. Morehead had the opportunity of observing some 
 of the hospitals and medical institutions in Madras, Calcutta, Colombo, &c. &c. 
 
 " Very numerous papers on Dysentery — Dracunculus — Diseases of the Abdominal 
 Viscera — Intermittent and Remittent Fevers — Delirium Tremens — Diseases of the 
 Brain — Hepatitis and Cholera — Measles in the Byeulla Schools, &c. &c, have been 
 inserted by him in the Edinburgh Medical and Surgical Journal. Transactions of the 
 Medical and Physical Society of Calcutta, and Transactions of the Medical and Physi- 
 cal Society of Bombay. 
 
 '• In the last work, too, at a comparatively recent date, five papers, based on obser- 
 vations chiefly made in the Clinical Wards of the Jamsetjee Jejeebhoy Hospital, on 
 the important subjects of Smallpox — Bright's Disease of the Kidney — Diseases of 
 tin' Heart — Pneumonia — and Beriberi — have been contributed, and there are 
 records from which to make the same kind of observations in respect to other im- 
 portant disi Line wards, such as Hepatic Abscesi Dysentery — 
 
 Fevers — Phthisis Pulmonalis — Paralytic Affections, ccc. &c. 
 
 "Having thus detailed the sources from which Dr. Morehead's experience and fit- 
 ness for the task which I have ventured to suj gi 31 have been derived, I may now add 
 a few words as to the nature of thai wanl which I propose he should supply; and here 
 I honestrj give it as my opinion, that till some work of the kind ! suggesl be broughl 
 forth, the efforts of Indian Governments and their servants in medical education will 
 be incomplete. At present, Graduates and Students of Indian Medical Colleges are 
 without any bonk "ii practice in Indian Disease, a- now generally followed, or as 
 requiring modifications to meel peculiarities of native habit and constitution. 
 
 ••The duties of the Clinical Wards in the Granl Mfedical College have been so 
 carried on. and bo re rded, a- to constitute an important collection of facts ami prac- 
 tice, which may he brought to hear on this want. The labour of collecting, digest- 
 nd condensing for such a work will he considerable, and. as it is valuable 
 for [ndian purposes, it should (it seems t,. me) receive support ami encouragement 
 
PREFACE TO FIRST EDITION. XI 
 
 from the Indian Government, which Dr. Morehead has so zealously and usefully 
 served. 
 
 " I, therefore, trust my colleagues will support my proposition, and recommend, that 
 after the expiration of the leave lately granted, Dr. Morehead may have, for the above 
 purpose, another year in England on Indian allowances, and to count as service, with 
 the right of returning to that place in the Grant Medical College, over which he has 
 so beneficially presided." * 
 
 In performing this duty I have endeavoured to embody my 
 experience in a connected form, and to illustrate my opinions by 
 cases which have passed under my immediate observation! and care ; 
 while, at the same time, I have not been inattentive to the views of 
 other inquirers. 
 
 My clinical researches have been directed to disease, as occurring 
 both in Europeans and in the Natives of India. I have aimed not 
 merely to increase practical knowledge of the diseases usually 
 termed tropical, as malarious fever, hepatitis, dysentery ; but, also 
 to show that affections — pneumonia, phthisis pulmonalis, peri- 
 carditis, Bright's disease — familiar to European observers, are 
 sufficiently common in India, more particularly in some classes of 
 the native community. 
 
 Cases have beeri introduced chiefly with the object of elucidating 
 the Symptomatology and Pathology of disease. They have been 
 used freely in the form of summaries, which have in every instance 
 been carefully prepared by myself. The graduates of the Indian 
 Medical Colleges, for whose benefit I have chiefly written, may 
 often, for many years yet to come, be placed in positions remote 
 from their professional brethren, and in circumstances ill adapted 
 for the prosecution of pathological research. The recollection of 
 this fact has removed any hesitation which I might othemvi.se have 
 felt relative to the expediency of inserting so many illustrative 
 details. But, at the same time, I have been careful so to arrange 
 the text of the work, that it may be readily perused independent of 
 the cases; and so to classify and indicate the cases, that they may 
 be referred to without difficulty by those who may be engaged in 
 the close investigation of the diseases to which they relate. 
 
 * Report of the Board of Education. Bombay, from May 1, 185-1, to April 30, 1855, 
 p. U4. 
 
 t The few cases not observed by myself which have been inserted, are indicated by 
 an asterisk. 
 
xii PREFACE TO FIEST EDITION. 
 
 In my remarks on the treatment of disease I have invariably 
 endeavoured to explain fully the principles, and to state the means 
 by which they may be best applied. Cases illustrative of treatment 
 have been sparingly used by me, because practical conclusions 
 arrived at, after a lengthened course of experience, are grounded 
 partly on cases successfully treated, partly on those which have 
 proved fatal, and partly on the observation of different methods in 
 the hands of others. Therefore the physician, on looking back to 
 the records of his practice through a long series of years, is not 
 likely to meet with many cases calculated to illustrate at all points 
 his matured therapeutic opinions. 
 
 Making exception, then, of the few cases which have been 
 detailed in explanation of treatment, I would request the reader to 
 refer exclusively to the text for my views on this important part of 
 my subject. Doubtless the principles inculcated by me will be 
 found applied in the management of many of the cases which have 
 been narrated with a different object ; but, on the other hand, I am 
 very sensible that some of them may be fairly open to criticism. 
 
 It was my desire to have concluded this work with a chapter on 
 the Diseases of Females and of Children, but the time at my com- 
 mand has come to a close. In respect to some of the diseases of 
 which I have treated, reference has been made to their occurrence 
 in females, and in the early periods of life ; and a little reflection 
 will readily suggest the modifications of the pathological and thera- 
 peutic principles, which I have endeavoured to enforce, to the cir- 
 cumstances of difference of sex and of age. Still, the subject is of 
 much interest and importance, and I would indulge the hope that 
 I may be permitted, at some future time, to supply the omission 
 which at present I have been unable to avoid. 
 
 Loudon, May, 1856. 
 
CONTENTS. 
 
 PAr.E 
 Preface to Second Edition ..... vii 
 
 Preface to First Edition ....... ix 
 
 CHAPTER I. 
 
 Introduction. — General Remarks on the Causes, Pathology, and Treat- 
 ment of Disease in India . . . . . . .1 
 
 CHAPTER II. 
 
 Remarks on the Statistics of the European General Hospital, and of the 
 Jamsetjee Jejeebhoy Hospital at Bombay . . . . .11 
 
 CHAPTER III. 
 General Remarks on Fevers in India . . . . .16 
 
 CHAPTER IV. 
 
 ON INTERMITTENT FEYER. 
 
 Section I. — Different Types of Intermittent Fever 
 
 Section II. — Simple Intermittent Fever. — Symptoms, Pathology, and Treat- 
 ment ......... 
 
 Section III. — Intermittent Fever complicated with Enlargement of the Spleen 
 — Symptoms. — Pathology. — Treatment .... 
 
 Section IV. — Intermittent Fever with Hepatic Complication. — Symptoms. — 
 Pathology. — Treatment ...... 
 
 Section V. — Intermittent Fever complicated with Jaundice, or Affections of th( 
 Stomach or Bowels ....... 
 
 Section VI. — Intermittent Fever complicated with Cerebral Affection 
 
 Section VII. — Intermittent Fever complicated with Bronchitis, Pneumonia 
 Rheumatism, Scorbutus, Pericarditis, Asthma 
 
 17 
 
 20 
 
 36 
 
 43 
 
 47 
 49 
 
 52 
 
XIV CONTENTS. 
 
 CHAPTER V. 
 
 ON REMITTENT FEVER. 
 
 PAGE 
 
 Section I. — The Diagnosis of Remittent Fever, from Intermittent Fever and 
 ardent Continued Fever. — Division into Simple and Complicated . . 56 
 
 Section II. — Symptoms of Remittent Fever. — Ordinary, Inflammatory, Ady- 
 namic, Congestive, Badly developed, with unexpected Collapse, with peculiar 
 Features. — Also complicated with Cerebral Affection, Irritability of Stomach, 
 Jaundice, Bronchitis, Pneumonia. — Diagnosis from Hectic and Symptomatic 
 Fever .......... 58 
 
 Section III. — Pathology. — Mortality from Remittent Fever. — Relation of 
 Type to Diathesis and previously existing Structural Lesions. — Complication 
 with Cerebral Affection and Consideration of the Pathological Import of 
 Cranial Serous Effusion. — Complication with Gastric Irritability, Affection of 
 the Bowels. — Hepatitis, Jaundice, Parotitis, and Pneumonia . . 75 
 
 Section IV. — Treatment. — Contrast of the Principles of Treatment of Malari- 
 ous Remittent Fever, and the Zymotic Continued Fevers of Cold Climates. — 
 Treatment of Ordinary, Inflammatory, Congestive, Adynamic, and Irregular 
 Types of Remittent Fever. — Then of those complicated with Cerebral Affec- 
 tion, Gastric Irritability, Jaundice, Hepatitis .... 105 
 
 Section V. — Treatment further considered in Remarks on Blood-letting, Mer- 
 cury, Cold Affusion and Wet Sheet Packing, Purgatives, Emetics, Blisters, 
 Opiates, Quinine, Diet, and Change of Air . . . . .122 
 
 CHAPTER VI. 
 On Certain Obscure Phenomena, probably Related to Malaria . . 153 
 
 CHAPTER VII. 
 On Adynamic Remittent Fever of Suspected Infectious Character . 155 
 
 CHAPTER VIII. 
 On Typhoid Fever .... .160 
 
 CHAPTER IX. 
 
 ON COMMON CONTINUED FEVER FEBRICULA AND ARDENT CONTINUED FEVER. 
 
 Section I. — General Remarks . . . . . . .162 
 
 Section II. — Common Continued Fever — Febrieula . . . .162 
 
 Section III. — Ardent Continued Fever . . . . .164 
 
 CHAPTER X. 
 
 < ).\ the Febrile Affections of Children m India. — Febricula. — Intermit- 
 tent and Remittent Fever . . . . . . .168 
 
 CHAPTER XI. 
 
 STATISTICS OF FEVER IN THE EUROPEAN GENERAL HOSPITAL, THE JAMSETJEE JEJEEBHOY 
 HOSPITAL, AND HYCULLA SCHOOLS, AT BOMBAY. 
 
 Section I. — European General Hospital. — Total Fevers . .170 
 
 Section II. — European General Hospital lnl.naitleiit Fever . 172 
 
CONTENTS. 
 
 Section III. — Jamsetjee Jejeebhoy Hospital. — Total Fevers . 
 Section IV. — Jamsetjee Jejeebhoy Hospital. — Intermittent Fever 
 Section V. — European General Hospital. — Remittent Fever . 
 Section VI. — Jamsetjee Jejeebhoy Hospital. — Remittent Fever 
 Section VII. — Byculla Schools Intermittent and Remittent Fever 
 
 ON epidemic cholera. 
 
 175 
 
 176 
 177 
 179 
 181 
 
 CHAPTER XII. 
 
 on eruptive fevers. 
 
 Section I. — Prevalence in the Native Army ..... 182 
 Section II. — Small-pox, as observed in Bombay. — Prevalence. — Prevention 
 
 by Vaccination . . . • • • • .182 
 
 Section III. — On Measles in Bombay and the Deccan . . .194 
 
 Section IV. _ Scarlatina. — Erysipelas. — Varicella. — Hooping Cough. — 
 
 Cynanche Parotidea . . - • • • • .199 
 
 CHAPTER XIII. 
 
 202 
 
 208 
 
 221 
 
 Section I. — Remarks on the Seasons of Prevalence and on the Causes of 
 Cholera .....•••• 
 
 Section II. — Symptoms considered in reference to their degrees of severity. 
 — Diagnosis from Bilious Cholera, Irritant Poisoning, and Collapse of Remit- 
 tent Fever .....-••• 
 
 Section III. — The General Rate of Mortality. — Its Relation to Age, Period 
 of Epidemic, and Duration before Admission considered. — General Pathology 
 shortly noticed. — Morbid Anatomy described .... 215 
 
 Section IV. — Treatment in the different degrees and stages of the disease. — 
 Recapitulation ....•••• 
 
 Section V. — Statistical Tables relative to Epidemic Cholera in European 
 General Hospital, the Jamsetjee Jejeebhoy Hospital and the Byculla Schools 
 at Bombay ....••-•• 233 
 
 CHAPTER XIV. 
 
 ON DYSENTERY. 
 
 Section I.— The Importance of Dysentery in India.— Order in which the subject 
 
 will be treated . . • • • • • .236 
 
 Section II.— Pathology.— Detailed Statement of the Morbid Anatomy . 237 
 
 Section III. — Etiology of Dysentery. — Importance of distinguishing exciting 
 and predisposing Causes. — Exciting Causes. — Cold, Food. — Predisposing 
 Causes. — Cachectic States. — Action of Malaria discussed . . • 273 
 
 Section IV. — Symptoms of Dysentery ....•• 2S0 
 Section V. — Treatment. — General Principles and Indications. — Detailed 
 Remarks on Blood-letting, general and local, Calomel, Mercurial Influence, 
 Ipecacuanha, Purgatives, Diaphoretics, Opium, Chloroform, Astringents, 
 Tonics, Fomentations, Blisters, Enemata, Diet, and Change of Climate . 2SS 
 
XVI CONTENTS. 
 
 PAGE 
 314 
 
 316 
 316 
 
 Section VI. — Dysentery in Children in India . . 
 
 Section VII. — On Gastro-Enteritis ..... 
 
 Section VIII. — On Diarrhoea ...... 
 
 Section IX. — Statistics of Dysentery in the European Hospital, and of Dysen 
 tery and Diarrhoea in the Jamsetjee Jejeebhoy Hospital and Byculla Schools 
 at Bombay ...-••• ■ 318 
 
 CHAPTER XV. 
 
 ON HEPATITIS. 
 
 Section I. — Comparative Prevalence of Hepatitis . . . .321 
 
 Section II. — Preliminary Remarks on the nature of the Symptoms of Hepatic 
 Disease. — Arrangement of the Subject ..... 323 
 
 Section III. — Pathology. — Preliminary Remarks on the General Pathology of 
 Hepatitis. — Morbid Anatomy of Stage of Vascular Turgescence, of Exudation 
 of Lymph, and Formation of Abscess explained. — The several Courses and 
 Situations of Rupture of Hepatic Abscess.— Abscess Absorption. — Secondary 
 Peritonitis and Formation of circumscribed Purulent Sacs. — Secondary 
 Pleuritis, circumscribed and general Empyema. —Secondary Pericarditis.— 
 General Secondary Peritonitis.— Colour of Pus in Hepatic Abscess . . 325 
 
 Section IV.— Etiology of Hepatitis. — Exciting Causes. — External Cold, elevated 
 Temperature, Intemperance, Mechanical Causes. — Importance of Predisposing 
 Causes stated. — The Complication of Hepatic Abscess and Dysentery consi- 
 dered in reference to the Pyoemic Theory of the Causation of Hepatic Abscess 361 
 
 Section V.— Symptoms of Hepatitis.— Early Stages.— Pain, Respiratory Move- 
 ments. — Physical Signs. — Altered Secretion, Jaundice. — Constitutional 
 Disturbance. — Suppuration. — Course of Hepatic Abscess . . . 370 
 
 Section VI.— Treatment of Early Stages. — Blood-letting, general and local. — 
 Mercurial and other Purgatives. — Mercurial Influence. — Blisters. — Treat- 
 ment when Abscess is forming and is perfected. — Question of Puncture 
 considered. — Change of Climate ...... 384 
 
 Section VII. — Hepatitis in Females and in Children .... 41.5 
 
 Section VIII. — Occasional Difficulties and Errors of Diagnosis . . 416 
 
 Section IX.— Statistics of Hepatitis in the European General Hospital and the 
 Jamsetjee Jejeebhoy Hospital, at Bombay . . . .417 
 
 CHAPTER XVI. 
 
 ON CIRRHOSIS, CONGESTION, LARDACEOUS AND FATTY ENLARGEMENT, CANCER AND 
 
 HYDATID OF THE I.IVER. AFFECTIONS OF THE BILIARY DUCTS AND GALL-BLADDER. 
 
 BILIARY CALCULI. — JAUNDICE. — INCREASED AND DEFECTIVE SECRETION OF BLLE. 
 
 Section I. — Cirrhosis.— Pathology. — Symptoms.— Treatment.— Complication 
 
 with Hepatic Abscess ......•• 421 
 
 Section II. — Congestion of the Liver. — (Edema . 426 
 
 & i i ion III— Lardaceous and Fatty Liver.— Cancer, and Hydatid Formations 428 
 Section IT.— Inflammation of the Gall-Bladder and Biliary Duets.— Distention 
 
 of the (Jail-Bladder.— Biliary Calculi . . . . . .431 
 
 Section V. — Jaundice. — Pathology. — Causes. — Treatment . • 433 
 
 Section VI. — On Increased and Defective Secretion of Bile . 440 
 
CONTENTS. XVU 
 
 CHAPTER XVII. 
 
 ON PERITONITIS, ILEUS AND COLIC. 
 
 PAGE 
 
 Section I. — Peritonitis. — Pathology. — Plastic and sero-puriform Exudations 
 
 related to Diathesis.— Chronic Tubercular.— Chronic not Tubercular, and not 
 
 Consecutive on Acute. — Treatment * 
 
 453 
 Section II.— Ileus and Colic ... 
 
 CHAPTEE XVIII. 
 
 affections of the stomach. 
 
 Section I. — Gastritis, Acute and Chronic ... 458 
 
 Section II. — Glossitis ...•••• 
 Section III.— Dyspepsia. — General reflections on Pathology and Principles of 
 Treatment ...••••• 
 
 CHAPTER XIX. 
 on bbight's disease of the kidney and albuminous ueine. 
 
 Section I.— Prevalence of Bright's Disease in the Hospital-frequenting classes 
 of the Natives of India ... ... 465 
 
 Section II.-^The Relation of Bright's Disease to Albuminous Urine stated.— 
 The Morbid Anatomy and Pathology of the Fluids.— Pathology of the Secon- 
 dary Affections.— The Urcemic Theory.— The Proximate Cause of Albumen 
 in the Urine .....••• 
 
 Section III.— Etiology.— Scarlatina not influential in India.— Relation to Caste, 
 Age, Occupation, Habits, Season.— Cold an exciting Cause sometimes of the 
 Kidney Disease, generally of the Secondary Affections 
 
 Section IV.— Symptoms.— Referable to the Kidney.— Condition of the Urine- 
 Treatment,— Of the Kidney Disease.— Of the Secondary Affections, chiefly the 
 Dropsical Effusions ....•••• 
 
 CHAPTER XX. 
 
 ON ABNOBMAL STATES OF THE Urine. 
 
 Section I. — Preliminary Pathological Remark. — A want of Information in 
 
 respect to the Normal Condition of the Urine in India . . • 497 
 
 Section II.— Chylo-serous Urine.— Short Notice of its Pathology and Treatment 498 
 
 Section III.— Saccharine Diabetes.— Infrequent in India.— Diuresis . . 502 
 
 Section IV. — Uric, Oxalic, and Phosphatic Diathesis .... 505 
 
 CHAPTER XXI. 
 
 ON PNEUMONIA. 
 
 Section I. — Pneumonia. — Rare in Europeans in Bombay. — Asthenic Form 
 common in Natives ....-••• °®° 
 
 Section II.— Etiology.— Relation to Sex, Age, Caste, Habits, Constitution, and 
 Season ......... &°9 
 
 466 
 
 487 
 
 491 
 
XVlll CONTENTS. 
 
 PA(iE 
 
 Section III. — Pathology. — Preliminary Question relative to the Affected Capil- 
 laries. — Rate of Mortality. — Duration of Illness before Admission.— Stage of 
 the Disease. — Which Lung most frequently Affected. — Period of Residence in 
 Hospital. — State of the Lung on Discharge. — Morbid Anatomy . . 512 
 
 Section IV. — Symptoms.— Fever, Pain, Dyspnoea, Cough, Delirium, Character 
 of the Sputa. — Physical Signs ...... 527 
 
 Section V. — Treatment. — General and Local Blood-letting, Tartar Emetic, 
 Mercury, Blisters, Quinine, Liquor Potassse, Stimulants. — Concluding 
 Remarks ......... 534 
 
 Section VI. — Statistics of Pneumonia ..... 547 
 
 CHAPTER XXII. 
 
 on pleuritis, bronchitis, and asthma. 
 
 Section I. — Pleuritis. — Symptoms, Causes, Pathology, Treatment . . 548 
 
 Section II. — Bronchitis. — Asthma ...... 552 
 
 Section III. — Statistics of Bronchitis ...... 553 
 
 CHAPTER XXIII. 
 
 ON PHTHISIS PULMONALIS. 
 
 Section I. — Causes, Symptoms, Pathology, and Treatment . . . 554 
 
 Section II. — Statistics of Phthisis Pulmonalis .... 560 
 
 CHAPTER XXIV. 
 
 ON PERICARDITIS AND ENDOCARDITIS. 
 
 Section I. — Introductory Remarks . . . . .561 
 
 Section II. — Causes, Symptoms, and Treatment » 562 
 
 CHAPTER XXV. 
 
 on organic disease of the heart and aorta. 
 
 Section I. — In Natives of India ...... 581 
 
 Section II. — In Europeans in India ...... 600 
 
 CHAPTER XXVI. 
 On Sun-stroke ........ 603 
 
 CHAPTER XXVII. 
 on delirium tremens. 
 
 Section I. — On the Symptoms and Treatment of Delirium Tremens in the 
 
 European General Hospital at Bombay ..... 624 
 
 Section II. On the Pathology, the Principles of Treatment, and Diagnosis . 641 
 
 Section III.— Delirium Tremens in the Natives of India . . . 645 
 
 Section IV. • Statistics of Delirium Tremens . . 646 
 
CONTENTS. XIX 
 
 CHAPTER XXVIII. 
 
 ON CEBEBBAL DISEASE AND PARALYSIS. 
 
 PAGB 
 
 Section I. — General Preliminary Remarks on the Pathology and Treatment of 
 Cerebral Disease ........ 648 
 
 Section II. — Apoplexy. — Meningitis. — Acute and Chronic Hydrocephalus. — 
 Morbid Growths within the Cranium. — Paroxysmal Headache . . 650 
 
 Section III. — Paralysis. — Hemiplegia. — Myelitis. — Paraplegia. — Paralysis 
 from Arsenic. — Facial Palsy ....... 658 
 
 Section IV. - Statistics of Paralysis . . . . . .671 
 
 CHAPTER XXIX. 
 
 ON TETANTS. 
 
 Section I. The prevalence of Tetanus in certain classes of the community in 
 
 India 672 
 
 Section II.— Pathology. — Nature of the Deranged Action -with reference to the 
 Physiology of the Spinal Cord. — Division into Idiopathic and Traumatic, 
 Acute and Chronic. — Morbid Anatomy ..... 673 
 
 Section III. — Etiology. — Diathesis, Cold, Entozoa? — External Injuries . 678 
 
 Section IV. — Symptoms. — Muscidar Rigidity and Spasms. — Respiration. — 
 Pulse. — Febrile Disturbance, &c. ...... 680 
 
 Section V. — Treatment of Tetanus . . . . . .683 
 
 Section VI. — Statistics of Tetanus . . . . . .688 
 
 CHAPTER XXX. 
 
 ON bydboprobia. 
 
 Section I. — Short allusion to Symptoms and Pathology. — Illustrative Cases 
 detailed 689 
 
 CHAPTER XXXI. 
 
 ON BLOOD DISEASES. 
 
 Section I. — Object of the Chapter explained ..... 692 
 
 Section II. — Pycemia. — Short notice of Symptoms and Pathology. — Illustrative 
 Cases. ......... 692 
 
 Section III. —Leprosy. — Tubercular and Anaesthetic. — Short account of the 
 Symptoms and Pathology ....... 695 
 
 Section IV. — Elephantiasis. — Symptoms. — Pathology. — Causes. — Treatment . 698 
 Section V. — Scurvy. — Prevalence in India. — Short Practical Remarks . .701 
 Section VI. — General Dropsy. — Beriberi. — Symptoms. — Pathology. — Treat- 
 ment. — Illustrative Cases ....... 704 
 
 Section VII. — Rheumatism. — Prevalence in India . . . .715 
 
 Section VIII. — On Snake Bite , . . . . . .716 
 
XX 
 
 CONTENTS. 
 
 CHAPTER XXXII. 
 
 ON DRACUNCULUS. 
 
 PAGE 
 
 Section I. — Prevalence of, in Bombay Presidency. — Relation to Season. — 
 Allusion to Theories respecting its mode of origin.— Short notice of Symp- 
 toms and Treatment .....••• 720 
 
 Section II. — Statistics of Dracunculus ..... 725 
 
 CHAPTER XXXIII. 
 On the Hill Sanitaria of the Deccan 
 
 728 
 
 APPENDIX. 
 
 A. — On the Meteorology of Bombay 
 
 B. — Sanitarium at Poorundhur 
 
 List of Cases ..... 
 List of Statistical anp Meteorological Tables 
 Index ...... 
 
 741 
 
 747 
 753 
 765 
 769 
 
ON 
 
 DISEASE IN INDIA. 
 
 CHAPTER I. 
 
 INTRODUCTION. — GENERAL REMARKS ON THE CAUSES, PATHOLOGY, AND 
 TREATMENT OF DISEASE IN INDIA. 
 
 Clinical research is the study of Pathology and Therapeutics, 
 by careful observation and comparison of numerous instances of 
 disease ; and in conducting it, the truth soon becomes evident that 
 the course and treatment of all forms of disease are modified 
 by previously existing habits of the body, congenital, or acquired 
 in one of the three following ways : — 
 
 1. By the neglect of a right condition of the agencies termed 
 vital stimuli, which are as essential to the physiological perform- 
 ance of function as organic integrity : they are food, water, atmo- 
 spheric air, heat, light, electricity, exercise- and repose of body 
 and mind. 2. By undue discharges from the blood. 3. By the 
 reception into the blood of external injurious agencies ---poisons; 
 or by the retention of excretions. 
 
 Under these heads may be classed— (a) States unduly plethoric or 
 sthenic ; (b) Asthenia and cachexia, from insufficient food, struma, 
 scurvy, vitiated atmosphere, elevated temperature, etiolation, de- 
 pressing mental affections, bodily fatigue, prolonged lactation, 
 haemorrhages, exhausting medical treatment — excessive in degree or 
 too long continued, malaria, syphilis, carcinoma, mercury, arsenic, 
 lead, alcohol, albuminuria, rheumatism, &c. Though in these 
 cachexise there may be peculiarities special to each, still there are 
 features common to all. The vital actions of the system are 
 defective, the nutrition of the blood and of the tissues is impaired, 
 
 D 
 
2 GENERAL REMARKS. 
 
 secretion is diminished and deranged, nervous influence and mus- 
 cular irritability are imperfect, and the generation of animal heat 
 is lowered in degree. 
 
 In my clinical remarks on the different forms of disease, 
 frequent reference will be made to these states under the 
 terms Asthenic and Cachectic : by the first is meant only a low 
 degree of function ; but by the second, a defect in quality as well 
 as in degree. 
 
 It is very probable that an essential condition of all cachectic 
 states is an altered quality of the blood, and that our present 
 ignorance of the alterations peculiar to each may be removed by 
 future pathological research. 
 
 In directing medical treatment, the physician is constantly 
 reminded of the obstacles which asthenic or cachectic states in- 
 terpose to the success of his remedies, and of the necessity which 
 exists of making 1 the removal of these states a leading indication in 
 the management of all forms of disease. Thus two important 
 practical lessons are enforced : — 
 
 1. Though the details of sanitary science and art are not 
 within the province of clinical instruction, yet the great import- 
 ance to the public health, and to the successful treatment of 
 disease, of a well-organised sanitary system, is a prominent in- 
 ference from clinical research. 
 
 2. The advantage derived in practice by the removal of the sick 
 from the influence of the causes productive of cachexias serves to 
 substantiate this truth : that a rational system of medicine is one 
 which includes a careful adjustment of the vital stimuli and the 
 removal of laedentia, as well as the use of medicines ; and that when 
 the cachectic condition is very marked, then the two first thera- 
 peutic principles are the most essential. 
 
 These doctrines will be frequently adverted to in my remarks 
 on different diseases. 
 
 The necessity of carefully considering the general condition of 
 the body, in the treatment of disease, is universally true: but 
 when investigation lias reference to a particular country, then the 
 preliminary question arises whether, as regards this Held of ol 
 vation, there are special causes exercising an influence on the 
 constitution of man. 
 
 In applying this rule to India, it may be stated that, on com- 
 paring tropica] with temperate climates, we find, 1st, that the heat 
 of the summer season of the former readily acts as the exciting 
 cause of serious forms of disease in the recently arrived plethoric 
 
CAUSES OP DISEASE — HEAT. 3 
 
 and sthenic natives of the latter ; 2nd, that in tropical countries, 
 not much elevated above the level of the sea, there are two special 
 causes of asthenia and cachexia, more or less prevailing — the 
 influence of long-continued and frequently repeated high tem- 
 perature, and the action of malaria. 
 
 The effect of elevated temperature on the European constitution, 
 in increasing and deranging the biliary secretion, has been a con- 
 stant theme with a succession of able writers on the diseases of 
 Europeans in tropical climates. Though the observations made on 
 the recently arrived, on which these opinions mainly rest, are 
 correct, still they are erroneous when applied to the far more 
 numerous class of established residents ; in them the secretion of 
 bile is not habitually increased. 
 
 One consequence of high atmospheric temperature on the animal 
 system is a diminished necessity for animal heat : hence there is 
 less demand for food, less metamorphosis of tissue, and less 
 excretion. This truth is made manifest by the asthenic condition 
 of the residents in warm climates, compared with the sthenic 
 state of the inhabitants of colder latitudes. 
 
 The European soldier or sailor, on arrival in India, does not 
 appreciate, and therefore does not readily adopt, the alteration in 
 habits of life necessary to the maintenance of health under the 
 circumstances of a warmer climate ; consequently the excesses, 
 which in the cold climate might be unattended by disorder, are, 
 under the predisposition caused by the action of increased heat, 
 followed by derangement. Ardent continued fever or febricula, 
 bilious cholera or diarrhoea, are under these circumstances very apt 
 to occur. The increased metamorphosis of tissue, or of constituents 
 of the blood, related to diathesis, or consequent on food taken in 
 excess of the normal requirements of animal heat, may in part 
 explain the proclivity to these forms of febrile disease. The theory 
 usually conceived of the biliary derangements may be correct : 
 viz. that the decreased elimination of hydro-carbon by the lungs, 
 resulting from the less demand for animal heat, is liable to lead to 
 the office of eliminating the excess of these elements present in the 
 system, being transferred to the liver. But it by no means follows, 
 that when there is the just relation between the quantity and 
 kind of food consumed and excretion, which is implied in the 
 habits of every prudent resident in a hot climate, there exists a 
 greater degree of action of the liver vicarious of that of the lungs 
 in the one climate than in the other. 
 
 Questions relative to the proportion of ingesta to excreta, and of 
 
 B 2 
 
4 GENERAL REMAKES. 
 
 the various excreta to each other, under varying circumstances of 
 the animal system, can only be satisfactorily determined by careful 
 observation and experiment. Inquiry of this kind, on an extensive 
 scale, is still amongst the desiderata of physiological science; and, 
 in the absence of the requisite data, all that can be safely affirmed 
 in reference to India and other tropical countries is, that in the 
 normal state of the system, all the solid * excreta are considerably 
 less in amount than in the colder climates of Europe. The 
 evidence that the biliary excretion is not increased, rests on the 
 fact, that in the natives of India, and in Europeans whose habits 
 of living have become adapted to the climate, derangement of this 
 kind is very rarely observed.! 
 
 Malaria is the exciting cause of the intermittent and remittent 
 types of fever. It also induces cachexia, either in consequence of 
 frequent febrile recurrences, or by the exercise of a slow and 
 gradual influence, irrespective of distinct paroxysms of fever. 
 To the terrestrial miasm, whatever it may be, which is believed 
 to produce these and other allied effects, the term Malaria will 
 be restricted throughout this work, and will never be used in that 
 more general sense, not unfrequently adopted by modern writers, 
 and which it may be feared is leading to needless confusion, and 
 obscurity in our views on the causes of disease. 
 
 The subject of Malaria is well and fully discussed by our best 
 systematic writers, and it will therefore be sufficient to state, very 
 shortly, the leading facts which are generally accepted relative to 
 the generation and action of this morbific cause. 
 
 1. The presence of malaria is determined by the occurrence of 
 certain derangements of health attributed to its influence, for as 
 yet all other means of investigation have failed in detecting it. 
 
 '2. A certain degree of heat acting on the earth's surface, 
 previously soaked with water, is essential to the production of 
 
 * I use the term solid, to exclude that water which has been received and 
 eliminated withoul resolution into its elements. 
 
 ■J When tlii- statemenl was written in the first edition of this work. I was not 
 aware thai a similar opinion had been expressed by Dr. Eenry Marshall, in his work 
 ,, i, the diseases of Ceylon. Confirmed by the previous observation of this distin- 
 guished medical officer, it is now repeated with assured confidence. Dr. Marshall 
 thus writes : "It is, I believe, a very common opinion, thai an excessive secretion 
 of bile is general in warm climates. Upon what foundation is ihis opinion assumed? 
 With regard to Europeans in health, I have not been able to observe any remarkable 
 ace between the Becretory functions of the liver in a tropical climate from that 
 of (|,, n in high latitudes; and with respeel to the indigenous inhabitants 
 
 of intrr-iioj.ii-. il regions, I am not convinced thai the biliary secretion is unusually 
 onth Medical Typography and Prevail D of Ceylon, p. 145. 
 
CAUSES OF DISEASE — MALARIA. 5 
 
 malaria. It is more certainly generated while the process of 
 drying is going on — when aeriform emanations exist, in degree 
 proportionate to the rapidity with which the desiccation is 
 effected. Hence malaria is most abundant in marshy grounds 
 after the quantity of water has been reduced by evaporation to 
 that condition when the drying of the surface of the ground 
 begins, and while the atmospheric temperature is still high. It 
 is then, after the heats of summer have passed, and the autumnal 
 season has set in, — the months September and October, — that 
 in marshy countries malarious fevers chiefly jDrevail. 
 
 3. In those tropical regions, in which there are periodical 
 rains associated with elevated temperature, the generation of 
 malaria coexists with the periods when the heavy falls have ceased 
 and the drying of the earth's surface is going on. Consequent on 
 the rains of the south-west monsoon, which commence about May 
 and terminate in September, malarious fevers are prevalent some- 
 times in July, but generally most extensively in October. But 
 there may be variations in respect to the particular months 
 in different years. The necessary conditions are such relation 
 between the rain-fall and the temperature as shall cause the 
 rapid drying of a surface previously soaked with moisture. 
 
 4. There are districts of countries, chiefly in the warmer 
 climates, subject to the periodical inundation of large rivers; 
 and, should the subsidence of the waters coexist with elevated 
 temperature, then the generation of malaria, as evidenced by 
 the prevalence of intermittent and remittent fever, takes place. 
 The Granges, the Indus, the Euphrates, and the Nile, are rivers 
 of this kind. Consequent on the melting of the snows in the 
 mountain regions, at the sources of these rivers, the supply of 
 water is increased. They begin to rise about the month of March, 
 and attain their greatest elevation, overflowing their banks and 
 covering extensive tracts of country, in the month of SejDtember. 
 Then they gradually fall ; and, as the surface of the inundated 
 tracts becomes exposed, rapid drying commences. It is under 
 these circumstances that malarious fevers appear in these dis- 
 tricts in their most aggravated form. 
 
 It would seem that, whether in tracts habitually swampy, 
 or regions wetted by periodical rains, or the overflow of large 
 rivers, still the autumnal season is that in which malarious fevers 
 are most prevalent. 
 
 5. Malaria seems to show a preference for low levels, and 
 
 B 3 
 
6 GENERAL REMARKS. 
 
 the surface of the ground, compared with elevated sites and 
 higher atmospheric strata. 
 
 6. It often coexists with decaying vegetation, hut not unfre- 
 quently occurs, independent of it, in situations where the surface 
 is sandy, dry, and bare, and where the drying — that essential 
 condition in the generation of malaria— must be going on in the 
 damp subsoil. 
 
 7. Its influence on the system is more surely experienced at 
 night, and near to the surface of the ground. 
 
 8. Malaria may be wafted by currents of air from the spot 
 where it has been produced, and thus infect adjacent localities; 
 or by the same power, combined with the tendency to remain 
 near the surface of the earth, it may be carried up the slope 
 of a mountain, just as fogs are. 
 
 9. Malaria is believed to lose its noxious properties by passing 
 over a surface of water even of small extent. It is attracted 
 by the foliage of trees, and thus accumulates around them, and 
 between them and the surface of the ground, rendering jungly 
 tracts in tropical countries very dangerous at the malarious 
 season of the year. This property of the foliage of trees, however, 
 may be made subservient to the protection of tracts of country, 
 when belts of wood are interposed between them and malarious 
 localities. 
 
 10. Malaria is lessened by cultivation and adequate population, 
 but becomes rapidly increased when lands have been deserted and 
 allowed to run waste.* 
 
 * Such general statements as these, relative to the generation and action of malaria, 
 rest upon evidence which maybe found in the Medical Statistical Reports of the 
 Eritish Army, and in the medical histories of military or naval expeditions to the 
 co;ii-, of Africa and Arracan, to Burmah, Java, the peninsula of Spain, and to other 
 countries. They are, moreover, amply confirmed by observations made in my own 
 field of research, or in districts adjacent to it. The fevers which occur in the months 
 of September and October in the provinces of Guzerat, Candcish, and Seinde, illus- 
 trate the relation of malaria to elevated temperature and rapid drying of the 
 earth's surface. In the Deecan, ami at Eursole, in Guzerat, there is evidence of 
 malaria without vegetable decomposition; while at Deesa they have occurred in 
 association together. The history of a fever which prevailed among the marines 
 of her .Majesty's frigate " Kndymion," in the dockyard at Bombay (to be more 
 particularly alluded to in the Chapter on Remittent Fever), affords a striking proof of 
 the greater influence of malaria, by night than by day. At Tatta and at Hyderabad, 
 in Seinde, the malaria generated in the adjacent lowlands was carried by the prevail- 
 ing winds up the hill slopes on which the troops were stationed. That malaria is 
 attracted by, and accumulates about, trees has been in too many instances painfully 
 proved by the history of detachments of troops injudiciously marched, at unseasonable 
 periods, through the extensive tracts of jungle ■which intervene between the provinces 
 of Candeish and Guzerat, In the fallen condition of the city of Ahmedabad, and in 
 
EXCITING CAUSES OF DISEASE. I 
 
 Exc'd'irtfi Causes of Disease, — Eeference has been made to 
 asthenic and cachectic states as predisposing to disease of all kinds, 
 and the importance of a right appreciation of their influence in 
 causing and modifying disease in India will be frequently incul- 
 cated in various parts of this work. Malaria has also been regarded 
 as a predisposing and exciting cause, and the other ordinary 
 exciting causes of disease in India must now be shortly alluded to. 
 Of these, external cold is the most common. In judging of the 
 facility with which the temperature of the surface of the body be- 
 comes reduced in India, we must bear in mind the diminished 
 power of generating animal heat characteristic of warm climates 
 and asthenic states ; and that consequently, in these circumstances, 
 the surface of the body may become lowered in temperature by an 
 amount of external cold inadequate to produce this effect in colder 
 climates or stronger constitutions. 
 
 In order to form a just estimate of this exciting cause of disease, 
 it is very necessary to study carefully, in respect to the sphere in 
 which we practise, the physical features of the country, and the 
 characters of the different seasons of the year ; more particularly 
 those conditions of the atmosphere which favour the abstraction of 
 heat, such as absolute lowness of temperature, diurnal range, mois- 
 ture, direction, duration, and force of the winds.* It is further of 
 importance to consider these atmospheric states in reference to the 
 presence or not of pre-existing causes of asthenia or cachexia, 
 as malaria, scarcity, elevated temperature, syphilis, &c. For it 
 is well known that cold, as well as other exciting causes of disease, 
 acts very readily on debilitated persons ; and if this fundamental 
 doctrine in etiology — the influence of predisposition — be neg- 
 lected, we shall often be unable satisfactorily to explain the 
 prevalence of disease, — as t} r pes of fever, diarrhoea, dysentery, 
 rheumatism, perhaps cholera, — in localities usually healthy, and 
 
 the state of health of the troops at Hyderabad immediately after the battle of 
 Meanee and the capture of Seinde, we have illustrations of the statement that the 
 production of malaria is favoured when districts are deserted, and previously cxilti- 
 Tated lands are left waste. The references made to the dockyard in Bombay, and to 
 Tatta ami Hyderabad, in Seinde, rest on my own observation and inquiry; those 
 relative to Guzerat, the Deccan, and Candeish, on two very instructive and interesting 
 descriptions of the provinces of Guzerat and the Deccan, by Mr. Gibson, published in 
 the first and second numbers of the " Transactions of the Medical and Physical Society 
 of Bombay;" also a "Beport on Candeish Fever," by Dr. Graham, in the fourth 
 number; ami one by Dr. Brown, on the "Diseases of the Horse Artillery at Deesa," 
 in the first number of the " Transactions" of the same Society. 
 * See Appendix. 
 
8 GENERAL REMARKS. 
 
 further be unable to account for the want of success attending our 
 treatment. 
 
 Though the elevated temperature of an Indian climate is chiefly 
 influential as a predisposing cause of disease, yet it is not to be 
 doubted that heat sometimes acts as an exciting cause in some 
 forms of fever, in some affections of the nervous system, and per- 
 haps in hepatitis, as will be explained more fully when these 
 diseases are treated of. 
 
 The exclusive observation of disease in unacclimatised sthenic 
 Europeans by a succession of writers on tropical diseases, and the 
 rapid course sometimes followed by bad forms of malarious fever 
 and of dysentery in such subjects, have created an impression that 
 inflammatory disease in India, compared with colder climates, is 
 characterised by speedy progress and excessive vascular action. 
 When, however, investigation is extended beyoud the limited 
 circle of this class, we find that this opinion is erroneous. It has 
 been already stated that the common type of disease in India, both 
 in Europeans and natives, is asthenic ; and the law in respect to 
 this type, verified in other countries, may be also safely affirmed of 
 disease in India, viz. that inflammations in asthenic and cachectic 
 habits are generally distinguished by an obscurity of symptoms 
 and a slowness of progress, in proportion to the degree of asthenia 
 or cachexia. 
 
 These features of asthenic disease often lead in India to neglect 
 of application for relief till disorganization of structure has well 
 advanced ; and they, moreover, sometimes tend to mislead the 
 practitioner in respect to the stage, and thus create the erro- 
 neous impression that the morbid changes have been rapidly 
 effected. 
 
 This belief in the severity of inflammatory disease in India, 
 originating in the manner just explained, naturally gave rise to 
 the opinion thai disease in India generally required to be met 
 by a freer use of active antiphlogistic remedies. But, if the state- 
 ment made relative to the frequency of asthenic forms of disease 
 be correct, then it follows that blood-letting, mercury, purga- 
 tives, and all other depressing antiphlogistic remedies, should as a 
 general rule be used with greater caution, not with more freedom, 
 in India than in colder climates. 
 
 The pathological doctrines now generally current on blood- 
 disease,, and en various forms of degeneration of tissue consequent 
 on defective or perverted nutrition, are very valuable in the study 
 of disease in India, and demand the careful attention of path olo- 
 
TAUTOLOGY AND THERAPEUTICS. 9 
 
 gists iu that country.* They, moreover, serve to enforce addi- 
 tional caution in respect to the abuse of antiphlogistic remedies, to 
 
 * Since this passage was written, a paper lias been published by Mr. Macnamara, in 
 the third volume of the "Indian Annals of Medical Science," the object of which is to 
 show that fatty degeneration of the liver and other organs is the chief cause of the 
 high rate of mortality among European troops in Bengal. The ' arguments 'are — 
 1. The statement that in twenty-four post-mortem examinations of men of the 
 1st European Bengal Fusdiers, made by the author, fatty degeneration existed in all, 
 with one exception, in the liver, the kidneys, the heart, and coats of the large blood- 
 vessels. 2nd. The diet ration is excessive, as regards both nitrogenous and car- 
 bonaceous principles. 3rd. The elevated temperature, close barracks, and indolent 
 habits of the soldier in India, are unfavourable to the pulmonary elimination of 
 hydro-carbon; and as these elements are rarely deposited in India in the form of 
 adipose tissue, their only remaining outlet is by fatty degeneration, — hence the 
 great frequency of this structural change supposed by Mr. Macnamara to exist in 
 India. The statements and the reasoning are not convincing, because, — 1st, A 
 succinct clinical history and description of the post-mortem appearances of not 
 one of the cases is given ; therefore, though they may satisfy the observer himself, it 
 does not follow that they will convince others ; 2nd. Though the ration may be 
 excesssive, — though there may be instances of gluttony and great indolence in the 
 barrack-room as well as elsewhere, — it does not follow that aU the food placed on 
 a 1 'arrack mess-table is uniformly eaten, anymore than it is at the officers' mess- 
 table ; 3rd. That in the hot season of India the soldier is little disposed for active 
 exercise in the heat of the day, and that there is great necessity for enlargement 
 of barrack-rooms, and covered workshops and buddings for in-door recreation, is very 
 true ; stdl this is not the habit of the European soldier in the cold season in India, 
 or when active exercise is likely to be beneficial ; 4. It does not accord 'with my 
 observation to say that the formation of adipose tissue is rare in India. Fat 
 Europeans and natives are common enough. 
 
 I still believe that, as a ride, there is no increase of elimination of hych'o-carbon 
 by the liver to substitute a supposed deficiency of that by the lungs, because the 
 appetite soon brings about the just harmony between assimilation and general 
 excretion, which must render vicarious action unnecessary. I do not look for fatty and 
 other degeneration in India as a consequence of excesses in food, but as the result of 
 the lowered nutrition of the system, proceeding from the continuance of climatic 
 and other debilitating influences. 
 
 The different transient effects produced on the portal blood or its secretion by 
 different kinds of food, during the passage of those constituents which pass by this 
 channel, not by the lacteals, are not here adverted to. 
 
 In Dr. Budd's work, fatty liver, consequent on fatty food, removable by change of 
 diet and active exercise, is sufficiently explained ; and Frerichs, in his late work, 
 '■Klinik der Leberkrankheiten," has added further to our knowledge by experiments, 
 which show that in dogs receiving in then* daily food from hah' an ounce to one ounce 
 of oil, the following changes take place in the hepatic cells : — After twenty-fom- hours 
 there is an increase of molecular contents ; after three days, numerous fat globules 
 are apparent; and, after eight days, the hepatic cells are almost completely filled with 
 larger and smaller fat globules. The fatty contents of the cells disappear after some 
 time, when the diet is changed; probably a part, as sivpposed by Frerichs, returns to 
 the blood as fat ; and another, according to the functional design of the liver, is expended 
 in the formation of bile. This, however, is not fatty degeneration of the liver, but the 
 normal condition of the organ when certain articles of food are used. Mr. Macnamara 
 seems to confound this normal fatty state with fatty degeneration. It is very 
 
10 GENERAL REMARKS. 
 
 enhance the importance of the judicious use of tonic regimen* and 
 medicines, and to suggest further inquiry into the therapeutic 
 value and rational use of eliminants and alteratives. 
 
 likely that the former existed in some of his cases ; but when it is stated that not only 
 was there fatty degeneration of the liver in twenty-four cases, but also fatty degenera- 
 tion of the heart, kidneys, and blood-vessels, then some fallacy in the observations 
 may be suspected ; and the absence of careful clinical histories, and descriptions of the 
 post-mortem appearances, must be felt as decisive against the acceptance of these 
 cases as authority on this question. 
 
 * I use the term to signify those just arrangements of food, atmospheric air, 
 exercise and repose of body and mind, and of water as regards the functions of the 
 skin, and its tonic action when cold, which conduce to the maintenance of health and 
 favour the elevation of the animal system from a state of debility to one of strength. 
 
11 
 
 CHAP. II. 
 
 REMARKS ON THE STATISTICS OF THE EUROPEAN GENERAL HOSriTAL, 
 AND OF THE JAMSETJEE JEJEEBHOY HOSPITAL AT BOMBAY. 
 
 In the clinical remarks on the various forms of disease treated in 
 this work, frequent reference will be made to the European 
 General Hospital and to the Jamsetjee Jejeebhoy Hospital at 
 Bombay, because much of my practical acquaintance with disease 
 in India has been acquired in these institutions. 
 
 The first-named hospital has accommodation for 120 sick. The 
 inmates are Europeans, partly military, partly sailors, and partly 
 the poorer classes of the civil community. The wives and children 
 of these classes are also received. I was the Eesident Assistant- 
 Surgeon in this hospital for a period of six years, — from June, 
 1838, to October, 1844. 
 
 The Jamsetjee Jejeebhoy Hospital has 300 beds : of these 240 
 are for males, and 60 for females. It is for the reception of native 
 sick of all castes and countries (Europe excepted). A large pro- 
 portion of the inmates belong to the poorer classes of the civil 
 population, and many of them are received into the hospital in 
 a very destitute condition. A smaller proportion consists of sick 
 labourers, artificers, lascars, and watchmen who are in the employ- 
 ment of Government. The hospital is open for the free admission, 
 on application, of the sick of those numerous classes for whose 
 relief it is intended. I discharged the duties of principal Medical 
 Officer of this hospital for a period of nine years, — from 1845 to 
 1854, and again for a year and a half between 1856 and 1859. 
 
 During the period of my service in the European General 
 Hospital, 9303 admissions took place : and during that in the 
 Jamsetjee Jejeebhoy Hospital 34,719 in-patients, and about 
 90,000 out-patients were treated.* 
 
 These statements are made with the view of showing a part of 
 the extent and kind of clinical experience, on the faith of which 
 I have ventured to express myself with some degree of con- 
 
 * The admissions during my service in this hospital subsequent to the publication 
 of the First Edition of this work are not included. 
 
12 REMARKS ON THE STATISTICS OF 
 
 fidence on several points of pathology and therapeutics. The 
 Tables hereto appended are inserted with a similar object, as 
 well as with reference to the few practical inferences which 
 may be deduced from them; and as affording data necessary 
 to the calculations in the tabular statements of jDarticular diseases 
 which will be found in different parts of this work. 
 
 Tables I. and IV. relate to periods of my own service in these 
 hospitals: Tables II. and III. have been supplied to me by the 
 kindness of Dr. Stovell, when surgeon of the European General 
 Hospital. 
 
 The inferences which may be drawn from these Tables, relative 
 to the proportion of sickness and death in Bombay in different 
 seasons of the year, are not to be received as absolutely correct ; 
 because the classes of the community, both European and native, 
 whose sick resort to these hospitals, are a fluctuating body, of 
 whose varying numbers at different seasons of the year there is 
 as yet no accurate census. Still the inferences, such as they are, 
 may be stated here. 
 
 In the fifteen years from 1838 to 1853, the admissions into 
 the European General Hospital amounted to 20,146, and the 
 average mortality to 6-3 per cent. Of these admissions 10,495 
 took place in the half-year from June to November*, and 9653 
 in that from December to May ; being an excess of 840 in favour 
 of the first period. But the mortality in the first stated half- 
 year was 5*7 per cent, and that in the second 6*9 ; beiDg an 
 excess of 1 *2 in favour of the latter. 
 
 In the six years from 1848 to 1853 the admissions (Table IV.) 
 into the Jamsetjee Jejeebhoy Hospital were 25,190, and the 
 average mortality 16 3 f per cent. Of these admissions 12,465 
 took place in the half-year from June to November, and 12,725 
 in that from December to May; being an excess of 259 in favour 
 of the latter. But the mortality in the first-stated period was 15*4 
 
 * 1 divide the year in tin's manner, because in Bombaj' from June to November 
 includes the rainy season and that immediately succeeding il, and, therefore, the 
 season in which malaria is chiefly generated. From December to May in Bombay 
 includes tin- .old and hoi months, and, therefore, the seasons in which both cold and 
 heat, as exciting ranges of disease, are influential. 
 
 f The statistical inquirer, possessing no other information respecting these hospitals 
 than that supplied by the figures, would conclude either thai disease is more fatal to 
 natives than to Europeans in Bombay, or that treatment was less judicious in the 
 Jamsetjee Jejeebhoy Eospita] than in the European Eospital. Both inferences would 
 
 be ei-roiu s. The explanation is simply this, that a large proportion of the inmates 
 
 of the Jamsetjee Jejeebhoy Eospita] is admitted in a destitute state, and in far 
 
 advanced Stages "f disease; hence the high mortality. 
 
TUB BOMBAY HOSPITAL*. 
 
 13 
 
 per cent, and that in the second 17*1 ; being an excess of 1-7 
 in favour of the latter. 
 
 I learn from Mr. Leith's Mortuary Eeturns of Bombay, that 
 the deaths in five years, from 1848 to 1853, amounted to 68,423; 
 of these, 29,667 took place in the half-year from June to Novem- 
 ber, and 38,756 from December to May : being an excess of 9089 
 in favour of the latter period. 
 
 These Returns, however, enable us further to divide this mor- 
 tality into that proceeeding from all causes except epidemics 
 (52,450), and that proceeding from epidemic causes, viz. cholera, 
 small-pox, measles (15,973), and to show that in the half-year 
 from December to May there is of the first class (all causes) 
 an excess in the mortality of 2300 ; and of the second (epidemic) 
 an excess of 6789. 
 
 Though the half-year from December to May is that in which 
 the fluctuating population of Bombay is most numerous, still I 
 think it may be fairly inferred from these several statements, 
 that the period which includes the monsoon and succeeding 
 season is that of the greatest amount of sickness not epidemic ; but 
 that the half-year which includes the cold and hot months is that 
 of the greatest mortality both from general and epidemic causes. 
 
 Table L* — Admissions and Deaths, vriih Per-centage, from all Diseases, 
 in the European General Hospital at Bombay for the Five Years from 
 July, 1838, to July, 1843. 
 
 
 
 
 Monthly 
 
 
 July, 1838, 
 
 to July, 1843. 
 
 Average. 
 
 
 
 Per Centage 
 
 
 Admissions. 
 
 Deaths. 
 
 of 
 Deaths on 
 Admissions. 
 
 January ....... 
 
 549 
 
 ■13 
 
 7-6 
 
 February 
 
 
 
 
 
 
 
 411 
 
 32 
 
 77 
 
 March 
 
 
 
 
 
 
 
 -506 
 
 33 
 
 65 
 
 April . 
 
 
 
 
 
 
 
 581 
 
 41 
 
 7* 
 
 May . 
 
 
 
 
 
 
 
 860 
 
 80 
 
 9-3 
 
 June . 
 
 
 
 
 
 
 
 781 
 
 51 
 
 6-6 
 
 July . 
 
 
 
 
 
 
 
 718 
 
 37 
 
 5-1 
 
 August 
 
 
 
 
 
 
 
 607 
 
 35 
 
 5.7 
 
 •mber 
 
 
 
 
 
 
 
 546 
 
 52 
 
 9-5 
 
 October 
 
 
 
 
 
 
 
 722 
 
 27 
 
 3-7 
 
 November 
 
 
 
 
 
 
 
 685 
 
 47 
 
 6-8 
 
 December 
 
 
 
 
 
 
 
 613 
 
 66 
 
 10-7 
 
 
 T( 
 
 >tal 
 
 
 
 
 
 7579 
 
 544 
 
 7-1 
 
 * In this Table, and in all the others throughout the work, the figured details 
 of each year were given in the First Edition, but it is now considered convenient to 
 orait them. 
 
14 
 
 REMARKS ON THE STATISTICS OF 
 
 Table II. — Admissions and Deaths, with Per-centage, from all Diseases, 
 in the European General Hospital at Bombay for the Five Tears from 
 1844 to 1848. 
 
 
 
 
 
 
 
 
 1844 to 1848. 
 
 Monthly 
 Average. 
 
 
 
 
 Per Centage 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 January ....... 
 
 617 
 
 46 
 
 7-4 
 
 February . 
 
 
 
 
 
 
 
 516 
 
 35 
 
 6-8 
 
 March 
 
 
 
 
 
 
 
 485 
 
 30 
 
 6-2 
 
 April 
 
 
 
 
 
 
 
 509 
 
 31 
 
 60 
 
 May 
 
 
 
 
 
 
 
 583 
 
 30 
 
 51 
 
 June 
 
 
 
 
 
 
 
 714 
 
 33 
 
 4-6 
 
 July 
 
 
 
 
 
 
 
 679 
 
 36 
 
 5-3 
 
 August 
 
 
 
 
 
 
 
 549 
 
 15 
 
 2-7 
 
 September 
 
 
 
 
 
 
 
 458 
 
 22 
 
 4-8 
 
 October 
 
 
 
 
 
 
 
 605 
 
 38 
 
 6-3 
 
 November . 
 
 
 
 
 
 
 
 559 
 
 31 
 
 OO 
 
 December . 
 
 
 
 
 
 
 
 522 
 
 40 
 
 7-6 
 
 T 
 
 3tal 
 
 
 
 
 
 
 6796 
 
 387 
 
 5-7 
 
 Table III. — Admissions and Deaths, with Per-centage, from all Diseases, 
 in the European General Hospital at Bombay for the Fire Yeco^s from 
 1849 to 1853. 
 
 
 
 
 
 
 
 
 1849 to 1853. 
 
 Monthly 
 Average. 
 
 
 
 
 Per Centage 
 
 
 Admissions. 
 
 Deaths. 
 
 ot 
 
 Deaths on 
 
 Admissions. 
 
 January ....... 
 
 450 
 
 39 
 
 8 
 
 7 
 
 February . 
 
 
 
 
 
 
 
 369 
 
 18 
 
 4 
 
 9 
 
 March 
 
 
 
 
 
 
 
 440 
 
 34 
 
 7 
 
 7 
 
 April 
 
 
 
 
 
 
 
 517 
 
 25 
 
 4 
 
 8 
 
 May 
 
 
 
 
 
 
 
 518 
 
 24 
 
 4 
 
 6 
 
 June 
 
 
 
 
 
 
 
 572 
 
 29 
 
 5 
 
 1 
 
 July 
 
 
 
 
 
 
 
 529 
 
 33 
 
 6 
 
 2 
 
 Augusl 
 
 
 
 
 
 
 
 494 
 
 38 
 
 V 
 
 7 
 
 September 
 
 
 
 
 
 
 
 356 
 
 25 
 
 V 
 
 
 
 October 
 
 
 
 
 
 
 
 395 
 
 23 
 
 5 
 
 8 
 
 N.i\ ember . 
 
 
 
 
 
 
 
 524 
 
 30 
 
 b 
 
 7 
 
 December . 
 
 
 
 
 
 
 
 608 
 
 40 
 
 66 
 
 T 
 
 .tal 
 
 
 
 
 
 
 5772 
 
 358 
 
 62 
 
THE BOMBAY HOSPITALS. 
 
 15 
 
 Table IV. — Admissions and Deaths, ivith Per-centage, from, all Diseases, 
 in the Jamsetjee Jejeebhoy Hospital at Bombay for the Six Years from 
 1848 to 1853. 
 
 
 
 
 
 
 
 
 1848 to 1853. 
 
 Monthly 
 Average. 
 
 
 
 
 Per Centage 
 
 
 Admissions. 
 
 Deaths. 
 
 of 
 Deaths on 
 
 Admissions. 
 
 January ....... 
 
 2090 
 
 450 
 
 21-5 
 
 February . 
 
 
 
 
 
 
 
 1894 
 
 319 
 
 16-8 
 
 March 
 
 
 
 
 
 
 
 2149 
 
 386 
 
 17-9 
 
 April 
 
 
 
 
 
 
 
 2105 
 
 343 
 
 163 
 
 May 
 
 
 
 
 
 
 
 2183 
 
 287 
 
 13-1 
 
 June 
 
 
 
 
 
 
 
 2083 
 
 307 
 
 14-7 
 
 July 
 
 
 
 
 
 
 
 2020 
 
 306 
 
 151 
 
 August 
 
 
 
 
 
 
 
 1999 
 
 328 
 
 16-4 
 
 September 
 
 
 
 
 
 
 
 2062 
 
 311 
 
 15.1 
 
 October 
 
 
 
 
 
 
 
 2134 
 
 339 
 
 15-9 
 
 November . 
 
 
 
 
 
 
 
 2167 
 
 331 
 
 15-2 
 
 December . 
 
 
 
 
 
 
 
 2304 
 
 397 
 
 17-2 
 
 T 
 
 i ... 
 
 otal 
 
 
 
 
 
 
 25190 
 
 4104 
 
 16-3 
 
16 
 
 CHAP. III. 
 
 GENERAL REMARKS ON FEVERS IN INDIA. 
 
 Idiopathic fevers constitute a very important class of disease 
 in iDdia, as is apparent from the following statement* which 
 exhibits the per-centage of admissions and mortality from fevers 
 in the European and Native troops of the three Presidencies : — 
 
 
 Europeans. 
 
 Natives. 
 
 Presidency. 
 
 Per-centage of 
 
 Admissions to 
 
 Strength. 
 
 Per-centage of 
 
 Deaths 
 
 to Strength. 
 
 Per-centage of 
 
 Admissions to 
 
 Strength. 
 
 Per-centage of 
 
 Deaths 
 
 to Strength. 
 
 Bengal 
 Bombay . 
 Madras . 
 
 72-64 
 61-93 
 31-62 
 
 1-99 
 1-37 
 0-37 
 
 48-50 
 41-20 
 25-04 
 
 •528 
 •57 
 •30 
 
 When attention is directed to the Native civil population, abun- 
 dant evidence of the importance of this class of disease also appears. 
 In the Island of Bombay, the deaths from fever, in five years, 
 amounted to 27,212 f, which is in the ratio of 40*26 per cent of 
 the total mortality. 
 
 Exclusive of the eruptive forms, they are limited to inter- 
 mittent and remittent fever, caused by malaria ; and to ardent 
 continued fever, and febricula (ephemeral, common continued 
 fever), excited by ordinary causes. 
 
 The occurrence of typhoid fever f, in some parts of India, has 
 also been lately established. 
 
 The plague, yellow fever, maculated typhus, and relapsing 
 fever, are as yet unknown in India. 
 
 * "Vital Statistics of the Armies in India." By J. Ewart, M.D. 
 
 f "Deaths to Bombay." By A. II. Leith. 
 
 J The term typhoid throughou.1 this work is restricted to the sense in which it is 
 used by \h: Jenner, as signifying the enteric or intestinal form of zymotic continued 
 fever. 
 
17 
 
 CHAP IV. 
 
 OB INTERMITTENT FEVER. 
 
 Section I. — Different Types of Intermittent Fever. 
 
 I shall restrict my remarks to the three principal types of inter- 
 mittent fever, — quotidian, tertian and quartan. The further 
 varieties — double and duplicated tertian and quartan — doubtless 
 occur, but the)' are practically unimportant : indeed, when the 
 object of treatment from the very commencement of an attack 
 is to prevent the recurrence of the paroxysm by antiperiodic 
 remedies, the character not only of these varieties, but also of the 
 leading types, is liable to be modified, and the opportunity of 
 studying the natural course of the disease is lost. 
 
 It has been generally stated by systematic writers that, of the 
 three leading forms, the tertian is the most frequent, then the 
 quotidian, and lastly the quartan. 
 
 The statement, relative to the quartan type, will be generally 
 accepted. Of 243 cases of intermittent fever in Natives of different 
 castes in Bombay, selected for the purpose of clinical instruction, 
 there was not a single instance of the quartan form. Of 1344 
 cases of intermittent fever treated dining the period of my service 
 in the European General Hospital, the quartans, if any, were 
 very few in number. 
 
 That tertians are more common than quotidians, is not con- 
 firmed by my experience, and is opposed to that of observers in 
 India generally. Of the 243 clinical cases, 211 were quotidians 
 and 27 tertians, and of 5 the type has not been recorded. In 
 the European General Hospital the greater prevalence of the 
 quotidian type, more particularly during the malarious months, 
 in first attacks, in seamen, the military staff of the garrison and 
 the poorer classes of the fixed resident European community, has 
 also been noted by me. Nor has my observation on this point 
 been confined to the Island of Bombay. At an earlier period of 
 my service, while doing duty with Her Majesty's 4th Light 
 
 c 
 
18 INTERMITTENT FEVER. 
 
 Dragoons, at Kirkee in the Deccan, the same fact respecting inter- 
 mittent fever in that regiment during the monsoon season was 
 noticed by me. 
 
 Though the quotidian is the most common form in India*, still 
 the tertian is also of frequent occurrence. Nor is it difficult to 
 explain the different circumstances in which these types resj^ec- 
 tively occur. 
 
 Quotidians will be found to prevail most generally at those 
 seasons of the year when the generation of malaria is supposed 
 to be actively going on ; and they may probably be viewed as 
 affording evidence of the recent action of the morbific cause. It 
 is the type which the disease for the most part assumes in first 
 attacks. 
 
 Tertians, on the other hand, usually occur in individuals who 
 have suffered on previous occasions, and in whom the fresh attack 
 is often traceable to ordinary and recently applied exciting causes, 
 as sudden alternations of temperature, atmospheric moisture, fatigue, 
 debauch, &c. The occurrence of this type may generally be re- 
 garded, not as the evidence of the recent introduction of malaria 
 into the system, but as that of a pre-existing abiding influence, 
 sometime dormant, now re-excited into action by an ordinary 
 cause. 
 
 If these views be correct, quotidians may be looked for chieffy 
 from May to October in districts within the range of the rains 
 of the S. W. monsoon, in November and December in those 
 subject to the influence of the N. E. monsoon, and from August to 
 October in tracts exposed to river-inundation and recession. Ter- 
 tians, on the other hand, may be expected in the colder months of 
 the year, December, January, and February ; also in the course of 
 the monsoon season on the occurrence of sudden changes of atmo- 
 spheric temperature or moisture. 
 
 Moreover, if it be true that the tertian type implies a pre- 
 existing malarious influence, then we may generally expect it to 
 appear in individuals who have been resident in malarious locali- 
 ties, and to be frequently complicated with splenic enlarge- 
 ment. Of the 27 clinical cases of tertian fever, the atmospheric 
 
 * Though tlif quotidian is the most common type in India, and in other countries 
 also, it does not follow that this is the proportion observed in all countries in which 
 intermittenl fevers prevail. It appears in the Statistical Report of the army of the 
 United States of America, that in the Northern Division, north of 40° N„ the Middle 
 Division, between 35° and 40° N., and the Southern Division, between 30° and 35°, 
 tertians predominate; bu1 thai in Florida, Texas, and California, quotidians pre- 
 ponderate. 
 
DIFFERENT TYPES. 19 
 
 vicissitudes of the monsoon season were influential on 18 : of 
 these, 16 were dockyard peons*, and in 14 splenic enlargement 
 was present. In the European General Hospital, the tertian type 
 was present most generally in individuals who had suffered from 
 the more obstinate intermittents of the autumnal months of other 
 localities; and who had been either sent to Bombay, with the 
 .view of deriving benefit from change of climate, or who had arrived 
 there at certain seasons in the course of their professional duties. 
 They consisted chiefly of European seamen, who had acquired the 
 disease while serving in the Persian Grulf, the Eed Sea, on the 
 Coast of China |, or in the steam flotilla of the river Indus. They 
 arrived in Bombay usually after the opening of the season subse- 
 quent to the monsoon, viz., in November, December, and January ; 
 and, under exposure to the atmospheric vicissitudes of these 
 months, became liable to tertian attacks. A cachectic state and 
 an enlarged spleen were also frequently present in this class of 
 seamen. 
 
 These opinions on the causes of the relative prevalence of the 
 
 * Of the 243 clinical cases, 85 were dockyard peons ; many of them, however, 
 readmissions, as the period extends to six years. I was previously familiar with the 
 dockyard at Bombay as a malarious locality, from my experience in the European 
 General Hospital, to which I shall have to allude in connection with remittent fever. 
 The frequent admission of these peons into the Jamsetjee Jejeehhoy Hospital, con- 
 firmed my former impressions, and I requested Dr. Bhawoo Dajee, at the time one of 
 my clinical clerks, to ascertain from one of the peons the leading facts connected with 
 their service. The following is a summary of the information thus obligingly obtained 
 for me : — 
 
 There are fifty dockyard peons. They wear a blue woollen dress, which they may 
 lay aside for a cooler material in the hot weather. Their pay is sufficient to supply them 
 with the food of good quality and adequate quantity used by their class. About one-half 
 are Hindoos, the other Mussulmans. They live within the precincts of the dockyard. 
 Their place of sleeping varies according to the duty of the day. They sleep in the 
 open air in the dry season ; in a shed during the monsoon, but are still liable to be 
 exposed to air currents. They are on duty four hours in the day and four in the 
 night. These periods are respectively divided into a service of two hours, and an 
 interval of rest for four hours; for example, a peon serving from 6 a.m. to 8 a.m. returns 
 at noon, precisely, to serve two hours more — 12 till 2 p.m. The same order is observed 
 in respect to the four hours' night duty. While on duty they are walking about 
 as guards of the stores, &c. In the day many use an umbrella to protect themselves 
 from the heat of the sun, but many do not. They do not get wet in the monsoon, for 
 they lvsort to guard-rooms and sheds for shelter. The sickness from fever, which 
 they are aware is considerable, and chiefly in the rains, is attributed by them to the 
 air and water of the place. There is no complaint of want of attention to clean- 
 liness, nor are they annoyed by disagreeable odours. The water they use is not 
 brackish. 
 
 t This was at a time when military operations were being carried on in China. 
 
 C 2 
 
20 INTERMITTENT FEVEK. 
 
 quotidian and tertian types*, might be readily strengthened by a 
 reference to other sources; but they are not brought forward with 
 any claim to novelty, nor with any desire to enforce them. 
 They have seemed to me to suggest a generalisation practical 
 in its tendency, and probably the best which at present can be 
 offered. 
 
 Section II. — Simple Intermittent Fever. — Symptoms, Pathology, 
 
 and Treatment. 
 
 Symptoms. — The intervals of twenty-four, forty-eight, and 
 seventy-two hours, which distinguish the quotidian, tertian, and 
 quartan t}-pes of intermittent fever, are so fully set forth in 
 systematic treatises on disease that it is unnecessary further 
 to describe them. The not unfrequent transition, however, of 
 one type into another, is a circumstance of practical im- 
 portance. The quotidian may become tertian in its character 
 before it finally ceases, and this change in type is an indi- 
 cation that the disease is in progress towards recovery. On 
 the other hand, the tertian (and it is occasionally observed in 
 the quartan also.) may pass into the quotidian type, or the 
 quotidian may assume the remittent form : these occurrences 
 evince an aggravation of the disease, and careful inquiry will 
 sometimes show that this has been coincident with the access of 
 inflammation in an important internal organ. 
 
 It is generally stated, that the period of attack of the quotidian 
 is the morning, of the tertian about noon, and of the quartan 
 the afternoon. Of the 243 clinical cases of which 211 were 
 quotidian, 27 tertian, and none quartan, the period is noted 
 in respect of 155 cases: of these it was between 6 a.m. and 
 2 p.m. in 74, and after 2 p.m. in 81. This statement, then, 
 does not accord with that of systematic writers, but their accu- 
 
 * The discrepancy in respect to the relative prevalence of tertians and quotidians 
 is also in part probably due to the very general sense in which the term tertian was 
 used by the old writers, Cleghorx, in his "Observations on the Epidemical Diseases 
 in Minorca from 1711 to 171!'." ases the term in a generic sense, and includes under 
 it intermittents and remittents of various types and severity. It would seem that the 
 word tertian suggested to these writers the doctrine of the odd days of Hippocrates, 
 and by such phrases as simple, double, triple, and semi-tertian, they are made to 
 accord with it. Gleghobn describes a tendency in these fevers gradually to lessen 
 and to terminate on the odd days, as the oth. 7th, 9th, and 11th; also the occasional 
 tendency of simple tertians to bee., me double, then remittent, and ultimately con- 
 1 i nued. 
 
SYMPTOMS — COLD STAGE. 21 
 
 racy is not, therefore, to be called in question, for it has been 
 already explained that the treatment of the disease by the 
 early exhibition of antiperiodics tends to destroy its natural cha- 
 racters, by either preventing or postponing the recurrence of the 
 paroxysm. 
 
 The division of the febrile paroxysm into cold, hot, and sweating 
 stages, the greater duration of the cold in tertians and quartans, 
 and that of the hot stage and indeed of the entire paroxysm in 
 quotidians are well known facts. It is assumed that the clinical 
 student is already acquainted with the phenomena characteristic of 
 these several stages ; but there are facts in respect to each which it 
 is important to impress upon him.* 
 
 First, of the cold stage it should be recollected that the action 
 of the heart is depressed from the sedative influence of the mor- 
 bific cause, and that the blood in consequence tends to circulate 
 languidly and to accumulate in important internal organs. Some- 
 times the congestion is present in unusual degree in particular 
 organs: giving rise in the brain to undue drowsiness and sense of 
 weight in the head, ringing in the ears, and various undefinable 
 sensations; occasioning, when in the lungs, the heart, and great 
 vessels, a sense of great precordial oppression, a respiration un- 
 usually hurried and sighing, and a pulse very feeble and depressed. 
 Or the undue congestion may exist in the stomach and liver, and 
 lead to much retchiug and vomiting, and derangement of the 
 biliary secretion ; or it maybe to the mucous membrane of the 
 intestinal canal, and be attended with copious intestinal discharges. 
 It should be further remembered that, associated with these several 
 local phenomena, there will be present some degree of the general 
 depressed state of the circulation characteristic of the cold stage, 
 indicated by a feeble pulse, a pale skin and features more or 
 less contracted. When these undue local congestions occur, the 
 duration of the cold stage is generally prolonged, and the hot 
 and sweating stages are sometimes so slight as readily to escape 
 notice. 
 
 These exceptional cases are important, not so much from being 
 generally attended with immediate danger to life, for such is not 
 usually the case; but from their nature being very often misunder- 
 stood. They are apt to be regarded as instances of congestion 
 
 * If the reader has not these details present in his mind, he should refer to some 
 systematic treatise; otherwise the occasional facts to which allusion is chiefly made ia 
 the text may assume undue prominence in his estimation. 
 
 c 3 
 
22 INTERMITTENT FEVER. 
 
 or other derangement, independent of malarious influence, and 
 thus to suggest needless alarm, and prompt to injurious and un- 
 successful treatment. The right diagnosis can only be established 
 by a careful consideration of all the circumstances of each par- 
 ticular instance ; such as the existence or absence of previous 
 attacks of malarious fever, or of exposure to malarious season or 
 locality, and the periodicity or persistence of the phenomena. 
 Inquiry on these points, coupled with due attention to the habits 
 of the individual, and a careful scrutiny into the physical condition 
 and functional state of all important organs, will generally conduct 
 to a satisfactory conclusion. 
 
 The kind of phenomena just alluded to have frequently been 
 described under the name of "Masked Intermittent."' But as they 
 are evidently more related to one stage than to the entire paroxysm, 
 there is a practical advantage in noticing them in connection with 
 that stage.* 
 
 Hot Stage. — The degree'of febrile reaction varies in the different 
 types of the disease, and is also related to the character of the 
 constitution of the individual affected. The excited circulation, 
 the increased heat of the surface, the diminished secretions, the 
 thirst, the coated tongue, the restlessness, and the headache are 
 present in greater degree in the quotidian than in the tertian type ; 
 and in the sthenic constitution of youthful Europeans lately 
 arrived in India, than in the more or less asthenic condition of 
 the old resident European and of the different classes of the 
 native population. 
 
 The state of the tongue is in many respects a useful practical 
 guide. It is frequently more coated in attacks of ephemeral fever 
 than in true intermittents : while in the latter the degree of fur 
 is not only related to the duration of the hot stage of each 
 paroxysm, but also to the state of the patient's system. The 
 tongue is more coated in the quotidian type and in sthenic 
 habits, than in the tertian type and in asthenic constitu- 
 tions: indeed, it frequently happens in tertians, sometimes even 
 in quotidians, in asthenic natives that the tongue is nearly 
 quite clean throughout the paroxysm as well as the inter- 
 mission. Again, in tertian fevers on the morning of the day 
 of the paroxysm we are occasionally, by the coated or clean 
 
 * The occasional occurrence of great and dangerous congestive phenomena at the 
 outset of malarious fevers will be noticed in connection with the remittent type ot 
 ferer, 
 
SYMPTOMS — IIOT AND SWEATING STAGES. 23 
 
 state of the tongue, enabled to judge of the probability of the 
 attack. 
 
 It is useful to bear these facts in mind, but in order to 
 appreciate them truly it is necessary to recollect another im- 
 portant fact, viz., that by the undue use, in fever, of mercurial and 
 other purgatives, and of preparations of antimony we may increase 
 and maintain a coated state of the tongue, and thus not only do 
 positive harm, but also vitiate the indications of a valuable 
 symptom. 
 
 Sweating Stage. — The disappearance of the febrile phenomena, 
 after more or less sweating, and the succession of a complete 
 intermission is the usual course observed in this disease. When 
 the subject of remittent fever comes under consideration, it will 
 be explained that occasionally, instead of the usual remission of the 
 febrile reaction, a state of dangerous . — it may be fatal — collapse 
 unexpectedly occurs. Though an event of this kind is unusual 
 after a paroxysm of intermittent fever, still there are cir- 
 cumstances under which it is necessary carefully to guard against 
 it : in all instances of intermittent fever in very asthenic indi- 
 viduals, whether Europeans or natives, the degree of exhaustion 
 which attends the close of the paroxysm must be attentively 
 watched. If this precaution be neglected we shall assuredly, 
 from time to time, experience the painful surprise of learning 
 that our patient has died suddenly, and to us unexpectedly, with 
 perhaps merely symptoms of general exhaustion, or it may be 
 with some degree of diarrhoea, or tendency to coma. If in these 
 cases we are satisfied with judging of the progress of the disease 
 by the amount of the hot stage, a very serious error will often 
 be committed ; for it not ^infrequently happens that a diminu- 
 tion in the degree of febrile reaction precedes death by ex- 
 haustion. Indeed, a failing pulse, increasing emaciation, and 
 decreasing heat, ought to lead us to anticipate early and rapid 
 sinking at the close of a paroxysm, and to provide against it 
 by assiduous care in the use of appropriate stimulants and 
 nourishment. My attention was first directed to these clinical 
 facts in respect to natives in the year 1831, when in medical 
 charge of detachments on field service, at Sassoor in the Deccan ; 
 then in January 1844, while serving at Hyderabad in Scinde, with 
 the 15th Eegiment Native Infantry; and latterly in the clinical 
 and other wards of the Jamsetjee Jejeebhoy Hospital at Bombay. 
 As regards Europeans, the most striking instance which occurs to 
 me is that of an officer of the loth Eegiment at Ghana in Scinde, 
 
 c 4 
 
24 INTERMITTENT FEVEE. 
 
 who had suffered some months previously from several attacks of 
 intermittent fever while at Hyderabad. I saw this officer during a 
 recurrence of the disease at Grharra, and then the single paroxysm 
 was succeeded by a state of alarming collapse, requiring the free 
 use of alcoholic stimulants for its removal. My further experience 
 in India, subsequent to the publication of the first edition of this 
 work, not only in my own practice, but also in that of others 
 known to me, when officiating as superintending surgeon at 
 Poona, has again impressed upon me the importance of watching 
 for indications of exhaustion in intermittent fever in asthenic 
 subjects. Several fatal cases of this nature were reported to 
 me in the Poona division, and in all of them the medical 
 officers were unaware of the true explanation of the unlooked- 
 for event. 
 
 Pathology. — Mortality from Simple Intermittent Fever. That 
 in the cold stage of intermittent fever there is a sedative 
 influence exercised by the morbific cause on the heart, and 
 a tendency in the blood to circulate languidly and to accumulate 
 in the capillary system of important internal organs, may be very 
 safely affirmed. But whether this influence 'first acts on the blood, 
 and through it on the fibre of the heart, or intermediately on the 
 nervous system, or in any of the other various ways which the 
 imagination may suggest ; and what the nature of the changes 
 effected in the blood may be, are questions which have been much 
 discussed, without as yet having led to a satisfactory solution of 
 the difficulties with which the subject is beset. 
 
 Into these speculations I shall not enter. They are foreign to 
 the spirit of safe and useful clinical instruction. 
 
 The mortality in India, resulting directly from simple inter- 
 mittent fever, is not great ; but it is not accurately known, nor can 
 it be determined by ordinary hospital returns. During my service 
 in the European Hospital, the returns show a mortality of 1*33 
 per cent, from intermittent fever. But the complicated cases are 
 also included ; and, from the greater number of deaths having 
 taken place in December, February, March, and April, it is evi- 
 dent that the fatal result must have arisen from the sequelae of 
 the disease. 
 
 Though the immediate risk to life from a paroxysm of inter- 
 mittent fever is slight, still the mortality to which the disease 
 indirectly leads is very great, though not expressed in statistical 
 tahles as at present framed. 
 
 Continued exposure to malaria or frequent recurrences of inter- 
 
PATHOLOGY AND MORTALITY. 25 
 
 mittent fever engender, as is well known, a cachectic state of 
 the system ; in which the nutritive processes of the tissues 
 and of the blood are defective and perverted, and in which 
 splenic, hepatic, and other local congestions, tend to occur. This 
 cachexia not unfrequently terminates in death by exhaustion. 
 But it is not in this manner that the indirect mortality from 
 intermittent fever chiefly arises. It takes place because the 
 cachexia caused by the fever is a state in which the system 
 becomes very predisposed to local inflammation or congestion under 
 the influence of external cold. The structure most liable to be 
 thus affected is the mucous lining of the intestinal canal ; and the 
 diseases induced are classed, in hospital returns, under the heads 
 diarrhoea and dysentery. There can be no question that much of 
 the mortalit}- attributed in India to "bowel complaints" is, though 
 indirectly, yet fairly chargeable to the account of malarious fevers. 
 The principal season of malarious fever, excited by the direct 
 action of malaria, and consequently the chief season during which 
 this deterioration of the system occurs may, in general terms, 
 be said to range from June to the end of November. Then follow 
 December, January, February, and March, with their lower ab- 
 solute temperature, their greater range, their frequent chilling 
 winds ; and it is in these months that the asthenic constitution is 
 liable to suffer from dysentery and diarrhosa. 
 
 Further, if the malarious season be preceded bv one of 
 exhausting heat, and succeeded by one of considerable reduction 
 and alternations of temperature, whether from great diurnal 
 range, varying humidity, or chilling winds, then we have con- 
 ditions of climate which lead to much mortality, from the conse- 
 quences of intermittent fever, unless it be prevented or lessened 
 by judicious sanitary measures. 
 
 It would be easy to accumulate illustrations of this pathological 
 law, but it will be sufficient to refer to the most striking which 
 have passed under my own observation. After the conquest 
 of the province of Scinde, in the spring of the }*ear 1843, 
 troops were stationed in the fort and town of Hyderabad, and 
 in many of the adjacent villages. In July, the canals were 
 sensibly filling with the water of the Indus ; and during the 
 latter part of that month, as well as in August, the inundation 
 was at its height : the subsidence commenced in September and 
 continued during October. 
 
 The loth Eegiment, Xative Infantry,* was stationed during 
 June, July, August, and part of September in a small village 
 
26 
 
 INTERMITTENT FEVER. 
 
 close to the west Lank of the Indus, surrounded by broken 
 ground, water-cuts, and cultivated fields interspersed with trees 
 and covered with underwood. It was then moved to another 
 position not less malarious, and finally located in the fort of 
 Hyderabad, where I assumed medical charge of this corps at 
 the end of December, continued with it at Hyderabad throughout 
 the greater part of January, and accompanied it down the Indus 
 to Tatta, thence to Grharra (where we were detained about fifteen 
 days), and finally by Kurrachee to Bombay, which we reached 
 towards the end of February. 
 
 The following statement shows the strength of this regiment, 
 with the numbers ill from fever, and the total mortality during 
 the greater part of the period above adverted to : — 
 
 15th Regiment Bombay Native Ixtaxtet. 
 
 1843. 
 
 Strength. 
 
 • 
 
 Fevers. 
 
 Total Deaths. 
 
 June ...... 
 
 887 
 
 97 
 
 1 
 
 July . 
 
 
 
 
 
 958 
 
 ■44 
 
 4 
 
 August . 
 
 
 
 
 
 1012 
 
 153 
 
 3 
 
 September 
 
 
 
 
 
 1046 
 
 580 
 
 6 
 
 October . 
 
 
 
 
 
 1024 
 
 973 
 
 6 
 
 November 
 
 
 
 
 
 998 
 
 1095 
 
 32 
 
 December 
 
 
 
 
 
 948 
 
 896 
 
 25 
 
 The great increase of fever in September and October is well 
 shown ; and of the cases under treatment in November and 
 December, a large proportion remained from the admissions 
 of the two preceding months, proving the obstinacy of the dis- 
 ease, and tin- frequent occurrence of its sequelae. 
 
 In November the tempei'ature at Hyderabad begins to fall, 
 and continues to decline in December and January. North- 
 easterly winds also commence, and are frequently fresh and 
 chilling. The comparison of the mortality of November and 
 DeceinlnT with that of the months preceding is very striking: 
 the great increase was caused chiefly by dysentery. The 
 precise number* of deaths in January ami February is un- 
 known to me; but th. greal mortality from bowel complaints 
 
 * The numbers given above, and those stated in Mr. Carter's paper <>n the preva- 
 lence of intermittent fever, &c«* in Sindh i Transactions, Bombay Medical and Physical 
 Society, No. 8, p. 32), will be observed to be the Bame. Both are taken from the 
 game source, my MS. d 
 
PATHOLOGY AND MORTALITY. 27 
 
 continued, and frequent bronchitic and occasional pneumonic 
 complications, with in some instances death, apparently from 
 oedema of the lungs, also occurred. 
 
 During part of the year 1843 the Bombay 2nd European 
 Regiment was divided. One wing was moved to Kurrachee 
 in Scinde in May, was healthy, and lost few men ; the 
 other wing was stationed at Bhooj in the province of Cutch 
 during the monsoon and suffered much, chiefly in September, 
 from intermittent and remittent fever. The sick of this wing 
 were sent to Mandavie, on the coast of the province, with 
 a view to their transport to Bombay, but they were delayed 
 there about a month, badly supplied with quinine and other 
 necessaries ; and then, instead of being sent to Bombay, were 
 shipped to Kurrachee, and arrived there in November. About 
 the middle of December, through the kindness of Mr. Cahill, 
 the surgeon of the regiment, I was permitted to visit the hospital 
 at Kurrachee. It contained 237 sick, chiefly men from Cutch, 
 and there were still upwards of 100 sick left behind at Mandavie. 
 In many the spleen was enlarged, and some were anasarcous ; 
 and 40 deaths, chiefly from dysentery, had taken place between the 
 beginning of November and the period of my visit. 
 
 During the monsoon of 1841, Her Majesty's 17th Regiment 
 was stationed in the barracks at Colaba, in the island of Bombay. 
 This season of that year was generally unhealthy in the island, 
 and the following admissions of malarious fever took place in 
 this regiment : — 
 
 In June 
 
 . 55 
 
 In November 
 
 . 180 
 
 July 
 
 . 136 
 
 December 
 
 . 180 
 
 August 
 
 . 165 
 
 January . 
 
 50 
 
 September 
 
 . 187 
 
 February . 
 
 . 3S 
 
 October . 
 
 . 37-5 
 
 
 
 Dr. A. S. Thomson, from whose report * this statement is taken, 
 thus writes : — " In October a few cases of dysentery occurred ; 
 but when the cold nights of November and December came, 
 dysentery became more prevalent, and 130 cases were admitted 
 during these two months, and 23 died." 
 
 During the month of October, 100 fever cases of the 17th 
 Regiment were treated in the European General Hospital ; all 
 came under my observation, and many under my immediate care. 
 
 * Transactions, Medical and Physical .Society of Bombay, No. 5. \\ 84. 
 
28 INTERMITTENT FEVER. 
 
 I had, therefore, a personal knowledge of the character of the fever 
 and of the condition of the men. 
 
 Treatment of Simple Intermittent Fever. — The treatment must 
 be considered with reference to the several stages of the paroxysm 
 and to the intermission. 
 
 If the cold stage merely threatens, if it be the first or second 
 paroxysm, if the tongue be coated, expanded and not florid, and 
 the constitution of the individual be good, and evacuant remedies 
 have not been previously exhibited, then an emetic of ipecacuanha 
 may be given with advantage. If, on the other hand, the circum- 
 stances which indicate the use of an emetic are not present, a mode- 
 rate opiate may be substituted. But when the cold stage has fairly 
 formed, all that can be done is to lessen the discomfort of the 
 patient by additional covering, the use of external heat to the 
 extremities and the exhibition of warm diluents. It may occa- 
 sionally happen, when the depression is very great, that the use of 
 ammoniated and other stimulants is indicated ; but this is seldom 
 necessary in Indian intei mittents, except in very asthenic indi- 
 viduals. 
 
 In the hot stage there is excess of vascular action, and the 
 indication is to carry the patient on to the sweating stage witli 
 as little of this excess of action or of derangement of other functions 
 as can be safely effected. To prevent this stage or materially 
 to shorten it is beyond our power, but by judicious management 
 the general discomfort and the amount of derangement of par- 
 ticular functions may be considerably mitigated. 
 
 In youthful sthenic Europeans at the commencement of first 
 attacks, when febrile excitement runs high with headache and 
 much flushing of the face and a pulse full and firm, then 
 general blood-letting, to the extent of sixteen or twenty ounces, 
 may occasionally be an expedient and useful proceeding; but 
 when carried beyond this or used at more advanced periods or 
 in other states of constitution, it is not only unnecessary but 
 becomes positively injurious: it accelerates the cachectic condition, 
 and not only does not check the progress of the attack, but tends 
 to protract it. 
 
 Undo- the usual circumstances of intermittent fever in India, 
 it is sufficient to allay the vascular excitement by light clothing, 
 the removal of all laedentia, sponging the surface of the body 
 repeatedly with tepid water, cold applications to the head, suitable 
 drinks, and the use of antimonials, ipecacuanha, aqua acetatis 
 ammoniae, or nitrate of potash, in moderate doses. In cases in 
 which headache Is much complained of, ami no contra-indication 
 
TREATMENT — DURING THE PAROXYSM. 29 
 
 exists*, leeches may be applied with advantage in the first or 
 second paroxysms. If the tongue be coated, expanded, not florid 
 at the tip and edges, the bowels confined, and the stomach not 
 irritable, and the paroxysm be the first or second, and not far 
 advanced, then an emetic of ipecacuanha, followed by a mild 
 purgative should be had recourse to. These evacuant remedies 
 are adopted partly with the view of lessening vascular excitement, 
 but chiefly with that of preparing the system for the fullest influ- 
 ence of the means of cure appropriate to the intermission. 
 
 During the siveatinq stage, under ordinary circumstances, there 
 is little to be done. The surface must be protected by adequate 
 coverings from the risks of too rapid evaporation on the one hand, 
 while on the other the excess of sweating which will result from 
 too much covering must be avoided. While these principles are 
 sufficient for the ordinary management of this stage, still what has 
 been already stated in respect to the occasional occurrence of great 
 and unlooked-for exhaustion must be carefully remembered. When 
 this event is indicated, then no suitable means of strengthening 
 the patient must be left untried, and towards the close of the 
 paroxysm stimulants and animal broths must be freely given. 
 
 It has been stated, that the treatment during the paroxysm is 
 palliative, and should be as little debilitating as possible ; but 
 nothing so certainly debilitates the system and accelerates cachexia, 
 with all its attendant evils, as a frequent recurrence of the febrile 
 paroxysm. Therefore, to prevent this is the leading indication in 
 the management of the intermission, and, it may be added, in 
 the treatment of this disease. This object is to be effected by the 
 exhibition of antiperiodic remedies ; and the earliest intermission 
 should, with this view, be taken advantage of. Quinine is the 
 only certain and generally appropriate medicine of this class. 
 There has been much discussion in respect to the best method 
 of using quinine ; but it will be sufficient for me to state the 
 opinions which I have myself formed from clinical experiment and 
 the study of the written observations of others : — 
 
 1. The quantity of quinine sufficient to prevent the paroxysm 
 
 * In recommending the use of leeches in India, it is impossible to he precise in 
 regard to the number. The leech varies much in size in different parts of the country. 
 The number must further depend on the state of the constitution and the degree of 
 local vascular derangement. I would, however, express my belief that local blood- 
 letting should, as a rule, not be carried to the degree of very sensibly depressing the 
 general action of the heart, but be used chiefly with a view to its local derivative 
 action. 
 
30 INTERMITTENT FEVER. 
 
 varies according to the severity of the attack, or, in other words, 
 the intensity of the malarious influence. 
 
 2. It should be given during the intermission in such manner 
 as to ensure the whole quantity being taken at least three hours 
 before the expected paroxysm, so that it may be absorbed and 
 assimilated. 
 
 3. In Indian intermittents, from twelve to thirty grains are in 
 general sufficient. In more intense intermittents it may be neces- 
 sary to give sixty grains and upwards, but of these larger quanti-. 
 ties I have no personal experience. The selection of the quantitv 
 in the first intermission will depend on the circumstances of the 
 case, indicating the probability of much or little malarious in- 
 fluence; and correct judgment in this particular can only be 
 acquired by careful clinical observation. 
 
 4. According to Briquet, quinine in doses of from two and a 
 half to four and a half grains stimulates the circulation, respiration, 
 and nutrition ; but in doses of from nine grains and upwards it 
 exercises a disturbing and sedative influence on the nervous s} T stem, 
 the circulation and general muscular system, which, when present 
 in great degree, may endanger life. These are the effects of qui- 
 nine on the system in a normal state ; but in intermittent fever 
 there is a tolerance of this agent, by which is meant that these 
 characteristic symptoms of depression (cinchonism) require a larger 
 quantity for their production ; therefore, generally speaking, there 
 will be tolerance of that quantity which, in particular cases, is 
 required to prevent the access of the paroxysm. Consequentlv 
 this quantity may be given in one dose with perfect safety. On 
 this point, however, my own experience does not extend beyond 
 doses of twenty grains.* But, in applying this rule, it is necessary 
 to remember that an exhausted state of the system diminishes the 
 tolerance for quinine; and that, therefore, even when there is evi- 
 dence of much malarious influence, large doses are unsafe in 
 states of exhaustion and collapse. From this it follows, that 
 where there is much sweating and debility at the close of the 
 paroxysm, the quantity of quinine allotted for the intermission 
 should be given at intervals, — in four or five-grain doses, — ac- 
 companied with suitable stimulants and nourishment. 
 
 5. The practice of giving the whole quantity at once, or in 
 
 * The exclusive exhibition of quinine in scruple or half-drachm doses, instead of 
 smaller ones frequently repeated, firsl followed by French ami American physicians, 
 has been chiefly advocated in the treatment of Indian intermittents by Drs. Corbyn, 
 Mackinnon, Maetier, ami 0. Murchison (" [ndian Annals of Medical Science," No. 1, 
 and "Edinburgh Medical and Surgical Journal for April, 18-3.3"). 
 
TREATMENT — DURING THE INTERMISSION. 31 
 
 divided doses, should vary in different cases. Assuming that the 
 quantity has been correctly determined with reference to the 
 tolerance, it will, in the great proportion of cases, be effective in 
 quotidians at whatever period of the intermission it is given, pro- 
 vided this be at least three hours before the expected paroxysm ; 
 and as tbe quantity in each case is supposed to be regulated with 
 reference to the tolerance, it may be given in one dose with safety, 
 and when there is not time for divided doses, it is best thus to 
 use it. 
 
 6. When there is doubt in respect to the quantity likely to be 
 required, when there is sufficient time, when there is an exhausted 
 state of the system, and when the type is tertian or quartan, then 
 quinine is most advantageously given at suitable intervals in from 
 three to six- grain doses, between the cessation of one paroxysm and 
 three hours from the expected period of the next. 
 
 7. Tt is unnecessary to give quinine till symptoms of cinchonism 
 begin to appear ; for this is to overstep the tolerance, in pursuit of 
 a guide which the experienced physician does not require. 
 
 8. Though the full quantity of quinine given in one dose in the 
 sweating stage is sufficient to prevent the accession in an ordinary 
 quotidian, still the conclusion, from my own clinical experience, is, 
 that its power is greatest when given nearer to the period of ex- 
 pected paroxysm, provided time is allowed for absorption and 
 assimilation. 
 
 9. The idea that quinine has a diaphoretic action would seem to 
 have arisen from inattention to the fact that a checked, but not 
 prevented, paroxysm may be evidenced merely by a sweating stage 
 unpreceded by a hot one; and this may suggest the belief of 
 diaphoresis from the quinine, when in fact the quantity had been 
 sufficient merely to modify, but not to prevent the return. 
 
 10. The efficiency of quinine is most certain when exhibited in 
 perfect solution. 
 
 11. When large doses of quinine are necessary, when it is of 
 much moment to ensure its fullest therapeutic effect, and an idio- 
 syncrasy adverse to its action is supposed to exist, it is of great 
 importance that the patient, after taking the quinine, should be 
 kept very quiet; that his senses should be little acted on by light, 
 sound, or other external influences ; and that the excitement of 
 trains of thought, by reading, or conversation, should be avoided 
 as much as possible.* 
 
 * I am indebted to Dr. McLennan for having called my attention to the great 
 advantage residting from these preeaiitious. He informs me that, by observing them, 
 
32 INTERMITTENT FEVER. 
 
 12. After the recurrence of the paroxysm has been prevented, 
 quinine should be continued in decreasing quantities for the three 
 or four succeeding days. 
 
 Arsenic, in the form of arsenious acid, is the antiperiodic remedy 
 next in power to quinine ; but it is not so generally appropriate, 
 and requires the exercise of much caution and the careful selection 
 of cases to insure its safe administration. 
 
 The results of my clinical experience* of this remedy are ar- 
 ranged under the following heads : — 
 
 1. The principles relative to the exhibition of quinine during 
 the intermission, and a tolerance proportionate to the intensity of 
 the malarious influence, equally apply to arsenious acid. 
 
 2. In Indian intermittents, an eighth to a fourth of a grain 
 — that is fifteen to thirty minims of liquor potassse arsenitis — given 
 in the intermission, has no evident antiperiodic power. 
 
 3. Half-a-grain — one drachm of liquor potassse arsenitis — given so 
 as to be all taken two hours before the expected period of paroxysm, 
 
 he had on several occasions been enabled to give quinine with excellent effect to 
 patients with whom it had been previously believed to disagree, and that he is satisfied 
 that much of the utility of this essential agent in the treatment of malarious fever is 
 often lost from their neglect. Further, he is of opinion that this benefit derived from 
 mental repose may often be readily secured in practice by selecting, when the intermission 
 or remission corresponds, the stillness and darkness of night for the period of exhibition. 
 
 * These statements relative to the anti-periodic power of arsenic differ mate- 
 rially from those in the first edition. They consist, not of a correction of 
 previous error so much as of the residts of an extended experience. When passing 
 through Paris, on my return to India, I was fortunate enough to meet M. Boudin in 
 his hospital. The use of arsenic in intermittent fever came under discussion. My 
 unfavourable results were stated. M. Boudin not only kindly showed me cases under 
 treatment, but favoured me with the subjoined memorandum on his method of using 
 arsenic — 
 
 "Acide arsenieux, on gramme; can distillee, mille grammes: /aire bouiller pendant 
 un quart d'heure. Ajoutez vin blanc, mille grammes. 
 
 '•(.'cut grammes de eette liqueur representent cinq centigrammes, ou un grain 
 d'acide arsenieux. On donne a Paris en moyenne un demi-grain par jour, clans l'inter- 
 valle des acces. .Mais on peul donner plus. 11 importe de fractionner la dose totale le 
 plus possible. La tolerance pour I'arsenic baisse en general avec la disposition de la 
 fievre. Le premier signc d'intolerance est I'eau a la bouche. II faut profiter do la 
 tolerance pour saturer le malade. 11 faut continuer plus ou moins longtemps apres 
 la cessation de la fievre Opposer a la diathese paludienne un diathese arsenicale; 
 
 voila le bul qui je me propose. 
 
 " Boudin. 
 •• Paris, Le 1 1 Juillet, 1856." 
 
 I have since carefully read M. Boudin's paper on intermittent fever in the supplement 
 to the •' Dictionnaire des Dictionnaires de Medicine," also the article at p. 530 of the 
 2nd volume of the "Traite de < leographie e1 de Sta1 isques Medicales," by the same 1 
 author. To these works I would refer the clinical student for full information on 
 this interesting and Lmportanl subject 
 
TREATMENT DURING THE INTERMISSION. 33 
 
 is sufficient to prevent the recurrence in mild intermittents in 
 India. It may be exhibited with safety in this quantity in cases in 
 which there is no tendency to gastric or intestinal irritation, and most 
 advantageously in repeated doses of ten minims or less, sometimes 
 combined with a few minims of tincture of opium. 
 
 4. Half a grain of arsenious acid has seemed to me to be about 
 equivalent in power to fifteen grains of quinine. It may, therefore, 
 be easily understood why the quantity — an eighth to a fourth of a 
 grain — usually given, has no sensible effect in intermittent fever in 
 India. Three grains and a half to seven grains of quinine would 
 be equally inefficacious. 
 
 5. As fifteen grains of quinine are insufficient to prevent the 
 accession of the severer and greater number of Indian intermittents, 
 half a grain of arsenious acid is equally so ; but we may, in many 
 cases, without incurring the risk of larger doses of arsenic, econo- 
 mise quinine by preventing the recurrence in the first place by an 
 adequate quantity of quinine, and then trusting to arsenious acid 
 for the completion of the cure. 
 
 6. My experience is limited to the quantity of half a grain 
 in the intermission; but the practical question remains, whether 
 in intermittent fever in India, uncomplicated with gastric or 
 intestinal irritation, arsenic can with safety be given to the 
 extent of one grain and a half and upwards, as by M. Boudin, 
 and thus suffice for the cure of all cases ? The answer may 
 probably be thus stated : — M. Boudin has shown that by divided 
 doses, enemata, &c, the full effect of arsenious acid may be 
 obtained ; just as former physicians, by pharmaceutic skill, 
 achieved more with the crude cinchona than is ever now 
 attempted. Used with the skill and precaution observed by 
 M. Boudin, arsenious acid may be adequate for the effective 
 cure of Indian intermittents ; but the treatment of a disease 
 so common cannot be safely left to the contingency of great 
 experience and tact. 
 
 My practical knowledge of other anti-periodic remedies* is con- 
 
 * The subject of febrifuge remedies has been fully discussed in the 3rd, 4th, and 
 5th volumes of the "Indian Annals of Medical Science," by Falconer, Cleghorn, 
 Macpherson, Cornisb, and Waring. 
 
 There are questions of special therapeutic interest to the medical inquirer in India : 
 — (1.) To substitute cheap and common indigenous articles of materia medica for the 
 rarer and more expensive products of other countries is very expedient, as a measure 
 of convenience and economy. (2.) To strengthen the materia medica by the removal 
 of inert drugs and the addition of others of undoubted efficacy, is very essential to 
 the character and usefulness of practical medicine. The Indian Government and 
 
 D 
 
34 INTERMITTENT FEVER. 
 
 fined to the sulphate of bebeerine, muriate of narcotine, chiretta, 
 cossalpinia bonducella, berberry, and atees (Aconitum heterophyl- 
 lum). These in my hands have proved unequal to preventing the 
 paroxysm of ordinary intermittent^ ; and in estimating the value 
 of remedies of this class, it should be remembered that they are 
 of little value unless they produce this effect. The tendency 
 of a large proportion of cases, more particularly quotidians, at 
 the commencement of the rainy season, in climates in which the 
 rain-fall is not great, is to terminate spontaneously after from 
 the fifth to the ninth paroxysm : therefore there is no proof of 
 a febrifuge effect from remedies in fevers which have followed 
 this course. 
 
 The extent to which mercurial and other purgatives should be 
 given in the treatment of intermittent fever, depends upon the 
 state of the constitution, the duration of the attack, the appearance 
 of the tongue, the character and amount of the alvine discharges, 
 and the co-existence or not of hepatic or splenic congestion. When 
 the system is asthenic, when the disease has continued for some 
 time, and purgative remedies have not been neglected in the early 
 stages of treatment ; then it matters not what may be the state of the 
 tongue, or of the alvine excretions, or what the condition of the 
 liver or of the spleen, the period for further evacuation* by purga- 
 tives or other means has passed ; for, if now had recourse to, it will 
 favour the development of cachexia, the recurrence of the paroxysm, 
 and the persistence of the attack. Purgatives, moreover, under 
 
 Medical Boards have evinced a laudable desire to advance these objects ; hut the 
 means usually adopted have been insufficient, and have generally failed of success. 
 They have consisted of casual and hasty experiments, without reference to the prac- 
 tical qualifications of the experimenters or regard to the adequacy or appropriateness 
 of the conditions of the experiment. The result is that medical literature has become 
 oppressed with feeble and trifling reports, and practical medicine invested with a 
 cter of vacillating imbecility, which forms no part of its scientific pursuit. To 
 test and determine the properties of medicines is a work which can only be safely 
 entrusted to physicians of large clinical experience, and of calm and matured judg- 
 ment, familiar with an enlightened pathology, and acquainted with the natural history 
 lit' disease, and the action of existing medicines. It may be that these qualities are 
 care; but it is, nevertheless, (rue. that it is only by these qualities that therapeutic 
 science can be advanced and entitled to confidence and respect. 
 
 * The careful reader will not understand ('lis passage as implying that in these 
 
 conditions of intermittent lever, the purification of the blood by excretion is to be 
 neglected. It musl be remembered thai this important function maybe in very useful 
 action without very evident evacuation, by attention to the purity and temperature of 
 the atmosphere, suitable ablution and clothing, well-arranged food and drinks, and the 
 use of appropriate tonic and alterative medicines. The influence of tonics and altera- 
 tives regimen and medicines — necessarily involves increased excretion. 
 
TREATMENT PURGATIVES. 35 
 
 these circumstances, are apt, by irritating the intestinal mucous 
 lining, to excite dysentery. 
 
 The use of purgatives in the hot stage, with the view of lessening 
 vascular excitement, and preparing the system for the full benefit 
 of anti-periodic remedies during the intermission, has been already 
 adverted to. Purgatives, however, act with more certainty during 
 the intermission, and when the object is merely to obviate con- 
 stipation, they are given with most advantage in this stage, 
 either in combination with quinine, or towards the end of the 
 paroxysm, so as to take effect early in the intermission ; but 
 they should never be used in such manner as to interfere with 
 the administration of the anti-periodic- remedy. Further precau- 
 tions are also necessary. The free action of a purgative towards 
 the end of a paroxysm should be avoided ; for it may induce dan- 
 gerous exhaustion : it is also apt, in the intermission and during 
 convalescence, to re-excite the paroxysm.* 
 
 Attention to the diet of those suffering from intermittent fever 
 is of very great importance. In sthenic subjects, with deranged 
 alvine secretions, the food during the two or three first days should 
 be spare, and the strength be chiefly sustained by moderation in 
 treating the hot stage, and by the adequate use of quinine during 
 the intermission. In asthenic subjects, from the commencement, 
 and in all constitutions in the advanced stages, support by suit- 
 able alimentation, and occasional stimulants, is a leading indi- 
 cation of treatment. The intermissions are the periods when 
 these means should be most assiduously used. It is by the careful 
 observance of this rule that the occasional occurrence of the 
 unlooked-for, and sometimes fatal, exhaustion at the close of a 
 paroxysm, already alluded to, can alone be prevented. This pre- 
 caution, necessary in the management of intermittent fever in 
 all asthenic individuals, is very essential in the asthenic natives 
 of India ; for I have in many instances seen reason to attribute 
 death to its neglect. 
 
 * It would be easy to confirm this latter observation by references to established 
 authorities. For example, Cullen writes: "But I can say that Sydenham and many 
 other practitioners have observed that we are in danger of bringing back intermittent 
 fevers if we employ purgative medicines soon after we have stopped them -with bark ; 
 and we have the same observation in De Haen." — The Works of Cullen, Edited by 
 John Thomson, M.D. vol. i. p. 612. 
 
 D 2 
 
36 INTERMITTENT FEVER. 
 
 Section III. — Intermittent Fever complicated with Enlargement 
 of the Spleen. — SympAoms. — Pathology. — Treatment. 
 
 SympAoms. — Enlargement of the spleen is the most common 
 complication of intermittent fever.* It does not usually occur in 
 first attacks, but after several recurrences of the quotidian or the 
 tertian type. If a first attack, however, has been badly managed, 
 and several paroxysms have taken place, then in it also splenic 
 enlargement may be looked for.f 
 
 This condition of the spleen is always associated with some 
 degree of cachexia ; and a dingy appearance of the conjunctivse, 
 with anoemic pallor of the surface and of the tongue, may serve to 
 excite suspicion and to direct inquiry. The enlargement may 
 range from the degree which can only be determined by careful 
 percussion to that which causes an abdominal tumour reaching to 
 the crest of the ilium and inwards beyond the mesial line. 
 
 The co-existence of systolic cardiac murmur with enlargement of 
 the spleen is occasionally observed ; and when this occurs without 
 any other physical sign of cardiac disease, there should be no hesi- 
 tation in relating the murmur to the altered condition of the blood, 
 which so generally attends splenic cachexia. But it is of import- 
 ance further to be aware, that enlargement of the spleen may cause 
 abnormal precordial dulness, and that cardiac murmur may be 
 associated with it. This dulness may be produced partly by dis- 
 placement of the heart upwards, and partly by the enlarged spleen 
 preventing the free descent of the diaphragm, and the full ex- 
 pansion of the lung, with complete overlapping of the left side 
 and base of the heart by its thin edge. The following cases will 
 illustrate this clinical observation : — 
 
 1. Abnormal Precordial Dulness from Enlarged Spleen. — Abdoola Ibrahim, a 
 Mussulman labourer, eighteen years of age, had for upwards of a year been 
 the subject of frequent attacks of intermitteni fever. He was admitted into 
 hospital uii the 23rd of June, 1851. enfeebled and reduced by disease. The 
 spleen was much enlarged ; a line drawn transversely from the cartilage of the 
 
 * As evidence of its frequency I find thai out of 243 clinical cases of intermitteni 
 fever, enlargemenl of the spleen was present in 91. It is unnecessary to collect 
 further proof of so familiar ;i fact. 
 
 i | : of the spleen is generally classed under "Splenitis" in Indian 
 
 Hospital Returns; but this is wry inaccurate. Inflammation of the spleen is very 
 rare; abscess I have never Been. The only appearance probably related to inflamma- 
 tion which I have witnessed, was a thickened, almost cartilaginous, state of the 
 capsule. 
 
SPLENIC ENLARGEMENT — SYMPTOMS. ,37 
 
 left sixth rib to the vertebral column marked its upper limit, and a curved line from 
 the same cartilage to the umbilicus, and thence to about an inch above the crest 
 of the ilium, marked the lower limit. The apex of the heart beat between the third 
 and fourth ribs ; and the precordial didness was confined to the third and fourth left 
 costal cartilages and the interspace between the second and third, and at the outer 
 lower limit was almost continuous with the splenic dulness. 
 
 2. Abnormal Precordial Dulness from Enlarged Spleen associated with Systolic 
 Murmur. — Hurreem Adamjee, twenty-three years of age, a Mussulman, native of 
 Ahmedabad, and frequently suffering from intermittent fever, was admitted into the 
 Jamsetjee Jejeebhoy Hospital on the 9th August, 1852. He was pale and anaemic. The 
 spleen was much enlarged, extending downwards almost to the crest of the ilium, internally 
 beyond the umbilicus ; and its upper limit, as indicated by percussion, reached to the 
 sixth left intercostal space. The precordial dulness commenced at the left second inter- 
 costal space, and became continuous with the splenic dulness. At the level of the third 
 intercostal cartilage it reached transversely from the middle of the sternum almost to 
 the nipple. The apex beat between the fourth and fifth ribs internal to the nipple. 
 A faint but distinct systolic murmur was heard at the left second intercostal space, 
 close to the sternum, but was not audible at the apex, where the sounds of the heart 
 were both distinct. There was no increased impulse. A distinct venous murmur 
 was heard at the junction of the jugular and subclavian veins of the left side. 
 
 3. Abnormal Precordial Dulness from Splenic Enlargement. — Systolic Murmur 
 present. — Abdul Cadur, fifteen years of age, a Mussulman peon, the subject of quo- 
 tidian intermittent fever for thirteen days before admission into hospital on the 16th 
 July, 1851. The spleen was not felt below the ribs ; but, as ascertained by percussion, 
 its upper limit was as high as the eighth rib, and its internal one was a vertical line 
 half an inch external to the nipple. Precordial dulness extended from the third to 
 the fifth rib, and between the nipple and the sternum. There was a distinct systolic 
 murmur not louder at the base than at the apex of the heart. On the 2nd August, 
 the internal limit of the splenic didness was a vertical line an inch external to the 
 nipple ; the upper limit was unchanged. The upper limit of the precordial dulness 
 was the upper margin of the fourth costal cartilage. The cardiac murmur was 
 disappearing. 
 
 4. Abnormal Prmeordied Dulness from Enlargement of the Spleen. — Systolic Murmur 
 present. — Francisco Antonio, twenty years of age, an inhabitant of Lisbon, of stout and 
 well-proportioned frame, the subject of tertian intermittent fever for fifteen days, was 
 admitted into hospital on the 25th July, 1851. The pulse was of moderate volume, 
 and somewhat jerking. The indurated edge of the spleen was felt below the margin 
 of the left ribs. Its upper limit was the ninth rib ; its internal limit a vertical line 
 about an inch external to the nipple. The prsecordial didness extended from the 
 lower border of the third rib to the lower border of the fifth rib, and externally to 
 about half an inch internal to the nipple. There was a distinct systolic aortic 
 murmur. The recurrences of fever were prevented ; and on the 2nd August, the 
 internal limit of the splenic dulness was a vertical line from the posterior fold of the 
 axilla. The upper limit of the precordial dulness was the interspace of the third 
 and fourth ribs ; and the external limit was a vertical line an inch internal to the 
 nipple. The systolic murmur had altogether disappeared. 
 
 These cases prove that disease of the heart is not necessarily 
 present when abnormal precordial dnlness, with or without cardiac 
 
 p 3 
 
38 INTERMITTENT FEVEE. 
 
 murmur, is associated with enlargement of the spleen. The ab- 
 normal dulness has been attributed to the mechanical influence 
 of the enlarged spleen on the heart, and on the expansion of the 
 lungs. But there is more than this. The prgecordial dulness and 
 murmur may exist in very ansemic states, without splenic enlarge- 
 ment, in consequence of the incomplete expansion of the lungs, 
 from the limited respiratory function, which necessarily attends on 
 a great degree of anaemia.* 
 
 The following case is illustrative of this last statement. 
 
 5. Extended Precordial Dulness, with Systolic and Vinous Murmurs, without Splenic 
 !■], largememt. — Antonio Domingo, a native of Goa, and following the occupation of a 
 shepherd. Had been out of health for some months, suffering from palpitation, precordial 
 uneasiness, occasional dry cough, (Edematous feet, and febrile accessions coming on 
 towards evening without distinct chills. He had never suffered from rheumatism. 
 He was admitted into hospital on the 1st January, 1854, presenting a very ansemic 
 appearance. The pulse was small, jerking, and somewhat frequent. The precordial 
 dulness was bounded superiorly by the third rib, internally by the median line, and 
 externally by a vertical line drawn a quarter of an inch external to the nipple, and 
 below by the sixth rib. A blowing systolic murmur was audible over the third left 
 costal cartilage, increasing in the line of the aorta upwards, loudest at the top of the 
 sternum, and decreasing in the direction of the apex, which beat in the intercostal 
 space between the fifth and sixth ribs, an inch and a half below and half an inch 
 external to the nipple. There was a venous murmur on the left side of the neck. 
 The abdomen was slightly full. There was slight enlargement of the liver, as indi- 
 cated by a distinct indurated edge felt below the right ribs. There was no enlargement 
 of the spleen. He continued under treatment till the 15th February. During this 
 time the febrile accessions frequently returned. The urine was often examined; it 
 was of low density, but gave no traces of albumen. 
 
 When discharged, he had lost much of his ansemic appearance. The jerking 
 character of the pulse was no longer observed, and the cardiac and venous murmurs 
 had almost ceased. The last note of the precordial dulness was on the loth January; 
 and it gives, as (he external limit, a vertical line drawn over the nipple. 
 
 Pathology.— Id. the cold stage of intermittent fever, the blood 
 is determined from the surface of the body to internal parts, and 
 is liable to accumulate in such venous arrangements as those 
 of the spleen, and the portal system of the liver ; and when 
 stagnating in the splenetic capillaries, its transfer, in undue 
 quantity, into the pulpy parenchyma of the organ, readily takes 
 place. Under recurrences of the cold stage, these events are 
 repeated, and the bulk of the spleen necessarily increases. 
 
 * Since these observations were written, I have had the advantage of referring to 
 Iir. Sibson's rery valuable and instructive work on Medical Anatomy. In the firsl 
 fasciculus this extension of praecordial dulness, by sin-inking of the Lungs, is pointed 
 out. 1 Leave the texl as originally written, for I find nothing at variance with it in 
 Dr, Sil son's remarks, 
 
SrLENIC ENLARGEMENT — PATHOLOGY. 39 
 
 The density of the enlarged spleen bears relation to the quantity 
 and quality of the blood present in the vascular system of the 
 organ, as well as on the increase and the condition of the paren- 
 chymatous pulp ; as whether any of the fibrinous or albuminous 
 constituent has become converted into tissue of low organization. 
 When this change of part of the fibrine or albumen into tissue 
 takes place, then some degree of enlargement will become per- 
 manent ; but when the enlargement depends merely on excess of 
 blood in the vessels, or excess of unorganized pulp, it may be con- 
 cluded that the organ may still be restored to its normal condition 
 by a gradual, slow process of absorption and elimination. 
 
 This accumulation of blood in the spleen, being an abstraction 
 of it from the purposes of the circulation, must derange that which 
 remains in the general vascular system by reducing the proportion 
 of corpuscles, of fibrine, and of albumen, and by increasing the 
 jDroportion of watery constituent. 
 
 If enlargement of the spleen only occurred as a result of inter- 
 mittent fever, the statement just made of its relation to the altered 
 condition of the blood, viz., that the enlargement is the antecedent, 
 the altered blood the sequence, might be sufficient. But when it 
 is recollected that enlargement of the spleen and concomitant 
 cachexia may take place from the influence of malaria, without 
 the intervention of fever, then the belief must be entertained that 
 malaria exercises a primary deteriorating influence on the blood ; 
 and that the altered state thus induced favours stagnation, and 
 in some circumstances is the chief, if not the only proximate 
 cause ; but that in others, it merely co-operates with the favour- 
 ing conditions of the cold stage. This view of the injurious 
 influence of malaria may the more readily be assented to, when 
 it is found that nothing so surely leads to removal of enlargement 
 of the spleen as well-directed means for improving the state of the 
 blood.* 
 
 * Feerichs — "Klinik der Leberkrankheiten" — endeavours to particularise the con- 
 dition of the blood brought about by recurring paroxysms offerer, and which leads to 
 general cachexia and structural change of organs, as the spleen, the liver, and kidneys, 
 and brain. He believes that it proceeds from an excess of dark pigment in the blood ; 
 that the blood, stagnating in the splenic venous system, has the colouring matter of 
 some of its corpuscles converted into black pigment ; that thus the corpuscular con- 
 stituent of the blood is diminished, and the pigment entering the circulation is 
 conveyed to, and accumulates in, the capillaries of different organs, causing dis- 
 coloration, with structural and functional derangement. The form of fever which he 
 has found usually to precede and accompany these changes he describes as inter- 
 mittent, generally quotidian or double tertian : of 51 cases, 38 proved fatal. In 28 of 
 the 51 cases, severe cerebral disturbance — delirium, convulsions, coma — -was pr< 
 
 D 4 
 
40 INTERMITTENT FEVER. 
 
 Treatment. — To prevent the paroxysms of intermittent fever, 
 to remove the cachectic state by all means which tend directly 
 to this end, and to avoid all measures which are calculated to 
 increase asthenia, or still further to deteriorate the blood, are 
 the leading indications of cure. 
 
 If the paroxysms still recur, they should be prevented by quinine. 
 When this has been effected, the cachectic state will be removed 
 more certainly by the continued use, for some time, of pre- 
 parations of iron in moderate doses than by any other means. 
 Sulphate of iron in combination with small doses of quinine, the 
 citrate of iron and quinine, the tincture of the sesquichloride and 
 the solution of the persesquinitrate are suitable preparations. The 
 treatment which lessens the cachexia will also be the most suc- 
 cessful in reducing the size of the spleen ; for improvement of 
 the general system and decrease of the splenic enlargement always 
 progress together, independent of any special local appliances. 
 Due attention must at the same time be given to all other 
 measures which are necessary to the preservation of health and 
 to its restoration when deranged, — as atmospheric purity, food 
 suited to the power of digestion and assimilation, and the judicious 
 regulation of the excretions. The state of the mind should also 
 be carefully considered, and cheerful occupation be provided. 
 
 The treatment of enlarged spleen by the periodical application 
 of leeches, and the daily use of moderate purgatives combined with 
 tonics, as recommended by Mr. Twining *, has not proved effica- 
 cious in my hands. The abstraction of blood is opposed to the 
 indications of cure, as already stated ; and though a mild purga- 
 tive, occasionally used when the alvine discharges are scanty and 
 cachexia not far advanced, is beneficial, still it may confidently 
 
 in 20 there was albuminuria ; and in 17 profuse diarrhoea. In all the fatal cases the 
 liver was rich in pigment. In 30 the spleen was enlarged and contained pigment. 
 
 The diagnosis chiefly rested on the peculiar ash-grey colour of the skin, and the 
 presence of numerous pigmenl particles in the blood when some drops were examined 
 under l he microscope. 
 
 On these statements of Frerichs I can only observe, that intermittent fever, with a 
 mortality so large, and complications so various, acute, and severe, lias not come 
 under my observation in India: and I am not aware thai this form of fever has 
 been described by any writer on tropical disease. Nor does it accord with my impres- 
 sions thai the viscera, alter death, in individuals who have suffered much from 
 intermittent fever, presenl any peculiar discoloration; bul to this remark I attach 
 little importance, for it is the statement of a general impression, and no1 of the result 
 of attentive observation directed to the question. 
 
 * "Clinical Illustrations of the most important Diseases of Bengal," vol. i. 
 Second Edition. 
 
SPLENIC ENLARGEMENT — TREATMENT. 41 
 
 be asserted, that when the cachexia is considerable, frequent 
 purgatives increase it and are very apt to excite dysentery. 
 
 The internal use of preparations of iodine and bromine has 
 been recommended. Experience does not enable me to speak with 
 certainty on this question of practice. In the treatment of the 
 disease among the better classes of Europeans, after benefit has 
 ceased to result from the measures already advised, change of 
 climate would be had recourse to as the most likely means of 
 cure. In hospital practice the patient is generally so fully satisfied 
 with the improvement of the general health and of the spleen 
 by the use of quinine, preparations of iron, and general tonic 
 management, that he is unwilling to continue longer under treat- 
 ment. For these reasons the opportunity is not often afforded 
 to the practitioner in India of testing the powers of iodine and 
 bromine at the period appropriate for their use. I say appropriate 
 for their use ; for it would be a grievous practical error to turn to 
 such remedies as iodine and bromine, and neglect the tonic prin- 
 ciple of management, of which the efficacy has been well proved and 
 the theory is so much in accordance with physiological and patho- 
 logical doctrine. When this principle has been fairly applied 
 and enlargement still remains, then preparations of iodine and 
 bromine may, with propriety, be had recourse to, if no contra- 
 indicating circumstance exists in the general state of the system, 
 or the condition of the digestive organs. It may be urged that 
 iodine or bromine may be used at the same time with preparations 
 of iron, and tonic management. The objection to this course is its 
 inexpediency, for it is impossible to estimate justly the value of 
 subsidiary means applied at the same time with remedies of ac- 
 knowledged efficacy ; and nothing so inj ures the character of 
 therapeutic science as desultory and inconclusive experiments. 
 
 To Mr. Twining * the merit is due of pointing out with 
 clearness and force the evils which attend the use of mercury 
 in enlargement of the spleen and its co-existing cachexia, viz. : 
 the great susceptibility to, and the destructive effects from, 
 its action. The changes effected in the blood by mercury are 
 probably not very different from those caused by malaria ; at all 
 events both are favourable to degeneration and destruction of 
 tissue, and unfavourable to restoration and repair. To the unbiassed 
 judgment it seems a strange idea to endeavour to correct the evils 
 of the one by the super-addition of the analogous evils of the 
 
 * "Clinical Illustrations of the most important Diseases of Bengal," vol. i. p. £52. 
 •Second Edition. 
 
42 INTERMITTENT FEVEI?. 
 
 other. Mercurial preparations are unquestionably injurious in 
 splenic enlargement and cachexia, and their use should be care- 
 fully abstained from. 
 
 The application of external remedies to the region of the spleen 
 
 — as sinapisms, lotions with iodine or nitro-muriatic acid, &c, — 
 is sometimes useful in relieving local uneasiness; and the two 
 last remedies may possibly exercise a deobstruent action ; but as 
 they are seldom used singly, it must be very difficult to isolate 
 their therapeutic value. Applications which vesicate or cause 
 pustular eruptions, should be avoided in a state of the system 
 prone to destructive ulceration and sloughing. Mr. Twining's 
 suggestion of passing long needles into the enlarged spleen is 
 hardly in accordance with the spirit of rational medicine. 
 
 The means as yet described for the cme of splenic enlarge- 
 ment and cachexia very often prove inadequate, and then change 
 to another locality in India, or to more temperate latitudes, is 
 a measure essential to recovery. It is vain to expect much 
 benefit from medical treatment in the hot and malarious seasons, 
 
 — from March to the end of November,— in the alluvial and lit- 
 toral plains and jungly tracts of India. Nor in these states of the 
 system are the hill climates, from the middle of June to the begin- 
 ning of March, more suitable : malaria may not be equally 
 generated ; but they are cold and wet, and therefore liable in mala- 
 rious cachexia to excite tertian fever, diarrhoea, and dysentery. 
 
 The part of India least likely to be injurious in splenic cachexia 
 in the malarious season, from the middle of June to the end of 
 November, is the strip of the Deccan table-land, between 20° and 
 15° N. lat. and from 60 to 100 miles east of the Western Grhauts. 
 There the fall of rain is inconsiderable, the temperature moderate, 
 and, in well-selected localities, the generation of malaria is not 
 great. In December, January, and February, the climate of the 
 sea-coast, and from March to the middle of June, a hill station, 
 with an elevation of from 4,000 to 6,000 feet, will prove the most 
 conducive to recovery. 
 
 But when changes of climate such as these, and the use of 
 suitable remedies, fail in reducing the spleen and removing the 
 cachexia, then there should be no hesitation in recommending an 
 early sea voyage, and a prolonged residence in a temperate climate. 
 Care should lie taken, when practicable, that the patient should arrive 
 in the temperate climate early in summer, and thus avoid the winter 
 and spring of the cold, and the summer and autumn of the hot lati- 
 tudes. In all changes from warm to cold, and from dry to damp 
 
HEPATIC COMPLICATION. 43 
 
 climates, great attention to clothing is necessary, in order that im- 
 pressions of cold on the surface of the body, and consequent attacks 
 of tertian fever, diarrhoea, and dysentery may be prevented. When 
 the patient comes at first under observation in a state of confirmed 
 malarious cachexia, and the season for removal to a temperate 
 climate is suitable, time should not be lost in expectation of benefit 
 from treatment and change of air in India. A change from India 
 to Egypt in the winter, and to Syria in the summer and autumn, 
 is sometimes had recourse to ; but it is an inexpedient measure. 
 In the year 1840, a medical officer of feeble constitution, who had 
 suffered from malarious fever in Guzerat, Bombay, and the Deccan, 
 left Bombay, on my recommendation, in the month of February, 
 for Egypt. At Cairo, from the influence of the Kamsin wind, he 
 suffered from congestion of the head and lungs ; was attacked with 
 remittent fever at Alexandria, and again in the month of May at 
 Smyrna, and subsequently at Constantinople, where the attack 
 proved fatal. Since the occurrence of this case, the history of 
 four other Indian invalids (two of them medical men) have come 
 to my knowledge, in which obstinate malarious fever was ac- 
 quired in Egypt or Syria; and it is a curious circumstance that 
 the febrile paroxysm was, in two of the cases, attended with severe 
 strangury. 
 
 Section IV. — Intermittent Fever with Hepatic Complication. — 
 Symptoms. — Pathology. — Treatment. 
 
 Hepatic inflammation or enlargement in intermittent fever has, 
 in my experience, been of rare occurrence, both in Europeans and 
 natives. 
 
 Of the 243 clinical cases of natives in the Jamsetjee Jejeebhoy 
 Hospital, completion of hepatic affection was observed only in 
 eighteen ; in six, it was considered to be inflammatory ; in twelve, 
 to be passive enlargement. Two cases, one of inflammation and 
 one of enlargement, are subjoined. . The first is of interest, because 
 death caused by cholera gave the opportunity of observing the 
 appearances presented by the liver. The absence of fibrinous 
 exudation is probably an illustration of the law established by 
 Dr. Alison, that when inflammation complicates idiopathic fever it 
 does not so readily pass on to its results, as when it is itself idio- 
 pathic. This pathological law, moreover, justifies caution in the 
 mercurial treatment of hepatitis when it co-exists with intermittent 
 fever : — 
 
44 INTERMITTENT FEVER. 
 
 6. Intermittent Fever complicated with Hepatitis. — Death from Cholera, — Liver in a 
 
 state of vascular Turgescence. — Mohedeen, a Mussulman sailor, of twenty years of age, 
 a native of Cochin, and suffering there on two or three occasions from febrile attacks. 
 While on a voyage from the Persian Gulf, he was wrecked on the coast adjoining the 
 island of Bombay, and consequent upon exposure to wet he became affected with fever, 
 which, preceded by chilliness, recurred in irregular paroxysms, and, after seven or 
 eight days' duration, was accompanied with pain of the right side of the chest. He 
 was admitted into hospital on the 17th June, 1851, ten days after the commencement 
 of his illness. There was pain of the right side of the chest, increased by full 
 inspiration and coughing ; also pain below the margin of the right false ribs, increased 
 by pressure. There was some degree of yellowness of the conjunctivae ; but no per- 
 ceptible induration or dulness below either margin of the ribs. The febrile accession 
 recurred twice in the twenty-four hours. He was treated with repeated four-grain 
 doses of quinine during the intermission. Leeches were applied to the right side of 
 the chest and to the margin of the ribs, followed by a small blister on the former. 
 Blue pill and ipecacuanha, with an occasional laxative, were also given. The fever 
 did not return after the 19th. On the 20th, the pain below the margin of the right 
 ribs was gone, and that of the chest very much lessened. In this state he continued 
 till 1 a.m. of the 27th, when he was attacked with cholera, and died at 3 p.m. 
 
 Inspection twenty-two hours after Death. — Both lungs collapsed freely, and were 
 crepitating. The costal and pulmonary pleurae of both sides were free of adhesions 
 or traces of lymph exudation. They were healthy, with exception that the inferior- 
 anterior part of the right costal pleura presented a slight blush of redness, which was 
 not the case with the corresponding portion of the opposite side. The heart was 
 somewhat "flabby, but its size and structure were healthy. The peritoneum was 
 healthy. The liver was much congested, and bled freely when cut into. The 
 stomach contained a small quantity of thin whitish fluid, and its mucous meml irane 
 was pale. Peyer's glands in the ileum were slightly enlarged. The kidneys were 
 flabby, but healthy in structure. 
 
 7. Intermittent Fever with enlargement of the Liver. — Saecaram, a Maratha 
 labourer, of thirty-three years of age, addicted to the moderate use of spirits, 
 was admitted into hospital on the 9th December, 1819. He was much emaciated, 
 and had been for four or five years the subject of epigastric swelling, attributed 
 to frequent attacks of fever. The irregular febrile accessions, generally pre- 
 ceded by chills, with increased epigastric fulness, for which he sought admis- 
 sion, had been present five days. The hepatic dulness reached to within an 
 inch of the umbilicus, and midway between the tenth rib and crest of the ilium. 
 There was sense of uneasiness and weight rather than distinct pain. He remained 
 under treatment till the 13th January. There was no return of fever after the day 
 subsequent to that of his admission. The urine was free, generally of low density, 
 and showing no traces of albumen. He was treated with quinine, the external 
 application of nitro-muriatie acid lotion, and latterly of an ointment containing 
 iodine. He was di-elmar'd much improved in general health, but with little 
 diminution of the size of the liver. 
 
 Pathology. — Enlargement of the liver, consequent upon in- 
 termittent fever or slow malarious influence, must be carefully 
 distinguished from that depending upon chronic inflammation.* 
 The diagnosis may be determined by the history of the case; 
 
 * It can hardly be necessary to suggest a caution againsl the possible error of mis- 
 taking enlargement of the liver from forming abscess, associated with hectic fever, for 
 
 the enlargement now under consideration, associated with malarious febrile accessions. 
 
HEPATIC COMPLICATION. 45 
 
 and it is important, for the treatment of the two affections is 
 very different. 
 
 The pathology of this enlargement resembles that of enlargement 
 of the spleen. It may result from recurrences of the cold stage, 
 or from a gradual malarious influence without the intervention of 
 febrile disturbance ; and may be assumed to arise from stagnation 
 of deteriorated blood in the venous system of the organ. 
 
 The proximate cause of enlargement of the spleen was supposed 
 to be vascular congestion, and addition to the splenic pulp and 
 to the connecting fibrous tissue by low organisation of exuded 
 ribrine and albumen. These three conditions, however, are not 
 all necessarily present. The last is the one most frequently 
 absent, and probably only occurs in cases of long persisting 
 enlargement. 
 
 The same view may be taken of malarious hepatic enlargement, 
 — that there is stagnation of blood in the portal and hepatic 
 venous systems, addition to the contents of the hepatic cells, and 
 perhaps exudation into the meshes in which the cells are placed. 
 In cases of long standing, the connecting areolar tissue probably 
 becomes hypertrophied by a low organising process. 
 
 The chief points which the microscope has still to determine are 
 the degree and character of the additions made to the contents of 
 the cells ; also, whether there is deposit external to the cells or 
 not, and if so, its nature. 
 
 Treatment. — If there be much that is common in the patho- 
 logy of hepatic and splenic enlargement, it is reasonable to con- 
 clude that similar principles of treatment are applicable to both 
 affections, though not necessarily to be carried out by the same 
 means. It may be anticipated that enlargement, dependent on 
 vascular congestion and excessive deposit in the cells, may in time 
 be recovered from by processes of slow absorption and elimination. 
 
 If febrile accessions still recur, the first indication is to pre- 
 vent them by the adequate exhibition of quinine, and the next 
 is to lessen the cachexia by change of climate, attention to the 
 general state of the excretions, and the use of small doses of quinine, 
 the mineral acids, and extract of taraxacum. The diet should 
 be carefully regulated with reference to the state of the digestive 
 organs and the assimilating powers ; and nitro-muriatic acid lotion, 
 or preparations of iodine may be applied externally with advantage. 
 
 The preparations of iron, though very important in the allied 
 affection of the spleen, have not been generally used, but they 
 seem to me worthy of careful trial in small doses. 
 
 The reasoning relative to the exhibition of purgatives in splenic 
 
4G INTERMITTENT FEVER. 
 
 enlargement also applies to the present affection. It is true that 
 derivation to the intestinal mucous surface reduces stagnation in 
 the vascular system of the liver more directly and surely than 
 that in the spleen, and that moderate purgatives may be used with 
 advantage in the early stages of enlargement, while as yet there is 
 little else than vascular congestion and only commencing cachexia. 
 But when the enlargement has been of some duration, and there is 
 probably more than mere congestion, and when the cachectic state 
 is fully developed, then even more caution than in the instance of 
 splenic enlargement must be observed, for the proclivity to dysen- 
 tery and diarrhoea is greater. Under these circumstances the first 
 indication is to mitigate the cachexia, and then, in addition, to have 
 recourse to gentle aperients.* 
 
 The observations made on iodine and bromine in relation 
 to the spleen may be repeated in reference to the liver, but with 
 the injunction of still greater caution and reserve. Lastly, 
 in respect to mercury. The milder preparations may be occa- 
 sionally used in small doses with advantage to produce a gentle 
 cholagogue action, but the constitutional influence of mercury is 
 as injurious in malarious cachexia with co-existing hepatic enlarge- 
 ment as in that with co-existing enlargement of the spleen, and for 
 the same reasons. That mercury acts on the secreting function 
 of the liver in a manner which may be turned to good practical 
 account in the treatment of various forms of disease is true ; 
 but that its constitutional influence has any effect on structural 
 changes of the tissues of the liver, different from that which it 
 exercises upon the analogous tissues of other organs, is, according 
 to my belief, altogether without proof; yet it would not be diffi- 
 cult to show that an opposite opinion has affected injuriously the 
 treatment of various forms of hepatic disease. 
 
 The occurrence of gastric or intestinal haemorrhage as a con- 
 sequence of enlargement of the liver or spleen and of the co- 
 existing cachexia, is an occasional, but, judging from my own 
 experience, a rare event, f 
 
 * It is after the cachectic condition has been materially lessened 1 >y change of 
 climate thai hepatic and splenic enlargement is often advantageously treated by (he 
 aperienl natural wafers of Germany and other spas; bu1 it by no means follows that 
 this kind of treatmenl is safe in the same condition of these organs while the patient 
 is ,-lill in India, with a constitution unimproved by removal from malarious influence. 
 
 On the ( fcrary, it maybe asserted with confidence, that a routine treatment by 
 
 purgatives under these circumstances "ill frequently Lead t>> a fatal result. 
 
 f Mr. Twin in-'s experience in Bengal on this point was different He saysj 
 "During the existence of diseases of the spleen attended with much enlargement of 
 
WITH JAUNDICE AND BOWEL AFFECTIONS. 47 
 
 Section V. — Intermittent Fever complicated with Jaundice, or 
 Affections of the Stomach or Boivels. 
 
 Jaundice. — This complication is not common in intermittent 
 fever. Of 243 clinical cases, it is noted only of three. Jaundice is 
 much more frequently observed in remittent fever, and will be 
 treated of in detail in connection with that type. 
 
 Affection of the Stomach and Boivels. — It is not my intention 
 to consider, under this head, those affections of the intestinal canal 
 which are produced in malarious cachexia by ordinary exciting 
 causes, to which the attention of the reader has already been 
 directed in my observations on the pathology of simple intermit- 
 tents, and which ought to be borne carefully in mind when we 
 estimate the direct and indirect mortality resulting from malarious 
 fever. These forms of disease will be elsewhere more appropri- 
 ately described. 
 
 My present inquiry relates to the complication of derangement 
 of the stomach and bowels with recent attacks of intermittent 
 fever. 
 
 In sthenic Europeans this form of fever is very rarely attended 
 with diarrhoea or dysentery ; and when gastric symptoms, as irrita- 
 bility of stomach, a tongue florid at the tip and edges, and some degree 
 of epigastric uneasiness are present, then the habit of spirit drinking, 
 or too much drugging with medicinal irritants may be suspected. 
 At a very early period of my practice— first with natives at Sassoor, 
 
 the organ, hemorrhages from the nose, lungs, or stomach, are very liable to occur." 
 Dr. Graham reports a striking case of gastric haemorrhage witnessed by him in the 
 Native General Hospital in Bombay — the same field in which, for many years. 
 my own observations have been made. (" Transactions. Medical and Physical Society, 
 Bombay," No. 5, p. 29.) In niy notes of sick officers, I find a case reported by 
 Dr. Don of an officer at Poona under his care in 1842. This officer had been affected 
 with enlarged spleen for fifteen years. He died on the 14th April. On the 10th he 
 vomited two pints of blood, and on the 11th a similar quantity, and on the 13th 
 a pint and a half; on the day of his death there was also a recurrence of the 
 hemorrhage. 
 
 In the year 1858-59, the 1st Bheel Corps was, consequent on the nature of 
 the service required of it, more than usually exposed to the malaria of Kandeish. 
 The number treated was 266 ; of these 19 were remittent, and 234 quotidian inter- 
 mittent. Though a considerable number of the eases were adynamic, some with 
 jaundice, vomiting, and much headache, others with dark, grumous, bloody discharges 
 from the bowels, or obstinate epistaxis, yet no deaths occurred. These facts arc- 
 extracted from the report of Mr. Burn, the medical officer in charge. 
 
48 INTERMITTENT FEVER. 
 
 and then with European soldiers of the 4th Light Dragoons at 
 Kirkee — I became convinced of the fact that irritability of stomach 
 was not unfreqently caused and kept up in quotidian fever by the 
 unnecessary use of calomel and purgatives during the hot stage.* 
 
 It is when intermittent fever attacks individuals of asthenic con- 
 stitution that it is apt to be complicated by gastro-intestinal irrita- 
 tion. The proportion of cases will be influenced by the system of 
 treatment ; for, as already explained, diarrhoea and dysentery are 
 in these states of constitution very readily excited by the injudicious 
 use of purgatives. 
 
 Affection of the stomach or bowels was present in twenty-two of 
 243 clinical cases, under the form of dysentery in eleven, diarrhoea 
 in seven, and gastric symptoms in one ; and to mark the relation of 
 this complication to diathesis, it further ajmears that, in seventeen 
 of the cases, an asthenic state was present. The tongue is usually 
 florid at the edges and tip, and not unfrequently is the first symp- 
 tom to arouse suspicion of the existence of this complication. 
 A florid tongue, however, may attend paroxysmal febrile phenomena 
 in asthenic individuals unaccompanied with gastric irritability or 
 diarrhoea ; and its presence should always excite apprehension, for 
 it not unfrequently exists in asthenic states in individuals affected 
 with hectic fever consequent on inflammatory action of some im- 
 portant organ. The practical rule in all asthenic cases is to main- 
 tain a careful watch over all important organs, for their structures 
 are apt to be invaded by processes of obscure degeneration and 
 destruction. 
 
 When diarrhoea co-exists with intermittent fever, a tendency in 
 the febrile accessions to alternate with the diarrhoea may occasion- 
 ally be noticed ; the one being present for three or four daj-s, then 
 ceasing, and being succeeded by the other. This feature of these 
 cases has been observed by me in Scinde, as well as in the Euro- 
 pean General Hospital and the Jamsetjee Jejeebhoy Hospital at 
 Bombay ; but it is generally a character of old fever cases, not of 
 recent ones. It was probably the observation of facts of this kind 
 that led Sydenham to regard dysentery as fever turned in upon the 
 bowels. 
 
 Treatment. — The treatment of gastro-intestinal derangement, to 
 be explained in its appropriate place, should be applied with due re- 
 gard to the asthenia generally present in these complications. But the 
 
 * Tin's question of practice is more important in reference to remittent fever, and 
 under thai head will be again noticed. 
 
AFFECTION OF STOMACH AND BOWELS. 49 
 
 important practical question is, whether, in eonsecpience of these 
 affections, quinine is to be withheld during the intermission. In 
 reply, it may he affirmed that whatever the complication of an 
 intermittent fever may be, — the use of quinine during the inter- 
 mission is always a ruling indication of treatment; because the 
 local derangement is sure to be aggravated during the paroxysm, 
 and to be mitigated during the intermission. Gastro-intestinal 
 irritation is the complication to which the applicability of this 
 principle might be justly doubted; but it is no exception, as 
 the following case illustrates : — 
 
 8. Inter mitt <nt Fever with Gastric Irritation treated with Quinine. — Dowlut 
 Sabajee, a Maratlia labourer, of twenty-nine years of age, frequently suffering from 
 intermittent fever in his native place, but free of it for a year past, during his 
 residence in Bombay. He was admitted into the hospital on the 26th October, 
 1849. He was a good deal reduced in strength, and indulged occasionally in the use 
 of spirits. He had for eight days been suffering from daily accessions of intermittent 
 fever, commencing with chills in the morning, and terminating with sweating towards 
 evening. The febrile symptoms were accompanied with frequent vomiting, headache, 
 soreness of limbs and slight cough, with tenderness of abdomen during the last three 
 days. There was no diarrhoea on admission. The abdomen was retracted, resistent, 
 and tender on pressure chiefly in the epigastric and left hypochondriac regions. The 
 spleen was enlarged and reached nearly to the level of the umbilicus. The tongue 
 was much coated, dryish, and rather florid at the tip and edges. The gums were 
 spongy, and somewhat discoloured. The pulse was very feeble. The day subsequent 
 to his admission was the single one of febrile recurrence. The only treatment used 
 was the exhibition of quinine, first in four-grain doses in powder, repeated six times 
 about the period of expected febrile accession, with intervals of two or three hours ; 
 then in five-grain doses in solution, with dilute sulphuric acid. The quinine was now 
 gradually reduced to three and two-grain doses given four times in the twenty-four 
 hours, and latterly was combined with half a grain of sidphate of iron. The only 
 other means used were the application of one sinapism to the abdomen, and effer- 
 vescing draughts on the day that the quinine was exhibited in powder. Under this 
 treatment there was no recurrence of fever or of vomiting. The tongue became 
 gradually cleaner and moister, and lost its florid tip and edges, and the patient was 
 discharged on the 12th November in much improved condition, and with the spleen 
 so decreased that it could no longer be felt under the false ribs. 
 
 Section VI. — Intermittent Fever complicated with Cerebral 
 
 Affection. 
 
 Symptoms and Pathology.— Head symptoms — drowsiness, con- 
 fusion of mind, suffusion of countenance — dependent on cerebral 
 congestion and followed by imperfect reaction, are occasionally 
 observed in the cold stage in sthenic habits. But somewhat 
 similar symptoms may also occur, in all states of the constitu- 
 tion, from the direct sedative influence of the morbific cause on 
 the nervous system, irrespective of local congestion, and may 
 
 E 
 
50 INTERMITTENT FEVER 
 
 in general be recognised by the co-existence of a feeble pulse, 
 pallid countenance, and low temperature of the general surface 
 of the body. 
 
 During the hot stage in sthenic habits there may also be 
 present such degree of headache as to call for special treatment ; 
 but there is seldom any considerable disturbance of the cerebral 
 functions. 
 
 In the congestive cases there is merely a greater degree, as 
 respects the head, of the kind of phenomena alluded to in my 
 remarks on the cold stage of simple intermittents : they are, how- 
 ever, apt to be misunderstood, as is shown in the treatment of the 
 following case : — 
 
 9. A gentleman, of stout habit, resident at Poona, on the 14th, 15th, and 16th 
 July, 1837, suffered from pains of the limbs, lassitude, and furred tongue. On the 
 17 th he experienced difficulty in articulating words, and numbness of the lower 
 extremities. The countenance was suffused. He was bled and leeched freely. At 
 noon on the 18th, 19th, and 20th, there was a slight recurrence of the same symptoms, 
 followed by sweating. He was now sent to Bombay, and experienced there several 
 febrile accessions ushered in with chills. In the treatment of this case quinine was 
 very feebly given at Poona.* 
 
 After several paroxysms in asthenic habits, the hot stage may 
 terminate with incoherence or delirium. This symptom, under 
 these circumstances, is generally indicative of exhaustion, and is 
 usually attended by other evidences of this condition. These 
 cases are also liable to be misunderstood, and to be improperly 
 treated. 
 
 Head symptoms in intermittent fever may likewise be related 
 to organic lesion of the membranes of the brain- The two follow- 
 ing cases illustrate this, and are otherwise instructive. They both 
 show that though the symptoms were dependent on structural 
 change, yet they were absent during the intermission, and only 
 present during the period of febrile accession. They, therefore, 
 verify the therapeutic principle of preventing a febrile recurrence, 
 as a means of lessening a local derangement. The first is also 
 an instance of death by unexpected collapse at the close of a 
 paroxysm, favoured by the injudicious use of depletion at that 
 period. The second exeinjdifies the curious fact that in com- 
 
 * Though T did not see this patient, yet I was in the neighbourhood of Poona at 
 the time, and know that at firsl the nature of the case was not rightly understood. 
 Ead it been ao, these would have bees Less depletion and a freer exhibition of quinine. 
 This gentleman is dow(1859) in good health, and has never, to my knowledge, been 
 (lie subject of apoplectic threatenings. 
 
WITH CEREBRAL COMPLICATION. 51 
 
 plicated intermittent fever, the period of accession is occasionally 
 characterised, not by febrile reaction, but only by symptoms of 
 the local derangement, 
 
 10. Intermittent Fever, with Chronic Meningitis. — Symptoms chiefly during 
 Accession. — Death from unexpected Collapse. — J. S., aged thirty-three, of stout 
 habit, not long resident in Bombay, and latterly occupied in conducting an 
 hotel, was admitted into the European General Hospital on the evening of the 
 24th September, 1840, at half-past o p.m. It was stated that for the five or 
 six previous days he had been affected with fever of the quotidian or tertian 
 type, and had suffered from a paroxysm ushered in with rigors at noon on the 
 day of admission. When seen he had pyrexia with slight wandering, tongue pretty 
 clean, pulse frequent and feeble, abdomen supple. An effervescing draught was 
 ordered every second hour for three or four doses, and twenty-four leeches were applied 
 to the temples and cold cloths to the head. A foot-bath was directed to be used 
 at bedtime, and a draught, c. tiuct. niuriat. morphia one drachm, to be exhibited, 
 should the headache cease and there be no delirium. Was reported to have had 
 no headache or wandering after the application of the leeches, and the skin to have 
 become cool. The draught was given about half-past 10 a.m. He was reported 
 to have got up to make water when he fell down convulsed. The head was imme- 
 diately shaved, and a blister was applied to the nucha. He died at 11 p.m. 
 
 Inspection fifteen hours after Death. — Body stout and loaded with fat. There were 
 purple sugillations of the depending and posterior parts of the body. Head. — The 
 sinuses and veins were turgid with blood, and there was a good deal of capillary vas- 
 cularity of the pia mater over the entire convex surface of the brain. The arachnoid 
 membrane was thickened and opaque, and in many places, chiefly at the dipping down 
 between the hemispheres, there were patches and granules of lymph between the 
 arachnoid and pia mater. The substance of the brain, when incised, showed nume- 
 rous bloody points, but was tolerably firm in texture. There was an ounce of serum 
 at the base of the skull, but not more than the usual quantity in the ventricles. 
 Chest. — The lungs were healthy and very little congested. The cavities of the heart 
 were moderately distended with blood. The inner lining of the aorta had a rosy 
 tint, and there was a commencing white deposit, in spots and streaks. The muscular 
 parietes of the heart were healthy. Abdomen. — The intestines and omentum were 
 loaded with fat. The former, distended with air, pushed the liver up to the level of 
 the fourth rib. The mucous coat of the stomach had a dusky leaden tint, and was 
 slightly more tender in texture than natural. The kidneys were healthy, and there 
 was no distension of the bladder. The spleen was considerably enlarged. The liver 
 was of a greyish tint when incised, but was natural in texture. 
 
 11. Intermittent Fever: some of the Paroxysms complicated with Convulsive Fits, 
 one of which terminated fatally. — Thickening and Opacity of the Arachnoid Membrane. 
 — Bichard Parkman, aged twenty-eight, seaman, Honourable Company's receiving 
 ship Hastings, after having been ill with intermittent fever for two or three days, was 
 admitted into the General Hospital on the 24th March, 1842. On that day he 
 experienced a febrile paroxysm attended with headache. An emetic was exhibited 
 and followed by repeated doses of quinine. On the 25th, there was neither fever nor 
 headache. On the evening of the 26th, he was seized with a convulsive fit, but 
 denied having been ever subject to such attacks. On the morning of the 27th, he 
 was free of fever or headache. Cold affusion to the head, with a hot foot-bath, was 
 used twice ; and the only complaint made that day was of a sense of constriction of 
 the throat towards night. On the morning of the 28th, he was free of fever, and 
 quinine was directed to be given. He had a convulsive fit in the course of the Jay. 
 
52 INTERMITTENT FEVER 
 
 and again at night. On the morning of the 29th he was free of complaint, and the 
 skin and pnlse were good. The liquor arseniealis was directed to be given thrice, 
 and cold affusion to be used to the head in the event of a recurrence of the fit. 
 Towards evening there was a slight febrile accession, but he slept well ; and, at the 
 morning visit of the 30th, he was reported to have no headache, and to have had no 
 return of the convulsions. The remedies used on the 29th were directed to be 
 repeated. About half an hour after that report, he was seized with convulsions 
 (reported to be not more severe than the former ones), and he died in about five 
 minutes. 
 
 Inspection. — Head. — On the upper surface of the brain there was a thin veil of 
 serum between the arachnoid and pia mater. The former membrane was opaquish 
 in parts, with here and there deposit of distinct yellow points, but in no great 
 number. The substance of the brain was healthy. There were about two ounces of 
 serum at the base of the skull. Chest. — The right ventricle of the heart was dis- 
 tended with blood; but the other contents of the chest were in a healthy state. 
 Abdomen.— Old adhesions bound the liver to the side. The viscera were otherwise 
 healthy. 
 
 Treatment. — When cerebral congestion is present in the cold 
 stage, general or local blood-letting, according to the state of the 
 constitution, the pulse, and the urgency of the symptoms, must 
 be had recourse to ; but these measures are not to be used to the 
 same extent as would be necessary if the congestion were inde- 
 pendent of a transient influence. The application of heat to the 
 extremities, and the use of purgatives, are also indicated. The 
 important consideration, however, in such cases is, a careful 
 diagnosis, and then prevention, by the adequate exhibition of 
 quinine ; for it is a serious error to neglect this, and to rest 
 satisfied with endeavouring to remove the cerebral symptoms by 
 the repeated use of evacuant remedies. 
 
 In asthenic states, when the nervous symptoms seem to de- 
 pend on exhaustion, suitable nourishment and stimulants, with 
 quinine during the intermission, are the means of cure. The rest- 
 lessness and wandering may perhaps suggest a full opiate towards 
 the close of the paroxysm ; but this proceeding under these cir- 
 cumstances is very dangerous, as case 1 1 has already illustrated. 
 
 The use of opiates in the treatment of malarious fever is an 
 important subject, and will be fully considered in connection 
 with remittent fever. 
 
 Section VII. — Intermittent Fever complicated with Bronchitis, 
 Pneumonia, Rheumatism, Scorbutus, Pericarditis, Asthma. 
 
 Bronchitis. — This complication is not common in Europeans in 
 India; but in natives, next to splenic enlargement, is the most 
 frequent. The cause of this difference between Europeans and 
 
COMPLICATED WITH BRONCHITIS, ETC. 53 
 
 natives is, probably, of easy explanation : the former are usually 
 much better protected from cold and wet. 
 
 Bronchitis has been observed by me in the fevers of natives in 
 the Deccan, Scinde, and in the Jamsetjee Jejeebhoy Hospital at 
 Bombay. It is also common in Guzerat, and presumably through- 
 out India generally, in places and at seasons when alternations of 
 temperature are considerable, rain frequent, and winds chilling. 
 
 It is in the cold months, December, January, and February, and 
 in June and July, — the months of commencing rain-fall in much 
 of the tract of country subject to the influence of the south-west 
 monsoon, — that this complication chiefly occurs.* It may be 
 associated with the quotidians and tertians of those seasons ; but 
 it must be remembered that bronchitis with febricula is apt to be 
 mistaken for the affection now under consideration. 
 
 Bronchitis is readily detected by the characteristic symptoms 
 and physical signs, and is usually slight; for when it becomes 
 extensive the fever tends to assume a remittent form. It was 
 present in 36 of the 243 clinical cases. 
 
 Treatment — Quinine, with small doses of tartarized- antimony, 
 is in general sufficient for the cure. 
 
 Febricula with a periodic tendency, associated with bron- 
 chitis, may be confounded with intermittent fever ; and this error 
 is sometimes corrected by the results of treatment. Cases, sup- 
 posed to be intermittents complicated with bronchitis, are occa- 
 sionally met with in wdiich quinine fails, and antimony proves 
 successful. These have not, in all probability, been true inter- 
 mittents, but rather instances of febrile and bronchitic phenomena 
 excited by cold or wet in individuals in whom there lingers some 
 degree of previous malarious taint, to which the intermittent 
 character of the fever may be attributable. Whether the expla- 
 nation now given be just or not, the therapeutic observation is 
 correct and useful to remember. 
 
 Pneumonia. — Pneumonia was present in 5 of the 243 clinical 
 cases of intermittent fever ; but this complication is much more 
 common in remittent fever, and will be considered in connection 
 with that type. 
 
 Rheumatism. — In 4 of the cases a degree of pain of the joints 
 coexisted with the paroxysmal febrile symptoms, sufficient to 
 justify the inference that some amount of the rheumatic diathesis 
 was present. 
 
 * In districts subject only to the north-east monsoon, the latter half of October and 
 NoTember probably take the place of June and July, 
 
 e 3 
 
54 INTERMITTENT FEVER 
 
 Scorbutus. — In 5 cases sponginess and discoloration of the 
 gums indicated the presence of this taint. The fever was attended 
 with more pain of the loins and limbs than is usual in this type ; 
 and in this and allied forms of cachexia, though observing distinct 
 accessions and intermissions, it is usually characterised by a less 
 amount of reaction, and the distinction into stages is often inap- 
 preciable : still, it is to be regarded as malarious, and as requiring 
 anti-periodic remedies, combined with the appropriate means of 
 correcting the cachexia. 
 
 Pericarditis. — This complication is rare, and the following 
 is the only case which has come under my notice. It illustrates 
 well the efficacy of that principle of treatment which combines 
 remedies for the inflammation and for the fever. The pericarditis 
 was accompanied with some degree of pneumonia of the right 
 lung. 
 
 12. — Intermittent Fever with Pericarditis and Pneumonia. — Recovery. — Joaquim 
 Manoel, an African sailor, of stout habit, and twenty-two years of age, was ad- 
 mitted into hospital on the 19th September, 1851, after four days' illness, which, 
 attributed to exposure to wet, commenced with febrile symptoms ushered in with 
 chills, and followed by precordial uneasiness. On the succeeding days inter- 
 vening between that of attack and admission into hospital, the febrile paroxysm 
 returned daily, with chills, at 11 a.m., and ceased, with sweating, at 5 p.m. "When 
 first seen there was febrile excitement, with full pulse. The tongue was thinly coated, 
 and was florid at the tip and edges. There was abnormal didness and bronchial 
 respiration in the right dorsal region. There was lancinating pain in the precordial 
 region, increased by cough and full inspiration. The precordial didness was bounded 
 aboTe by the third left rib, below by the sixth, internally by the left margin of the 
 sternum, and externally by a line perpendicular from the nipple. A rough murmur, 
 obscuring both sound 3, was heard generally over the precordial region ; but it 
 was most distinct aii inch internal to and a Little above the nipple. There was 
 no induration or dulness below the margin of the false ribs of either side. He had 
 never suffered from rheumatism. He indulged moderately in the tise of spirits. 
 Fifty leeches were applied to the precordial region ; and a pill of five grains 
 of calomel, with ipecacuanha and opium, one grain each, was given. On the morning 
 of the 2nd there was febrile intermission, the precordial pain was much less, the 
 murmur was not audible, and crepitus began to be heard in the right dorsal region. 
 (Quinine, in five-grain dusts, was given in the usual way, a blister was applied to the 
 precordial region and warm turpentine to the right dorsal region, and the pill 
 Mas repeated at bed-time. From this time there was no recurrence of fever, and 
 there was gradual amendment of the signs of pericardial and pulmonic affection. 
 The quinine was continued; the pill was repeated on the 21st; then discontinued. 
 The quinine was subsequently given, in combination with Dover's powder. He was 
 discharged on the 28th, when the precordial dulness was bounded above by the fourth 
 rib, below by the filth, internally by the tefl sternal margin, and externally by 
 a perpendicular line half an inch internal bo the nipple. With exception of slight 
 harshness of the firs! sound, nothing abnormal was heard. The dulness of the right 
 
 dorsal region was nearly gone, and vesicular respiration was present. The urine was 
 frequently examined. It was scanty at first; then became more abundant; the 
 specific gravity ranged from 1019 to 1025 ; it gave no traces of albumen. 
 
COMPLICATED WITH ASTHMA. 55 
 
 I 
 
 Asthma. — The following is the only instance of this complica- 
 tion: — 
 
 13. Intermittent Fever complicated with Asthma. — Chitim, a Hindoo drummer, of 
 thirty years of age, of stout frame, and a native of Golconda, had suffered for about 
 eight months from intermittent fever and asthma, which was liable to return at inter- 
 vals of fifteen days. He was admitted into hospital on the 2nd August, 1850. The 
 physical signs of emphysema of the lungs were present. The paroxysm of fever and 
 of dyspnoea recurred together at night, and ceased towards the morning. He 
 was treated with quinine in four-grain doses, at first uncombined, then with sulphate 
 of iron (one grain) and dilute sulphuric acid. No treatment, except rubefacients to 
 the chest, was specially directed against the asthmatic symptoms. On the first and 
 second day after admission, the fever and asthma were much less : they ceased on the 
 third day. He was discharged on the 8th August. 
 
 This case is interesting from its bearing on the therapeutic fact, 
 that some cases of spasmodic asthma in India are most successfully 
 treated with quinine and small doses of sulphate of iron during 
 the absence of the paroxysm, and in these it is reasonable to 
 infer that the asthmatic symptoms have been related to malaria 
 as a cause. To determine the probability of a previous malarious 
 influence, by inquiry into the history of the case and the condition 
 of the spleen, constitutes an important part of the examina- 
 tion of asthmatic patients in India. If there be good reason 
 for suspecting it, quinine and iron are indicated, and a more 
 favourable prognosis than in asthma under other circumstances, 
 provided the emphysema is not great, may be entertained. 
 
 Prevention of the paroxysm, by an anti-periodic remedy given 
 during the intermission, has throughout these remarks been in- 
 culcated as the ruling therapeutic principle in the treatment of 
 intermittent fever, simple and complicated; but means appro- 
 priate for the complications, when existing, are not therefore 
 excluded. On the contrary, they are also to be adopted, in the 
 modified manner suggested by the diathesis, and the fact of the 
 control exercised by the prevention of the paroxysm. 
 
 E 4 
 
56 REMITTENT FEVEE, 
 
 CHAP. V. 
 
 ON REMITTENT FEVER. 
 
 Section I.— The Diagnosis of Remittent Fever, from Intermittent 
 Fever and ardent Continued Fever. — Division into Simple 
 and Complicated. 
 
 The causes of remittent fever are the same as those of intermittent 
 fever. The essential difference between the two types is, that in 
 the remittent there is merely an abatement — a remission — of 
 the febrile reaction ; but in the intermittent, a complete cessa- 
 tion — an intermission. As in the remittent form there is a 
 longer period of fever, it is necessarily a more serious disease ; 
 and its prevalence may be looked for when the causes are intense, 
 or the state of predisposition is great. 
 
 The evidence that remittent and intermittent fever are different 
 degrees of the same kind of derangement, is of the following 
 nature : — 
 
 It is often observed that when the conditions of malaria exist 
 in great degree, remittent fever prevails; but that when these 
 lessen, the type becomes intermittent. It is not unusual for cases 
 of fever, remittent at their commencement, to become intermittent 
 before their close, or for cases that have been intermittent at the 
 outset to pass into the remittent form in their advanced stages. 
 Instances are also not unfrequently met with which seem to occupy 
 an intermediate position, which by some would be classed as inter- 
 mittents, by others as remittents, — cases in which there is an in- 
 termission of the pyrexia, but in which the tongue continues 
 coated, the secretions more or less deranged, and the succeeding 
 paroxysm comes on gradually without rigor. 
 
 In well-marked rases the diagnosis is easy ; and in respect to the 
 intermediate ones, it is not of much practical importance, for the 
 principles of treatment are similar. 
 
DIAGNOSIS. 57 
 
 The common continued fever which occurs in many parts of 
 India in the hot, dry months of the year, chiefly in April 
 and May, in its most aggravated form in recently-arrived robust 
 Europeans, often favoured by intemperance and fatigue, also re- 
 quires to be distinguished from remittent fever. 
 
 This diagnosis is materially assisted by bearing in mind 
 whether the season is one generally free from malaria or not, 
 whether the temperature is high, and whether the sufferers have 
 been previously exposed to malarious influence or not. The 
 character of the febrile disturbance likewise assists us, — as whether 
 reaction is great, whether there is much cerebral or gastric com- 
 plication, and whether the remission is distinct. 
 
 If the attack be in a hot and non-malarious season, in a recently- 
 arrived European, and the febrile excitement be high and con- 
 tinued, there need be no hesitation in considering the disease to be 
 continued fever, not malarious remittent. The diagnosis is im- 
 portant, for, as will afterwards be explained, the principles of 
 treatment are different ; but unfortunately, it is not generally of 
 this simple nature. High fever with cerebral and gastric disturb- 
 ance may occur in lately-arrived sthenic intemperate Europeans 
 in June, July, August, September, October, months in which, in 
 many parts of India, elevated temperature and the conditions of 
 malaria coexist ; or fever in April or May (non-malarious months) 
 may attack Europeans or others, who, though tainted by the ma- 
 laria of a previous season, are still sthenic, perhaps intemperate, 
 and frequently exposed to the sun : but the fever, if closely watched, 
 will in both instances be found to be characterised by distinct, 
 though perhaps short remissions. The simplest and most practical 
 view of this last, and in European troops at some stations* in India, 
 not infrequent form of fever, is to consider it as compound in its 
 nature, the product partly of malaria, and partly of elevated tem- 
 perature cou joined with other ordinary exciting causes, acting on 
 sthenic constitutions. The principles of treatment will necessarily 
 consist of a combination of th,ose applicable to the unmixed con- 
 tinued and remittent forms. 
 
 Eemittent fever may be divided into simple and complicated. 
 In the first, the derangement of different functions is not greater 
 than is usual in the severer forms of all fevers. In the second, 
 there is present either a local inflammation, or an aggravated de- 
 
 * As in the plains of the Ganges and Indus and their tributaries, the Catomandel 
 coast, and the table-lands of the Deccan and Malwa. 
 
58 EE3IITTENT FEVER. 
 
 gree of some other kind of local derangement. It will be prac- 
 tical and convenient to treat of simple and complicated remit- 
 tent fever under the separate heads of Symptoms, Pathology, and 
 Treatment. 
 
 Section II. — Symptoms of Remittent Fever. — Ordinary, Inflam- 
 matory, Adynamic, Congestive, Badly developed, ivith un- 
 expected Collapse, ivith peculiar Features. — Also complicated 
 with Cerebral Affection, Irritability of Stomach, Jaundice, 
 Bronchitis, Pneumonia. — Diagnosis from Hectic and Sym- 
 ptomatic Fever. 
 
 Ordinary Remittent Fever. — The first accession of remittent 
 fever is generally preceded by a sense of chilliness, slight, however, 
 in comparison with the rigor which usually ushers in an attack of 
 the intermittent type. The chilliness is succeeded by heat of skin, 
 headache, flushing of the face, frequency of pulse, occasional vomit- 
 ing, furred tongue, thirst, pain of the loins and limbs, deficient, 
 vitiated alvine secretions, and scanty, high-coloured urine. These 
 symptoms continue for a period of varying duration, and are 
 then followed by a stage of abatement or remission ; when the pulse 
 falls in frequency but does not return to the natural standard ; the 
 headache, with the pain of the loins and limbs, becomes less, but 
 is not altogether removed ; the temperature of the skin decreases, 
 but does not fall to the normal degree ; the skin becomes softer, 
 with even a little moisture about the head and trunk ; the thirst 
 decreases, and the tongue becomes moister, though still coated. 
 
 This remission of the febrile symptoms continues for a time 
 varying in different cases, or in different endemics ; and then the 
 exacerbation recurs, sometimes, but this is rare, with commencing 
 chilliness, as on the first accession. Most commonly, however, there 
 is no sense of coldness, but a gradual increase of the fever, till it 
 afjain reaches its acme. 
 
 In intermittent fever the duration of the paroxysm and of the 
 intermission, and the periods of accession, may vary; and so may 
 the duration and periods of the exacerbation and of the remission 
 in remittent fever. 
 
 1. There are cases in which the exacerbation comes on about 
 noon and declines before midnight. The remission continues 
 during the night, and till the noon of the following day, when the 
 exacerbation again recurs. 
 
 2. The exacerbation comes on about midnight and continues 
 
ORDINARY FORM SYMPTOMS. 59 
 
 till morning, when the remission takes place and remains till night. 
 It is not improbable that in these cases it will be frequently found 
 that the exacerbation has become postponed from the influence of 
 quinine : but on this point I do not speak with confidence. 
 
 3. The exacerbation comes on about noon, and is succeeded 
 towards evening by a remission which continues till midnight. 
 Then an exacerbation again takes place, to be followed by a morn- 
 ing remission. This variety is by no means uncommon, and in- 
 dicates a severe form of the disease, — one in which the fever shows 
 a tendency to become continued, and in which adynamic symptoms 
 are likely to arise. 
 
 4. It is sometimes observed that the exacerbation takes place at 
 different hours on alternate days, being on one day earlier, on the 
 other later. In this respect there is an analogy to the double 
 tertian.* 
 
 Such are the variations in regard to the duration and periods of 
 exacerbation and remission ; but it is impossible to anticipate which 
 of them a particular case will assume : nay more, the natural 
 course of the disease may be changed by treatment, as happens 
 in intermittent fever. 
 
 This uncertainty in regard to the periods of exacerbation and 
 remission makes it necessary that the peculiarities, in this respect, 
 of each case, should be ascertained by careful frequent observation. 
 
 It will not, however, fail to be remarked that there is one feature 
 common to all, — the morning is the most certain period of re- 
 mission.f 
 
 * No observer of tropical fevers has written with more accuracy on this and other 
 points than Dr. Francis Balfour, in his collection of treatises on the effects of sol- 
 lunar influence ; but his labour has been in a great measure lost, in consequence of 
 his practical researches being obscured by trifling theories and affected language. 
 His statement respecting the periods of exacerbation and remission in remittent 
 fever, divested of its pecidiar phraseology, amounts to this. The day and night are 
 divided into four periods. Two consist of seven hours each, — viz., from 8.30 a.m. to 
 3.30 p.m., and from 8.30 p.m. to 3.30 a.m. These are the times of exacerbation, and 
 the latter or nocturnal one is that in which the paroxysms generally appear first, 
 disturbing rest, obscure, often not recognised by the patient, or scarcely recollected 
 after the slumber which succeeds it; and as the disease advances, the febrile symptoms 
 are higher in it than in the diurnal period ; and again, as the fever declines, the 
 paroxysm often continues to recur in the nocturnal, after it has ceased to appear in 
 the diurnal, period. The remaining two divisions consist of five hours each, — viz., 
 from 3.30 to 8.30 p.m. and from 3.30 to 8.30 a.m. These are the periods of remission, 
 and at the beginning of fever the first or evening one is distinct ; but as the disease 
 advances, and the febrile symptoms run high, it becomes so obscure as not to 
 be observed. The second or morning 'period of remission is, in all cases, more dis- 
 ti/ict, and is almost invariably present in some degree. 
 
 t Hunter, in his observations on the diseases of the army in Jamaica (1779), states 
 
60 KEMTTENT FEVER. 
 
 These variations in the period of exacerbation and remission 
 are not peculiar to the ordinary form of simple remittent fever, 
 but are also observed in those other varieties which we shall find 
 owe their peculiarities to an aggravated degree of the stage of ex- 
 acerbation, or of that of the initiatory cold stage, or to a decreasing 
 period of remission and an increasing duration of exacerbation ; 
 while there are others characterised by adynamic phenomena, or 
 complicated by inflammation of an important organ, or other local 
 derangement. 
 
 This description of the symptoms of ordinary remittent fever 
 applies to the disease as observed in the European General Hospital 
 at Bombay in seamen*, more or less habituated to a tropical 
 
 that the practice of -risking hospitals in the early morning originated in this being the 
 usual period of remission in remittent fever ; and it is very probable that the similar 
 practice in India had a similar origin. It is essential to the successful treatment of 
 remittent fever that this fact should not be overlooked, and that the tendency, which I 
 have noticed in medical officers not acquainted with tropical disease, To visit their 
 hospital at a later hour should be checked. 
 
 * In some — and these, in some instances, the worst cases — the fever was attributed 
 to the malaria of the dockyard, a locality afready alluded to by me. 
 
 At the time of my service in the European General Hospital, with the view of 
 ascertaining to what extent the crews of ships undergoing repairs in the dockyard at 
 Bombay were liable to be affected with fever, I obtained, through the kindness of 
 Captain Ross, the Master Attendant, a list of ships of all kinds received into 
 the dockyard during the period (viz., from 1st July, 1838, to 1st July, 1843), to 
 which my notes on fever in the European General Hospital have reference, with 
 the date of docking and undocking each ship. The number of ships amounted to 170. 
 This list I compared with the Hospital Register, and noted opposite to the name of 
 each ship the number of the crew admitted for fever into hospital during the time the 
 vessel was in dock. The following is the residt: — Of the steamer Atalanta, in dock 
 from the 23rd October, 1839, to the 19th February, 1840, 9 fever cases; of the 
 private ship Orleana, in dock from 13th October to 11th November, 1840, 12; of the 
 ship Herefordshire, in dock from the 13th October to 10th November, 1840, 10 ; of 
 the private ship Morlcy, in dock from the 22nd July to the loth August, 1841, 10; of 
 the remaining ships, 3 fever cases were admitted from one, 2 cases from three, and 
 one case from ten, respectively. From the remaining 152 ships, there were not any 
 admissions of fever during the time they were in the dockyard. 
 
 The fevers from the ships Orleana and Herefordshire I recollect very distinctly: I 
 am in possession of a memorandum to the effect that, on the 8th November, 1840, 
 there were 26 casesof fever in the hospital, of which there were 22 from these two ships, 
 showing that the shipping in the harbour was comparatively free from the disease. 
 The type was chiefly the mild remittent. The admissions from the ship Morlci/ were 
 of similar type; and during the time that the ship was in dock, H. M.'s frigate 
 
 Endi/midii was also there, and part of her crew suffered severely from fever of a very 
 adynamic type. There were not inure than 3 or 4 cases admitted into the General 
 Hospital from the Endi/mion ; but the following facts have been extracted by me from 
 
 official records to which F have been allowed to refer. 
 
 The Eudtimion was in dock from the l!)fh July to the 19th August, 1841. On the 
 28th July, the first cases offerer among the marines took place; from that date 
 to the 12th August, 27 cases occurred; and to the 23rd, 11 more, and 2 additional 
 
INFLAMMATORY FORM — SYMPTOMS. 61 
 
 climate, and usually seeking admission into hospital, after having 
 Leen ill three or four days : it also applies to the disease as occur- 
 ring in natives of good constitution. 
 
 Inflammatory Remittent Fever. — It was stated, in reference to 
 intermittent fever, that the amount of febrile reaction in the hot 
 stage had relation to the sthenic or asthenic state of the constitu- 
 tion : so it is also in remittent fever. In robust Europeans, lately 
 arrived in India, exposed to malarious influence, and neglectful of 
 the ordinary means of preserving health, remittent fever, with 
 severe exacerbations, is likely to occur, attended with much head- 
 ache, pain of limbs, restlessness, flushing of the face, perhaps deli- 
 rium. The skin is hot and pungent, and the pulse full and frequent. 
 A sense of oppression is experienced at the epigastrium, accompanied 
 by nausea and frequent vomiting. The tongue is much coated, and 
 its edges and tip are often florid. Thirst is urgent, and the excre- 
 tions are scanty and vitiated. The remissions are well marked, but 
 they are proportionate to the severity of the exacerbation, so that 
 the febrile state in them may almost equal in degree that of the 
 exacerbation in the ordinary mild form of the disease. The term 
 inflammatory, as applied to remittent fever, is not to be understood 
 as implying the presence of local inflammation : it is used merely 
 to express a high degree of febrile reaction. 
 
 If to this variety of remittent fever, as now described, the influ- 
 ence of exposure to elevated temperature, or of excesses in drinking 
 be added, then that compound form to which I have already alluded, 
 — in which the exacerbation is of longer, and the remission of 
 shorter duration, and in respect to the classification of which, as 
 continued or remittent, there is often doubt, — will be produced. 
 
 cases were subsequently admitted, making altogether 40 marines affected with fever 
 in one month, all of whom had slept on board in the tour of their duty during 
 the time the Endymion was in dock ; and in addition to these 40, there were only 2 
 others who slept on board. Thus of 42 who slept on board occasionally, 40 were 
 affected with remittent fever ; and to mark the severity of the type, up to the 30th 
 of August 14 had died, and 10, several of whom were in a doubtful state, remained in 
 hospital. Whilst such was the extreme suffering of the marines of the Endymion, 
 whose duty as sentries over stores led to their exposure to the ndxious night air of the 
 dockyard, the following was the condition of the seamen. From the 24th June, the 
 date of the arrival of the Endymion in Bombay, to the 30th August, there were 
 95 seamen (blue-jackets) ill with fever. In none of these did the type resemble that 
 of the marines, and none proved fatal ; and it is distinctly noticed that the carpenters 
 employed during the day upon the repairs of the bottom of the vessel, with one 
 exception, escaped any severe attack, and several of them were not attacked at all. 
 
 It is a rule of the dockyard that the crews shall not sleep on board whilst the ship 
 is undergoing repairs there ; and the statements which have been just made show I he 
 salutary operation of this very necessary regulation. 
 
62 REMITTENT FEVER. 
 
 Remittent Fever tending to become continued, then adynamic 
 in character. — It has been stated that sometimes in ordinary re- 
 mittent fever the exacerbations are double, — one in the day, 
 another in the night. Such cases are generally severe, because 
 the hours of exacerbation are increased in number ; and it often 
 happens that after the first or second day of the double exacerba- 
 tion, or it may be from the very commencement of the attack, 
 the remissions are so slight as to be hardly observed : the fever 
 becomes almost continued in character.* This may proceed from 
 the intensity of the malaria acting on an ordinary constitution, or 
 from a less degree of malaria acting on an asthenic constitution, or 
 (and this is probably a very frequent cause) from the early exacer- 
 bations not having been judiciously managed — from neglect of the 
 withdrawal of causes of irritation or excitement, or by the applica- 
 tion of means of cure too depressant. Finally, the continued form 
 may be favoured by the access of local inflammation. 
 
 When remittent fevers, which have thus passed into the almost 
 continued form, do not prove fatal in the early stages from sudden 
 depression of the vital actions of the nervous system or of the heart, 
 or from congestion, or inflammation of some important organ, but 
 continue beyond the eighth day, or earlier when the asthenia has 
 been great, then a new train of symptoms begins to appear. The 
 pulse becomes more frequent and feeble, the tongue dry, brown 
 and unsteadily protruded. The hands are tremulous, with tendency 
 to subsultus tendinum. There is more or less muttering delirium 
 and drowsiness, and death takes place from exhaustion or coma. In 
 other words, the remittent fever has assumed an adynamic character. 
 With this form of the disease in Europeans I became familiar in 
 the General Hospital at Bombay ; and in natives not only in the 
 Jamsetjee Jejeebhoy Hospital, but also in all the other various 
 circumstances in which I have had the opportunity of observ- 
 ing their diseases. 
 
 When these phenomena of depressed vital action are present in 
 their most aggravated degree, petechial spots may show themselves 
 
 * The term " continued " having been already applied to a different set of circum- 
 stances from that in which it is here used, it would have been well, to prevent the 
 risk of confusion, to substitute another term; but I am nc4 prepared to suggest 
 departure from usage. It can only be a very careless reader who will confound 
 the oom/mon or unit, it continued fever of the hot months, occurring in sthenic 
 individuals, with fever generally remittent at the beginning, then becoming continued, 
 occurring at malarious seasons, in constitutions asthenic at the outset, or made so by 
 the intensity of the cause or injudicious treatment in the early stages. 
 
ADYNAMIC FORM — SYMPTOMS. 63 
 
 on the surface of the body, or there may be oozing of blood about 
 the gums and lips, or epistaxis, or vomiting of blood or of 
 dark-coloured grumous-looking fluid ; or inceloena or haeniaturia may 
 be present. These symptoms prove that the chemical and vital 
 conditions of the blood have become signally deranged. To remit- 
 tent fever thus characterised by petechias and haemorrhages, the 
 term malignant has been applied. In its aggravated form it is 
 seldom observed in Bombay ; but in its slighter degree it occasionally 
 occurs. 
 
 To what are these adynamic symptoms to be attributed ? To 
 the intensity of the cause, to the greater amount of febrile excite- 
 ment consequent upon the fever having become continued, to the 
 previous influence of predisposing causes, as insufficient food, 
 lengthened exposure to hot weather, intemperance, depressing 
 passions, bodily fatigue, or previous disease : or they may arise from 
 medical treatment having been neglected at the commencement, 
 or from its having been too depressing in character, — too much 
 general blood-letting, leeching, antimony, calomel, catharsis, and 
 the neglect of quinine and nourishment.* 
 
 "When several of these conditions co-exist, — as intense malaria, 
 predisposition, and injudicious medical treatment, — then are com- 
 bined the conditions most calculated to produce a fever of a highly 
 adynamic and malignant character. 
 
 * Fevee, -with an unusual proportion of adynamic cases, and consequent mor- 
 tality, prevailed in the gaol at Sattara from October 1858. to May 1859. A short 
 account of the leading facts will serve to illustrate some of the statements in the 
 text. 
 
 The gaol is very faulty in construction, and badly situated ; but, generally speaking, 
 has not been unhealthy. The system of dieting and general management has for 
 the most part been good. On the 4th of August, 1858, the dietary was modified by 
 the Assistant-Judge in such a manner as to create general discontent, and affect the 
 comfort and health of the prisoners; but the original system was reverted to on the 
 2nd of October. The prisoners had also been imperfectly clothed during the greater 
 part of the monsoon and the commencement of the cold season. 
 
 A new gaol, distant about a quarter of a mile from the old one, was being built by 
 the prisoners. All, without reference to then- previous occupations, were, after a 
 slight meal, marched daily at 6 a.m. to work at the new building, and continued 
 so engaged till 3 p.m., when the labour of the day was finished, and the prisoners 
 returned to the gaol for their principal meal. Consequent on the increase of fever, 
 and the discovery that some of the drains in the gaol were foul, the prisoners were 
 removed on the 23rd of December to the fort of Sattara, placed on a hill 1200 feet 
 above the city, nearly 4000 feet above the sea, and about a mile and a half distant 
 from the new gaol. Thus the prisoners were exposed to greater fatigue in going 
 to and from work, and to greater cold from elevation. The fever and mortality 
 increased, work was intermitted for a time, and the prisoners returned to the old 
 gaol, which had been thoroughly cleaned and whitewashed, on the 15th February, 1859. 
 
 The admissions and deaths from fever were as follows : — 
 
64 
 
 REMITTENT FEYEE. 
 
 Congestive Remittent Fever. — The term congestive is used in 
 the sense in which it has been generally applied by late writers* 
 
 
 Admissions. 
 
 Deaths. 
 
 
 10 
 
 1 
 
 
 16 
 
 3 
 
 
 24 
 
 1 
 
 
 34 
 42 
 37 
 
 4 
 5 
 
 5 
 
 
 15 
 
 
 
 178 
 
 24 
 
 With the view of determining the characters of the lever, I examined 93 diaries 
 of recovered cases, and made the following classification with reference to month of 
 admission and type : — 
 
 
 Intermittent. 
 
 Remittent. 
 
 Febricula. 
 
 November ..... 
 December and "^ 
 January J 
 February ..... 
 March ..... 
 April ..... 
 
 11 
 
 10 
 
 24 
 
 13 
 
 6 
 
 
 
 2 
 
 4 
 5 
 
 
 
 
 
 
 9 
 7 
 2 
 
 64 
 
 11 18 
 
 The 75 intermittents and remittents presented no peculiarity; they were the ordi- 
 nary types which prevail in the Deeean, more or less, every year from October to 
 February. Slight jaundice was present in 16, delirium in 5, and epistaxis in 2. 
 The cases of febricula were also of the type usually prevailing in the Deccan in 
 February, March, and April, more or less, according as the ordinary exciting causes 
 — heat, exposure, fatigue, vicissitudes of temperature — and the predisposition from 
 a plethoric or debilitated state, are present. They occurred in greater proportion 
 among lately arrived ramosees, goldsmiths, writers, and shopkeepers, — classes whom 
 the out-door labour of the gaol system was likely to affect injuriously. They were 
 mostly a few days under treatment, and there was nothing in their origin, type, 
 and course to justify a suspicion (which the gaol authorities were disposed to enter- 
 tain) that infection from old fever cases acting on new arrivals was the cause. 
 
 The notes of 21 fatal cases are before me. They are all remittent, with, in 
 Borne, a commencement as intermittent. Death was caused by prostration, in some 
 coming on quickly, in others after the lapse of several days. There was jaundice 
 in 7. Six of the fatal cases were under two months' residence, and their ages were, of 
 two 32, and one 35, 48, 65, and 80. 
 
 Of the recovered and fatal cases, 1 were stated to have been in attendance on the 
 sick when taken ill. Two recovered; < an ordinary intermittent, the other a mild 
 
 * " Outlines of Physiology and Pathology." By Dr. Alison, p. 485. 
 
CONGESTIVE FORM. — SYMPTOMS. 65 
 
 to a state of depressed action of the vascular and nervous systems 
 in the early stage of fever ; the former characterised by a feeble 
 pulse, a cold often damp skin, sighing respiration, and defective 
 secretions ; the latter by languor and drowsiness. This condition 
 is probably correctly attributed to the intensity of the malarious 
 poison. Death may take place speedily in the stage of congestion 
 without distinct febrile excitement ; or reaction may follow, and 
 the remittent character become well marked and the disease 
 under careful management terminate successfully; or the remis- 
 sions may be indistinct, the fever almost continued in type, and 
 adynamic symptoms early evolved. There is, as has been re- 
 marked by Dr. Alison*, considerable analogy between the sym- 
 ptoms of this form of fever and those of cholera. The collapse 
 of cholera resembles in many features the stage of congestion, and 
 w T hen secondary fever occurs, it is not unlike the reaction which 
 sometimes attends the congestive form of remittent fever. The 
 secondary fever of cholera is, however, apt to run a longer course, 
 and to be complicated with subacute inflammation of important 
 organs. Congestive remittent fever is occasionally observed in the 
 European General Hospital, as well as in Europeans elsewhere 
 
 remittent. Two died ; one, set. 41, after one year and six months in the gaol, and 
 one month's attendance on the sick ; the other, set. 52, after 15 years and six 
 months in gaol, and three months' attendance on the sick. There is, therefore, 
 nothing in these facts to justify the suspicion of infection, and it is further probable 
 that these men -were selected for this duty because unequal to hard labour. The 
 symptoms and course of the fatal cases — the prostration, the attendant jaundice — in 
 no respect differed from those usually observed in adynamic cases of remittent fever 
 in India, when occurring in persons previously debilitated and out of health. 
 
 The medical treatment was faulty : it favoured the duration of the attacks, and the 
 change of type from intermittent to remittent, and from the latter to continued, with 
 development of adynamic phenomena. The defects were. 1. Too active treatment of 
 the stage of reaction by leeches, antimony, calomel, and purgatives. 2. The inadequate 
 use of quinine during the remission : it was often too long delayed, the period was 
 not watchfully selected, and the quantity was insufficient. 3. Insufficient support 
 by frequently repeated suitable nourishment and stimulants chiefly during the 
 remissions. 4. The neglect of an improved and appropriate diet to restore 
 strength before discharge from hospital and return to the system and work of the 
 gaol ; hence relapses, with increasing adynamia in each. Several cases were said to 
 be free of fever, but they sank from exhaustion, or, to express it more distinctly, from 
 inanition. In this record there is illustrated — 1. The influence of temporary errors 
 in dieting and clothing, of fatigue, and of vitiated atmosphere, in creating a predis- 
 position to be acted on by the malaria of the locality, and the reduced temperature of 
 season and of elevation — tlms increasing the [quantity of fever. 2. The effect of the 
 predisposition thus engendered and of ill-directed medical treatment and manage- 
 ment in aggravating the type and augmenting the mortality. 
 
 * " Outlines of Physiology and Pathology," loc. citat. 
 F 
 
66 REMITTENT FEVEK. 
 
 in Bomba}^, chiefly in the malarious season of the year : it has 
 also been noticed by me in the cold season in asthenic natives, 
 who had been badly fed and clothed, and exposed to inclement 
 weather.* 
 
 Remittent Fever with badly-developed Symptoms. — In inter- 
 mittent fever in asthenic individuals, there is not unfrequently, as 
 already explained, an irregularity in the characteristic stages of 
 the paroxysm. Instances of remittent fever similar in kind may 
 also occur : it is a form of disease little calculated to arrest at- 
 tention. The exacerbation is badly marked, is attended by little 
 heat of skin or vascular excitement; indeed, these symptoms of 
 fever may be absent, but instead of them, there may be some 
 degree of undue restlessness or fretfulness, or incoherence of mind, 
 with tremulous hands, and a tongue coated in the centre; or 
 nausea with tendency to vomit or to diarrhoea may be present. 
 The remission is distinct, but the nights are generally restless. 
 With each recurring exacerbation, the pulse loses strength, the 
 tongue becomes drier and tremulous, tremor of the hands in- 
 creases, the slight wandering passes into muttering delirium, and 
 perhaps unexpectedly, about the tenth or twelfth day or earlier, 
 the delirium lapses into coma ; or the exacerbation terminates 
 with extreme collapse and death. 
 
 Mr. Twining's " Insidious Congestive Fever of the Cold Sea- 
 son," f is, it seems to me, of this nature. But this form of fever 
 
 * A greater degree of these congestive phenomena, in very malarious districts, has 
 been described by authors. The term has, however, been applied by English writers to 
 other forms of febrile disease. This is much to be regretted. Mr. Twining's " insidious 
 congestive fever of the cold season" is different, and relates to sets of symptoms, 
 some of which I have already alluded to under the head of adynamic remittent fever, 
 and others of which I shall subsequently have to advert to ; but none of Mr. Twining's 
 descriptions express merely an undue degree and continuance of the phenomena 
 characteristic of the cold stage. This seems to me the sense in which we should 
 apply the term congestive fever, and. while we thus use it, it by no moans fol- 
 lows that we are subscribing to any particular pathological doctrine, as, for example, 
 that which attributes the phenomena of failing heart and nervous system to ante- 
 cedent congestion of blood; on the contrary, all the phenomena seem to me to In- 
 coincident and sequences of the influence of the morbific cause. 
 
 Again, the term congestive has been used, as in Reports of the 4th Dragoons, in my 
 
 -i..n. in fche sen-' of remittent fever, witli marked congestion of the mucous 
 
 membrane of the Btomach or bowels, or of the liver. This is also a faulty use of 
 the term. 
 
 t Dr. Edward Goodeve, in a clinical lecture on typhoid frwr. published in No. XI. 
 
 , ■• indi.iu Annals of Medical Science," suggests that Mr. Twining's "insidious 
 
 congestive fever of the cold Beason" is that form of continued fever now designated 
 
 "typhoid;" and much consideration is due t.> the opinion of this accurate and 
 
 experienced physician. Though the view taken in the text of similarity between 
 
UNEXPECTED COLLAPSE. — SVMrTOMS. 67 
 
 is not peculiar to this season, for I have witnessed it in Eu- 
 ropeans in June and July. The last case which came under my 
 notice was that of an old officer about to leave India, who, in his 
 journey to the coast, sustained a severe fracture of the fore-arm. 
 The injury with other causes of anxiety and long service in India 
 had impaired his constitution. He became affected by the obscure 
 symptoms just described, — restlessness, slight incoherence, then 
 delirium, tremor of the hands, tongue coated and tremulous. 
 The exacerbations and remissions were well marked, and death 
 took place by coma. 
 
 This form of disease is important, and liable to be over- 
 looked. It requires careful treatment and close watching. If 
 there be much prostration, increasing from day to day, without 
 any very evident cause, it may be assumed that at some time or 
 other in the twenty-four hours a febrile exacerbation takes place, 
 and the period should be ascertained without delay. If the tongue 
 tends to become coated in the centre, then brown and dry, the 
 existence of a febrile period becomes certain. 
 
 This variety of fever may be apprehended in persons whose 
 constitutions have become deteriorated by exposure for successive 
 seasons to elevated temperature, anxiety of mind, intemperance, the 
 causes of scurvy, secondary syphilis, the abuse of mercury, the in- 
 fluence of malaria ; and it is not unlikely that in some instances it 
 may depend on previously existing structural disease. But to this 
 latter condition further allusion will be made under the head 
 Pathology. 
 
 Remittent Fever with unexpected Collapse, — It was stated 
 that in asthenic individuals the third stage of intermittent fever 
 is sometimes attended by so much exhaustion as to require the 
 assiduous use of stimulants and nourishment. The same feature, 
 is much more frequently observed in remittent fever ; and there is 
 no practical fact of greater importance to remember in the manage- 
 ment of this disease, than the marked tendency to great collapse 
 so often evinced towards the close of an exacerbation — collapse 
 not unfrequently terminating in death.* 
 
 We have learnt that from malaria, habit of body, and continuance 
 
 Twining' s insidious congestive fever and the varieties described by me as adynamic, 
 remittent fever with badly developed symptoms may be incorrect ; still I retain 
 the conviction that none of the forms of fever described in this chapter are of 
 the nature of true " typhoid." 
 
 * It is probably to the occurrence of this collapse early in the disease, that the 
 term Algide has been applied by Dr. Haspel and other writers on the diseases 
 of Algeria. 
 
 F 2 
 
68 REMITTENT FEVER. 
 
 of febrile excitement, there takes place, sooner or later, in all pro- 
 tracted cases of fever, a marked depression of vital action, chiefly of 
 the heart and nervous system. In remittent fever, when this state 
 supervenes, it generally first appears at the commencement of a 
 remission, or just as the exacerbation is passing into it. Therefore, 
 under these circumstances, it is necessary that towards the close of 
 the exacerbation, all agencies — leeches, purgatives, antimonials, 
 — calculated to hurry on and increase the depression, should 
 be carefully avoided; for it is by the injudicious employment of 
 such means that unlooked-for collapse — thready pulse, shrunken 
 features, a cold and damp skin — is apt to occur.* Hence the 
 practical lesson, that in all remittents after the 7th or 8th day, 
 or earlier if the pulse has been feeble, or the hands and tongue 
 tremulous, or the mind wandering, or any other symptom of de- 
 bility present, we should be careful to avoid depressant means of 
 treatment, more especially towards the close of the exacerbations, 
 and to give suitable nourishment and stimulants assiduously during 
 the remission. At the close of a paroxysm symptoms of exhaustion 
 should be carefully watched for, and should they threaten, then 
 stimulants and nourishment, as ammonia, wine, and strong animal 
 broths, must be liberally administered. Cases of remittent fever 
 have, to my knowledge, been lost, from want of forethought and 
 preparation to carry out these very evident indications of treat- 
 ment. The following is an instance of unlooked-for collapse 
 terminating fatally. 
 
 14. — Remittent Fever fatal from unexpected Collapse. — A gentleman of about fifty 
 years of age, of sallow complexion, who had lived several years at different times in 
 tropical climates, and had experienced his share of the cares of life, became, in 
 Bombay, the subject of remittent fever. After the illness had continued four or five 
 days, his medical attendant, not satisfied with the state of his patient, yet not 
 anxious in regard to his safety, wrote to me at one of his evening visits a note request- 
 ing me to meet him the following morning. The note was not to be delivered till the 
 early morning, but it was sent at midnight, accompanied with an urgent verbal 
 
 * It was in Mr. Twining's writings that I first became acquainted with the full 
 importance of this truth, and it is among the most valuable of his many excellent 
 clinical lessons. It is now upwards of twenty-five years since this accurate observer 
 published his "Clinical Illustrations," yet I am satisfied, from personal observation 
 and the perusal of the diaries of eases, thai this important feature of remittent fever 
 is not yet generally understood and appreciated by medical men in India. It is still 
 not uncommon to hear of '•anomalous" cases of fever terminating fatally, unex- 
 pectedly, "notwithstanding the usual treatment having been actively followed." — the 
 marvel being, not the occurrence of death, but the want of knowledge of the disease, 
 the consequent surprise at the result, and the neglect of the means of its pre- 
 vention. 
 
UNEXPECTED COLLAPSE. — SYMPTOMS. 69 
 
 message, begging me to come immediately. The house was in my neighbourhood, 
 and I was there in a very short space of time, but I found that the patient had just 
 died. The evening febrile exacerbation had terminated in unexpected and fatal 
 collapse. 
 
 In Dr. A. S. Thomson's report * on fever in Her Majesty's 17th 
 Kegiment, at Colaba, in the year 1841, an epidemic to which I have 
 already alluded in the chapter on intermittent fever, there is the 
 following case : — 
 
 15.* Great Collapse in the course of Remittent Fever. — Recovery by Stimulants. 
 
 " Private W. S., aged twenty-two years, in India three years, sanguine habit. Admitted 
 on the 1st July, 1840, complaining of general debility, &c. A vein was opened, but 
 he fainted before many ounces slowly came, and no more could be got ; had an emetic 
 and purgative ; he afterwards complained of headache and had sixty leeches applied 
 to the head, and a diaphoretic mixture constantly given. 2nd of July : Pulse 84, 
 skin hot and moist, no pain. Continued the diaphoretic mixture. At night occa- 
 sional delirium, skin moist and hot bowels open, eyes wild, pulse 124, soft ; 
 complains of abdominal pain. A blister was applied to the neck and head, and 
 a draught composed of wine, tinct. morph. muriat. and tartar emetic given ; the head 
 to be rubbed over with strong tartar emetic ointment. 
 
 3rd. Slept a little after draught ; pulse 120, skin moist, bowels open, much 
 irregularity in his manner. Diaphoretic mixture and wine every second hour, with 
 forty drops of tinct. muriate of morphia at night. 
 
 4th. Pulse 79: skin moist; eruption on head from antimony ; slept none; bowels 
 open ; occasional delirium. The wine and diaphoretic mixture continued ; at night 
 five grains of calomel and five of hyoscyamus. 
 
 5th. Slept well last night, no fever ; pulse 76. Six grains of quinine every third 
 hour. Vespere. Calomel, antimony, and hyoscyamus. 
 
 6th. Fever with delirium came on yesterday at noon, and has continued since ; had 
 sixty leeches to the head, and this morning pulse 109; skin hot and dry; head warm 
 and temples throbbing ; thirty leeches applied to the head and diaphoretic mixture 
 given. 
 
 7th. The most fearful collapse followed the application of the leeches and the 
 fever; skin covered with cold perspiration and pulse scarcely felt. Brandy and 
 carbonate of ammonia given every ten minutes. Had forty drops of tincture of 
 morphia last night and slept well. Pidse 106 this morning; skin cold and clammy; 
 no pain ; the brandy and carbonate of ammonia to be continued. 
 
 8th. Strength impaired; pulse 120; skin hot. Diaphoretic mixture to be given 
 with wine ; bowels open. 
 
 9th. Pulse 96 ; skin hot and moist ; no pain ; occasional delirium. 
 
 It is useless to detail this case further. No violent paroxysm of fever occurred 
 again, although there was occasional slight increase of fever. He was convalescent 
 on the 31st of July, but was not fit for duty until the 11th of September, 1840." 
 
 It is almost a corollary from the feature of remittent fever which 
 has just been considered, that the period of death in protracted 
 fatal cases will be not the exacerbation but the remission. 
 
 Certain other occasional Features of Remittent Fever. — 1. It 
 occasionally happens that cases of remittent fever which ultimately 
 
 * " Transactions of the Medical and Physical Society of Bombay," No. 5, p. 84. 
 
 r 3 
 
70 REMITTENT FEVER. 
 
 prove severe, have not this character at the commencement, but 
 assume it after two or three slight exacerbations. This is best 
 explained by supposing that at first the incubation is not per- 
 fected, and that its completion is followed by the aggravation. 
 It may be further suggested that, if this explanation be true, we 
 can readily understand how treatment, unduly depressing in the 
 early days, may intensify the action of the malaria and advance its 
 incubation. 
 
 2. In remittent fever in asthenic constitutions there may be 
 a decreasing degree of the febrile exacerbations, but, if this be at- 
 tended with marked increasing asthenia in the remissions, we must 
 be careful not to interpret favourably the lessening exacerbation : 
 it is generally otherwise — the febrile excitement has merely 
 diminished in consequence of the sinking power of the vital ac- 
 tions. Such cases if misunderstood, and not very carefully 
 watched and treated, are apt to terminate fatally by collapse at the 
 close of an exacerbation. 
 
 3. In remittent fever a state of great exhaustion sometimes 
 takes the place of the period of exacerbation ; and if such cases do 
 well, the recurrence of febrile reaction at the period of exacerba- 
 tion is probably of favourable import. I quote a fatal case in 
 which this feature was observed. 
 
 1G. Exhaustion taking the place of Exacerbation in Remittent Fever. — A gentleman, 
 some years resident in India, living freely, and suffering from occasional attacks 
 of intermittent fever with irritability of stomach in the malarious season of the year 
 consulted me for irritability of stomach, which soon ceased, but left complete disin- 
 clination for food. Some nights he slept badly, others well; sometimes from a 
 morphia draught, sometimes without one. He complained only of great languor, and 
 looked very exhausted. Three or four glasses of wine, with beef-tea and jellies, were 
 taken daily. He continued for three or four days to attend to his avocations, till one 
 afteraooon febrile heat of the skin was for the first time noticed; it was present 
 during the night ami the following morning, but then in less degree. Eight-grain 
 doses of quinine and nourishment were given. At noon there was exacerbation, but 
 towards the after part of the day he became very feeble and exhausted. Wine 
 and nourishment were freely given. He rallied towards night, and passed the night 
 quietly. On the following morning he was tree of all fever, and mueh less exhausted 
 than on the previous day. The quinine was resumed, and beet-tea and wine were 
 freely given. At 1 p.m. there was rat her more exhaustion, but no fever. The wine 
 was more frequently given, and the quinine and nourishment continued, but without 
 effect. The exhaust ion increased towards evening. Brandy was substituted for the 
 
 wine. He continued quite collected till midnight, when he became somewhat drowsy, 
 and died at four o'clock of the following morning. In this case there was no vomit- 
 1:1 . The wine and nourishment, were retained. There was no diarrhoea. 
 
 Complicated with Cerebral Symptoms. — Under this head are 
 included cases of remittent fever in which there is evident de- 
 
CEREBRAL COMPLICATION. — SYMPTOMS. 71 
 
 rangement of the cerebral functions, as delirium, drowsiness, con- 
 vulsion. 
 
 Delirium occurs under two sets of circumstances. It may- 
 come on in the early exacerbations attended with much headache, 
 flushing of the face, vascularity of the conjunctivas, and may be 
 more or less active : this is its usual character in sthenic con- 
 stitutions, and at the commencement it is unattended with failing 
 action of the heart. In less sthenic individuals there is inco- 
 herent rambling, with less headache and flushing ; and though 
 there may be no distinct adynamic phenomena, the pulse is 
 deficient in power. Delirium is present chiefly in the exacerba- 
 tions; and when not altogether absent in the remissions, is gene- 
 rally much moderated. Should medical treatment fail in check- 
 ing the fever and removing these head symptoms, then, after a 
 time, varying in different cases, the delirium gradually passes 
 into drowsiness, coma, and death. This change is generally 
 first observable towards the termination of an exacerbation, 
 and is always attended with failing action of the heart. When 
 these symptoms occur under the circumstances just described, 
 they may be regarded as depending upon the co-existence of 
 inflammation or undue determination of blood to the brain and 
 its membranes. 
 
 Delirium, however, may commence at a more advanced stage 
 of the fever, as after the eighth or tenth day, or later when the 
 constitution has been good, and earlier when it has been bad. 
 It is low and muttering, without headache or flushing of the 
 face; and is attended with commencing adynamic symptoms, as 
 tremor of the hands, twitching of the fingers, a tongue tremulous 
 and dryish, and a pulse of increasing frequency and decreasing 
 strength. Should amendment not take place, the delirium will 
 after a time pass into drowsiness, and death by coma will succeed, 
 unless this event has been anticipated by collapse at an earlier 
 period before the stage of coma has arrived. Symptoms of de- 
 ranged and failing cerebral function, in adynamic fever, merely 
 express the concurrence of the brain in the general failure of 
 vital actions. 
 
 From this description of delirium in fever, it would seem that 
 the difference between that from adynamia and from active deter- 
 mination to the brain, is the co-existence, in the former, of tremors 
 of the tongue and hands, and twitching movements of the fingers. 
 Too much importance, however, may be attached to these deranged 
 muscular actions as diagnostic of merely an adynamic state; for 
 
72 REMITTENT FEVER. 
 
 they are not vmfrequently met with in association with subacute 
 cerebral inflammation, either idiopathic or complicating fever, and 
 are to be regarded as indicative of adjmamie derangement of the 
 nervous system, only when the other phenomena of adynamia are 
 well marked, and the history of the case distinctly points to the 
 same conclusion. 
 
 It has been stated that the delirium when continued passes into 
 drowsiness.* This symptom, when thus arising, is of most un- 
 favourable prognosis. But drowsiness occasionally appears in re- 
 mittent fever, unpreceded by delirium, generally in the earlier 
 stages and usually associated with a slow pulse and other con- 
 gestive phenomena. Drowsiness under these circumstances is by 
 no means' so dangerous a symptom as when it follows delirium : 
 care should be taken not to confound these two conditions. The 
 first is probably dependent on passive congestion ; the second on 
 commencing serous effusion. Lastly, there are occasional cases 
 with delirium or tendency to drowsiness coming on early in the 
 disease, towards the end of a paroxysm in fevers of bad type, 
 accompanied with signs of general collapse and dependent on en- 
 feebled nervous energy. 
 
 In the chapter on Intermittent Fever a case is narrated in which 
 only the period of paroxysm was marked by cerebral derangement. 
 This feature may also occur in remittent fever. In asthenic cases 
 with cerebral symptoms the period of exacerbation is sometimes 
 indicated by increase of delirium or of drowsiness, rather than 
 by distinct aggravation of febrile excitement. 
 
 In some cases convulsion comes on intermediately between deli- 
 rium and coma. This event may generally be referred to excesses 
 in drinking, to derangement of excretion from structural or other 
 causes, or to inflammatory action of the membranes or substance 
 of the brain. 
 
 Complicated iv it h Irritability of Stomach. — Occasional vomit- 
 ing may be present in ordinary remittent fever, and may occur in 
 greater degree in the inflammatory form of the disease ; but under 
 these circumstances it is merely one of the symptoms of an uncom- 
 plicated type. 
 
 But gastric irritability may be urgent, attended with uneasiness 
 and tenseness of the epigastrium and a tongue florid at the tip or 
 
 * The liability to retention of urine in this state of the cerebral functions is so 
 well known that it seemfi almost unnecessary to allude to it. Yet I have seen it over- 
 looked sufficiently often to convince me that attention cannot be called too frequently 
 to the fact. 
 
JAUNDICE, BRONCHITIS, ETC.— SYMPTOMS. 73 
 
 edges. In this state there is probably some degree of gastritis, 
 and it may exist in constitutions either sthenic or asthenic. Re- 
 mittent fever thus complicated has been termed Gastric Remittent. 
 At other times the vomiting is frequent, and the matters ejected 
 are tinged with bile, and the tongue is covered with a yellow fur, 
 but without florid edges and tip. This form- of the disease is 
 confined to sthenic constitutions, and has been termed Bilious 
 Remittent. 
 
 Complicated ivith Jaundice. — This complication exists occa- 
 sionally in Europeans, but still more frequently in natives. The 
 notes of twenty-seven cases treated in the clinical ward are before 
 me, and they will be particularly alluded to in the Section on the 
 Pathology of the disease. 
 
 The presence of jaundice is easily recognised by the tint of the 
 skin and conjunctivas, the state of the urine, and the generally 
 pale colour of the alvine discharges ; and there is usually present 
 some degree of tenderness below the margin of the right false 
 ribs. Jaundice is rarely observed from the very commencement 
 of the attack. It generally comes on after the fifth day, and 
 has not, as a rule, in my experience, been attended with irritability 
 of stomach. The tongue for the most part has a yellow slimy 
 appearance, and general soreness of the body is not unfrequently 
 complained of. 
 
 The few observations which I have to make on affections of the 
 boiuels, the liver and spleen, as complications of remittent fever, 
 will be included under the head Pathology. 
 
 Complicated ivith Bronchitis and Pneumonia. — These affec- 
 tions do not frequently complicate remittent fever in Europeans in 
 India; but we are told by Dr. R. H. Hunter*, in his interesting 
 Medical History of the Queen's Royal Regiment in Affghanistan 
 and Beloochistan, in 1838 and 1839, that in the colder climate 
 of these countries, chiefly in the winter months, pneumonia was 
 a frequent complication of remittent fever. 
 
 Bronchitis is a common accompaniment of remittent fever in 
 natives of India; and in the Jamsetjee Jejeebhoy Hospital at 
 Bombay pneumonia is the most usual of all the inflammatory 
 complications in asthenic subjects. Indeed, so often is pneumonia 
 present, that great risk is incurred of overlooking its existence in 
 this class of patients, unless, in the management of all fever cases, 
 we observe the rule of careful examination by percussion and 
 
 * " Transactions of the Medical and Physical Society of Bombay," No. 3, p. 183. 
 
74 REMITTENT FEVER. 
 
 auscultation. But it is not only in hospital patients that this com- 
 plication is met with. It occurs in all classes of the native com- 
 munity, and I have been consulted in not a few instances in which 
 it had been previously overlooked, to the great hazard of life, 
 merely because it had not been sought for. 
 
 The detailed consideration of this important subject will be 
 included in the Chapter on Idiopathic Pneumonia. 
 
 Diagnosis of Remittent Fever from Hectic and Symptomatic 
 Fevers.— The distinction of remittent from intermittent and con- 
 tinued fevers has already been noticed ; but the further diagnosis 
 will be more conveniently considered now. The frequent com- 
 plication of inflammation of important internal organs with this 
 type of fever has been stated. In a general hospital, into which 
 patients are admitted often at advanced periods of disease, and in 
 which a large proportion of the inmates are asthenic, affected with 
 local inflammations characterised by great obscurity of symptoms, 
 it may happen that hectic may be confounded by the superficial 
 observer with remittent fever.* Careful inquiry into the previous 
 history of the case and scrutiny into the state of all important 
 organs ought to prevent an error of this kind. 
 
 When an abiding malarious influence is present, febrile disturb- 
 ance excited by ordinary causes generally assumes more or less of 
 a periodic character; and when an individual thus tainted with 
 malaria becomes affected with idiopathic inflammation of an im- 
 portant organ, the symptomatic fever is also often characterised by 
 periodicity: it may, indeed, be distinctly remittent.f 
 
 It is in individuals who have been long resident in tropical 
 climates that this tendency of symptomatic febrile disturbance to 
 become remittent is chiefly observed ; and consequently when local 
 inflammation and remittent fever co-exist in such subjects, it may 
 be often doubtful whether the fever is idiopathic and complicated 
 with an inflammation, or the inflammation idiopathic and the fever 
 symptomatic. In determining this question the history of the 
 attack affords material assistance. The inflammatory complications 
 of remittent fever do not generally arise till several days after the 
 commencement of the fever ; whereas the symptoms of idiopathic 
 inflammation and the febrile disturbance are nearly coincident. 
 Moreover, in idiopathic fever, the febrile phenomena are greater in 
 
 * The diagnosis between remittenl fever and the adynamic febrile disturbance of 
 pycemia will be considered in Hi" Section on Pycemia in the Chapter on Blood Diseases. 
 
 f The same faci is often ob erred in Burgical practice, when individuals of this 
 kind of constitution become the subjects of serious injuries. 
 
PATHOLOGY.— MORTALITY. 75 
 
 proportion to the inflammatory action, and are attended by a <*reater 
 amount of general derangement of function than usually obtains in 
 symptomatic fever. Notwithstanding attention to these considera- 
 tion, the diagnosis is often uncertain, for in hospital practice the 
 history of disease is generally imperfect. It is fortunate, how- 
 ever, that the doubt which may thus arise does not affect the 
 treatment ; for the same therapeutic principles are in a great 
 measure applicable to both forms of disease. 
 
 Section III. — Pathology. — Mortality from Remittent Fever. — 
 Relation of Type to Diathesis and previously existing Struc- 
 tural Lesions. — Complication with Cerebral Affection and 
 Consideration of the Pathological Import of Cranial Serous 
 Effusion, — Complication with Gastric Irritability, Affection of 
 the Bowels. — Hepatitis, Jaundice, Parotitis, and Pneumonia. 
 
 When the effects of malaria are compared -with those of the special 
 causes of the zymotic continued fevers of colder climates, this 
 striking difference is observable : in the former, there are daily 
 suspensions of the influence with a return more or less complete 
 to normal action ; in the latter, the influence is continuous for many 
 successive days. On this distinction centres the difference in the 
 principles of treatment. 
 
 The rate of mortality from remittent fever depends upon the 
 t} r pe of the disease. I am not acquainted with any data which 
 give the mortality of ordinary remittents separated from the other 
 forms : it is doubtless very small. The inflammatory, congestive, 
 adynamic and complicated varieties occasion the chief mortality ; 
 and in general hospitals the frequent lateness of the period of 
 admission tends to increase it. 
 
 In 113 selected clinical cases of natives, 19 deaths occurred. 
 Nine of these were complicated with jaundice, 3 with cerebral 
 affection, 3 with pneumonia*, 2 with bronchitis, 1 with dysentery, 
 and 1 with splenic enlargement. In 7 of the 19 fatal cases the 
 fever was adynamic, viz. in the 3 with cerebral affection, the 2 with 
 bronchitis, 1 with pneumonia, and 1 with jaundice. 
 
 Through the courtesy of the Medical Board of Bombay, the 
 opportunity has been afforded me of referring to the fatal cases 
 of European officers in the Bombay army and civil service ; and 
 
 * These are distinct from the cases which I shall have to notice -when considering 
 idiopathic pneumonia. 
 
76 REMITTENT FEYER. 
 
 also to the cases of those recommended for change of climate, 
 from the year 1829 to 1848. They amounted to 1699. Notes 
 were made of the recovered cases of chief interest : they were 372 
 in number, and 49 were of remittent fever. I have also notes of 
 311 fatal cases which constitute nearly the whole mortality of the 
 period : of these there were 90 deaths from remittent fever, that 
 is, 28*7 per cent, of the total mortality. On inquiring into 
 the character of the fever in these 90 fatal cases, it appears that in 
 33 death took place by coma preceded by delirium, with inter- 
 mediate convulsion in some. In a considerable proportion irrita- 
 bility of stomach was present : in 6 it was the most prominent 
 symptom. Death occurred from early and speedy collapse in 12 
 cases, and in the greater number of them the influence of depres- 
 sant remedies, pushed too far in the exacerbation, was very apparent. 
 Adynamic symptoms were present in 8, and congestive phenomena 
 also in 8. Jaundice complicated, 7, and hepatic inflamma- 
 tion, 2.* 
 
 Before proceeding to the consideration of the pathology of the 
 several varieties of remittent fever, it is desirable that attention 
 should be directed to two general observations which are applicable 
 to all. 
 
 Inattention to the diathesis and habits of the affected, and 
 to the intensity of the morbific cause, has led to needless con- 
 fusion in the pathology, and to serious errors in the treatment of 
 remittent fever. The discrepancy of opinion on these points, be- 
 tween the writers on tropical diseases towards the end of the 18th 
 century and those of a later period, is best explained by this over- 
 sight. The first class observed the disease in individuals tainted 
 with scurvy, and excited by intense malaria ; the second, in persons 
 of sthenic constitution, and excited by a less degree of the morbific 
 cause. The one trusted to bark and stimulants for the cure ; the 
 other, to bloodletting, mercury, and purgatives. Both were in 
 extremes. The truth lies between. 
 
 2. In my report f on remittent fever in the European General 
 Hospital in Bombay, published in 1843, there is the following re- 
 mark : "In regard to the character of the subjects in whom these 
 congestive symptoms are likely to appear, my impression is that 
 they will be found to occur most frequently in persons who have 
 passed the meridian of life, and in whom there exists more or less 
 
 * I shall return to the mortality from remittent fever in Chap. VI. 
 
 t '• Transactions of the Medical and Physical Society of Bombay," No. 4, p. 186. 
 
TEE-EXISTING LESIONS. — TATIIOLOGT. 77 
 
 long-standing organic disease of the heart, the liver, or the kid- 
 neys." Subsequent experience has confirmed the importance of 
 this suggestion, not only as regards congestive symptoms, but 
 also all other phenomena of depressed action, as well as some of 
 the complications, particularly the cerebral. 
 
 Indeed it is very evident that we cannot fully comprehend any case 
 of fever, or direct its treatment with advantage, unless by close in- 
 quiry into the previous history and careful scrutiny of the state of 
 all important organs, we have determined whether it is an idio- 
 pathic fever in a system previously sound, or in one generally 
 deteriorated or the subject of structural imperfection of an im- 
 portant organ. 
 
 Haspel*, in his treatise on the diseases of the French troops in 
 Algeria, expresses the same idea, when he suggests that the pheno- 
 mena of Algide fever are probably related to a structurally feeble 
 heart. 
 
 In my notes on the fatal cases of sick officers, there are three of 
 remittent fever in which after death Bright's disease of the kidney 
 was found ; but in only one is the character of the febrile symptoms 
 noted, they were obscure, the stomach was irritable, and death 
 took place by coma. 
 
 The five following cases f, illustrative of these remarks, were 
 observed by me in the European General Hospital, and in the 
 Jamsetjee Jejeebhoy Hospital. 
 
 17. Remittent Fever. — Death by coma. — Bright's disease of both kidneys. — John 
 Robinson, aged thirty-seven a stout sailor of intemperate habits, was in the European 
 General Hospital from June 28th to July 1st, 1838, affected with anasarcous swelling 
 of the feet and legs. He was discharged and had returned to his duty on board one of 
 the steam- vessels. He was again brought to the hospital on the 12th July in a drowsy 
 state. The pulse was frequent and small and the skin warm. The tongue had a 
 yellow fur at the sides, but was florid in the centre. It appeared from his own state- 
 ment that he had suffered from fever since the 8th, with vomiting and diarrhoea, but 
 that "he had not been ashore since he left the hospital on the 1st instant. The head 
 was shaved, a blister was applied to the neck, and ten grains of calomel were given. 
 At 6 p.m. the drowsiness had increased, the skin was moist and cold, the pulse 
 frequent and feeble, and the bowels had not been opened. A turpentine injection 
 was exhibited, sinapisms were applied to the feet, and a blister to the epigastrium, 
 and a draught with camphor mixture, carbonate of ammonia, and nitrous ether, was 
 given every third hour. On the 13th, the bowels had been freely moved, there was 
 less drowsiness, and the pulse was 100, small and sharp. The draughts were directed 
 
 * " Maladies de l'Algerie," vol. ii. p. 320. 
 
 f These cases are quoted merely as illustrative of febrile phenomena in individuals 
 with old structural disease of important organs. I do not stop to inquire whether the 
 treatment might have been better or not. 
 
78 REMITTENT FEVER. 
 
 to be continued, with the addition to each of fifteen minims of colchicum wine, and a 
 scruple of calomel was given at bed-time. The drowsiness recurred, and increased to 
 coma, the pulse sank, and he died at 4 a.m. of the 14th. 
 
 Inspection four hours after death. — The body was stout and muscular. Head. — The 
 membranes and substance of the brain were congested. — Cheat. The lungs did not 
 collapse fully, and there were costal adhesions of the right one. The heart was soft, 
 flabby, and contained fibrinous eoagida. Abdomen. — The liver was pale, and parts of 
 its surface were marked with cicatrices, as if from former abscesses. The mucous 
 coat of the stomach was of dark red colour and softened. That of the colon and 
 rectum also was of dark red tint. Both kidneys were enlarged to double their 
 natural size, and had undergone yellow degeneration. 
 
 18. Remittent Fever with adynamic symptoms. — Serum underneath the arachnoid 
 and at the base of the cranium. — No coma. — The liver much enlarged. — Dark rosy 
 tint of the mucous coat of the stomach. — John Martin, aged fifty-eight, cook of 
 the ship Herefordshire, was admitted into hospital on the 31st October, 1840. He 
 stated that for two days he had suffered from vomiting, purging, headache, and sense 
 of oppression at the lower part of the sternum, attributed to exposure to the sun 
 whilst the ship was undergoing repairs in dock. On admission, the face was flushed, 
 there was anxiety and oppression; the pulse was 120, jerking and easily compressed, 
 abdomen full, tongue dryish and florid, and the skin hot and dry. He was freely 
 leeched on the epigastrium and blistered, was cupped on the nucha, and subsequently 
 blistered. He took two or three ten-grain doses of calomel, and one of a scruple. 
 The symptoms altered little. There was much restlessness and moaning, oppressed 
 breathing, frequent vomiting, dejections of dirty light grey colour and watery, tongue 
 dry and florid, pulse frequent and compressible, skin dry and generally above the 
 natural temperature, and the abdomen full. He continued quite sensible, and died in 
 the forenoon of the 2nd November. 
 
 Inspection five hours after death. — Head. There was a thin veil of serum under the 
 arachnoid membrane on the convex surface of the brain, and an ounce at the base of 
 the skull. On incising the substance of the brain, more than the usual number of 
 bloody points were observable. Chest.— There were old adhesions of the right lung. 
 Both were moderately collapsed, and there was no congestion of the posterior parts. 
 The cavities of the right side of the heart were full of blood, and there was com- 
 mencing disease of the aortic valves and beginning of the aorta. Abdomen. — The 
 omentum was loaded with fat, and the intestines, both great and small, were col- 
 lapsed. The liver enlarged reached to the crest of the os ilium and to the umbilicus, 
 was of pale yellow colour, and, when incised, did not give out much blood. The gall- 
 bladder was rather flaccid. The spleen was soft and pulpy. The mucous coat of the 
 stomach had a dark rosy tint throughout, with dark brown patches, but the texture 
 was not softened. The kidneys were somewhat lobulated and rather small, but there 
 Mas no well-marked disease of their structure. 
 
 19. llcmittcnt Fever with irregular symptoms in an intemperate man of very corpu- 
 lent habit, and in whose head, hart, liver, and kidneys there was extensive old 
 organic disease. — Thomas Moss, aged thirty-seven, an engineer of the steam depart- 
 ment, of full and corpulent habit, who had served (en years in the West Indies and 
 leu months in Bombay, was admitted info the European General Hospital on the 5th 
 April, 1811. The abdomen was full and uneasy but not very tender on pressure, the 
 skin was dry and of the natural temperature, the pulse loo and sharp, and the tongue 
 l"'"> clean, lie stated that since the previous day he had suffered from pain of 
 abdomen with occasional bilious vomiting and purging, lie was bled to twenty 
 ounces, and some leeches were applied to the abdomen, a warm bath used, and fifteen 
 -rains of calomel, one grain of ipecacuanha, and two -rains of opium given at bed- 
 time, lie passed a restless night, and on the morning of the 6th the breathing was 
 
ME-EXISTING LESIONS. — PATHOLOGY. 79 
 
 hurried and oppressed. The abdomen was full, with dulness on percussion for two or 
 three inches beyond the margin of the right ribs and extending across the epigastrium 
 to the left hypochondrium, and between the last left false ribs and the os ilium. 
 The pulse was 120, easily compressed but wiry, the action of the heart and the 
 sounds were confused, tongue coated, bowels not opened, no vomiting, and the 
 conjunctiva? were yellowish. He was cupped on the cardiac region, a scruple of 
 calomel was given, and afterwards a purgative draught. The bowels were freely 
 moved, but the symptoms were unchanged, with exception that the pulse on the 
 evening of the oth was feeble. It was now reported that he had been a man of 
 intemperate habits. A blister was applied over the cardiac region, and diuretics 
 with gin were given repeatedly. The symptoms continued with failing pulse and 
 coldish skin, and on the morning of the 7th, commencing coma: he died at 10 a.ji. 
 of that day. 
 
 Inspection five hours after death. — The body was extremely corpident ; there was a 
 layer of fat fully two inches thick in the abdominal parietes. Head. — Much blood 
 flowed on separating the scalp from the cranium. All over the convex surface of the 
 hemispheres the arachnoid was pearly, and in many places much thickened; and 
 underneath it there was a layer of serum veiling in many places the interspaces of the 
 convolutions. There were abotit three drachms of serum in the lateral ventricles, and 
 two ounces at the base of the skull. In the coats of the basilar artery and of those of 
 the vessels forming the circle of "Willis, and given off from it, there was much thicken- 
 ing from white deposit, in places, almost ossific in character : in these vessels there 
 was a small coagulum of blood moulded to their shape. Chest. — Adhesions connected 
 both lungs to the costal pleurae. The greater part of the lower lobe of the right lung 
 was in a state of red hepatisation, and when cut serum streamed from it. The left 
 lung was cedematous posteriorly, but not hepatised. The heart was the size of a 
 bullock's chiefly from hypertrophy with dilatation of the left ventricle, the right 
 ventricle was rather small, the right auricle was dilated and filled, as well as the 
 ventricle, by a firm yellow fibrinous coagulum. There was commencing yellow deposit 
 on the inner surface of the aorta, but it had proceeded to no great extent. Abdomen. 
 — The contents of the abdomen ascended to the level of the fourth rib, and thus 
 encroached on the capacity of the chest. The omentum was much loaded with fat, 
 the mesentery consisted of a layer of fat fully a quarter of an inch thick, and the 
 intestines were in general contracted and looked like a fringe to the more conspicuous 
 mesentery. The Liver was much enlarged, of bright yellow colour externally and 
 internally, and the incised surface had a small granular aspect. Spleen healthy. 
 Both kidneys were considerably enlarged, with cysts from the size of a pea to a 
 filbert standing in relief from the surface. The substance of the kidneys was also 
 occupied by similar cysts ; and the contents of some consisted of a dark grey 
 grumous fluid, while that of others was straw-coloured serum. In one of the kidneys 
 there was also a good deal of yellow degeneration. 
 
 20. Remittent fever in a person of very intemperate habits, with symptoms in some 
 respects resembling delirium tremens. — - Death by coma. — Three ounces of serum 
 at the base of the skull; Liver much enlarged. — Commencing degeneration of the 
 kidney. — Mucous coat of the colon softened, with here and there red patches, with a 
 'mucous follicle in the centre of each discoloration. — Softening of the mucous coat of the 
 stomach. — Thomas Chittenden, aged thirty-four, an engineer of the steam department, of 
 intemperate habits, and frequently in hospital suffering from febrile attacks, was 
 admitted on the 30th of August, 1839. He stated that for eight or nine days he had 
 been affected with febrile symtoms attended with irritability of stomach. On admis- 
 sion he complained much of headache, and the bowels were relaxed and the tongue 
 yellow. Thirty-six leeches were applied to the temples, and six grains of calomel, one 
 grain of ipecacuanha and one of opium were given. At the evening visit it was reported 
 that he had vomited frequently and been affected with general tremors which con- 
 
80 REMITTENT FEVER. 
 
 tinned. The tongue was tremulous and yellow, the abdomen was somewhat full and 
 tender on pressure at the epigastrium and right ribs, there was much headache, the 
 skin was covered with moisture, and the pulse was compressible. The bowels had not 
 been opened. A purgative enema was ordered, blisters were directed to the epi- 
 gastrium and to the nucha, and ten grains of calomel and two of opium were given at 
 bedtime. The blister acted well, and on the morning of the 31st (full moon) the 
 headache was lessened, the pulse 90, and the tongue not so tremidous. He was 
 ordered saline mixture with tartar emetic and tincture of hyoscyamus. He slept for 
 two hours during the day and his bowels were freely moved. During the night, 
 there was no sleep, and on the morning of the 1st of September the tongue and 
 hands were tremulous, the countenance flushed, the pupils dilated, and the pulse 96. 
 Cold affusion was ordered to the head, and saline mixture with two drachms of tinc- 
 ture of hyoscyamus every second hour for three doses. At the evening visit he was 
 still tremulous, his manner was startled, and he muttered to himself, the pulse was 
 feeble and the skin moist. One dark-coloured dejection had been passed. Cold affu- 
 sion to the head. Camphor mixture one ounce and a half, antimonial mixture four 
 drachms, tincture of hyoscyamus two drachms every second hour till he sleeps ; brandy 
 one ounce every hour for three doses, and then every second hour, and calomel 
 eight grains, opium one grain h. s. The pills were taken, also four ounces of 
 brandy and the dnuight three times, but he continued agitated, talking incoherently 
 and tearing the dressings from the blister, and at midnight there was constant 
 inarticulate muttering, spasmodic action of the muscles of the face, piipils dilated and 
 insensible to light, skin hot, and the pulse rapid and feeble. Cold affusion was 
 directed to be used to the head every hour while the scalp continued hot, sinapisms 
 were placed on the feet and the other remedies omitted. He became comatose and 
 died at 6 a.m. 
 
 Inspection nine hours after death, — The body stout, and the external surface 
 tinged deeply yellow. Head. — The dura mater was faintly tinged yellow. The 
 vessels of the membranes were moderately congested. The convolutions of the 
 convex surface of the depending parts of the hemispheres were veiled with serum 
 effused beneath the arachnoid membrane, and there were between two and three 
 ounces at the base of the skull. Chest. — The lungs were emphysematous and only 
 partially collapsed. The heart was healthy. The cavity of the chest was encroached 
 on by the liver which on the right side reached to the fourth rib and coursed 
 obliquely across to the seventh rib of the left side. Abdomen. — Omentum loaded 
 with fat. The liver weighed seven and a half pounds, was externally mottled choco- 
 late and buff, and admitted of a ready separation of the peritoneal coat; the incised 
 surface was of yellow colour, mottled and softened. The gall-bladder contained about 
 an ounce of thin bile. The mucous coat of the cardiac end of the stomach was of 
 dark-marbled red colour, somewhat thinned and somewhat softened, of the pyloric end 
 pale and mammillated. There was vascularity of the commencement of the mucous 
 coat of the duodenum but the texture was sound. The large intestine was distended 
 throughout but there was no thickening of its walls, the mucous coat was tinged 
 yellow, thinned, and generally softened, the mucous follicles were in many places ap- 
 parent but not prominent ; and throughout the colon there were red patches here and 
 there, mostly the size of a split pea, some larger, with a follicle in the centre of many 
 of them, and in these places the mucous coat was thin, soft, and pulpy, and after its 
 removal the areolar tissue underneath presented in some instances a vascular patch. 
 The bowel was filled with thin yellow feculence. The spleen was of natural size. 
 The kidneys were aearly natural, with perhaps commencing yellow degeneration of the 
 cortical substance, evinced by buff streaks. 
 
 21. "Remittent Fever with adynamic symptoms. — Obscure pneumonia. — Diath 
 without coma. "Bright s disease of both kidneys. - -Crooshnah Sutooa, aged twenty- 
 six, a Maratha labourer, was brought to the Jamsctjee Jejeebhoy Hospital on the 6th 
 
CEREBRAL COMPLICATION. — - PATHOLOGY. 81 
 
 of July, 1852, being the fhvst day of his illness, with febrile symptoms. There was 
 slight jaundice, and he was reported to have been delirious during the night. There 
 were irregular exacerbations and remissions, and the pidse was frequently badly deve- 
 loped. He had uneasiness at the margin of the right ribs. There was not much 
 delirium, neither brownness nor dryness of tongue. The breathing was hurried, but 
 no signs of pneumonia were noted before the 13th, when there was slight dulness of the 
 right dorsal region which, however, did not increase, and on the 20th occasional 
 crepitus was detected in the right lateral region. He had occasional cough. On the 
 evening of the 20th there was commencing erysipelatous inflammation of the back, 
 with large bullae resting on a dark base. On the 21st the pulse became feeble, the 
 breathing more hurried, and he died without coma on the 23rd. The state of the 
 mine had not been inquired into. 
 
 Inspect Ion eighteen hours offer death. — Chest. There were old adhesions of the 
 third lobe of the right lung to the parietes and to the diaphragm, and slight 
 serous effusion in the sac of the right pleura. There was increased redness of the 
 substance, and considerable oedema of the right lung, with hepatised nodides here and 
 there in the upper and third lobes. Of the left lung there were slight adhesions, 
 slight oedema with increased redness, and here and there hepatised nodides. The 
 heart was healthy. Abdomen. — The stomach and intestines were distended with 
 flatus. The liver was slightly enlarged, flabby, and of pale yellow colour. The 
 kidneys were both enlarged, the right weighed seven ounces, the left six and a half. 
 On removing the capsule from the right kidney the surface was observed to be mottled 
 dark red and yellow, and the cortical substance was of dark red colour and encroached 
 on the tubular portion which was hardly distinguishable. The left kidney was exter- 
 nally mottled yellow and red ; the cortical portion internally was of fatty appearance 
 and yellow colour and was considerably increased in size, with merely traces of the 
 tubular part here and there. 
 
 This case was treated and reported by Mr. S. Carvalho. The treatment consisted 
 of quinine, diaphoretics, and stimulants. The wet sheet was twice used with removal 
 of the febrile heat ; but it seemed to me that it increased the internal congestions. 
 
 Complicated Remittent Fever. — Cerebral Complication. — 
 The pathology of this complication is very important ; for fully 
 one third of the fatal cases of remittent fever in European 
 officers in the Bombay Presidency is of this nature, and it is 
 probable that the proportion is still" greater in the remittents 
 of sthenic European soldiers. But the cerebral affection is 
 not, in all cases, attributable to malaria alone, but is often 
 caused by undue exposure to the sun, or intemperance. The 
 influence of mental anxiety ought also to be regarded; and, in 
 natives, the habit of opium eating and ganja smoking must not 
 be lost sight of. 
 
 When describing the symptoms of this complication, I stated that 
 they might depend on different conditions of the brain. 
 
 1. Headache, flushing of the countenance, delirium occurring 
 early in the attack — due to the direct influence of the causes, 
 and not merely to that of frequently recurring exacerbations — 
 depend, for the most part, on active determination of blood to 
 the membranes and substance of the brain which, unless re- 
 
82 REMITTENT FEVER. 
 
 moved or prevented by treatment, is likely to terminate in serous 
 effusion. 
 
 The following six cases are illustrative of cerebral symptoms 
 appearing under these circumstances, and in four of them the in- 
 fluence of intemperance is apparent. 
 
 22. Remittent Fever — Death by convulsion and coma. — Vascular congestion of the 
 vessels of the pia mater. — Rosy tint of the substance of the brain. — One ounce of 
 serum at the base of the skull. — The heart dilated and its tissue pale and flabby. — 
 Partial redness, thinning, and softening* of the mucous coat of the stomach. — 
 Peycr's glands enlarged. — The spleen enlarged and softened, and the kidneys con- 
 gested. — Laurence Fearon, aged thirty-seven, an engineer of the steam department, 
 and of fall habit. During the four months of his residence in Bombay, he had been 
 several times in hospital ill with fever, attended with gastric irritability. He was 
 again admitted on the evening of the 2nd of September, 1839, having been ill with 
 fever for about a week before admission. There was headache with pain at the margin 
 of the right false ribs, diarrhoea, thirst, febrile heat, pulse 108, full. He was bled 
 to sixteen ounces, the head was shaved and cold cloths applied, a warm bath was or- 
 dered at bed-time, and six grains of calomel and one grain of opium with ipecacuanha. 
 On the morning of the 3rd there was no headache, and the epigastric uneasiness was 
 removed, the skin was covered with moisture, but the bowels had not been opened. 
 An ounce of castor oil was given. At the evening visit the pulse was 96, there was no 
 local pain, the bowels had been moved, and the evacuations were bilious. A warm bath 
 was directed at bed-time, and two grains of quinine early the following morning, and 
 to be repeated every second hour for three doses. On the morning of the 4th general 
 uneasiness of the upper part of the head was complained of, the pulse was upwards of 
 100 and the urine scanty. The quinine was omitted, and rhubarb and magnesia with 
 colchicum wine given. At the evening visit the bowels had not been moved, and at 
 noon there had been rigors followed by pyrexia; the pulse was 116, the epigastrium 
 tender, the pupils slightly dilated, and some confusion of thought and slight tremors 
 of the muscles were present. A purgative enema was exhibited, thirty leeches were 
 applied to the temples, and fifty to the hypochoudrium, and a blister was placed be- 
 tween the scapula. At midnight he had a convulsive fit, and about twenty minutes 
 afterwards, was found with dilated pupils, breathing heavily, and passing into coma ; 
 the skin was covered with sweat, and the pulse was full; the bowels had not been 
 opened. He was cupped on the temples to ten ounces, a purgative enema with tur- 
 pentine oil was exhibited, fifteen grains of calomel were given, and after two hours, 
 four ounces of haust. cathart. were directed to be taken. About an hour afterwards 
 he was again much convulsed; the bowels had not been moved. Afoot-bath at temp. 
 110° was ordered, and a blister to the epigastrium. At 2 a.m. he had passed into 
 perfect coma, with stertorous breathing and convulsive movement of the arms and 
 Legs ; surface hot. He died at 1 p.m. of the 5th. 
 
 Inspection twenty-three hours after death. — Body stout. H>ad. — There was a 
 general bright red Mush of the smaller vascular ramifications of the pia mater, and 
 the medullary Bubstance presented a pale cosy tint There was aboul an ounce of 
 Be ,.,,„, at the base of the skull bul none elsewhere. Chest. The Lungs were emphy- 
 sematous anteriorly, and adhered freely to the costal pleurae; there was very little 
 congestion posteriorly. The nearl was aboul twice the size of the fist ; all its cavities 
 v,,re dilated, but chiefly the left ventricle, the walls of which were somewhat thinner 
 jl,.,,, na tiiral. The muscular tissue of the nearl was pale ami flabby, there was a 
 fibrinous coagulum in the Left ventricle, hut the cavity was no1 distended with blood. 
 'II,,. |im'n g membrane of the commencement of the aorta had a deep cosy colour (im- 
 i. and the surface was roughened by cartilaginous deposit. The aortic and the 
 
CEREBRAL COMPLICATION. — TATIIOLOGY. 83 
 
 auriculo-ventricular valves were healthy. Abdomen. — The stomach was dilated. The 
 liver reached about two inches below the right false ribs, extended to the left of the 
 mesial Kne about four inches, adhered closely to the diaphragm, and was natural in 
 texture but of greenish olive tint. The stomach contained about half a pint of dark 
 green fluid, and at the cardiac end there was a dark red patch, and the mucous coat 
 was thinned and pulpy ; elsewhere the coat was of natural thickness, of leaden grey 
 colour, and generally somewhat softer than natural. At the end of the ileum the 
 solitary glands were prominent. The mucous coat of the colon was of grey tint, but 
 of natural texture, with the follicles not distinguishable. The spleen was considerably 
 enlarged and softened. The kidneys were considerably congested, chiefly in their 
 tubular part. 
 
 23. Remittent Fever in ei man of intemperate habits. — Fatal with convulsion, coma, 
 and tumultuous action of the heart. — Considerable effusion of serum in the head. — 
 Streaked redness and softening of the mucous membrance of the stomach. — Deep red 
 tint of the endocardium and muscular tissue of the heart. — James Riley, aged 
 twenty, a boiler maker of stout habit and a few months resident in India, was 
 admitted into the European General Hospital on the 2nd of July, 1838, affected 
 with mild febrile symptoms. He stated that for several days previously he had 
 suffered from a sense of oppression of the chest which he had attributed to cold but 
 which did not prevent him from following his occupation of boiler-maker. It was 
 subsequently ascertained that he was a man of intemperate habits, and that he had 
 been drinking to excess before his present illness. On the morning of the 3rd, after 
 a restless night, the skin was warm and soft, pulse soft and of natural frequency, 
 tongue slightly furred in streaks, thirst considerable, no uneasiness of the chest or 
 fulness of abdomen. About six p.m. there was tenderness of the epigastrium, pulse. 
 frequent, hard, and sharp, manner excited and skin hot. He was bled, but fainted 
 after the loss of sixteen ounces of blood. Ten grains of calomel with quarter of a 
 grain of tartar emetic and a similar quantity of opium were given. During the night 
 the bowels were frequently moved and the evacuations were green and watery. On 
 the morning of the 4th the skin was warm and soft, pidse 80 and firm, tongue 
 moist and little furred, no excitement of manner. Five grains of calomel and twelve 
 grains of Dover's powder were given. At the evening visit he felt better, the bowels 
 had been twice moved, and the evacuations were dark and bilious. He was ordered 
 a warm bath and a powder of chalk and mercury with Dover's powder. The night 
 was passed without sleep; skin cool. Cold affusion was used, and he took during the 
 daytime two doses of antimonial mixture with one drachm of tincture of opium. 
 Sleep did not residt, and after the evening visit the cold affusion was again used, and 
 a draught with one drachm and a hah' of tincture of opium was given. He slept for 
 several hours, but on the morning of the 6th he continued nervoiis and agitated, and 
 the action of the heart and of the carotids was strong. He was directed to be cupped 
 on the cardiac region ; but whilst the operation was being performed he was seized 
 with convulsions, and died comatose after about an hour. 
 
 Inspection six hours after death. — Much of the external integuments v. 
 purple tint. Head. — There was considerable effusion of serum at the base of the 
 skull and between the membranes of the brain. Chest. — There were old costal 
 adhesions and considerable infiltration of the lungs. The lining membrane of the 
 heart and also the muscular tissue were of a deep red tint : The valves were healthy. 
 Abdomen. — The substance of the liver was paler than natural and variegated here 
 and there with large spots of dark red. The mucous coat of the stomach was 
 streaked dark red and softened. The spleen was soft and large ; and the kidneys 
 were normal. 
 
 24. Remittent Fever in a man of intemperate habits. — Death by coma* — Incr 
 
 vascularity of the membranes of the brain and considerable effusion of scrum. — 
 
84 REMITTENT FEVER. 
 
 ning and vascularity of the mucous coat of the stomach and large intestine. — 
 I meriting degeneration of the kidneys. — The commander of a merchant brig, 
 aged forty-seven, of intemperate habits, was brought to the European General 
 Eospital on the 13th July, 1838. It was stated that he had been feverish for 
 some days, and had been drinking to excess. On admission he laboured under 
 mental illusions, but when his attention was kept fixed on one subject he answered 
 questions rationally regarding it. There was no tremor either of the hands or 
 tongue. After cold affusion and a draught with a drachm of tincture of opium 
 and a third of a grain of tartar emetic he became composed but did not sleep. 
 The tono-ue was clean and the pulse frequent towards night. The bowels were 
 freely moved, but the pulse became feeble. Stimulants were substituted for the 
 antimonial, and after the second dose he slept several hours. On the morning of the 
 14th, the hands and tongue were tremulous, skin natural, pidse 96, full and 
 soft. Camphor mixture with diffusible stimulants was directed to be given every 
 second hour. Towards noon, the skin became hot, the pulse increased in frequency, 
 the tono-ue became dryish and more tremulous, and the delirium and general tremors 
 increased. Twenty-four leeches were applied to the temples, and at 8 p.m. a blister 
 to the back of the neck, and a draught with two drachms of tincture of opium was 
 o-iven. An hour afterwards he fell asleep. In the middle of the night the pulse 
 became thready. He was roused with difficulty, then became completely comatose, 
 and died at 10 a.m. of the loth. 
 
 Inspection five hours after death. Head. — There was much vascular congestion of 
 the pia mater, with considerable effusion of serum between that membrane and the 
 arachnoid, and also into the ventricles. Chest. — The lungs did not collapse. The 
 heart was flabby, and filled with fluid blood. Abdomen. — The liver was of dark 
 grey colour and softened. The mucous coat of the stomach and large intestines was 
 vascular and softened. The spleen was enlarged and reduced to a bloody pulp. In 
 both kidneys the distinction between the tubular and cortical substance was ill 
 defined. 
 
 25. Ecmittcnt Fever. — Simulating delirium tremens. — Pia mater very vascular, 
 with bulla: of air between the arachnoid and pia mater and in the vessels. — William 
 
 ( a cred twenty-nine, a conductor in the Ordnance Department, of slight frame 
 
 and frequently affected with febrile attacks in which the head was more or less 
 implicated. On the 11th May, 1839, he was admitted into the General Hospital, 
 suffering from diarrhoea for which chalk mixture and calomel with opium were given. 
 On the morning of the 13th (new moon), his skin was hot. he was excited, talked 
 incoherently, and had been walking about the ward a great part of the night. The 
 pulse was frequent and the tongue rather furred in the centre. Cold affusion was 
 used, and antimonial mixture with tincture of hyoscyamus was directed every two 
 hours. At the evening visit the skin continued hot, and he had not been asleep. 
 The cold affusion was repeated, and calomel four grains, tart, antimon. quarter of a 
 grain, opium two grains were directed to be given at bed-time, and ol. ricini. four 
 drachms the following morning. Towards midnight he became troublesome and 
 , zcited, and the scalp was hot. Cold lotion was applied to the head, and a Mister to 
 ,],,. nucha. Aboul S a.m. of the 14th he became comatose with sinking pulse and 
 aboured respiration. Green-coloured dejections were passed in bed. Ee died a1 
 
 8 A.M. * 
 
 Inspection fivi hours after death. — Examination of the head was only permitted. 
 The vessels of the pia mater were generally turgid with dark-coloured blood to their 
 
 * In these three case- the influence of intemperate habits is well marked. In all 
 :i opiate was injudiciously given. In the two first the remissions wen 
 marked, but no advantage was taken of them in the treatment 
 
CEREBRAL COMPLICATION. — PATHOLOGY. 85 
 
 minute ramifications, and there were bullae of air here and there in the vessels and 
 also between the pia mater and arachnoid membrane. The sinuses were filled with 
 blood which was coagulated in some of them. There -was about half an ounce of 
 serum in the ventricles, and an ounce at the base of the skull. The substance of the 
 brain was natural, and did not present many bloody points. 
 
 26. Remittent Fever proving fatal by collapse and coma at the close of an exa- 
 cerbation. — No serous effusion in the head. — Dotted redness and softening of 
 the mucous membrane of the stomach. — Enlargement of the mucous follicles of 
 the colon and of Peycr's glands. — Lumbrici in the small intestine. — George 
 Castor, aged twenty, a seaman of stout habit, was admitted into the European 
 General Hospital on the 23rd of June, 1838. He stated that he had been ill with 
 fever for five days, during which time there had been headache and occasional vo- 
 miting. On admission his manner was sluggish, skin hot, pulse 120, full, but com- 
 pressible, tongue furred and expanded. Six dozen leeches were applied to the temples, 
 and pills of extract of colocynth, calomel, and tartar emetic were given. On the 2 tth 
 the head, though relieved, was still uneasy, the skin was cool and moist, pulse 120 
 and feeble, the abdomen was soft, and during the night there had been seven watery 
 bilious evacuations. A blister was applied to the back of the neck, which rose well, 
 but caused strangury. At the evening visit there was less sluggishness, the skin was 
 cool, pulse 120, soft, the bowels had been freely moved, and the tongtie was cleaner. 
 Draughts with nitrous ether were ordered, and pills of blue pill and ipecacuanha. 
 The night was passed without sleep. On the 2oth questions were answered freely, but 
 giddiness was complained of. There was also uneasiness across the umbilicus, and 
 there had been several ineffectual calls to stool, thirst moderate, tongue more furred 
 and expanded. Compound powder of jalap was given with ether and camphor mix- 
 ture. At the evening visit it was reported that he had slept, the skin was cool and 
 moist, and no medicine was given. During the early part of the succeeding night he 
 rested well, but towards morning there was a return of slight headache, increased by 
 motion, with some intolerance of light, and flushing of the face. The skin was cool 
 but dry, pidse 100, soft and of good strength, bowels freely opened, the tongue less 
 furred, but somewhat florid at the edges. Six dozen leeches were applied to the 
 temples, and a diaphoretic draught given every three hours. At the evening visit the 
 head was easier, and the skin cool and moist. The sttceeeding night was passed 
 without sleep, and at 3 p.m. of the 27th, there was a febrile exacerbation followed 
 by much collapse in the night time. He became comatose and died at 7 a.m. of 
 the 28th. 
 
 Inspection five hours after death. — Head. There was no increased vascularity of 
 the membranes, or substance of the brain. There was about one drachm of serum in 
 the left lateral ventricles, and about half an ounce at the base of the skull. Chest. 
 — With the exception of some old costal adhesions, the thoracic viscera were healthy. 
 Abdomen. — The liver was healthy and the gall-ducts free. The nrucous lining of the 
 cardiac end of the stomach for a space larger than the hand was of dark red colour, 
 dotted, marbled, and its texture softened : towards the pyloric end the colour was na- 
 tural, but the tissue was softened. The small intestines were filled with lumbrici. 
 The aggregated glands of Peyer were enlarged. The mucous coat of the ccecuni and 
 colon was of dark grey colour, and studded throughout with dark points (enlarged 
 follicles).* 
 
 * This case will be again alluded to as the single instance in my notes of head 
 symptoms during life, withotit morbid appearances in the head after death. The 
 treatment was defective in the neglect of quinine during the remissions, and U>" much 
 depletion in the exacerbations. The appearance of the mucous lining of the large in- 
 testines indicated an undue use of irritants. 
 
 G 3 
 
86 REMITTENT EEYER, 
 
 27. Bemittent Fever. — Drowsiness and co-ma. — Considerable quantity of serum effused 
 head. — Vascularity and thickening of the mucous membrane of the stomach. — ■ 
 
 Mary Anne Moor, aged forty-seven, a native of India, a fat corpulent woman of in- 
 temperate habits, was admitted into the European General Hospital on the 8th Oc- 
 tober. She stated that she had suffered from fever for five or six days. The skin, on 
 admission, was hot, but soft, pulse 112 of good strength. The abdomen was dis- 
 tended but without pain. On the 9th there was slight delirium, and her hands were 
 tremulous. This state continued till the 11th, when she was roused with difficulty, 
 and when so, moaned and muttered to herself, the tongue was dryish, and the central 
 part furred. This state continued with little alteration — the skin was dry but not 
 often above the natural temperature, the pulse frequent and becoming feebler — till 
 the loth, when the drowsiness had increased and on the morning of the 16th had 
 passed into coma. She died at 10 a.m. The treatment consisted in shaving the 
 head, applying blisters to the nucha and scalp, free purging, and the use of antimo- 
 nials with small doses of tincture of opium. Quinine and calomel were given in com- 
 bination on occasions when there appeared a remission in the symptoms. 
 
 Inspection eight hours after Death. Head. — There was a considerable quantity of 
 serum effused between the layers of the arachnoid membrane, and into the ventricles. 
 The brain was firm in substance. Abdomen. — The integuments were loaded with fat. 
 The mucous coat of the stomach was thickened and vascular, with abrasions here and 
 there. 
 
 In the section on symptoms it was stated that delirium with 
 tendency to drowsiness, associated with signs of general collapse 
 and dependent on enfeebled nervous energy, was apt to come on 
 early in fevers of bad type towards the end of a paroxysm. 
 Head symptoms very similar in character sometimes occur, after 
 the fifth or sixth day, in cases in which the treatment of the re- 
 missions has been neglected and that of the exacerbations has been 
 injudiciously de]Dressant. 
 
 In my notes on the cases of sick officers there are several which 
 seem to have been of this nature, and it is of importance to bear 
 them in recollection, for it would be a serious error to treat head 
 symptoms thus arising in the same manner as those caused by 
 cerebral determination. The following may be received as an 
 illustration. 
 
 28. Bemittent Fever. — Coma from exhaustion. — A gentlemen in the public service 
 became affected with febrile symptoms al Tauna on the 4th of September. No treat- 
 ment was adopted. He wenl to Bombay, and remained there also without treatment, 
 expi riencing febrile accessions till the 8th, when he returned to Tauna. He had rigors 
 in the boal two hours before landing. On the morning of the 9th there was remis- 
 sion, and towards evening an exacerbation, for which an emetic and a purgative of 
 
 en. On the 10th, al -1 p.m.. there was again an exacerbation, with 
 Bense of swimming in the head. Eight dozen Leeches were applied to the temples. 
 There were rigors a1 midnight, followed by coma and death al 8 a.m. of the 11th. 
 
 2. Cerebral symptoms depending on inflammation of the mem- 
 branes <>r substance of the brain also occur in the course of 
 remittent fever; but this event is rare compared with determi- 
 
CEREBRAL COMPLICATION. — rATIIOLOGY. 87 
 
 nation of blood. Among the fatal cases of sick officers there are 
 only two of this nature. The following three illustrations are taken 
 from my own observations. 
 
 29. Remittent Fever.— Meningitis. — Effusion of serum in the cavity of the arach- 
 noid and sub-arachnoid space. — Opacity and thickening of the arachnoid membrane. 
 — William Woodward, aged seven, an Indo-Briton, was admitted into the sick ward 
 of the Byculla Schools on the 6th June, 1838. He was affected with febrile symptoms, 
 which did not attract much attention till the 10th, when there was increased heat of 
 skin, and frequency of pulse, with a tendency to drowsiness. Twenty-four leeches 
 were applied to the temples, a blister to the nucha, and the bowels were freely acted 
 upon. During the two succeeding days the skin continued hot, the pulse was about 
 120, and the drowsiness remained unabated. An attempt was made to affect the sys- 
 tem with mercury, the bowels were kept free, and a blister was applied to the scalp. 
 On the 13th, there was frequent screaming and moaning, there was strabismus with 
 dilated pupils, and the head was frequently raised from the pillow and moved slowly 
 about, as if in search of some object. The symptoms progressed ; the pulse continued 
 frequent, and became feeble, the coma became more complete, and death resulted at 
 midnight of the 14th. 
 
 Inspection twelve hours after death. — Head. There was more than usual vascu- 
 larity of the pi'a mater, where it dips down between the convolutions of the brain. 
 There was a considerable quantity of serum effused between the arachnoid membrane 
 •and the pia mater, chiefly on the superior and posterior parts of the hemispheres, and 
 in these situations the arachnoid membrane was milky, firm, and thickened. There 
 were adhesions between the arachnoid membrane and the falx, caused by small granules 
 of lymph. There was also a considerable quantity of serum at the base of the skull, 
 and more than the natural quantity in the ventricles. There were bloody points 
 apparent on slicing the substance of the brain. The viscera of the thorax and abdo- 
 men were healthy. 
 
 30. Remittent Fever' admitted after a week's illness. — Head symptoms chiefly marked 
 by unsteadiness of manner, and latterly drowsiness. — Arachnoid membrane opaque and 
 thickened. — Increased serous effusion. — William Subbeter, aged sixteen, after having 
 been ill for a week with headache and fever, was admitted into the General Hospital on the 
 9th May, 1842. There was heat of skin, flushed countenance, undecided manner. The 
 tongue was yellow in the centre and florid at the tip, and the epigastrium was tender. 
 Twenty-four leeches were applied to the temples, and thirty-six to the epigastrium, the 
 head was shaved, cold applications were used, sponging of the general surface had recourse 
 to, effervescing draughts were exhibited from time to time, and some blue bill and ipeca- 
 cuanha given at bed-time. On the morning of the 10th there was still heat and dryness of 
 of skin, but in other respects the symptoms were improved. In the evening there was a dis- 
 tinct febrile exacerbation. Sponging, cold applications, and effervescing draughts were 
 continued, and the blue bill and ipecacuanha were repeated. On the morning of the 
 11th, still pyrexia, pidse 92, tongue slimy and tremulous, bowels rather relaxed, and 
 manner unsteady. The remedies were continued, with addition of spirit, sether. nit, to 
 the effervescing draughts, and the application of a blister to the nucha. On the 12th, 
 febrile heat and other symptoms continued, accompanied with slight subsultus. Cam- 
 phor mixture c. spirit, sether. nit, was given every third hour, also chicken soup. On 
 the 13th, pulse 104, four dejections feculent. In other respects as on the 12th. Sago 
 and milk morning and evening, chicken soup for dinner, and the camphor mixture con- 
 tinued. On the morning of the 14th there was a distinct remission, and quinine and 
 blue pill were ordered every second hour, with effervescing draughts. The evening 
 accession was milder. On the 15th and 16th, the febrile exacerbation seemed to be 
 
 c 4 
 
88 REMITTENT FEVER. 
 
 somewhat chocked under the use of the quinine ; but on the 17th the symptoms were 
 all again aggravated. On the 18th he vomited several times, and passed three copious 
 watery evacuations, followed by sunken features, feeble pulse, and damp skin. These 
 symptoms continued, with the addition of drowsiness on the 21st ; and death took place 
 on the morning of the 24th. 
 
 Inspection eight hours after death. — Head. The arachnoid membrane over the con- 
 vex surface of the brain was opaque and thickened with here and there small rounde 1 
 granules of lymph, the size of a pin's head. There was about an ounce of serum in the 
 lateral ventricles, and about an ounce and a half at the base of the skull. The sub- 
 stance of the brain was firm. Chest. — Old adhesions connected the right lung to the 
 pleura ; but the substance of the lungs was crepitating. Heart healthy. Abdomen. — 
 The liver was healthy. The colon distended, but its mucous coat healthy. The 
 mucous coat of the stomach was of dark grey tint with dark red streaks, but was sound 
 in texture. 
 
 31. Remittent Fever, admitted in an advanced stage. — Death by anna. — Extensive 
 lymph and serous effusion in the sub-arachnoid space. — Hepatization of both lungs. 
 — Bappoo Mahomed, fort} 7 years of age, a Mussulman sailor, was admitted after twenty 
 days' illness with fever on the 10th September, 1849, into the clinical ward of the 
 Jamsetjee Jejeebhoy Hospital. There was trembling of the whole body and frequent 
 twitching of the muscles of the forearms. He was affected with low muttering, deli- 
 rium and drowsiness, the skin was above the natural temperature and dry, the pulse 
 was frequent and feeble, he could not protrude the tongue, and the respiration was 
 short and hurried. Anteriorly and laterally on the right side of the chest there was 
 dulness on percussion and absence of breath sounds. He died on the afternoon of the 
 11th. 
 
 Inspection seventeen hours after death. — Between the pia mater and the arachnoid 
 over the entire convex surface of both hemispheres of the 1 train, but greatest in degree 
 on the left side and depending parts, there was effusion of lymph and serum, to such 
 extent as to give a yellow opaque appearance to the surface. Similar effusion also 
 existed over the cerebellum and in a slight degree over the pons varolii and medulla 
 oblongata, but not elsewhere at the base of the brain. The surface of the convolutions 
 of the brain was of natural appearance and consistence, and the substance of the brain 
 elsewhere was also quite healthy. There were from six drachms to an ounce of 
 serous fluid in the lateral ventricles, and about two ounces at the base of the 
 skull. 
 
 The whole of the upper lobe of the right lung, except about half an inch of the apex, 
 and also the whole of the middle lobe, were in a state of red hepatisation, having, 
 when incised, a granular appearance with considerable oozing of frothy serum on pres- 
 sure, and readily breaking down under the finger. The rest of the lungs was crepita- 
 ting. The free anterior border of the lobe of the left lung, for about three inches, was 
 in a state of red induration; the rest was healthy. The heart and pericardium were 
 healthy. The large and small intestines were distended with air. The liver was of 
 natural size and consistence, but was congested. The kidneys were not examined. 
 
 3. When delirium, drowsiness, and coma come on in the more 
 advanced stages of remittent fever, associated with adynamic phe- 
 nomena, then more or less increased serous effusion in the cavity 
 of the cranium, unattended, however, with any great degree of 
 va cular turgescence, is generally found after death, lint it is 
 very doubtful, for reasons presently to lie particularly alluded to, 
 whether, in a large majority of eases of this kind there is any 
 
CEREBRAL COMPLICATION. — TATIIOLOGY. 89 
 
 relation between the Lead symptoms and the increased effusion. 
 The following are cases of adynamic remittent fever fatal with 
 coma. 
 
 32. Remittent Fever with adynamic symptoms. — Slight vascularity of the mem- 
 branes of the brain with air in the vessels and beneath tht arachnoid. — Turgescence 
 and ulceration of Peyer's glands at the end of the ileum.* — John Steptoe, private 
 of her Majesty's loth Hussars, two months resident in Bombay, was admitted into 
 hospital on the 6th February, 1840, and died on the loth. He had been ill before 
 admission. The following were the leading features of the disease. Pyrexia almost 
 constant with an occasional remission in the middle of the day, hands tremu- 
 lous, pulse from 100 to 120, and compressible, tongue coated and dry in the centre, 
 florid at the tip, sordes about the teeth, thirst, and more or less diarrhoea. On one 
 occasion there was pain between the right ribs and crest of the os ilium. The eyes 
 were suffused. At first there was wandering delirium at nights, and on the latter days 
 drowsiness not amounting to coma. 
 
 Inspection. — Head. There was moderate turgescence of the vessels of the mem- 
 branes of the brain, with numerous globides of air in the vessels or underneath the 
 arachnoid. 3Iore than the tisual number of bloody points in the brain, and an ounce 
 of serum at the base of the skull. Abdomen. — The liver was quite health)-. The 
 mucous coat of the cardiac end of the stomach was dotted dark red, but without soften- 
 ing. The mucous coat of the end of the ileum was of dark red colour, the patches of 
 Peyer's glands were red, turgid, and prominent, and several of them were in different 
 stages of ulceration. Close to the ileo-colic valve there was an ulcerated patch the 
 size of a rupee. The mucous coat of the coecum was of dark red colour, but not ulcer- 
 ated. The rest of the large intestine was healthy. 
 
 33. Remittent Fever. — Symptoms adynamic and badly-developed. — Serous effusion 
 and slight vascular congestion in the head, also air in the vessels. — The colon dis- 
 tended and in part displaced. — Neil Wallace, aged twenty-eight, seaman of the ship 
 
 I, was admitted into the European General Hospital, on the 21st October, 1841. 
 He stated that for a fortnight past he had experienced a sense of weight at the centre 
 of the chest, for which he had taken much medicine. On admission he inspired freely, 
 and there was neither pain of chest nor cough, the skin was dry and above the natural 
 temperature, the pulse frequent and of moderate strength, and the tongue florid. It 
 was supposed that he had been living freely for some days. On the 22nd and 
 23rd the abdomen was full, the pulse from 88 to 92 and feeble, and on the latter 
 day his manner and expression were dull and heavy. He was blistered on the 
 nucha, a full dose of calomel (ten grains) was given, followed by castor oil, and 
 on the morning of the 24th he was more alert. The bowels had been opened 
 twice, the skin was moist, and the pidse 92 and feeble. Port wine and sago were 
 given. At the evening visit the pulse still feeble, but there was febrile heat of skin, 
 the tongue was florid, and the sluggishness of manner had increased. The head was 
 shaved, cold applied, and a nitro-muriatic acid foot-bath used. He continued 
 to lose ground, there was generally a morning remission and evening exacerbation 
 of fever, the pulse became feebler, the hands tremulous and with subsultus ten- 
 dinum, the tongue dry. the drowsiness increased, and at last passed almost into complete 
 coma. He died on the 31st October. 
 
 Inspection fourteen hours after death. — Head. A thin veil of serum was effused 
 between the convolutions on the convex surface of the brain. The small ^ 
 
 * "While retaining this case in its original position I must admit that recent inquiry 
 may suggest that it was true typhoid, not adynamic remittent. 
 
90 
 
 REMITTENT FETER. 
 
 of the pia mater were in part injected with blood and the larger ramifications con- 
 tained air. No increased quantity of serum in the ventricles or at the base of the 
 skull. Chest. — The lungs did not collapse freely. Heart healthy. Abdomen. — The 
 liver was healthy. The colon was much distended with air and the sigmoid flexure 
 thrown across the small intestines was applied to the inner aspect of the ascending 
 colon. The large intestine was sound in texture. 
 
 "When, as in the first* series of cases, we find head symptoms 
 coming on early in the disease, and after death more or less vas- 
 cular turgescence with increased serous effusion in the cranium, or, 
 as in the second, head symptoms with opacity of the membranes or 
 with lymph and serous exudations, there need be no hesitation in 
 relating the morbid appearances found after death to the symptoms 
 present during life. 
 
 But when, as in the last set of cases, the head symptoms which 
 indicate failing function of the brain have been coincident with 
 failure of other vital actions then it is very doubtful whether 
 a relation between these symptoms and increased cranial serous 
 effusion can be viewed as a probable inference. This so-called 
 morbid appearance may, in adynamic states, be otherwise ex- 
 plained. 
 
 Thus, on carefully examining the reports of 205 fatal cases of 
 disease observed by me in the European General Hospital at 
 Bombay, it appears that while, on the one hand, of 59 cases in 
 which head symptoms during life were well marked there is only 
 one in which there was an absence of morbid appearances after 
 death |, there are, on the other hand, 50 cases in which there were 
 no head symptoms during life, but in which appearances in the 
 contents of the cranium generally considered morbid were observed 
 after death. 
 
 Of these 50 cases, the ages of the individuals were as fol- 
 lows : — 
 
 Between 10 and 15 years, inclusive 
 
 16 
 
 „ 20 
 
 21 
 
 „ 25 
 
 26 
 
 „ 30 
 
 31 
 
 , 35 
 
 36 
 
 , 40 
 
 41 
 
 „ 50 
 
 51 
 
 ,. GO 
 
 61 
 
 , 7«) 
 
 Ages 
 
 ool given 
 
 2 
 4 
 14 
 7 
 7 
 2 
 7 
 4 
 1 
 2 
 
 50 
 
 * With one exception, No. 26. 
 
 t No. 26. 
 
CEREBRAL COMPLICATION. — PATIIOLOCY. 
 
 91 
 
 The deaths took place in the following months 
 
 . 4 
 
 July . 
 
 . 3 
 
 . 5 
 
 August . 
 
 . 4 
 
 . 6 
 
 September 
 
 . 4 
 
 5 
 
 October 
 
 . 1 
 
 . 6 
 
 November 
 
 . 2 
 
 . 2 
 
 December 
 
 . 4 
 
 28 
 
 
 18 
 . 4 
 
 January 
 
 February 
 March . 
 April . 
 May . 
 June 
 
 Months not stated . 
 
 Of these 50 cases, the deaths were occasioned by the following 
 diseases : — 
 
 Tubercular Phthisis 7 
 
 Pleuritis ........... 1 
 
 Disease of the Heart ......... 1 
 
 Hepatic Abscess .......... 8 
 
 Dysentery . . . . . . . . . . .11 
 
 Peritonitis ........... 4 
 
 Scurvy ............ 3 
 
 Spasmodic Cholera . . . . . . . . . .14 
 
 Kupture of the Spleen 1 
 
 50 
 
 In 4 of the 50 cases the morbid appearance consisted of increased 
 vascularity of the membranes of the brain. These were all in- 
 stances of epidemic cholera. 
 
 In 19 cases both increased vascularity and increased serous effu- 
 sion within the cranium were present. Death took place from 
 the following 1 diseases : — ■ 
 
 Epidemic Cholera . 
 Disease of the Heart 
 Dysentery 
 Peritonitis 
 Hepatic Abscess 
 Gastro-enteritis 
 
 9 
 1 
 4 
 
 2 
 2 
 1 
 
 19 
 
 In 27 cases there was increased serous effusion within the cranium 
 without increased vascularity. 
 
 Death in these instances was caused by the following diseases :— 
 
 Tubercular Phthisis 
 
 Hepatic Abscess 
 
 Dysentery 
 
 Peritonitis 
 
 Epidemic Cholera . 
 
 Pleuritis 
 
 Rupture of the Spleen 
 
 Scurvy . 
 
 Rheumatism (Scorbutic) 
 
 7 
 G 
 6 
 2 
 1 
 1 
 1 
 2 
 1 
 
 27 
 
92 REMITTENT FEVER. 
 
 Iii regard to the facts which have just been stated, it may be 
 observed. 
 
 1. They do not show any relation between absence of head 
 symptoms, associated with increased vascularity and serous effusion 
 within the cranium, and particular age or season. 
 
 2. They show a relation between the absence of head sym- 
 ptoms, associated with increased vascularity with or without increased 
 serous effusion within the cranium, and a state of general venous 
 congestion dependent upon a feebly acting heart. 
 
 3. They show a relation between absence of head symptoms, 
 associated with increased serous effusion without increased vascu- 
 larity within the cranium, and death taking place by gradual 
 asthenia. When death takes place after this manner, serous trans- 
 udations from serous linings and into areolar tissue are familiar 
 events : the cerebral serous effusion now referred to is analogous 
 to these. 
 
 4. The increased vascularity in these cases is of congestion, 
 not of inflammation. The increased serous effusion is not the 
 result of inflammation, but of congestion and of those conditions of 
 the tissue and of the blood which are believed to favour serous 
 transudation. 
 
 They confirm therefore the opinion of Dr. Abercrombie, — that 
 the head symptoms of acute hydrocephalus do not depend upon the 
 presence of serous effusion within the cranium, so much as on the 
 deranged capillary circulation (inflammation) of which the serous 
 effusion is the consequence. 
 
 The serous effusion in the cases of which I now treat was not the 
 result of this deranged state of the capillary circulation (inflamma- 
 tion) ; hence, though present within the cranium, head symptoms 
 were not necessarily induced by it. 
 
 5. It should be borne in mind that increased vascularity and 
 serous effusion within the cranium, found after death, does not neces- 
 sarily prove their presence there during life. They may have taken 
 place in some instances during the agony of death, or after the fatal 
 event. 
 
 G. These facts which show a want of relation between increased 
 vascularity and serous effusion within the cranium found after death 
 and the proximate cause of the fatal result should be remembered 
 in judicial inquiries on bodies found dead, and of the previous history 
 of which Dothing is known. In such cases, if there be present 
 withi/n the cra/n/i/um only increased vascularity or increased 
 serous effusion separately or associated together, we can never 
 
GASTRIC COMPLICATION. - TATKOLOGY. 93 
 
 be justified in attributing death to these conditions. These 
 statements have been entered into not only from their relation to 
 the similar after-death appearances in fatal cases of adynamic re- 
 mittent fever, but also because they tend to confirm observations 
 of a like tenor in the writings of Louis*, Abercrombief, and 
 Bright J; and because facts of this kind are of much importance 
 in reference to the pathology of the brain. 
 
 Gastric Irritability. — I pass over the occurrence of occasional 
 vomiting as one of the deranged actions of the febrile state and 
 here direct attention to those greater degrees of irritability of the 
 stomach which depend upon local disease. 
 
 In the severe forms of remittent fever in sthenic Europeans 
 cerebral symptoms and gastric irritability are very frequently com- 
 bined. This was the case in the remittent fevers from which her 
 Majesty's 4th Light Dragoons suffered so much at Kaira. In 
 these it was very common to find after death increased vascularity 
 of the vessels of the brain with some degree of increased serous 
 effusion, and at the same time a deeply reddened state of the 
 mucous membrane of the stomach and sometimes of the intestinal 
 canal. It is very probable that the deranged capillary circulation 
 was similar in both organs,— not inflammatory but rather pas- 
 sive congestion or active determination. In other instances the 
 gastric complication is the principal : this occurred in 6 of the 90 
 fatal cases of officers formerly alluded to. 
 
 As respects the pathology of that form of remittent fever called 
 bilious, I cannot view it in any other light than as a coincidence 
 of the state now under consideration and the presence of a con- 
 siderable quantity of bile in the gall-bladder and in the biliary 
 ducts, ■ — hence the notable admixture of bile in the ejected 
 matters.§ The term has been too frequently and too vaguely 
 used by writers on tropical fevers, and will not be repeated in this 
 work. 
 
 Irritability of stomach also occurs in the course of remittent 
 fever, both in sthenic and asthenic constitutions, developing itself 
 somewhat more gradually, generally with distinct epigastric un- 
 easiness, and a tongue more or less florid at the tip and edges and 
 depending on inflammation of the mucous membrane. Evidence 
 
 * "Researches on Phthisis." 
 
 t " On Diseases of the Brain." 
 
 \ " Reports of Medical Cases." 
 
 § I am aware that there may also eo-exist a similarly deranged capillary com 
 of the liver; but that this, during the presence of the febrile slate, leads l" increased 
 hepatic secretion is very doubtful. It is more likely that the secretion is antecedenl 
 and hi excess in the biliary passages and reservoirs at the on • •■' of the fi 
 
94 EEMITTENT FEVER. 
 
 of this will be found in cases 17, 18, 20, 22, 30, quoted in this 
 chapter. 
 
 In 114 selected clinical cases of natives, gastric irritability is 
 noted of 2 only. 
 
 Habits of intemperance as an auxiliary cause of head symptoms 
 have already been adverted to. The same remark applies still 
 more forcibly to irritability of stomach, whether of the nature first 
 noticed, or that depending on gastric inflammation. 
 
 When treating of intermittent fever I expressed my conviction 
 that irritability of stomach was not unfrequently caused and kept 
 up in the quotidian type by the unnecessary use of calomel and 
 purgatives in the hot stage ; and this belief is still stronger in re- 
 spect to remittent fever, because in it these means have been abused 
 in still greater degree. The practitioner who uses these medicines 
 guardedly, and with a clear apprehension of their evils as well as of 
 their advantages, will find vomiting a less frequent symptom of 
 remittent fever than it has usually been represented to lie. This 
 impression, left on my mind from a careful review of the whole 
 subject, is sustained by the fact that in 357 cases of fever inter- 
 mittent and remittent treated by me in natives in the clinical ward 
 gastric irritability was present only in 6. 
 
 Affection of the Boivels. — The occurrence of dysentery in the 
 early or advanced stages of remittent fever in sthenic or asthenic 
 constitutions has been a rare event in my experience. From the 
 writings of Mr Twining, and more lately from those of Mr. Hare*, 
 it would appear that this complication has been more frequently 
 observed in Bengal, and that the type of the fever has generally 
 tended to be congestive or adynamic and the dysentery to be 
 hemorrhagic in character. It may be also inferred from Has- 
 pel's work on the diseases of Algeria and Bleeker's report on the 
 dysentery of Bataviaf that the co-existence of dysentery and of 
 remittent fever is not unusual in these countries. It is in localities 
 in which the period of the production of malaria is coincident with 
 much atmospheric moisture and vicissitude that d} r sentery occurs, 
 combined or contemporaneous with remittent fever. Since the doc- 
 trine that malaria is the exciting cause of intermittent and remit- 
 tent fever became established, the co-operating and modifying action 
 of ordinary causes — cold, wet, heat, intemperance has been too 
 much overlooked, and our knowledge of the etiology of the dif- 
 ferent forms and varieties of fever has in consequence been im- 
 paired, 
 
 ■• [ndian Anting of Medical Science," No. 2. 
 f Ibid. No. I. 
 
ENTERIC COMPLICATION. — TATIIOLOGY. 95 
 
 Diarrhoea is, according to my observation, a more frequent com- 
 plication of remittent fever, and is sometimes accompanied with 
 gastric irritability; but it cannot be said to be common, for it was 
 present in only 6 of 114 clinical cases in natives. 
 
 In fatal cases in which increased alvine discharges have been 
 present during life we may expect to find evidence of inflamma- 
 tion having existed in the mucous membrane of the end of the 
 ileum or of the large intestine. Cases 17, 26, 32, illustrate this 
 observation, and the two following are further confirmatory of it. 
 
 34. Remittent Fever, with head and gastro-cnteric symptoms ; two or three ounces 
 of serum in the cranium. — Firm granular exudation on the mucous surface of the 
 colon. — Dark redness of the end of the ileum. — The subject of a large hydrocele. — 
 John Daniel, aged fifty, a person of colour, born in Ceylon, of feeble and emaciated 
 habit, was sent to the hospital on the 5th September, 1839, having been found in a 
 state of destitution on the road. He was unable to give any account of himself, his 
 tongue was dry and covered with a yellow crust, pulse 116, skin not of increased tem- 
 perature. He was also the subject of a large hydrocele. He died on the 16th Sep- 
 tember. The leading symptoms during his residence in hospital were frequent hiccup 
 and incoherent muttering, pulse generally about 100 and feeble, tongue crusted in the 
 centre, and florid at the tip, the skin generally not above the' natural temperature, two 
 or three evacuations daily, passed in bed, feculent and containing lumbrici. Little food 
 was taken. The treatment consisted of quinine with small doses of calomel, a blister 
 to the epigastrium, wine and light nourishing food ; and on one occasion an enema with 
 ol. terebinth. 
 
 Inspection eight hours after death. — Body much emaciated, the skin and fibrous 
 tissues deeply tinged yellow. Head. — The convex surface of the brain was partially 
 veiled with serum ; and there were between two or three ounces of it effused at the base 
 of the skull. Chest. — Both lungs adhered to the costal pleurae, but their substance was 
 healthy. In both sides of the heart there were fibrinous polypi, entwining round the 
 cords of the auriculo-ventricular valves. Abdomen. — The intestines externally had a 
 dark greenish tint. The liver was of dark green colour and the gall-bladder was nearly 
 empty. The stomach was contracted, and much of its mucous lining was manimillated, 
 and thickened, — this was chiefly in the body and at the pyloric end. The mucous 
 coat of the colon had a general dark grey tint, and in the cceciun, the descending 
 colon, and the rectum there were extensive patches of lymph effused in detached 
 pieces, presenting a roughened surface like shagreen. This lymph adhered firmly 
 to the mucous coat which underneath presented a dark dotted red appearance, was 
 firm and somewhat thickened with the submucous tissue more fibrous than is natural. 
 At the end of the ileum there was much dark vascularity of the mucous coat. 
 There was one lumbricus in the colon and one in that part of the small intestine which 
 was opened. The kidneys were healthy. There were about ten pints of dark red 
 turbid fluid, in the tunica vaginalis which was thickened, cartilaginous, and pre- 
 sented an inner surface of dark red tint roughened by closely adherent fragments of 
 very firm lymph. 
 
 35. Remittent Fever. — Peyer's glands enlarged and ulcerated. — Head symptoms 
 with moderate turgescence of the vessels. — Caroline Smith, an Lido-Briton, aged nine. 
 On the 7th July, 1839, after having been in the sick ward for two or three days with 
 mild febrile symptoms was observed to be affected with slight drowsiness and heat of 
 head, for which twelve leeches were applied to the temples, and the bowels freelyacted 
 on with calomel, followed by senna mixture. On the 8th there was still heat of skin 
 and of the head. The head was shaved and cold applications used. On the 9th she 
 
96 REMITTENT FEYEB. 
 
 seemed drowsy and the scalp was hot and the pulse frequent, the tongue was more 
 florid than natural, she had vomited several times, and the bowels were open. Six 
 leeches were applied to the temples and six to the epigastrium, cold applications were 
 continued to the head, a blister was applied to the back of the neck, and effervescing 
 draughts were given every fourth hour. She passed an uncomfortable night with fre- 
 quent moaning. On the morning of the 10th there was a good deal of heat of scalp, 
 and the general surface was above the natural temperature ; the pupils contracted freely, 
 but she lay with her eyes shut as if annoyed by the light, there was tenderness on 
 pressure of the epigastrium ; and the bowels had been opened during the night. Six 
 leeches were applied to the margin of the right ribs, cold wash continued to the head, 
 and an enema directed at noon. At the evening visit she was reported to have been 
 cool and more lively at noon, but there was again a febrile exacerbation, bowels moved 
 01 ce. Calomel grs. iii. pulv. jalap grs. vi. to be taken at bedtime. She vomited the 
 powder but passed the night quietly. On the morning of the 11th, bowels not opened, 
 abdomen full, tongue pretty clean, skin cool but dry, pidse rather frequent, and she 
 was still sluggish. A domestic enema, with turpentine oil, was directed to be used, 
 and the following pills prescribed : — quinine sidph. and pil. hydrarg. aa. grs. iv. 
 ipecac, gr. iss. tere bene ft. pil. iii., one to be taken every second hour, for four doses, 
 should there be no fever, aLso chicken soup. She vomited several times during the 
 day, and at the evening visit the pulse was 104. slight heat of skin and less drowsi- 
 ness, and abdomen still full ; the bowels had been opened by the enema but not other- 
 wise, tongue not furred, and tolerably moist. Eepet. enema e. ol. terebinth, and give 
 an effervescing draught every fourth hour. During the night time, she vomited fre- 
 quently, and was purged four or five times. Sinapisms were applied to the stomach, 
 and a powder with hydrarg. c. cret. given. At half-past 7 a.m.. of the 12th, the 
 skin was cold, the pulse thready, and the tongue not coated. Recipe : quinine grs. vi. 
 opii. gr. half, confect. aromat. q. s. at. ft. pil. iv. one to be given every third hour, and 
 sago with wine or brandy occasionally. She vomited the sago and brandy. There was 
 no recurrence of purging. At noon the pulse was hardly perceptible. Liquor lyttse 
 was applied to the epigastrium, and the remedies continued. The vomiting of ingesta 
 continued, and she died about 10 p.m. 
 
 Inspection ten hours after death. — Head. There was moderate vascular turgescence 
 of the membranes of the brain, and dotted points on incising its substance, and about 
 an ounce and a half of serum at the base of the skull. Chest. — The lungs, partially 
 collapsed, were somewhat emphysematous, and without congestion of their pi - 
 part. Abdomen. — The liver was healthy. The stomach was contracted, and its mucous 
 coat normal. At the end of the ileum the glands of Peyer were distinct, and there 
 were three or four round ulcers, each the size of a split pea ; cicatrization had 
 commenced. In the colon the follicles were distinct, but the mucous coat was 
 healthy. The mesenteric glands ranged in size from a pea to a horse bean, but were 
 not tubercular. 
 
 The observation made in reference to affection of the bowels in 
 intermittent fever, viz., that its frequency will be found to bear 
 relation to the injudicious use of purgatives, is equally applicable 
 to remittent fever. 
 
 Hepatic Affections. — Hepatitis has been, in my field of practice, 
 an unusual feature of remittent fever. It was so in the European 
 General Hospital and in 138 cases of remittent fever in European 
 officers it is noted only of 7, and of these 5 were recoveries. 
 In 114 clinical cases in natives, hepatitis was present in 3. The 
 in-.;, be enlarged in the early stages of remittent fever from 
 
WITH JAUNDICE. — rATIIOLOGY. 97 
 
 congestion, and this enlargement may also be an occasional 
 sequence of the remittent just as it frequently is of the inter- 
 mittent type. 
 
 Splenic enlargement existed in 20 of the clinical cases, and 
 when occurring in remittent fever it may generally be viewed as 
 indicative of former attacks of the intermittent form. This lesion 
 has been already so fully considered in connection with inter- 
 mittent fever, that further notice here would be superfluous. 
 
 Jaundice was present in 28 of 114 selected clinical cases of 
 natives, and 10 of them proved fatal. Of the 90 fatal cases of 
 remittent fever in European officers 7 were of this comj)lication ; 
 and though it was not a common occurrence in the European 
 General Hospital at Bombay, yet a season seldom passed without a 
 few instances being met with. It varies in frequency, however, 
 in different years : it was more common in 1848 in the clinical 
 ward than in any of the five following years. 
 
 As the pathology of jaundice is not yet well understood, the narra- 
 tion of the 10 fatal cases will be useful. When these are compared 
 with the recoveries it appears that the average duration of illness 
 of the former before admission has been about eleven days, and 
 that of the latter about eight, a difference of three days. 
 
 Mr. Twining believed that jaundice was sometimes caused by 
 the mechanical pressure of enlarged lymphatic glands situated near 
 the entrance of the common biliary duct into the duodenum, and 
 the confirmation or correction of this opinion is important. With 
 this view the state of these glands is generally noticed in the 
 reports of the fatal cases : they were considered to be enlarged in 
 6 of the 10, but, with one exception, there was no reason to 
 think that they had pressed on the duct ; and in this case (39) the 
 pressure was caused rather by the head of the pancreas than by the 
 enlarged glands. In one of the 6 cases the hepatic and common 
 ducts were obstructed by an impacted lumbricus ; and in 2 there 
 was constriction of the cystic duct but it was independent of 
 glandular enlargement, and in both the gall-bladder was full of 
 bile. 
 
 Traces of inflammation of the mucous membrane of the duode- 
 num and stomach were observed in 6 cases, and in 3 of them the 
 lymphatic glands were also enlarged, but in 2 of the remaining 3 
 the glands were not enlarged, and in one their condition was not 
 noted. Of the remaining 4 of the 10 fatal cases, in one the state 
 of the duodenum was not noticed, in one there was obstruction of 
 
 II 
 
98 REMITTENT FEVER 
 
 the ducts from a lumbricus, in one neither enlarged glands nor 
 gastro-duodenitis, and in one enlarged glands and pancreas without 
 gastro-duodenitis. 
 
 These data are not sufficient to justify a positive opinion, 
 but they cannot be regarded as confirmatory of Mr. Twining's 
 views. When it is recollected that jaundice seldom comes on 
 before the fifth day of the fever and is almost invariably attended 
 with tenderness below the margins of the seventh, eighth, and 
 ninth right ribs, it is probable that its most important relation is 
 to inflammation of the mucous membrane of the duodenum. This 
 conclusion is supported by the fact that remittent fever compli- 
 cated with jaundice is best treated by the moderate use of leeches, 
 small blisters, mild alterative aperients and quinine in the re- 
 missions, and is sure to be aggravated by the injudicious use of 
 calomel and purgatives. As vomiting is frequently absent, the 
 s3 T mptoins appear to be referable rather to the inflammatory 
 condition of the duodenum than to the gastritis which generally 
 co-exists. 
 
 These cases do not indicate a frequent dependence of jaundice 
 on inflammation of the mucous lining of the ducts, for it was 
 not observed in any of them. They are defective in that the 
 microscope was used only in three, but in these the hepatic cells 
 presented no abnormal appearance. None of these cases, however, 
 had the characters of the yellow atrophy of Eokitansky in which 
 head symptoms are prominent and the course rapid from probable 
 direct destruction of the vitality of the cells by the influence of the 
 morbific cause.* 
 
 36. Remittent Fever with jaundice. — Drowsiness. — Biliary congestion of the lm r. 
 Enlarged lymphathic glands in the course of the common duct. — Slight dilatation 
 of the hepatic duct. — Gastro-duodenitis. — Granular exudation on the mucous sur- 
 face of the i!i"„, ami mfim. — Nodules of pulmonary apoplexy, one softened into 'a 
 cavity. — Nuthagee, a Hindoo labourer of twenty-five years of age, was admitted into 
 ho ipital, aft.r ten days' illness with fever, on the 14th of September, 1848. The pulse 
 was feel ilo. the skin was coldish, the bowels relaxed, the tongue coated ami slimy, hic- 
 cup was present and the conjunctive were yellow. He was somewhat drowsy, hut 
 pointed to the right side as the seat of pain. The symptoms continued with little 
 ■•■ (.ill the 18th, when he became more drowsy and died, having expectorated some 
 bloody serous fluid aboul ten hours before death. He was treated with quinine and 
 Dover's powder, light nourishment and stimulants, and a blister was applied to the 
 right side. 
 
 fourteen hours after death. — Abdomen. The liver, somewhat enl: 
 mieeie 1 to the diaphragm by "Id adhesions, and was of olive-green tint when 
 
 I shall again return to the Pathology of Jaundice in connection with the diseases 
 of the liver. 
 
WITH JAUNDICE. — PATHOLOGY. 99 
 
 incised. The gall-bladder was full, but not distended. Just beyond the junction of 
 the cystic and hepatic ducts there commenced a chain of lymphatic glands, which sur- 
 rounded and accompanied the common duct to its point of entrance into the duodenum. 
 The thickness of the chain of glands was equal to that of a swan's quill. The hepal ic 
 duct was somewhat dilated. There was no redness of the mucous lining of the biliary 
 ducts. The mucous lining of the duodenum presented a surface of bright red patches 
 covered with adhesive mucus, but the tissue was not softened : similar patches were 
 observed at the commencement of the jejunum. About two feet of the end of the 
 ileum and the eoecum were laid open. The inner surface of the ileum was bright red 
 in patches, which followed the transverse folds of the membrane, and were covered 
 with granular lymph ; in scraping off the lymph no softening of the membrane was 
 found. Similar red patches, but without the granular effusion, occupied the mucous 
 surface of the eoecum and commencement of the colon. There was not a trace of ulcer- 
 ation, and the groups of Peyer's glands at the end of the ileum ware free of disease. 
 The mucous surface of the stomach presented patches of redness at its cardiac end. 
 Chest. — Lungs did not collapse. In both, but chiefly in the left, there were several 
 black nodules from extravasated blood (pulmonary apoplexy) ; in one the texture of 
 the lung had been broken down, and cavities had formed, the smallest was the size of 
 a pea, the largest that of a pigeon's egg. There was also a good deal of oedema of the 
 lungs. The heart was healthy. 
 
 37. Eetnittent Fever with jaundice. — Tenderness at margin of right ribs. — Coma. 
 — Gastro-duodenitis. — Enlarged lymphatic glands in the course of the com/men 
 Duct. — Biliary congestion of the liver. — Meerza Khan, a Mussulman peon of 
 twenty-six years of age, a native of Peshawur, was, after eight days' illness, admitted 
 into hospital, on the 21st of October, 1S48. The surface of the body and the con- 
 junctivae were tinged of a deep yellow coloiir. He complained of pain, much increased 
 by pressure at the margin of the right false ribs, and there was some fulness there. 
 The tongue was much coated and dryish in the centre, and the bowels were reported 
 to be confined. The pulse was quick, full, and soft. No heat of skin. He continued 
 in hospital till the 26th, when he died. The exacerbations were marked by exciteim nt 
 of manner, not by increased heat of skin. The alvine and renal excretions were scanty. 
 The pulse lost strength. The jaundice continued. He became drowsy on the 25th, 
 then comatose. He was treated with twenty-four leeches to the margin of the right 
 ribs, followed by a small blister. Mercurial purgatives were given, also quinine in two 
 or three-grain doses with an equal quantity of blue pill, ever}' third or fourth hour. 
 As the pulse failed, wine and ammonia were given, and attention was paid to suitable 
 nourishment. On the 2oth a blister was applied to the nucha. 
 
 Inspection five hours after death. — All the tissues were deeply tinged yellow. 
 Chest. — The lungs did not collapse freely, but were otherwise free of disease. The right 
 side of the heart was distended with blood. The ascending aorta was a good deal 
 dilated, and part of its inner surface was irregular. Abdomen. — The liver was uol 
 enlarged, but was of olive-green tint. The mucous membrane of the stomach and 
 duodenum was clotted red, but sound in texture. The lining of the ileum was also red- 
 dened, but neither softened nor ulcerated. Lymphatic glands the size of a small bean 
 embraced the common biliary duct near to its termination in the duodenum. On the 
 external surface of both kidneys there were puckered cicatrices, which gave a tabulated 
 appearance to the organ. In the left kidney, situated in a calyx, and brandling into 
 others, there was a calculus. The spleen adhered closely and firmly to the stomach 
 and diaphragm. The head was not examined. 
 
 38. Fever with jaundice. — Tenderness at the margin of the right ribs. — Drowsi- 
 ness. — Biliary congestion of the liver. — Obstruction of the I 
 
 bricus, of which (here were many in the duodenum and stomach. — No go 
 
 nitis. — Enlargement of the lymphatic glands in the course of the common duct. 
 
 H 2 
 
100 REMITTENT FEYER 
 
 Hepatic cells distinct. — Chottoo Ram, a Hindoo peon of twenty-fire years of age, was, 
 after ten days' illness, admitted into hospital on the 2nd February, 1849. He was 
 much exhausted, there was heat of skin, a feeble pulse, yellow conjunctivae, tenderness 
 at the margin of the right ribs, and some degree of drowsiness. He died on the 4th, 
 two days after admission. 
 
 Inspection twelve hours after death. — The tissues were tinged deeply yellow. The 
 viscera of the chest healthy. Abdomen.— There was no peritonitic inflammation. The 
 colon and coecum were distended with air. The stomach contained greenish viscid 
 mucus, and five or six lumbriei, and the contents of the duodenum were similar, with 
 four or five lumbriei ; the mucous coat of both was healthy. Liver. — The substance 
 was of very yellow tint in places. The hepatic cells were seen distinctly under the 
 microscope. The gall-bladder, not distended, was, however, full of dark thick bile. 
 The hepatic duct was distended by a lumbricus, the sharp end of which extended into 
 the common duct for about an inch beyond the junction of the cystic duet. The lum- 
 bricus was traced in the duct beyond its division, for about three inches into the 
 substance of the liver, and in following the branch of the duct had been subjected to 
 considerable curvature ; but it was not traced to its end in the liver, for it had been 
 accidentally cut across. There was no redness of the mucous membrane of the duct. 
 The chain of glands along the lower side of the common duct equalled a swan's quill 
 in thickness. 
 
 39. Remittent Fever with jaundice. — Tenderness at the margin of the right rils. 
 — Drowsiness. — Enlarged lymphatic glands. — Enlarged head of the pancreas. — 
 No duodenitis. — Biliary congestion of the liver. — Balloo, a Hindoo labourer of 
 thirty-five years of age, after suffering for fifteen days from fever characterised by even- 
 ing exacerbations and morning remissions, was admitted into hospital in a reduced 
 state on the 11th June, 1849. He had been jaundiced for six days. The tongue was 
 streaked yellow, and somewhat florid at the tip and edges. There was tenderness, 
 with resistance, below the margin of the right false ribs, and the edge of the spleen 
 was perceptible under the left, During his stay in hospital the evening exacerbation 
 was well marked, but frequently the remission in the morning was very slight. The 
 jaundice persisted, the urine was of a deep brown colour, generally about twenty ounces 
 in the twenty-four hours. The alvine discharges were of a pale colour, and there was 
 no vomiting. He was quite collected on admission, but on the 20th June muttering 
 delirium was first noticed. The pulse became feebler. There was subsultus on the 
 25th, and bleeding from the gums on the 26th. He became drowsy on the 28th, and 
 died on the 5th of July, but without complete coma. The treatment consisted of 
 twenty-four leeches to the margin of the right ribs, followed by a small blister, mer- 
 curial and other purgatives, quinine in three and-four grain doses, with blue bill and 
 ipecacuanha during the remissions, frequent sponging of the surface of the body with 
 tepid water, saline diuretics, sago and chicken broth. 
 
 Examination eight hours after death. — All the tissues were tinged yellow. Chest. — 
 Left lung was collapsed, crepitating, and healthy. The right lung adhered by tender 
 bands to the costal pleura, but was crepitating and healthy. Abdomen. — The intestine - 
 both small and large were contracted. The liver was somewhat enlarged, yellowish in 
 colour, but natural in consistence. The gall-bladder contained some bile, but it was 
 not distended. The common duct was surrounded in three fourths of its circumference 
 by the head of the pancreas, which seemed somewhat indurated, and larger than 
 natural, and there the duct was somewhal contracted. On the other side of the duct, 
 in contact with it, was an enlarged lymphatic gland, about an inch and a half in 
 length and a quarter of an inch thick. The common, hepatic, and cystic ducts were 
 permeable. The mucous membrane of the duodenum was healthy, and covered 
 with bile. 
 
 •to. Bemittent Fever with jaundice. — Tenderness at the margin of the right ribs. 
 
WITH JAUNDICE. — rATHOLOGY. 101 
 
 Death from exhaustion. — Enlargement and biliary congestion of the liver. — Gastro- 
 duodenitis. — Hepatic cells distinct. — Sutwa Purojee, a Hindoo rope-maker of 
 twenty-seven years of age, and stout habit of body, after suffering for twelve da; 
 from febrile symptoms, without, as reported, distinct remissions, was admitted into 
 hospital on the 7th August, 1849. The abdomen was full, without induration, but with 
 tenderness at the margin of the right ribs. He had occasional vomiting, and the 
 tongue was coated. The bowels were reported to be regular. He admitted that he 
 made occasional use of spirits. Thirty-six leeches were applied to the epigastrium, 
 quinine in four-grain doses, with blue bill and ipecacuanha, was given during the 
 remission. There was not much heat of skin on the 9th and 10th, the pain was re- 
 lieved, and the vomiting had ceased. Some compound powder of jalap was given on 
 the 10th. On that evening there was a febrile exacerbation, which continued on the 
 11th (there having been shivering at midnight), with increase of tenderness at the 
 epigastrium and margin of right ribs, dulness to within an inch and a half of the \\m- 
 bilicus, and commencing jaundice. Respiration short and hurried, pidse frequent and 
 small, and tongue dry, with dark fur. Fifty leeches were applied to the margin of the 
 ribs, and ten grains of calomel, with four of compound extract of coloeynth, were given. 
 At noon, the skin was cool, the pulse feeble, and one pale evacuation had been passed. 
 The side was said to be easier, but the breathing continued hurried, and he died about 
 an hour after the report.* 
 
 Inspection three hours after death. — ■ The body was not much reduced, and the 
 tissues were tinged deeply yellow. Chest. — The lungs were crepitating, but somewhat 
 inflated. There were no adhesions between the pidmonary and costal pleura?. The 
 heart was healthy. Abdomen. — The liver was much enlarged, and reached beyond the 
 margin of the false ribs, from the tenth rib of the right side to within an inch and a 
 half of the umbilicus, and thence to the most prominent part of the seventh left rib. 
 No adhesions existed between it and the surrounding parts. When incised, the surfaces 
 were of a mixed red and olive-green tint, and the substance was softer than natural 
 throughout. The gall-bladder contained serous-looking bile. The stomach was full 
 of half digested food, and its mucous membrane was of a uniform rose colour except in 
 a few places where there was a deeper dotted redness with some degree of softening. 
 The inner surface of the duodenum was tinged with bile, and its mucous membrane, 
 as well as that of the large intestine, was of a redder colour than natural. The 
 kidneys were large, and of a dark (almost black) red colour throughout, evidently 
 from congestion of blood. The spleen was not enlarged. The head was not examined. 
 — A small portion of the glandidar substance of the liver was examined under the 
 microscope, and exhibited the hepatic cells distinct. 
 
 41. Remittent Fever with jaundice in an opium-cater. — Tenderness at the epigas- 
 trium. — No coma. — Death from exhaustion. — Enlargement and biliary congestion of 
 the liver. — No duodenitis. — No enlargement of the lymphatic glands. — Synd Eux, 
 a Mussulman, a native of Mooltan, sixty years of age and following the occupation of 
 a Fakir, was in the habit of taking opium, but only he said to the extent of two grains 
 daily. After twelve days' illness with fever and epigastric tenderness he was ad- 
 mitted into hospital on the 23rd January, 1850. There was tenderness on pressure ai 
 the epigastrium, and dulness for two inches and a half below the ensiform cartilage. 
 The spleen was also enlarged. The pulse was frequent and feeble. The tongue 
 dryish with a yellow central coat and florid tip and edges. The conjunctivae were 
 yellow. On the 23rd, 24th, and 25th there was a febrile exacerbation. The urine 
 was high coloured, the alvine discharges scanty and pale. From the 26th to the 
 
 * In this case the fatal result was expedited by the injudicious use of depressants 
 
 in the advanced state of fever; indeed, it is not improbable that the exacerbati i 
 
 the 10th was favoured by the purgative then given. 
 
 3 
 
102 BBMITTENT FEYEK 
 
 1st of February, there was very little febrile disturbance and the jaundice seemed to 
 lessen somewhat, but there was no improvement in the strength of the pidse, the 
 emaciation rather increased, and the movements of the linibs were tremulous. On the 
 1st of February, his manner was sluggish, and from this time increase of the febrile 
 disturbance and of the asthenia took place. He died on the 7th without coma. 
 
 The treatment consisted of a small blister to the epigastrium, an occasional 
 laxative, and quinine in four-grain doses in solution combined with nitrate of potass 
 and spiritus setheris nitricus during the remission, also chicken soup and wine. 
 
 Inspection seventeen hours after death. — The tissues of the body, chiefly the adipose 
 and areolar, were tinged yellow. On opening the chest the lungs remained slightly 
 inflated. There were some old adhesions between the outer and back part of the 
 right lung and the costal pleura. The substance of both lungs was crepitating. The 
 walls of the heart generally were thin, but there was no structural change of the 
 org m. Abdomen. — The liver was enlarged and extended across the epigastric region 
 reaching on the right side to the ninth rib. and on the left to the cartilage of the 
 eighth rib. The liver presented a uniform olive-green appearance, evidently 
 from biliary congestion, but there was no structural change. The gall-bladder con- 
 tained some bile. The common, hepatic, and cystic ducts were pervious. There was 
 no enlargement of the lymphatic glands or of other structure about these duets. The 
 contents of the duodenum were tinged with bile and the mucous membrane was 
 apparently healthy. The spleen was considerably enlarged, reaching from the sixth 
 to the last rib. The stomach was somewhat contracted. The transverse colon was 
 displaced, one portion of it forming an angle with another which was directed down- 
 wards. The kidneys were healthy. 
 
 42. Remittent Fever with jaundice. — Tenderness at the margin of the right ribs. — 
 T) ath from exhaustion. — Cirrhosis. — Gall-bladder distended. — Enlarged lymphatic 
 glands around the common duct. — Duodenitis. — Granular exudation on the mucous 
 rm mbrane of the ileum and large intestine. — Elaee Buccus, a Mussulman subsisting 
 by begging, of sixty years of age and visiting Bombay on his way to Mecca, was 
 admitted into hospital in a reduced state on the 10th July, 1850.* He stated that 
 he had been ill with fever for about thirteen clays. He was jaundiced. There was 
 tenderness below the margin of the right ribs and dulness for the extent of two inches, 
 enlargement of the spleen, increased heat of skin, tongue dry and coated in the centre, 
 and florid at the tip and edges, and the bowels were reported to be slow. Calomel 
 six grains with extract of colocynth eight grains were given, and on the following 
 morning pulv. jalap, comp., one drachm, but with the effect of causing little action of 
 the bowels. Twelve leeches were applied to the margin of the ribs followed by 
 a small blister. On the 13th. quinine in four-grain doses was given and repeated 
 daily, and from that time to the 24th there was no recurrence of fever. The abdo- 
 minal tenderness and the jaundice also gradually disappeared, the urine was no longer 
 tanged green by nitric acid, and the tongue cleaned and became moist ; but there was 
 little improvement in strength. On the 24th, abdominal uneasiness was complained 
 of and a rhubarb draught was given, but it produced no effect. In the evening there 
 was recurrence offebrile exacerbation, and on the 26th dysenteric discharges. Under 
 these symptoms, but without return of jaundice, he continued losing strength till the 
 2nd August, when he died without coma. 
 
 Inspection U n hours afti r death, — The body was much emaciated. Chest. — The right 
 
 collapsed freely and there -were two or three large emphysematous bullae at its 
 
 anterior margin, but otherwise it was healthy. The left lung was connected to the 
 
 * In this case, as w<-ll as that which immediately precedes it. there was a cluck to 
 the fever from the use of quinine, but no tendency to the recovery of strength, owing 
 probably to the advanced age and asthenia of the subjects. 
 
TVITn JAUNDICE. — PATHOLOGY 103 
 
 costal pleura by firm adhesions, also its base to the diaphragm and its anterior edge 
 to the pericardium, but its substance was crepitating. The heart was healthy. 
 Abdomen. — The liver consisted almost entirely of the right lobe. The gall-bladder 
 
 distended, readied nearly to the centre of the epigastric region, and was situated over 
 the gastro-hepatic omentum. The external surface of the liver was somewhat irr 
 but the substance was not indurated, and though when incised the surface pre 
 here and there white streaks apparently from hypertrophy of areolar tissue, there was 
 however no distinct lobular appearance. The lymphatic glands about the common 
 duct were about the size of an olive, but they did not press upon the duct, which 
 seemed more dilated than usual: this duct, and the hepatic and cystic ducts, were 
 permeable, and when laid open the mucous membrane presented the usual reticulated 
 character, but not a trace of redness. The contents of the gall-bladder were dark 
 green, and very adhesive from admixture of mucus. The mucous membrane of the 
 stomach was very rugous, mottled red towards the pyloric end, but without softening. 
 There was a good deal of dark redness of the mucous coat of the duodenum arranged 
 in streaks and patches, and chiefly occupying the apices of the rugse. Brunner s 
 glands were distinct, numerous, and elevated, and the mucous lining of the duodenum 
 was neither softened nor thickened. The inner surface of the lower end of the ileiim, 
 — about two feet of it — also of that of the ccecuni, the ascending and transverse 
 colon presented a dark red mottled appearance, with exception of the ccecum, where 
 the redness was uniform. Here and there there was grairalar exudation on the sur- 
 face, to a slight degree in the ileum, but more general on parts of the large intestine, 
 and in places the exudation had a dark grey colour, and there was abrasion of 
 portions of the mucous membrane, as if from superficial ulceration. In these situations 
 the lining membrane was connected to the subjacent tunic more closely than natural. 
 The spleen was somewhat enlarged (six inches in length), but apparently healthy in 
 structure. The kidneys were healthy. 
 
 43. Fever with jaundice. — Died exhausted. — Biliary congestion of the liver. — ^So 
 enlargement of the lymphatic glands. — Contraction of the cystic duct. — Distension of 
 the gall-bladder. Mucous membrane of gall-bladder and ducts normal, with exception of 
 slight vascularity of common duct at point of entrance into duodenum. — Hepatic cells 
 distinct. — Sukeah, a Hindoo, of twenty-two years of age, was admitted into hospital 
 after nine days' illness on the 28th of August, 1850. He was jaundiced, drowsy, and 
 very exhausted. He died ten hours after admission. 
 
 inspection ten hours after death. — AH the structures were tinged yellow. 
 Abdomen. — The liver projected about two inches below the ensiform cartilage and 
 right false ribs ; and its incised surface presented generally a yellowish appearance 
 with natural consistence. On examination under the microscope the hepatic cells 
 were distinctly seen. The hepatic and common ducts were of natural dimensions, not 
 turgid with bile, and when laid open, the mucous surface presented its normal 
 appearance, with the exception of sbght vascularity at the termination of the common 
 duct in the duodenum. The lymphatic glands around the common duct were 
 not increased in size. The gall-bladder was distended with bile of a dark green 
 (almost black) colour. The cystic duct was very much contracted, and there was 
 some obstruction at its commencement which prevented the point of a probe from 
 entering the gall-bladder, but the mucous lining was healthy. The mucous membrane 
 of the duodenum presented a dark grey colour, with here and there streaks of redness, 
 and the glands of Brunner were very turgid, but neither softening nor ulceration was 
 detected. The stomach contained a few ounces of dark-coloured liquid, its mucous 
 surface was of dark grey colour with patches of redness over the prominent rug! 
 two or three small projections apparently caused by some deposit, one (the largest) 
 about the size of a pea, was covered with coagulated blood. There were - 
 three small ulcerated spots on the mucous membrane of the stomach which could be 
 
 H 4 
 
104 REMITTENT FEYER. 
 
 easily peeled off from the subjacent tissue. The small intestines were rather con- 
 tracted. The kidneys were natural in size and structure, but the substance was tinged 
 yellow. The heart was healthy. 
 
 44. Remittent Fever with Jaundice. — Drowsiness, — Enlarged lymphatic glands in 
 course of common duct. — Constricted cystic duct. — Gall-bladder full. — A Hindoo, 
 about thirty years of age, was admitted into the hospital in February 1849, with fever, 
 drowsiness, and jaundice, and died about twenty- four hours after admission. 
 
 Inspection thirty-three hours after death. — The gall-bladder was full of bile but 
 not distended. Along the common duct for about two inches and reaching almost 
 to the duodenum there were enlarged lymphatic glands, both below and above the 
 duct, each about the size of a small olive, and when cut giving out a brown 
 turbid fluid the result of decomposition. The hepatic duct was pervious, but the 
 cystic duct above its junction was so constricted as not to admit the small end of the 
 blow-pipe. 
 
 45. Remittent Fever vAth jaundice. — No tenderness at margin of ribs. — Drowsi- 
 ness. — No enlargement of lymphatic glands. — Dark redness of mucous membrane of 
 duodenum. — Syed Mohedeen, a Mussulman beggar of forty years of age and of feeble 
 constitution, after suffering for twelve days from febrile symptoms coming on at 
 irregular periods, preceded by chilliness and attended during the last eight days with 
 looseness of the bowels, was admitted into hospital on the 28th August, 1850. He 
 was jaundiced. There was no induration or dulness at the margins of the ribs and 
 he made no complaint of pain. The pidse was feeble, and the tongue coated in the 
 centre was florid at the tip and edges. He died on the 12th September. Whilst 
 under observation the bowels were relaxed; the evacuations were generally of a 
 yellowish colour, sometimes scanty and passed with straining, but not tinged with 
 blood. From the 31st to the 5th there was improvement, the febrile disturbance 
 lessened, the tongue became more natural, and the jaundice decreased ; but from the 
 Cth there was again aggravation with (on the 10th) tremulous hands, brown dry 
 tongue, and drowsiness. The urine throughout was scanty and high-coloured, but 
 showed no traces of albumen. 
 
 Examination thirteen hours after death. — Head. The vessels of the dura mater 
 were found turgid with blood, and the tissue somewhat tinged yellow. The vessels 
 of the pia mater were also congested. On the inferior surface of the posterior lobe of 
 the right side, and extending into its sulci, there was some extravasation of blood 
 into the meshes of the pia mater. The substance of the brain was free from structural 
 change, but when incised it presented some bloody points here and there. There was 
 no increased serous fluid found in the ventricles, and no extravasation of blood into 
 the substance of the brain. Chest. — The upper lobe of the left lung and the thin 
 anterior edge of the lower one were soft and crepitating, but the rest of the 
 lower lobe was in a state of red hepatisation. The whole of the right lung 
 was healthy, excepting the thin posterior margin of its lower part which was in a 
 state of red engorgement. The structure of the heart was healthy, but its valves 
 were tinged yellow. Abdomen. — The substance of the liver was healthy in 
 structure. The stomach contained yellow brown mucous-like contents with several 
 lumbrici, but its inner coat was healthy. The lining membrane of the duodenum 
 presented dark red patches, and the glands of Brunner were more than usually 
 prominent. No compression of the biliary ducts from enlarged glands was detected, 
 and the common and hepatic ducts were found permeable. On the mucous membrane 
 of the large intestines there were patches of red and grey discoloration, most marked 
 in the ascending colon and coecum, but no traces of ulceration nor change in the 
 consistence of the tissue were observed. The mucous membrane of the ileum was 
 healthy with the exception of patches of tain) redness here and then' and the glands 
 of Peyer were normal. The spleen was much enlarged, measuring six inches by five, 
 
GENERAL PRINCIPLES OF TREATMENT. 105 
 
 but was of natural structure, except at its convex surface, where there were two 
 deposits of tubercular-like matter each the size of a small bean. The kidneys 
 were healthy in structure, but tinged yellow. 
 
 Parotitis. — Considerable tumefaction, ending in suppuration, 
 in the situation of one or both parotid glands is an occasional 
 occurrence in remittent fever. I have witnessed it only in natives 
 and always associated with febrile symptoms of marked ady- 
 namic character. The notes of three cases, the subjects of which 
 recovered after a long and tedious illness are before me. 
 
 Pathology of Inflammatory, Adynamic, and Congestive 
 Remittent Fever. — The pathology of these modifications of 
 remittent fever has already been incidentally considered in con- 
 nection with the symptoms : their relation to particular states of 
 the constitution, degrees of the morbific cause, and previously 
 existing structural disease are the leading facts which should be 
 borne in mind. 
 
 Pneumonia. — This complication and idiopathic pneumonia 
 will be treated of together. 
 
 Section IV. — Treatment. — Contrast of the Principles of Treat- 
 ment of Malarious Remittent Fever, and the Zymotic Continued 
 Fevers of Cold Climates. — Treatment of Ordinary, Inflam- 
 matory, Congestive, Adynamic, and Irregular Types of 
 Remittent Fever. — Then of those complicated ivith Cerebral 
 A feet ion, Gastric Irritability, Jaundice, Hepatitis. 
 
 It has been already stated that the essential difference between 
 intermittent and remittent fever is that in the former a periodic 
 cessation — intermission — of the febrile phenomena takes place, 
 while in the latter there is only abatement — remission. 
 
 Both these forms of fever depend on different degrees of the 
 same morbific cause — malaria, — a materies morbi generated 
 without and received into the blood. Theory suggests that similar 
 principles of treatment must apply to diseases so nearly allied, and 
 clinical experience confirms the inference. 
 
 It may, therefore, be useful to preface the details of the treat- 
 ment of remittent fever by recapitulating the leading principles 
 which have already been inculcated in respect to intermittent fever, 
 and then pointing out the general character of the modifications 
 which the difference in degree of the morbid actions in the two 
 types may require. When a paroxysm of intermittent fever has 
 
106 REMITTENT FEVER 
 
 fairly commenced, a certain course which we are unable to check 
 must be run before it comes to a close ; and this fact of clinical 
 observation is in harmony with the nature of the cause. 
 
 The susceptibility of enfeebled persons to attacks of intermittent 
 fever and the tendency of the disease in them to be protracted, that 
 is, to be liable to recurrences of the paroxysm — may be safely 
 admitted. Clinical observation teaches us that if much debility be 
 produced by treatment in intermittent fever, this greater liability 
 to a protracted course becomes materially increased, and serves to 
 illustrate the law that a morbific cause when in action is always 
 more influential on the predisposed from debility, however in- 
 duced. 
 
 If there co-exist with the febrile disturbance such derangement 
 of the capillary circulation of important organs as is likely to injure 
 their structures, or otherwise seriously to impair their functions, 
 then the means appropriate for the removal of this complication 
 must be had recourse to. 
 
 Though a paroxysm of intermittent fever cannot be stopped, yet 
 the degree of vascular excitement may be modified in such manner 
 as to lessen discomfort and mitigate local derangements when 
 they exist. This object may be effected by ventilation, purity 
 of atmosphere, reduction of the temperature of the surface of 
 the body by the external application of cold, and attention to 
 quietness and repose. These means do not abstract any of the 
 constituents of the blood, and therefore do not debilitate. But the 
 same end may be accomplished by blood-letting, purgatives or other 
 evacuants, but agencies of this kind enfeeble, and they ought not 
 to be used except in cases in which the necessity for decided and 
 prompt reduction of vascular excitement or for free elimination is 
 so pressing as to justify our disregarding for the time the lesser 
 because the remoter evil. 
 
 Although a paroxysm of intermittent fever when once formed can- 
 not be checked, yet after in its natural course it has ceased we have 
 in quinine an effective means of preventing its return ; and when 
 we compare this statement with that of our inability to stop the 
 paroxysm, it becomes evident that therapeutic force in this disease 
 is confined to the period of intermission. 
 
 These general principles are equally applicable to the treatment 
 of remittent fever, and it shall now be my endeavour to explain in 
 what respect they require to be modified when applied to this 
 type. 
 
 In intermittent fever there is for the most part little risk of 
 
GENERAL I'HINCirLES OF TREATMENT. 107 
 
 injury to important organs during the stage of febrile reaction. A 
 frequent recurrence of the paroxysm is not in general attended with 
 immediate danger to life, but injures by deteriorating the constitu- 
 tion. In remittent fever, on the other hand, there is greater likelihood 
 of harm from the increased vascular excitement of the exacerbation, 
 and therefore recurrences of this stage are not unfrequently attended 
 with immediate danger to life from lesion of important organs, or 
 depression of vital actions. Hence, in the treatment of remittent 
 fever, though there is often necessity for the reduction of febrile 
 excitement in the exacerbation by depletory means, yet at the same 
 time there is greater demand for the exercise of discriminating judg- 
 ment, for the evils of the injudicious use of depressant remedies are 
 more immediate, more certain, and more serious. If such are the 
 dangers which may attend the exacerbation of remittent fever, then 
 the prevention of its recurrence by the efficient use of quinine given 
 during the remission is even more urgent than the same indication 
 in the intermission of intermittent fever. 
 
 If it be true that at some periods of the exacerbation of remittent 
 fever there may be risk of injury to important organs from excessive 
 vascular action calling for control by depletion, and that, at other 
 periods, there may be danger to life from exhaustion requiring the 
 prompt use of stimulants and nourishment ; if it be also true that 
 the time of exacerbation and remission is liable to vary in different 
 cases, that it is most important to prevent the exacerbation, and that 
 we are able to effect it ; then it follows that there cannot be success- 
 ful treatment of remittent fever, justice to the sick, or loyalty to 
 the profession of medicine, unless our visits to the sick be frequent 
 and our watching attentive and well-timed.* 
 
 * Since the publication of the first edition of this work, I have found in " Obser- 
 vations on the Diseases of the Army in Jamaica, by John Hunter, M.D., Physician 
 to the Army, 1788," these principles inculcated with so much truth and force, thai 1 
 here quote the passage for the instruction of the reader, and with the view of enforcing 
 the analogous statement in the text : 
 
 " A surgeon that would do justice to the men under his care must be very frequent 
 in his visits to the hospital ; for unless he watch assiduously the remissions of the, 
 fever, and be ready to take immediate advantage of them, he will not be able to check 
 the disease speedily, without which both the constitution and life of the patient will 
 be in imminent danger. A man that has three or four fits of the fever is in great* r 
 danger of dying than one that has only one or two; but laying the risk of death out 
 of the question, a man that has his fever stopped after the first or second fit, n 
 nerally be restored to health in a few days, whereas if he have four or five fits, it will 
 often require as many weeks to recover the same degree of strength in the latter case 
 as days in the former. It must, therefore, be obvious how much the diligence and 
 attention of the surgeon importeth, of which a very striking proof occurred in a regi- 
 ment which was strong and consisted of twelve companies. The regiment was pro 
 
103 REMITTENT FEVER. 
 
 At the opening of the section on the pathology of remittent fever 
 it was stated that when remittent fever is compared with the 
 zymotic continued fevers of the colder climates this striking dif- 
 ference is observahle. In the former there are daily remissions of 
 the fever, that is a return, more or less complete, to normal actions ; 
 but in the latter the fever is continuous and unabated for many suc- 
 cessive days. This difference materially affects the principles of 
 treatment. In both the. febrile reaction is caused by a materies in 
 the blood whose power when thus in operation we are unable to 
 stop. In both, but more in remittent fever than in the others, there 
 may be danger to important organs from deranged capillary circu- 
 lation rendering necessary the adoption of means for lessening vas- 
 cular excitement. In both there is danger to life from depression 
 of vital actions — from the sedative influence of the cause, the con- 
 tinuance of the febrile disturbance, the previous condition of the 
 subject, or of all combined — requiring stimulants and support, 
 
 In remittent fever there are periodic abatements of the febrile 
 state, and there is an agent which, when effectively used in the re- 
 mission, tends to prevent the recurrence of the exacerbation, and 
 thus most materially to shorten the general course of the disease. 
 On these circumstances our chief power in the treatment of remit- 
 tent fever depends, but it has no place in that of the zymotic con- 
 tinued fevers. In these there is less frequently necessity for con- 
 
 vided with two hospitals and two surgeons, each of whom took charge of the sick of 
 six companies. It was presently found that one hospital was much fuller than the 
 other which did not appear to proceed from a greater sickness among one division of 
 the companies than the other, for there was no material difference in the number of 
 sick sent from the several companies. In order to bring the sick in the two hospitals 
 to an equality, a company was taken from one division and annexed to the other. The 
 sick of the five companies were, however, still more numerous than that of the seven ; 
 and after a short trial, they were divided into four and eight companies, and then the 
 sick in the two hospitals were nearly equal, and varied from forty to sixty in each. It 
 may be supposed that so great a difference depended upon the method of treatment 
 being entirely different in the two hospitals. That, however, was not the case ; the 
 general plan of treatment was nearly the same in both, and not materially different 
 from what has been mentioned in speaking of the cure of the remittent fever. It was 
 owing to the following circumstances : one surgeon visited his hospital four or five 
 times a day, the other only twice a day; the first seldom allowed any remission to 
 pass without taking advantage of it, the latter often; one was always at hand to pal- 
 liate the untoward symptoms, as vomitings or pnrgings, proceeding fit her from the 
 medicines or the disease; the other not. Add to these, that vigilance in the surgeon 
 al the head of an hospital extends itself to the servants and nurses under him, and 
 i a greater degree of attention both in administering nourishment and medi- 
 cines. The effect of all those causes was, that the men recovered in half the time in 
 one hospital that they did in the other, and therefore the hospital for eighl i ■ 
 tter number of sick than that for four." 
 
ORDINARY FORM. — TREATMENT. 109 
 
 trolling local capillary derangements and little risk of sudden 
 unexpected exhaustion. The course of the disease is, compared 
 with that of remittent fever, steady and prolonged, and the main 
 indication of cure is, by warding off undue prostration, to conduct 
 the patient safely to its close. The treatment is, therefore, expec- 
 tant and for several days in succession maybe continued with little 
 change. Contrast this with what has been already said of remit- 
 tent fever, the changes from exacerbation to remission taking place 
 within a few hours at varying periods, and requiring a decided 
 modification of the remedies. 
 
 It was in order to point to this contrast in the principles of treat- 
 ment that I have entered into this comparison between remittent 
 and zymotic continued fever and have shown the invariable 
 necessity of constant watching and action in the one, and the suf- 
 ficiency, for the most part, of expectant principles in the other. It 
 is well to fix attention on these doctrines, for observation has con- 
 vinced me that medical men whose practical knowledge of fever 
 has been acquired in hospitals in European countries do not quickly 
 realise to themselves the frequent changes which take place from 
 the very outset in remittent fever, the importance of watching them, 
 and of regarding them in treatment. On the other hand, when we 
 look back to the state of practice in fevers in India twenty years 
 ago, it is evident that principles of treatment in the zymotic fevers 
 of the colder climates which are equally applicable to remittent 
 fever were lost sight of and neglected ; principles which acknow- 
 ledge our inability, in the present state of medical art, to cut 
 short the febrile * disturbance of a zymotic cause, and which 
 admit great danger to life from depression of vital actions, con- 
 sequent on the persistence of the febrile state. 
 
 The treatment which is applicable to the different circumstances 
 of remittent fever will be first described, and then a few observa- 
 tions will be offered on some of the principal remedies. 
 
 Ordinary Remittent Fever. — The description of the treatment 
 of this form is chiefly derived from my experience in the European 
 General Hospital at Bombay. The subjects were, in great part, 
 seamen, and were admitted generally about the third day of the 
 disease. In the exacerbation there was headache, with flushing of 
 the countenance, and, in a small proportion of cases, vomiting, with 
 some degree of epigastric tenderness. In the greater number the 
 tongue was coated yellow in the centre, in some expanded, in others 
 
 * In applying this principle to remittent fever, I speak of the febrile disturbaiM 1 
 
 the stage of exacerbation. 
 
110 KEMITTENT FEVER. 
 
 contracted and pointed with florid edges and tip. The pulse was 
 generally neither firm nor full, but frequent and moderate in 
 strength. In a great many instances the secretions from the 
 bowels were dark or greenish in colour, but became natural as 
 the tongue cleaned. The remittent character of the fever was 
 well marked. 
 
 In treating the exacerbation, general blood-letting was un- 
 necessary. In cases in which there was much headache and 
 flushing of the face, from thirty-six to sixty leeches to the temples, 
 and cold applications to the head were required. In cases in 
 which there was tenderness at the epigastrium, and a contracted 
 tongue with florid edges and tip, there was necessity for more or 
 less leeching of the epigastrium, the use of effervescing draughts, 
 cold drinks in small quantity at a time, and the avoidance of eme- 
 tics, antimonials, mercurials, and purgatives. When the headache 
 was moderate, and gastric irritation was absent, then cold applica- 
 tions to the head, frequent tepid sponging of the surface of the body, 
 antimony in small doses, or aqua acetatis ammonias, sufficed for 
 reducing the febrile excitement. 
 
 Emetics were often useful at the commencement of the attack, but 
 it was necessary to give them with much discrimination. In cases 
 in which the tongue was foul and expanded but not florid, and in 
 which there was nausea without vomiting or epigastric tenderness, 
 twenty-five grains of ipecacuanha was the emetic which was generally 
 used with advantage. 
 
 During the first two or three days of the attack, when the tongue 
 was foul but not florid, the alvine excretions vitiated, the abdomen 
 full and resisting, and the vascular excitement steady and without 
 tendency to depression, it was an important part of the treatment 
 to give a ten-grain dose of calomel, combined with a few grains of 
 antimonial powder, and some hours afterwards an aperient, as the 
 compound powder of jalap. The calomel was most generally ad- 
 ministered at bed-time, and the compound powder of jalap in the 
 morning. Calomel and purgatives, even to the extent now recom- 
 mended, are seldom expedient after the third or fourth day of the 
 disease, and they are unnecessary, even at an earlier period, if the 
 abdomen be soft and without fullness, notwithstanding the presence 
 of disordered alvine excretions and a coated tongue. 
 
 After the first or second exacerbation a full dose * of muriate of 
 morphia was exhibited in many cases at bed-time with much bene- 
 
 * This recommendation musl In- carefully considered in connection with my subse- 
 quent remarks on (he use of full opiates in remit lent fever, 
 
ORDINARY FORM. TREATMENT. Ill 
 
 fit. When there is headache with great heat and dryness of skin 
 and a full and frequent pulse, morphia is contra-indicated ; hut 
 in most cases when there has been good management at the com- 
 mencement — adequate leeching, the appropriate use of calomel and 
 purgatives — there follows, on the succeeding night, slight pyrexia 
 with restlessness, but without headache, a supple abdomen, a tono-ue 
 still foul but moist, a pulse above the natural frequency but soft. 
 In a case of this kind, calomel or blue pill, in a dose proportioned 
 to the state of the tongue and the condition of the secretions in 
 regard to quantity and quality, with a grain of ipecacuanha and one 
 of muriate of morphia, preceded by a foot-bath, perhaps by a few 
 leeches to the temples, will generally be succeeded by a quiet night, 
 and a forenoon remission so distinct as to admit of quinine being 
 freely exhibited. This method, moreover, tends to restore a natural 
 state of the secretions with less risk of gastro-enteric irritation. 
 
 The remedial means as yet referred to are used with the view of 
 decreasing the vascular excitement of the exacerbation, protecting 
 organs important to life from harm by undue determination of 
 blood, and correcting deranged functions. These are very important 
 considerations, but they are subordinate to the main indication of 
 cure in remittent fever, which assimilates in every respect to that 
 already insisted upon in the intermittent type, viz. to take advan- 
 tage of the earliest remission by adopting means to prevent a return 
 of the exacerbation, or failing this to postpone its access or lessen 
 its severity : and for this purpose quinine is as efficacious as in the 
 intermission of intermittent fever. The same course should be ob- 
 served in all subsequent remissions, irrespective of local complica- 
 tions, which may require special means for their removal, and which 
 it is very important not to neglect, but which should not be allowed 
 materially to interfere with the steady pursuit of the leading indi- 
 cation of cure as now stated. 
 
 The earliest remission should be regarded, and quinine be given 
 in from four to six-grain doses every second or third hour, for four 
 or five times. Should the exacerbation return the quinine is to be 
 omitted, but should it not recur, the quinine is to be continued 
 every third or fourth hour, till the febrile phenomena have disap- 
 peared, and the probability of return has ceased. 
 
 But in ordinary remittent fever derangement of functions 
 often co-exists with the remission, and requires attention in the 
 treatment. Though such derangements are most certainly and 
 speedily corrected by the mere prevention of the exacerbation, yet 
 advantage may often result from remedial means more especially 
 
112 REMITTENT FEVER. 
 
 directed against them. It may be acknowledged as a therapeutic 
 principle in remittent fever, that all medicines not used merely to 
 reduce excessive vascular action, are given, with less likelihood 
 of harm and more probability of benefit, during the remission 
 than during the exacerbation. Nor is it difficult to suggest the ex- 
 planation. The less abnormal state of the general and capillary 
 circulation, characteristic of remission, is more favourable to absorp- 
 tion and the other processes concerned in therapeutic actions. 
 Thus it will sometimes be useful, when an aperient is indicated, to 
 combine two drachms of sulphate of magnesia with the first and 
 second doses of quinine, or when the bowels are slow and the tongue 
 much coated, a grain or two of calomel or blue pill with aloes may 
 be substituted for the salt. If there be tendency to diarrhoea, 
 the quinine may be combined with appropriate opiates. If there 
 be nausea, the use of effervescing draughts with the quinine is often 
 beneficial. But while we act on these principles we must always 
 remember that they are subordinate to the prevention of the exacer- 
 bation, and if their application at all interferes with this they ought 
 for the time to be set aside. 
 
 These remarks on the treatment of ordinary remittent fever, 
 though based on clinical observation in the European General 
 Hospital, are equally applicable to this form of the disease in more 
 sthenic Europeans and at earlier stages, with this addition, that at 
 the outset of the attack a general blood-letting of from sixteen to 
 twenty ounces may often be an expedient measure. They also 
 apply to the same type of fever in natives of good constitution, with 
 this exception, that in them there is less necessity for leeching, 
 calomel, purgatives, and a full opiate used in the manner recom- 
 mended. 
 
 In regard to diet. In ordinary remittent fever so treated that 
 there occurs no undue exhaustion from the injudicious use of 
 depressant means, stimulants are unnecessary, and animal broths 
 are not required till convalescence has fairly commenced. 
 
 On examining the diaries of sixteen well-marked cases of ordi- 
 nary remittent fever treated in the European Hospital in accordance 
 with these principles, it appears that from the commencement of the 
 attack to the perfect cessation of all febrile symptoms, the average 
 period was six days and a half : of these, two were passed before 
 admission, and four and a half under treatment in hospital. The 
 time occupied in the cure is an important consideration from its 
 bearing on the degree of efficiency of the patient after recovery : this 
 will always be in proportion to the judgment displayed in abstaining 
 
INFLAMMATORY FORM— TREATMENT. 113 
 
 from unnecessary depressants in the exacerbations, and in the early 
 prevention of exacerbations by the adequate use of quinine in 
 the remissions. The stage of convalescence, moreover, will vary 
 according to the nature of the treatment and the duration of the 
 attack. If the management has been skilful, convalescence will be 
 attended by little derangement of function, and will require only 
 a moderate use of stimulants and special articles of diet ; but if 
 depletion, purgatives, and mercury have been used in excess, and 
 quinine insufficiently in the remission, convalescence will be cha- 
 racterised by much debility, splenic enlargement, dyspepsia, palpi- 
 tation, intermittent headache, and tendency to diarrhoea or dysen- 
 tery ; and stimulants and extras will be largely consumed. 
 
 When a body of men — a regiment — in India is not, or has 
 not lately been very unfavourably placed, as respects locality and 
 general sanitary conditions, and its hospital returns show a large 
 proportion of dyspepsia and cardiac affections — palpitation — with 
 a large consumption of wine and beer, the inference may be safely 
 hazarded that its fevers have been unskilfully treated. 
 
 Inflammatory Remittent Fever. — In this form in sthenic 
 Europeans recently arrived in India, in consequence of the 
 greater febrile excitement, and cerebral and gastric derangement, 
 depletion is more indicated in the exacerbation. There is more 
 need for general and local blood-letting, and the assiduous appli- 
 cation of cold to the head. In many cases in which the skin is dry 
 and steadily hot, cold affusion may be used from time to time with 
 great advantage ; but emetics and antimonials are in general contra- 
 indicated from the tendency to gastric irritability which usually 
 exists. 
 
 Though to increase hepatic and intestinal excretion, with the 
 view of lessening febrile reaction by evacuation and of removing 
 the products of augmented metamorphosis of tissue, is a distinct 
 indication, yet we are frequently obliged to be very cautious 
 in the use of calomel and purgatives ; for there is often present 
 congestion of, or determination to, the gastro-intestinal lining, 
 very apt to be increased or to pass into inflammation by the 
 use of irritants, and thus to aggravate the fever. In this difficulty 
 we must keep these opposing principles before us, and lean to one 
 or other as our judgment may dictate in particular cases. We 
 shall often succeed best by premising leeches to the epigastrium 
 during the exacerbation, and deferring the one or two ten-grain 
 doses of calomel which may be necessary till the period of remis- 
 
 i 
 
114 REMITTENT FEVER. 
 
 si on, and then combining them with opium, while at the same 
 time we exhibit quinine. 
 
 In the treatment of inflammatory remittent fever, freer deple- 
 tion is required, but still it should be used with watching and 
 caution, and the safest time is at the height, not the close, of 
 an early exacerbation. Nor should we forget that evacuants are 
 had recourse to, not in the hope of cutting short the attack, 
 but merely of lessening the risk of injury from vascular excite- 
 ment; and that they are being used in a disease which, if it 
 persists, is sooner or later sure to terminate in signal depression of 
 the vital actions. The best guide to the successful application of 
 depletory remedies is the presence of a dry skin of steadily 
 increased temperature, and a pulse frequent, firm, and of good 
 volume, associated with hypercemia of an important organ ; but it 
 must not be supposed, that a sthenic constitution, and an early stage 
 of the attack, necessarily indicate the propriety of free depletion and 
 other depressing means. It should be borne in mind that in all 
 states of constitution, the sedative influence of malaria may be great 
 at the very outset of the disease, and that then depressants are 
 likely to be injurious. If then (it matters not w 7 hat the consti- 
 tution, or the duration of the attack may be) the pulse be badly ' 
 developed and easily compressed, and the general surface of the 
 body not steadily dry and of augmented temperature, we must be 
 very cautious. I do not say that under these circumstances general 
 blood-letting may never be had recourse to ; but I am certain that 
 we should be very watchful, that the finger should be on the pulse 
 as the blood flows, and if the action of the heart does not speedily 
 improve, which it seldom will, then the further abstraction of blood 
 must be stopped. 
 
 Such then are the principles to be observed in the treatment of 
 the exacerbation in inflammatory remittent fever. They must be 
 considered in connection with what has previously been said on the 
 management of the same stage of the ordinary form of the disease. 
 
 In the remission the principles advocated in ordinary remit- 
 tents still more forcibly apply to the present form. Quinine 
 in from five to eight-grain doses should be given every second 
 hour, or it may be necessary, when the remission is very short, to 
 give it every hour ; and continue or intermit it in the manner 
 already explained. 
 
 In the first section of this chapter, the diagnosis between remit- 
 tent and common continued fever is stated, and it is remarked 
 that under certain circumstances, in the plains of the Ganges and 
 
CONGESTIVE FOIOI — TBBATMEKT. 115 
 
 Indus, the Coromandel coast and the table lands of the Deccan 
 and Malwa, a compound type is occasionally met with, in which 
 the remissions, though more marked than is usual in continued 
 fever, are slighter than is commonly observed in the remittent 
 form. This variety bears depletion better than pure remittents, 
 because the sedative influence of malaria is less operative ; and 
 though quinine, in doses of from two to five grains, is necessary in 
 the remission, a larger quantity is often badly borne, because the 
 tolerance is less. It not un frequently happens, in cases of doubtful 
 diagnosis, that we are materially assisted by watching the effect of 
 quinine. 
 
 Congestive Remittent Fever. — Having in the course of my re- 
 marks on the treatment of inflammatory remittent fever enjoined 
 caution in the use of blood-letting, when the symptoms tend to be 
 congestive, there need be no hesitation in condemning it when the 
 congestive form is distinctly developed. 
 
 Viewing the internal congestion of blood, which doubtless exists 
 in these cases as one of the conditions necessarily resulting from a 
 depressed state of the vital actions of the vascular and nervous 
 systems, general blood-letting has always seemed to me contra- 
 indicated in theory ; and my experience, so far as it has gone, has 
 confirmed this opinion. 
 
 The treatment should consist of the judicious external use 
 of stimulants, and the exhibition of calomel and quinine fre- 
 quently repeated. The instance in which I have witnessed the 
 most marked benefit from these remedies was in a seaman 
 of the name of Crookberry, attacked with fever after exposure 
 in the dockyard at Bombay, in October 18-10. The skin 
 was coldish and damp, the pulse frequent, compressible and 
 becoming feeble, the manner heavy, with drowsiness and wander- 
 ing delirium, and the secretions from the liver and intestines 
 suppressed. He continued in this state for twenty-four hours, not 
 improving under the use of free doses of calomel, a blister to the 
 nucha, and wine. Quinine and calomel were then given in two- 
 grain doses of each, and repeated at intervals.* The pulse and 
 the skin improved, then followed two or three days of febrile 
 exacerbation, succeeded by recovery. 
 
 When the symptoms of congestion cease and reaction follows, 
 then the subsequent treatment should accord with the principles 
 already inculcated in the ordinary and inflammatory forms, or 
 with those which are about to be noticed in the continued and 
 
 * The quinine should certainly be given in larger doses than in this case. 
 
 I 2 
 
116 REMITTENT FETER. 
 
 adynamic types — as the one or the other happens to apply to the 
 particular instance. 
 
 The suggestion made at the commencement of the pathological 
 remarks on remittent fever — that congestive symptoms may in 
 some cases be related to old-standing disease of the heart, the liver 
 or kidneys — is an additional reason for observing great caution in 
 the treatment of this form, more particularly in the use of deple- 
 tion and other sedative remedies. 
 
 Remittent Fever tending to become continued, then adynamic 
 in character. — In years and at seasons when the causes are intense 
 or the predisposition great, remittent fever is frequently of an 
 aggravated character, evinced not by assuming the inflammatory 
 form, but by the remissions becoming less apparent, and the exacer- 
 bation, in the worst cases, putting on an almost continued form for 
 two or three successive days. Cases of this kind are more difficult 
 to cure, because quinine, in doses sufficiently large to make any 
 great impression on the disease, is for a time often inappropriate ; 
 still even when the remission is very imperfect, it should be tried, 
 and repeated, or not, in subsequent remissions, according to the 
 effect. 
 
 When the evidence is good that quinine is not beneficial, 
 all that can be done is to recollect the principles applicable to 
 typhus and typhoid fever, and guide the patient through the 
 attack, protecting important organs from undue determination of 
 blood, and taking care that this indication is not effected by 
 means which will too much depress the vital actions of the system, 
 and favour the accession of adynamic symptoms ; and then, so 
 soon as a remission becomes marked, to have recourse to quinine. 
 Though thus conceding that cases of remittent fever may occur in 
 which, unfortunately, it is not admissible to use quinine very early 
 in the disease, still I am convinced that the more closely such 
 doubtful cases are watched, the more frequent the opportunities 
 of exhibiting this remedy will be found to occur. This watchful- 
 ness should be enforced from the very commencement of the 
 attack ; for, as already stated, the tendency to a fair remission 
 is very often greater during the two or three first days, — the 
 continued character coming on as a subsequent event. 
 
 When remittent fevers have thus passed into the almost con- 
 tinued form, they are, after a time, as explained in my notice 
 of the symptoms, liable to evince a train of adynamic phenomena, 
 and then the only method of managing them is, to recollect the 
 principles laid down by Cullen, that '-fevers tend to cure them- 
 
ADYNAMIC FORM — TREATMENT. 117 
 
 selves," and that the indication of cure is " to obviate the tendency 
 to death."* In fact, all that can be aimed at in such cases is to 
 reduce the increased temperature of the surface by tepid spong- 
 ing; to sustain the pulse by light nourishment, wine and other 
 stimulants ; to attend to the excretions ; and to apply cautiously 
 small blisters over the organs which seem to be chie% affected, 
 taking care that they are not used to the degree of increasing 
 febrile excitement, and recollecting that in the adynamic state of 
 remittent fever, in the advanced stages, a tendency to run into 
 gangrene is evinced equally as in European typhus. 
 
 Such are the resources to which we are restricted when adyna- 
 mic symptoms co-exist with fever in which the remissions are not 
 marked ; but should a remission become distinct, dryness and 
 brownness of the tongue offer no drawback to the use of quinine. 
 I have seen cases, and of one the diary is before me, that of Penn, 
 aged twenty-one, of her Majesty's ship Endyrnion, ill with dock- 
 yard fever, in which, after about ten days of almost continued 
 febrile excitement, attended in the last days with brown dry tongue 
 and other adynamic symptoms, a remission was taken advantage 
 of and quinine was freely given and continued with marked benefit 
 through each succeeding remission. The exacerbations decreased 
 and quickly ceased, and, coincident with this result, the tongue 
 became cleaner and moister, — because the dryness was but a 
 sequence of the persistence of the febrile state, and one of the 
 proofs of diminished secretion. Not only did the tongue in this 
 instance become moist, but, for a similar reason, the secretions 
 from the bowels became more regular, freer, and more natural 
 in appearance. 
 
 We have every encouragement, under these circumstances, to 
 persevere in the appropriate course of treatment ; for, in young and 
 previously healthy subjects, recovery not un frequently takes place 
 from an unfavourable train of adynamic symptoms, including more 
 or less delirium, with well-marked tendency to drowsiness. 
 
 Remittent Fever with badly developed symptoms; with 
 symptoms of unexpected collapse; with certain occasional 
 features. — Under these heads, in the Section on Symptoms, 
 
 * Under these circumstances to attempt to affect the system with mercury, or to 
 hope to control local inflammations by free leeching, or to correct the abdominal secre- 
 tions by active purgatives, are measures so totally at variance with the indications < 
 cure, and so destructive of the faint hope of recovery which it is xiseful to maintain. 
 that were it not for the indiscriminate manner in which these means have been and 
 still are frequently used it would be unnecessary to allude to them here. 
 
 I 3 
 
118 REMITTENT FEVER. 
 
 phenomena are described, which all point to the tendencj', in 
 remittent fever, of vital actions to become depressed, and thus 
 lead to death. In noticing these phenomena, with reference 
 to treatment, all that can be said is, that they forcibly inculcate 
 the necessity of familiarising ourselves with the principles which 
 regulate the application of depressant remedies ; and while 
 they impress upon us the evils of the injudicious use of these 
 means, they teach us to be prompt with those appliances — 
 quinine, stimulants, and nourishment — which prevent prostration, 
 or counteract it when present. 
 
 Remittent Fever with Cerebral Affection. — We have found that 
 this complication is a frequent and fatal one in the remittent fevers 
 of sthenic Europeans, and also in the adynamic forms of the disease. 
 In order to understand the treatment, the remarks already made on 
 the symptoms and pathology of this complication must be borne 
 in mind. Headache, delirium, flushed countenance, with steady 
 heat of surface, and a well-developed and firm pulse- — present 
 in sthenic Europeans — should be met during the exacerbation 
 by detraction of blood, both general and local, the appli- 
 cation of cold to the shaven head, free action of the bowels by 
 mercurial purgatives, and the use of small doses of tartar emetic, 
 when the state of the stomach will admit. But it is only in the 
 very early exacerbations that we may hope to use these means with 
 good effect. So soon as the pulse, still increasing in frequency, dis- 
 tinctly fails in strength, and the delirium becomes muttering and 
 alternates with tendency to drowsiness the stage for evacuants has 
 passed, — their use will merely hasten the fatal issue. In bad re- 
 mittents this state may come on as early as the fourth or fifth day 
 of the attack, or earlier where the phenomena have been congestive 
 at the commencement. Further, the remark made under the head 
 Pathology, that undue depletion in the exacerbation sometimes leads 
 to the development of head symptoms — muttering delirium, and 
 tendency to drowsiness — at the close of a paroxysm, must be 
 remembered. 
 
 These facts, which bring again before us the important truth of the 
 marked tendency to prostration in remittent fever, and again point 
 to the evils of undue depletion, are not, however, to be advanced as 
 arguments against the use of evacuant means in appropriate cir- 
 cumstances. They teach us to be very watchful for the first symp- 
 toms of cerebral complication, and to be very prompt, but not rash, 
 in the application of our remedies; to observe with care their effect 
 on the cerebral symptoms and on the pulse ; to be very assiduous 
 
CEREBRAL COMPLICATION TREATMENT. 119 
 
 in the application of cold to the head, and to enjoin great quietude, 
 and the removal of all sources of excitement. It is by attention to 
 principles such as these that we may hope to secure those advan- 
 tages which depletory treatment, used with judgment and caution, 
 is most certainly capable of conferring, and to avoid those evils 
 which will as surely result from its abuse in unsuitable states of 
 constitution and stages of disease. 
 
 When the period for local detraction of blood has passed, but 
 head symptoms still continue and tend to drowsiness, a blister * 
 may be applied to the nucha with advantage ; and the time which 
 should be selected is the commencement of a remission, not the 
 height of an exacerbation. 
 
 Such, then, are the means of treatment when cerebral symptoms 
 depend on determination or congestion. They must be viewed in 
 connection with the principles elsewhere laid down for the treatment 
 of the exacerbation in uncomplicated remittents. 
 
 Head symptoms, dependent on inflammation of the membranes 
 of the brain passing on to effusion of lymph, are rare compared with 
 those caused by other conditions. They are usually characterised 
 by milder delirium, by less febrile reaction, by greater persistence 
 of the symptoms during the remission, by agitated movements of 
 the hands and fingers, and occasional convulsion ; and are most 
 likely to occur in the less sthenic states of constitution. They 
 must be met by a judicious application of antiphlogistic therapeutic 
 principles. 
 
 The muttering delirium and tendency to drowsiness coming on 
 in more advanced stages of fever, and associated with adynamic 
 phenomena, are to be controlled by means altogether different. 
 The adynamia must be treated by appropriate stimulants and 
 nourishment, and depressant remedies of all kinds must be abstained 
 from. When, however, the tendency to drowsiness begins to ap- 
 pear, a small blister should be applied to the nucha, or, should that 
 be inconvenient, to some part of the head. Under these means 
 recovery not unfrequently takes place, particularly in youthful 
 subjects. 
 
 Treatment of the pathological states of the brain, which cause 
 head symptoms, by the induction of mercurial influence, has been 
 practised, and the question of its propriety may be here discussed. 
 
 * The blistering preparation which I have generally used was introduced into hos- 
 pitals in India on the recommendation of Dr. Donald Young in 1S35, under the name 
 of liquor lyttse. It is considerably stronger than the acetum cantharidifi of the 
 Pharmacopoeia. The latter preparation often fails. 
 
 I 4 
 
120 REMITTENT FEYEU. 
 
 Viewing the head symptoms apart from the fever which they com- 
 plicate, mercurial action is clearly contra-indicated in the ady- 
 namic form, as w T ell as in that depending on determination or 
 congestion of blood, with threatening serous effusion : it is not 
 sanctioned by any reasonable therapeutic doctrine. But in that 
 train of head symptoms depending on inflammation tending to 
 terminate in exudation of lymph, mercury may be proposed on 
 theoretic grounds ; and in occasional cases, in which the diagnosis 
 is clear and the constitution suitable, it may be expedient to have 
 recourse to it in the remission. Yet on the whole my judgment 
 is opposed to this means as a rule of practice, for the following 
 reasons. 1. Meningitis is rare, compared with other proximate 
 causes of head symptoms in remittent fever, and it occurs more com- 
 monly in asthenic than sthenic constitutions. 2. It is often dif- 
 ficult to distinguish the symptoms depending on inflammation from 
 those resulting from other pathological states, for which mercury is 
 either unnecessary or injurious. 3. Mercurial influence and the 
 process by which it is induced very generally prove injurious in that 
 state — the fever — of wdiich the meningitis is a complication ; and 
 it may be received as a pathological law, that whatever aggravates 
 an idiopathic fever must aggravate the local derangement which 
 complicates it. 
 
 The general question of the mercurial treatment of remittent 
 fever will be considered in a subsequent part of my observations ; 
 and the use of opiates, which has also reference to the management 
 of head symptoms, will likewise be afterwards discussed. 
 
 These remarks on the treatment of cerebral complication have 
 hitherto referred to the stage of exacerbation. "When explaining 
 the treatment of the complicated forms of intermittent fever, I 
 took the opportunity of stating my conviction that, whatever the 
 complication might be, the adequate exhibition of quinine during 
 the intermission was a ruling indication of cure. This rule of practice 
 is equally true of remittent fever. It matters not what the nature 
 of the cerebral symptoms may be, the sufficient use of quinine must 
 never be neglected. There has, I am aware, been very often doubt 
 and hesitation in giving quinine in the remissions of fever with 
 head complication ; not only is this unnecessary, but the suspicion 
 may be entertained that part of the mortality from this compli- 
 cation has been due to the want of the remedial benefit of this 
 agent. It is almost needless to add, that while we exhibit quinine 
 we are not to neglect the other efficacious means which are also 
 applicable to the stage of remission. 
 
GASTRIC COMPLICATION — JAUNDICE — TREATMENT. ] 2 1 
 
 Remittent Fever with Gastric IrritcMlity. — The observations 
 made on the symptoms and pathology of this complication suggest 
 the treatment. It should consist chiefly of local abstraction of 
 blood from the epigastrium,*i'ollowed by blisters when the further 
 loss of blood is contra-indicated. As in the case of all inflammatory 
 complications of remittent fever, the exacerbation is the appropriate 
 period for leeching, the remission for blisters. The internal use of 
 ice is also important. 
 
 We must be very guarded in giving mercurial preparations 
 and purgatives, and should, on other grounds, the indication for 
 their exhibition be pressing, then, after preliminary leechino- in 
 the exacerbation, they should be used in the remission rather than 
 the exacerbation, and the calomel should be combined with opium. 
 Quinine should be had recourse to in the remission, and it is im- 
 portant on this account so to manage the irritability of stomach 
 during the exacerbation, as to render the rejection of the quinine 
 in the remission less likely. Should this fail, it may be exhibited 
 by enema. 
 
 Remittent Fever with Jaundice. — The co-existence of tenderness 
 at the margin of the right ribs, with jaundice, suggests the presence 
 of inflammatory action, and our pathological research has shown 
 that the mucous membrane of the duodenum and of the stomach is 
 frequently the seat of the inflammation. Observation has further 
 taught us that jaundice generally does not appear till several days 
 after the commencement of the fever. These facts inculcate 
 watchfulness for the first indication of tenderness below the right 
 ribs, and on its appearance, without reference to the presence or 
 not of jaundice, the adoption of the remedies for inflammation 
 appropriate to the particular case, as well as abstinence from the 
 means likely to excite irritation of the mucous lining of the 
 stomach and duodenum. 
 
 When jaundice is present, the treatment should consist of the 
 application of leeches or small blisters to the tender part below the 
 right ribs, and the use of quinine during the remission, combined 
 with small doses of aloes and mild mercurials, or of some saline 
 aperient. 
 
 Of the ten fatal cases which have been detailed by me (36 to 
 45), there are five in which, judging from the colour of the liver, 
 biliary congestion was present ; in 3 the colour of the organ is not 
 mentioned, and in one it was streaked white. It may, therefore, 
 be inferred that in cases of jaundice complicating remittent fever ? 
 the proximate cause is usually not defective action of the hepatic 
 
122 REMITTENT FEVER. 
 
 cells, but rather some obstacle to the passage of the bile from the 
 liver. The occurrence of jaundice in cases of remittent fever in 
 which there had been free use of calomel and purgatives, is a fact 
 which has long been familiar to me, and I deduce from these two 
 statements, and the two previously made, viz. — that gastro-duo- 
 denitis is frequently present, and that jaundice is generally not a 
 complication of the early stage of fever — that full doses of calomel 
 and the free use of purgatives form no part of the treatment of re- 
 mittent fever complicated with jaundice. On the contrary, they 
 are likely to cause an aggravation of the symptoms, and to accelerate 
 the period of prostration. 
 
 As a subsidiary means benefit is sometimes derived from the 
 use of saline diuretics, at the same time with the remedies already 
 advised. They seem to expedite the elimination of the biliary pig- 
 ment from the blood. 
 
 Remittent Fever with Hepatitis. — As already stated, the com- 
 plication of remittent fever with hepatitis, either in Europeans or 
 natives, is, according to my observation, a rare occurrence. The 
 only question of treatment which arises is the expediency or not of 
 inducing mercurial influence. On this point of practice it may be 
 assumed that the doctrines advanced on the treatment by this 
 means of a complicating meningitis, are equally applicable to a 
 complicating hepatitis. 
 
 The management of hepatic and splenic enlargement, co-existing 
 with or subsequent to intermittent fever, has been fully explained. 
 The same principles apply to these enlargements when co-existing 
 with or consequent on remittent fever. 
 
 Remittent Fever with Dysentery. — The general rule which I 
 have endeavoured to establish in respect to the treatment of all the 
 complications of remittent fever, should be also observed in this 
 particular one. While we treat the fever with quinine during the 
 remissions, we must fulfil, in so far as it may be practicable, the 
 indications which I shall have to explain elsewhere, as appropriate 
 in the treatment of dysentery. 
 
 Section V. — Treatment further considered in Remarks on Blood- 
 letting, Mercury, Cold Affusion and Wet Sheet Packing, Pur- 
 gatives, Emetics, Blisters, Opiates, Quinine, Diet, and Change 
 of Air. 
 
 General Blood-letting. — It has been explained that general 
 blood-letting is an expedient and useful measure — sometimes a 
 
GENERAL BLOOD-LETTING TREATMENT. ] 23 
 
 very necessary one — in reducing the high vascular excitement of 
 the early exacerbations of remittent fever in sthenic and lately 
 arrived Europeans, as well as in lesser degrees of excitement, when 
 in this state of constitution and stage of fever there co-exist con- 
 siderable determinations of blood to important vital organs. The 
 extent to which blood-letting should be carried in suitable cases is a 
 point on which the physician must exercise his discretion — keep- 
 ing in view the ultimate advantage of effecting the indication aimed 
 at with as little loss of blood as practicable, and recollecting that 
 the judicious removal of sources of irritation, the adoption of free 
 ventilation, the well-timed use of emetics, cold affusion, tepid 
 sponging, and antimonials, are all measures of considerable influ- 
 ence in lowering febrile excitement, which it is of essential conse- 
 quence to employ with assiduity in order to lessen the necessity of 
 large evacuations. In the treatment of remittent fever in Euro- 
 peans some time resident in India, and in all classes of the native 
 community, general blood-letting is, with few exceptions, an unne- 
 cessary and often injurious proceeding. 
 
 Throughout these observations it has been my object to inculcate 
 the following principles: — 1. That in the great majority of in- 
 stances the danger in remittent fever consists in prostration 
 of the vital actions of the heart and nervous system. 2. That 
 not only exhaustion, but also the protraction of the disease, is 
 favoured by needless and undue evacuations. 3. That evacuant 
 means used in the exacerbation have no power in shortening the 
 duration of the attack. 
 
 The opportunity has at different times been afforded me of wit- 
 nessing the treatment of the exacerbations of remittent fever by 
 repeated venesection, and its injurious tendency was very ap- 
 parent. It is true that the vascular excitement of an exacerbation 
 may be lessened, and the symptoms depending on that excitement 
 may be for the time alleviated by blood-letting; but the par- 
 oxysm nevertheless recurs, and after repeated depletion the febrile 
 disturbance becomes more severe and continuous, with not un- 
 frequently an aggravation of all the local complications. This 
 latter fact was known to Pringle, who says : " But repeated bleed- 
 ings, unless upon evident marks of a fixed inflammation, were so 
 far from producing the desired effect, that they were apt to render 
 the fever more obstinate." * Lind writes much to the same pur- 
 pose : " This fever (remitting), unless brought to a speedy remis- 
 
 * " Observations on the Diseases of the Army." London, 17G5, p. 208. 
 
124 EEMITTENT FEVER. 
 
 sion, is attended with considerable danger ; and if large quantities 
 of blood be repeatedly taken from patients labouring under it, by 
 mistaking their disease for a true inflammatory fever, its obstinacy 
 and fatality are greatly increased."* Dr. Stokes remarks : " From 
 what .1 have seen I am disposed to conclude that bleeding in the 
 cold stage, when it does alter the type of intermittent fever, has a 
 tendency to convert tertian into quotidian and quotidian into re- 
 mittent or continued fever. I never saw any example of the con- 
 verse, or in which quotidian was converted into tertian."f Mr. 
 Twining observes : " A remarkable fact may be here noticed, 
 namely, that the employment of blood-letting in the cold stage 
 of intermittent fever is occasionally, though rarely, followed by 
 continued fever." J 
 
 The practice of blood-letting in the cold stage of intermittent 
 fever, first recommended nearly thirty years ago by Dr. Mackintosh 
 of Edinburgh, was warmly advocated by Mr. Twining in his clinical 
 illustrations of the diseases of Bengal. Though this mode of treat- 
 ment is not, so far as I am aware, at present followed in any part 
 of India, I may not, on an important point of practice, pass unnoticed 
 the opinion of one of our best authorities on Indian disease. It is 
 not my intention to enter into any examination of the principles 
 on which this practice is grounded, or on the evidence on which its 
 efficacy is supposed to rest. The perusal of Mr. Twining's remarks, 
 in connection with what I have myself written on the treatment of 
 intermittent fever, will at once show the reasons of my dissent 
 from the course which he recommends. 
 
 The question was ably inquired into by Dr. Stokes of Dublin in 
 1829 ; and the evidence on both sides has since been fairly stated 
 by Mr. Martin §, and a conclusion unfavourable to the practice has 
 been drawn by him. 
 
 Dr. Stokes thus states the results of his observations : — 
 
 " From the examination of these cases I apprehend that an impression -will be re- 
 ceived certainly against the indiscriminate or even frequent use of bleeding in the 
 cold stages of ague. It may be remarked that, in the great majority, quinine had to 
 be administered before the disease was eradicated; that many of them had an ex- 
 fcrem I y slow and dangerous convalescence ; that in several instances the disease, so 
 far from being relieved, appeared exasperated by the practice ; that local inflammatory 
 
 * " Essay on Diseases incidental to Europeans in Hot Climates." By James Lind, 
 Physician to the Hospital at Haslar. 3rd Edition, London, 1777, p. 310. 
 
 f "Edinburgh Medical and Surgical Journal," vol. xxxi. ]». 13. 
 
 J "Clinical Illustrations of Diseases of Bengal." 2nd Edition, vol. ii. p. 233. 
 
 § "On the Influence of Tropical Climates, &c." By James Johnson and James 
 Ranald Martin. 1841. P. 159. 
 
MERCURIAL TREATMENT CONDEMNED. 125 
 
 affections occurred several times after the operation ; and lastly, that the bleeding ap- 
 pears to hare a tendency to convert intermittent into continued fever. In one case, 
 that of Casey, death from pneumonia and softening of the brain occurred. In none 
 of my cases did any bad effects from sinking of the powers of life follow the practice 
 immediately. But I am informed that in the practice of a highly respectable indivi- 
 dual, there, oerarred two cases in which the patients did not recover from the collapse 
 produced by bleeding in the cold stage. Those facts should make us very careful how 
 we interfere with nature by means of the lancet, when we have so certain, and, as far 
 as I have seen, so infallible a remedy as the sulphate of quinine." * 
 
 Calomel and other Mercurials. — The circumstances under 
 which calomel may be used with advantage in the treatment of 
 remittent fever, with the view of increasing the excretions from 
 the liver and intestinal canal, have been already explained. 
 
 The practice, at one time too common, of exhibiting calomel 
 in doses of four or five grains three or four times in the course of 
 the day, without any very definite object, and continuing it for 
 a succession of days, cannot be too strongly condemned. Not only 
 is it unnecessary, but, for the following reasons, often positively in- 
 jurious. 1. In watching the progress of cases thus treated, it is 
 not difficult to detect a train of symptoms more fairly attribu- 
 table to the treatment than to the disease, because it is in cases 
 thus treated that it has been chiefly observed. The symptoms 
 alluded to are uneasy feelings, sometimes amounting to pain, with 
 a sense of oppression or sinking at the epigastrium, and occasional 
 griping of the abdomen, for which leeches are not unfrequently 
 applied, and purgatives unnecessarily given. 2. The frequent repe- 
 tition of the calomel keeps up a furred state of the tongue, with 
 nausea and irritability of stomach, aggravates the febrile excitement, 
 and produces an irritable state of the bowels, indicated by frequent 
 watery discharges. 3. The convalescence of cases thus treated is 
 always tedious, and frequently complicated with diarrhoea and clay- 
 coloured dejections. 
 
 The question of the efficacy of the constitutional effect of mer- 
 cury in stopping the febrile excitement of remittent fever, and the 
 expediency of, at all hazards, endeavouring to produce it, has been 
 at different times much debated. To induce mercurial influence 
 with this view was, when I entered on practice in India and for 
 many years afterwards, an article of therapeutic faith, and possibly 
 this grave error may not yet be altogether dispelled. I shall first 
 state the conclusions to which I have myself arrived on this question 
 of practice, and the reasons upon which they are grounded ; then 
 notice the opinions of some other writers; and finally examine the 
 
 * "Edinburgh Medical and Surgical Journal," vol. xxxi. p. 17. 
 
]26 REMITTENT FEVER. 
 
 origin of the practice and the nature of the experience which gave 
 rise to it, and exercised so much influence upon the minds of 
 others. 
 
 Cases have occurred under my own observation in which fever 
 persisted notwithstanding well-developed mercurial influence. 
 
 An officer in Gfuzerat was attacked with remittent fever on the 
 16th of June; he was salivated on the 18th, but the febrile state 
 recurred and continued. The salivation ceased. The fever became 
 adynamic with sense of great exhaustion. There was again a free 
 exhibition of calomel, and an inefficient use of quinine ; finally de- 
 lirium and death on the 23rd. 
 
 Dr. Stovell, in his reports* of the European General Hospital, 
 details two cases of remittent fever, continuing, becoming ady- 
 namic and proving fatal with co-existence of mercurial salivation : 
 and in his statistical notice of this hospital for ten years, from 
 1846 to 1856, he thus concludes his matured review of this 
 question : — 
 
 " I need not waste time by giving more proofs of the correctness of my statement. 
 It was the observation in earlier days of cases and facts such as these that assisted in 
 shaking my faith in the soundness of the mercurialising doctrines of Drs. Annesley 
 and Johnson, whose works were in those days unfortunately the chief authorities for 
 Indian practice. Greatly should I deplore a retrograding return to these mercurialising 
 views ; and I shall therefore, I trust, be excused for venturing to caution the inexpe- 
 rienced against the injudicious use of mercury, in any shape or form, either in remit- 
 tent fever, or in any disease whatever."! 
 
 Mr. Walbran, surgeon of the 4th Light Dragoons, thus writes J 
 
 of the fevers at Kaira in 1824 : — 
 
 " To affect the system with mercury, with the object of restoring the balance of the 
 sanguiferous system, was always kept in view as a primary object. When ptyalism 
 was induced, the patient generally recovered. There have been, however, instances 
 in which the ptyalism had been free for some days, the evacuations had assumed a 
 healthy colour, and every trace of fever had gone off, yet, notwithstanding the greatest 
 care, the ptyalism was checked, the patient immediately became anxious and restless, 
 pulse quick and full, skin burning hot, restlessness and delirium supervened, and death 
 followed in a few hours. This suppression of ptyalism taking place in the course of a 
 few hours is not of very frequent occurrence in other fevers, and I can only account 
 for it in the cases above alluded to by supposing that the inflammation of the villous 
 coat of the stomach and intestines was incompatible with life, and the cessation of 
 ptyalism was the forerunner of that state of the system previous to death." 
 
 If the diaries of fatal cases of remittent fever, treated on the 
 mercurial plan, be carefully studied, it will be found that the 
 
 * " Transactions, Medical and Physical Society of Bombay." No. ix. p. 54, and 
 No. x. p. 88. 
 t lb. New Series. No. iii. p. 17. \ MSS. Reports. 
 
MERCURIAL TREATMENT CONDEMNED. 127 
 
 prominent facts are a free use of calomel, persistence of febrile 
 disturbance, and the non-induction of mercurial influence. 
 
 If, on the other hand, the diaries of recovered cases, treated 
 on the same system, be considered, then a free use of calomel 
 with coincidence of ptyalism and cessation of febrile disturbance 
 will be frequently observed. This coincidence, however, is some- 
 times only temporary, and followed by recurrence of fever and 
 cessation of ptyalism. 
 
 The difficulty of affecting the system with mercury during the 
 presence of high febrile excitement is acknowledged by all ; but 
 when ptyalism and cessation of fever concur, the advocate of mer- 
 curial treatment looks upon the former as the cause, the latter the 
 effect; and when there is coincidence of febrile recurrence and 
 cessation of ptyalism, then the latter is regarded as the cause, and 
 the former the effect. Such reasoning, however, is surely erroneous. 
 It is not an unusual circumstance, in remittent fevers treated in 
 their early stage with calomel, to observe, after the recurrence of 
 the fever has been prevented by quinine, slight mercurial action 
 on the second or third day ; though not more than a few grains of 
 calomel or blue pill, in combination with quinine, had been given 
 on these days. Under these circumstances the relation of events 
 is so evident that the question of antecedence and sequence is no 
 longer open for argument ; and surely in other instances in which 
 the only difference is that there has been no agency employed of 
 acknowledged power to prevent the return of fever, we ought to 
 recollect the natural tendency of the disease to remit, and after a 
 time to cease; and avoid the illogical position of attempting to 
 account for the same coincident phenomena by inverting the order 
 of causation. 
 
 For these reasons, then, an endeavour to induce mercurial 
 action in remittent fever appears to me erroneous in theory and 
 of no value in practice. But the question may not thus easily be 
 disposed of. Not only is the practice unsound in theory and of 
 no value, but it is contrary to all rational theory, and very injurious. 
 If it be true that prostration of vital actions and a deteriorated 
 state of the blood are very unfavourable conditions in remit- 
 tent fever, and that mercury deteriorates the blood and favours 
 prostration — on what principle of reasoning can it be maintained 
 that mercurial influence induced by the physician can have any 
 other than an injurious effect in remittent fever? I have, on 
 several occasions, pointed out the tendency of malarious fever to 
 produce a cachectic state of the system, and have endeavoured to 
 
128 REMITTENT FEVER. 
 
 inculcate the importance of guarding against the increase of this un- 
 favourable diathesis by medical treatment. To all who, within the 
 last twenty years, have had the opportunity of extensively observing 
 disease in India, in the various classes of the European community — 
 asthenia, dyspepsia, injured teeth, pains of sides and loins, palpita- 
 tion, habitually foul tongue, constipated bowels, pale alvine evacua- 
 tions, depressed spirits, and a sense of sinking at the epigastrium 
 ■ — all clearly traceable to the abuse of mercury — must be familiar 
 facts. 
 
 Such then are the reasons, drawn from my own sphere of obser- 
 vation, which have led me to the conclusion, that the induction of 
 mercurial influence in the treatment of malarious fever has been 
 a great and grievous error in therapeutics. I now inquire whether 
 other observers have held similar opinions. 
 
 Dr. Leonard Gillespie, in his observations on the diseases which 
 prevailed in a naval squadron on the Leeward Islands Station, be- 
 tween November 1794, and April 1796, at a time when salivation 
 by large doses of calomel was the system of treatment of disease in 
 full force in the West Indies, ably discusses the practice, and un- 
 equivocally condemns it. 
 
 Dr. Robert Jackson, in the year 1817, concludes his review of 
 the mercurial treatment of fever in the following words*: — 
 
 " Upon the whole, I venture to maintain, that if the results of what is termed 
 mercurial treatment in fever, and even in dysentery, particularly in British military 
 hospitals, where it has been most extensively employed, be candidly reviewed, the 
 high, or rather the extravagant, opinion which has been, and which is even now, en- 
 tertained of the salutary powers of that remedy, is not well supported. The advocates 
 of mercurial treatment generally assert that no one dies from fever after salivation is 
 fully established. The assertion is not altogether correct ; but even if it were, and if 
 it appear, on a reference to hospital case books, that there is one in three of the more 
 concentrated forms of endemic fever in which calomel, given alone or in combination 
 with opium, to the amount of a thousand grains or more, produces no increase of the 
 salivary secretion, consequently does not produce the effect which controls the fatal 
 tendency of the disease ; and further, if it appear, through the same channel of infor- 
 mation, that the same disease, when left to its own course or opposed by ordinary 
 means of treatment, does not destroy Life in more than one case in three, the most 
 prepossessed in favour of the remedy will not maintain that we gain anything by the 
 experiment ; and it is evident that, if we gain nothing certain, we lose time and 
 chances of gain from other means. But though the effect of mercury, even where it 
 docs produce an increased discharge of the salivary secretion, is not uniformly decisive 
 of the cure of fever; and though the action of the remedy, without artificial prepa- 
 ration, by bleeding or other means not implied in the plan of mercurial treatment, be 
 extremely uncertain, the practice still holds its ground, and it probably will maintain 
 it for many years (o come. It hangs on a specious delusion, viz. the expectation of 
 
 * "Sketch of the History and Cure of Febrile Diseases," &c. By Robert Jackson, 
 BID., 1817, p. 243. 
 
MERCURIAL TREATMENT CONDEMNED. 129 
 
 an effect considered as in some measure specific of cure. I abstain from further re- 
 mark on the subject, only adding, that if the ease be viewed without prepossession, 
 and if the hospital returns of the person* who first adopted the practice at Grenada 
 in the year 1793, and of those who have pursued a similar practice in the different 
 military hospitals in the "West Indies since that time, be admitted as documents of 
 effect, the arguments for the continuance of it do not appear lo he strong." 
 
 Dr. Copland observes: — 
 
 •• Mercury f, pushed so far as to affect the mouth, or to produce salivation, has been 
 considered Loth a prophylactic } and a cure for fever. I have tried to affect the 
 system in the most malignant forms of fever in warm climates without succeeding ; 
 and where I have succeeded there was every reason to believe that recovery would 
 have taken place nevertheless." 
 
 Mr. Martin, in the last edition of Dr. Johnson's work on tropical 
 diseases, after long and varied experience in India, says, " I have 
 also seldom had occasion to urge mercury to the degree of saliva- 
 tion, during the whole period of my service in India." 
 
 Dr. (xeddes, in his " Clinical illustrations of the diseases of 
 India," writing of eighty-seven cases of fever in the 1st Madras 
 European regiment, treated with mercury, concludes his remarks 
 with the following words § : — 
 
 '• The number of those altogether in whom the disease was stopped before the 
 affection of the mouth bj- mercury, amounted to 48 ; and of those in whom this cir- 
 cumstance took place after such an event to 28. From these facts, there is reason to 
 doubt whether the mouth becoming affected is not rather a conseqtience of the cessa- 
 tion of the fever than the latter a result of the system having come under the 
 influence of mercury; but in some chronic cases, where the contrary appeared to 
 occur, an increase of frequency of the pulse, and of feverish irritation in the remis- 
 sions, has been observed to take place in a gradual manner as the mercurial action 
 
 * Dr. Colin Chisholin is referred to by Dr. Jackson. 
 
 t " Medical Dictionary," vol. i. p. 928. 
 
 \ But the induction of mercurial influence has been looked upon as not only 
 curative of malarious fever, but as also preventive of the action of malaria, and has 
 been recommended as a prophylactic measure. It can hardly be necessary to observe, 
 that the relation between debility as a predisposing, and malaria as an exciting, cause 
 is well understood. It is irrational to suppose that debility caused by mercury can 
 differ in this respect frorn that induced in any other way. On this question Dr. Cop- 
 land remarks, " That mercury possesses no prophylactic influence against fevers has 
 been satisfactorily shown by several able writers, and proved by my own experience. 
 A person whose mouth was affected for the cure of syphilis was seized with malignant 
 remittent fever in Africa, in 1817, and came under my care soon after the attack. He 
 died a few days afterwards ; the most active treatment having failed in developing 
 vascular reaction and in supporting the vital powers. A nearly similar case is men- 
 tioned by Dr. Graves in his excellent lectures." — Dictionary, vol. i. p. 929. 
 
 Hunter, in his "Observations on the Diseases of the Army in Jamaica" (p. 287\ 
 writing of syphilis, says : " It is worth remarking that mercury had no effect upon the 
 constitution to render it less susceptible of fevers ; for persons under a course of that 
 medicine were seized with the remittent fever, which, however, did not appear to be 
 aggravated by the presence of the mercury in the body." 
 
 § Page 189. 
 
 K 
 
130 BEMITTENT FEVER. 
 
 Showed itself ; and this was considered to act by breaking in upon the habitual pro- 
 gress of the disease, which accordingly ceased to recur. In many instances, however, 
 after a short interval of freedom from its attacks, these have returned before the 
 affection of the mouth had entirely left the patient ; and otherwise, it will be seen 
 from the Table now alluded to, that 37 of those who had been under the influence of 
 mercury in the earlier months of the season had been seized with relapses before its 
 expiration. From these circumstances — combined with a consideration of the occa- 
 sional affection of the bowels, often amounting to a dysenteric state, produced by the 
 calomel ; and of what has been mentioned in speaking of the prognosis regarding the 
 lengthened sickness of the patient, in consequence of his sore mouth — the reader will 
 readily form an opinion of the relative value of mercury and quinine in putting a 
 stop to that tendency to febrile exacerbation which constitutes the main feature of the 
 remittent and intermittent fevers of the East." 
 
 The history of the mercurial treatment of fever in India may 
 now be briefly noticed. In the last quarter of the eighteenth cen- 
 tury, hepatic affections were treated in India by mercurial influence, 
 and Clark thought highly of a combination of calomel and opium 
 in allaying irritation of the bowels, and promoting their secretions 
 in malarious fevers ; but I am not aware that mercury had been 
 much given in fevers to the degree of producing salivation, before 
 it was used with this view, in Grenada in 1793, by Dr. Colin 
 Chisholm.* 
 
 The general introduction of this system of treatment into India 
 must be traced to Dr. James Johnson's work on Tropical Diseases, 
 first published in 1813.t 
 
 At this period there were, as authorities on the treatment of 
 remittent fever, Pringle, Cleghorn, and Jackson, who advocated 
 the use of blood-letting and other evacuants, with bark during the 
 
 * Page 110. 
 
 f Wade, whose work was published in 1791, is mentioned as one of the earliest 
 writers on Indian disease who recommended the mercurial treatment of fever, by Dr. 
 H. H. Goodeve, in his very interesting "Sketch of the Progress of European Medicine 
 in the East," published in April. 1837, in the " Quarterly Journal of the Medical and 
 Physical Society of Calcutta." This sketch fairly represents the opinions of Bontius, 
 Clark, Lind, and others ; but from the too great prominence given to the phraseology 
 of the time, it is evident that there was not a full appreciation of the merits of these 
 eminent men. Indeed, it could not lie otherwise, for at the time when Dr. Goodeve 
 wrote, medical opinion in regard to the treatment of tropical disease was in a very 
 vacillating state. I feel assured, however, that I do not go beyond my knowledge 
 of the present opinions and sentiments of the able author of this sketch — with whom 
 for a long series of years I have enjoyed the privilege and advantage of a free inter- 
 change of opinion on this and kindred subjects — when I say that were he now to 
 review the progress of European medicine in the East, the sketch woidd, in some 
 respects, evince a different spirit. No one more early than Dr. Goodeve became 
 satisfied qf the evils of an excessive depletory and mercurial treatment, and of the 
 advantages of quinine, in malarious fevers. No one, whether in medical practice or 
 in the diffusion of medical education in India, has been more liberal in his judgment 
 Of others, or has co-operated with them in a freer and a franker spirit. 
 
HISTORY OF THE MERCURIAL TREATMENT. 131 
 
 remissions. Clark and Lind, on the other hand, deriving their 
 experience from observation in Bengal, in 1762 and 1773, of 
 an adynamic type of the disease in seamen of scorbutic taint, 
 enjoined extreme caution in blood-letting, and recommended 
 a moderate use of purgatives, opiates, stimulants, and bark. 
 Moreover, in Cullen's "First Lines of the Practice of Physic," 
 there was open to the medical inquirer a philosophic statement of 
 the principles which should regulate the treatment of the differ- 
 ent forms and modifications of febrile disease. At this epoch Dr. 
 James Johnson, at an early period of his professional life, arrived 
 in the Hooghly in the month of September, after a short run of 
 little more than three months from England, in charge of a crew 
 untainted, we may presume, with scurvy. He adopted, as he 
 believed, Clark and Lind, as his practical guides, to the neglect, it 
 would appear, of all other authority and in forgetfulness of the 
 circumstances under which these excellent physicians had observed 
 the disease, and to which their system of treatment exclusively 
 applied. 
 
 Dr. Johnson * makes the following quotation from Dr. Clark : 
 "As soon as the intestinal tubes have been thoroughly cleansed, 
 the cure must entirely depend upon giving the Peruvian bark in 
 as large doses as the patient's stomach will bear, without paying 
 any regard to the remissions or exacerbations of the fever." He 
 then continues : " Such are the plain and easy instructions which 
 Dr. Clark and Lind have left for our guides in this fearful 
 endemic. They certainly are not apparently difficult to follow ; 
 and Heaven knows, I endeavoured, most religiously, to fulfil every 
 iota of their injunctions ; but with what success a single case will 
 show." 
 
 It is true that Clark recommends the use of bark in the 
 exacerbations, but it would have been just to that physician 
 had Dr. Johnson extended his quotation to the sentence which 
 immediately follows that which he has cited, viz. — " If the re- 
 missions be distinct, the bark, indeed, will have a more speedy 
 effect in subduing the fever ; but even if it become continual, by 
 a regular and steady perseverance in the medicine, it will be effec- 
 tually prevented from growing dangerous or malignant." f 
 
 It is evident from this sentence, as well as from a perusal of the 
 
 * " On the Influence of Tropical Climates." By James Johnson. London, IS 11, 
 p. 107. The italics are Dr. Johnson's. 
 
 f " Observations on the Diseases which prevail in long Voyages to hot Count riea 
 By John Clark, M.D. Second Edition, 1792, p. 184, vol. i. 
 
132 REMITTENT FEVEB. 
 
 cases recorded by Clark, that his practice was to give bark chiefly 
 in the remission ; but to use it also in the exacerbation, in those 
 cases which from the remittent had passed into the continued 
 type. 
 
 Lind is represented by Dr. Johnson as holding the same 
 opinion as Dr. Clark relative to the use of bark in the exacer- 
 bation. Such, however, does not appear to have been the case. 
 Dr. Lind of Windsor, the author, referred to, of a " Treatise on 
 the Putrid and Remitting Marsh Fever of Bengal," not only did not 
 give bark in the exacerbations, but not even in the first remission. 
 His words are : " For my part, I have always given the bark during 
 the second remission, as all my care during the first was to cleanse 
 the prima; vise. But it is to no purpose to give the bark till the 
 necessary purgations are over." * 
 
 I shall now quote that case in which Dr. Johnson believed that 
 he was religiously endeavouring to fulfil every iota of the injunc- 
 tions of Clark and Lind, and the ill success of which led him 
 to abandon the therapeutic principles of a long line of able 
 and observing men, and to promulgate a very different system of 
 practice : — 
 
 " A young man of good constitution, in the prime of life and health, had been 
 assisting, with several others, to navigate an Indiaman through the Hooghly. The 
 day after he returned he was seized with the usual symptoms of this fever. I did 
 not see him till the cold stage was past ; but the reaction was violent — the headache 
 intense, skin burning hot, great oppression about the praecordia, with quick hard 
 pulse, thirst, and nausea. An emetic was prescribed, and towards the close of its 
 operation discharged a quantity of ill-conditioned bile, both upwards and downwards : 
 soon after which a perspiration broke out, the febrile symptoms subsided, and a 
 remission, almost amounting to an intermission, followed. I now with an air of con- 
 fidence began to ' throw in ' the bark, quite sanguine in my expectations of soon 
 checking this formidable disease. But, alas ! my triumph was of short duration ; for 
 in a few hours the fever returned with increased violence, and attended with such 
 obstinate vomiting, that, although I tried to push on the bark through the paroxysm 
 by the aid of opium, effervescing draughts, &c, it was all fruitless ; for every dose 
 was rejected the moment it was swallowed, and I was forced to abandon the only 
 means by which I had hoped to curb the fury of the disease. The other methods 
 which I tried need not be enumerated ; they were temporising shifts, calculated, in 
 medical language, ' to obviate occasional symptoms.' 
 
 " The truth is, I knew not what to do; for the sudden and unexpected failure of 
 that medicine on which I was taught to depend, completely embarrassed me, and 
 before I could make up my mind to any feasible plan of treatment, my patient died 
 on the third day of his illness, perfectly yellow, vomiting to the last a dark fluid 
 resembling vitiated bile, and exhibiting an awful spectacle of the effects which a 
 Bengal fever is capable of producing in so short a period on a European in the vigour 
 of manhood." f 
 
 * Base 65. + Page m; of Edition of is 11. 
 
HISTORY OF THE MERCURIAL TREATMENT. 133 
 
 The body was examined after death, and Dr. Johnson found - - 
 
 " The liver so gorged, as it were, with blood that it actually fell to pieces on 
 handling it. Indeed, it appeared as if the greater number of the vessels had been 
 broken down, and almost the whole of the interior structure converted into a mass 
 of extravasation. The gall-bladder contained a small quantity of bile, in colour and 
 consistence resembling tar, and the ductus communis choledochus was so thickened 
 in its coats and contracted in its diameter that a probe could scarcely be passed into 
 it. Marks of incipient inflammation were visible in some parts of the small intes- 
 tines, and the internal surface of the stomach exhibited similar appearances. The 
 thorax was not examined, on account of the time taken up in getting at the brain. 
 Marks of turgescence, in the venous system of vessels particularly, were there quite 
 evident, and more than the usual quantity of lymph was found in the ventricles, but 
 no appearance of actual inflammation." 
 
 The narration of this case is followed by remarks on the unsuit- 
 able character of the treatment, on the uncertainty of medicine, 
 and the evils of being led by authority. 
 
 It is far from my desire to review in a critical spirit the practice 
 of one who, after a life of active usefulness, has passed away. Still 
 it is impossible to avoid observing, that a dispassionate considera- 
 tion of this case — upon which so much of the treatment of fever 
 in India for a quarter of a century has rested — and of the thera- 
 peutic principles of the best authorities in medicine of that day, 
 must lead to the conclusion that these principles were not rightly 
 appreciated or correctly applied by Dr. Johnson. To say nothing 
 of Pringle, Cleghorn, Cullen, and Jackson, I cannot suppose that 
 either Clark or Lind would have treated a case, even of the ady- 
 namic type, with which they were familiar, in the manner which 
 has just been detailed. Be that as it may, it is difficult to believe 
 that either of these observant and able men would have treated 
 remittent fever in a sthenic European after the fashion which has 
 been attributed to them. 
 
 After this first failure, Dr. Johnson treated his subsequent cases 
 by free blood-letting and alvine evacuations. But there were men 
 of the crew who, from various circumstances, did not bear deple- 
 tion so well as others. This led to treatment by induction of mer- 
 curial influence, by repeated doses — from five to ten grains — of 
 calomel " as the sine qua non in the medical treatment of this 
 fever as well as many other fevers in the East." * 
 
 Dr. Johnson's treatment of remittent fever consisted, then, in 
 free bloodletting and alvine evacuations, opium combined with 
 calomel f in large doses when the stomach was irritable, the 
 
 * " On the Influence of Tropical Climates," p. 110. 
 
 t The combination of calomel and opium — five grains of the former and one of the 
 latter — was highly thought of by Dr. Clark when the stomach was irritable, and aa 
 
 K 3 
 
134 REMITTENT FEVER. 
 
 induction of mercurial influence, with subsidiary measures, as 
 leeches and cold applications to the head — and neglect of the use 
 of bark. 
 
 It appears, then, that on the authority of a single case — the 
 first seen by a young naval medical officer in the Hooghly — the 
 principles in respect to the use of bark in remittent fever, laid 
 down from observations made in various countries and circum- 
 stances by Pringle, Cleghorn, the two Linds, Clark, Cullen and 
 Jackson, were ignored for a quarter of a century by the medical 
 profession in India; and, it maybe added, in tropical countries 
 generally. 
 
 As to the treatment recommended by Dr. Johnson, we are 
 left in ignorance of the amount of experience on which it was 
 based. There is no statement of the length of his stay in the 
 Hooghly, of the number of cases treated, or of the proportion of 
 recoveries. But of this we may be certain, that the experience of 
 a few months, in the crew of a single ship, could not be authority 
 sufficient for that subversion of medical doctrine and practice 
 which unfortunately resulted from it. 
 
 But, while we deplore this defection from sound principles, and 
 the evils to which it gave rise, we must not be unjust to its author. 
 
 Dr. Johnson did not appreciate the circumstances under which 
 remittent fever was observed by Clark and Lind. Nor have his 
 followers in this respect been just to him. 
 
 Dr. Johnson says *, " I now carried the evacuating plan with a 
 high hand, and with much better success than I expected. For- 
 tunately for my patients, a great majority of them were fresh from 
 Europe, and high in previous health and strength ; these recovered 
 wonderfully after bleeding and evacuations, though not always." 
 Again f : " The fear of debility and putrescency still paralyses the 
 arras of medical men in hot climates, notwithstanding the clearest 
 evidence in favour of general and local bleeding, particularly where 
 the subject is lately from Europe, and not broken down by the 
 climate." 
 
 Yet — notwithstanding these clear indications that a system of 
 treatment based at best on very limited experience, could only be 
 successfully followed in fresh Europeans high in previous health 
 
 favouring the subsequent action of milcl purgatives. It would have heen right on the 
 pari <>f Dr. Johnson, while condemning Dr. Clark, to have acknowledged the source 
 from which he probahly derived the calome] and opium part of Ids own system, 
 
 * Page 109. 
 
 t I'age 110. 
 
HISTORY OF THE MERCURIAL TREATMENT. 135 
 
 and strength, and not broken down Ly climate — the followers of 
 Dr. Johnson have applied the treatment to the long resident as 
 well as to the lately arrived, and to asthenic natives as well as to 
 sthenic Europeans. 
 
 But it is necessary to explain why I have now entered into 
 these details on a mode of practice at present generally disapproved 
 of, and one which its talented author had himself virtually 
 abandoned before the close of his long and useful career — as we 
 learn from the following observations written in 1841 : — 
 
 "It is necessary to observe, also, that the fevers, even of the same place, are not 
 of the same type in all years ; and consequently they require modifications of treat- 
 ment. The above was the nature of the fever on the banks of the Ganges thirty-five 
 years ago, and the general mode of treatment described was found most beneficial. I 
 have no doubt, however, that fevers in such places will often be effectually combated 
 by early depletion, especially purging, and then, when a remission takes place, by 
 administering bark, particularly the quinine, so as to prevent the return of the 
 paroxysms. Particular organs are to be guarded by local blood-letting and blister- 
 ing, while the glandular secretions of the chylopoietic viscera are to be kept in order 
 by appropriate doses of calomel or the quicksilver pill."* 
 
 My reasons for having enlarged on this subject are — 
 
 1. The importance of the lesson which it teaches. The cau- 
 tion which it enjoins against accepting new systems of treatment 
 without a careful examination of the evidence and the principles on 
 which they rest. The practice of medicine will never be free from 
 
 ^errors of this kind, unless all who exercise it give their minds to 
 patient observation and the study of principles, and are fully 
 impressed with the responsibility which it involves. 
 
 2. In the second number of the " Indian Annals of Medicine," f 
 there is a paper on " Tropical Fever and Dysentery " by Mr. Hare. 
 He speaks with much truth of the opinions of several of the older 
 physicians, and also treats of those historical details with which 
 we have just been engaged. 
 
 But in Mr. Hare's communication are the following remarks, 
 from which, after the opinions expressed in various parts of this 
 work, I need hardly say that I altogether dissent: — 
 
 " There cannot be a doubt, that if not calomel, yet certainly salivation, is an 
 antidote to malarious fever. The instant a patient's mouth is sore the fever leaves 
 him ; the mercury produces not the shghtest effect till then, but from that moment 
 the disease vanishes as if charmed; the change is from death to life, from extremity 
 of suffering to calm and comfort." J 
 
 * Page 113. t April, 1SJ4. 
 
 t " The Annals of Medicine," No. 2, pp. 4GS, 4G9. 
 
 K 4 
 
136 REMITTENT FEVEE. 
 
 Again : — 
 
 '• Numerous instances, too, of the safety which salivation gives from the effects of 
 the malarious poison may he found in Dr. Johnson's hook, viz. patients salivated for 
 syphilis sleeping with impunity in places which were fatal to every one of their com- 
 panions; and also many cases on record of officers in India passing in a state of 
 salivation hy dak unharmed through the most deadly jungles." 
 
 It is this revival at the present day of doctrines from whose evil 
 influence the practice of medicine has too slowly emerged, that has 
 induced me to deviate from the course which I pursued in 1843, 
 when writing on this disease.* Then I assumed that the necessity 
 of discussing the question of the treatment of remittent fever by 
 mercurial salivation had passed awa} 7 . 
 
 The supposed sedative influence of large doses of calomel on 
 the mucous membrane of the stomach, first assumed by Sir James 
 Annesley, and then adopted by many writers on materia medica 
 and on tropical disease, may now be shortly noticed. 
 
 Annesley's opinion was founded on the results of some experi- 
 ments on dogs. In the year 1841 Mr, Murray, at the time surgeon 
 of the convalescent station on the Mahubuleshwur Hills, and well 
 known to his professional brethren in India as a zealous and suc- 
 cessful cultivator of medical science, published in the fourth 
 number of the " Transactions of the Medical and Physical Society 
 of Bombay" a paper entitled "Experiments illustrative of the 
 physiological effects of calomel on the gastro-intestinal mucous^ 
 membrane of dogs," which proved that Annesley's conclusion was 
 erroneous — and that large doses of calomel increased the vas- 
 cularity and secretions of the gastric as well as of the intestinal 
 mucous membrane. 
 
 But the question is now one of comparatively little importance, 
 for the latest investigations seem to show that only a very small 
 portion of the insoluble preparations of mercury — blue-pill and 
 calomel — are dissolved by the gastric and enteric secretions and 
 absorbed. Dr. Headland thus alludes to the subject f : — 
 
 "Some have, without sufficient reason, assumed calomel to he a sedative when 
 given in large doses. To act in this way, very large doses have heen recommended, 
 and given in fever and malignant cholera. Calomel is naturally an insoluble sub- 
 stance ; and in these cases the function of absorption is at the very lowest ehh ; so 
 that it is probable that the large doses are often left unabsorbed, and pass out of the 
 bowels very much as they entered, producing scarcely any more effect than so much 
 chalk mixture." — Page 391. 
 
 * "Transactions, Medical and Physical Society of Bombay," No. 6, p. 199. 
 t "An Essay on the Action of Medicines."' V>y F. W. Headland, M.D. &c. 
 Third Edition, 1859, 
 
COLD AFFUSION — WET-SHEET PACKING. 137 
 
 Again : — 
 
 "Their action does not in reality depend much on the dose given. This may bo 
 often increased with little effect. Until the amount of solvent matter in the stomach 
 or bowels is increased, the amount of mercury taken into the system will be much the 
 same. In fevers and cholera, when the dissolving power is little, and the function of 
 absorption at a low ebb, calomel may often be poured in with no effect at all. As the 
 patient recovers, a dangerous salivation may occur ; and in some idiosyncrasies, some 
 peculiarly susceptible states of the absorbent surfaces, one to two grains of calomel in 
 the stomach, or one drachm of mercurial ointment rubbed into the skin may be followed 
 by violent mercurialism, or produce necrosis of the jaw and death." — Page 381. 
 
 Gold Affusion — in cases and stages of the paroxysm in which 
 the skin is dry and steadily above the natural temperature, and the 
 pulse of good volume — is of great use, by lessening vascular ex- 
 citement, and, when the head is the organ affected, alleviating 
 the headache, and either doing away with the necessity of applying 
 leeches, or reducing considerably the number required. But it is 
 contra-indicated in fever, as in other diseases, when there is com- 
 plication of pectoral affection, and also probably when gastro-enteric 
 symptoms are present. 
 
 When cold affusion is doubtful, or when the suitable stage has 
 passed, tepid sponging may be had recourse to with very good 
 effect whenever the skin is above the natural temperature. And in 
 all cases of remittent fever extending to two or three paroxysms, in 
 which the vascular excitement during the stage of exacerbation is 
 considerable, or in which the head is affected, the scalp should be 
 shaved, and cold assiduously applied. 
 
 Wet-Sheet Packing. — Within the last few years the treatment 
 of remittent fever and other acute forms of disease by this 
 method has at different times been brought under my notice in 
 India ; and it has seemed to me that injury to medical practice 
 is not unlikely to result from the routine and injudicious use of 
 the wet -sheet. 
 
 I have tried it in a few cases, and have watched its application 
 by others in a greater number, with the following results: — 
 
 1. In the conditions which justify cold affusion, it is possible 
 enough that the wet sheet, renewed every ten minutes, or quarter 
 of an hour, for two or three times, may be a convenient and effective 
 manner of reducing the temperature of the body; but on this point 
 I do not speak from experience. Should there be tendency to hepatic 
 or splenic congestion, then the wet sheet used in the manner above 
 stated is likely to do harm by increasing the congestion : this state- 
 ment is made from personal observation. 
 
 2. The treatment of the height of the exacerbation, by wet- 
 
138 REMITTENT FEVER. 
 
 sheet packing after the manner of the hydropathic system, has been 
 to my knowledge adopted in some cases. Without denying that 
 the moisture of the surface of the body may somewhat modify 
 the action, there can be little doubt that this mode of treating 
 fever is a retrograde movement towards that sweating system 
 which, nearly two centuries ago, the genius of Sydenham 
 banished from the practice of medicine. But even if it can be 
 shown that wet-sheet packing is useful in lessening the exacerba- 
 tion of remittent fever, surely it is well understood that this is not 
 a leading indication in the cure of the disease ; and that means 
 which merely aim at this can never occupy other than a subsidiary 
 position. 
 
 3. If wet-sheet packing be used towards the close of an exacer- 
 bation, when the circumstances have been such as to render undue 
 collapse at this period an event not improbable, then there can be 
 no doubt that the increased diaphoresis caused by the wet sheet 
 will increase exhaustion, and may produce it when it otherwise 
 would not have occurred. I have never witnessed this effect from 
 the wet sheet in remittent fever ; but I have observed it in the 
 treatment of tetanus — a disease in which a tendency to death 
 by failure of the action of the heart is also well marked. In the 
 case alluded to, death was undoubtedly hastened by this proceeding. 
 
 4. A routine system of wet-sheet packing, by directing the 
 chief curative means to the reduction of febrile heat, must tend to 
 withdraw attention from the sedulous use of those methods by 
 which local inflammation or other disease may be detected. It is 
 opposed to careful and accurate diagnosis. Then in regard to the 
 diaphoretic action of the wet sheet in the treatment of disease, 
 there can be no question of the advantage of making the skin per- 
 form its share of increased elimination when this becomes an 
 indication of cure; but can there be a greater error in practice 
 than that of acting on the skin alone, and neglecting the other 
 important excretory organs ? 
 
 These are not theoretic objections. I have witnessed the diag- 
 nosis of local inflammation overlooked, and the symptomatic fever 
 treated by wet sheets to the neglect of the inflammation — under 
 circumstances in which I felt convinced that treatment conducted 
 on generally received principles, and by ordinary means, would 
 have led to a different course and termination of the disease. 
 
 On the Use of Purgatives, — Of the necessity in remittent fever 
 of the moderate use of purgatives, more or less active according to 
 the circumstances of particular cases, no question can arise; but the 
 
USE OF TURGATIVES — TREATMENT. 1.'59 
 
 bad effect of keeping up a constant state of irritation of the intes- 
 tinal lining is equally certain. 
 
 After the first two or three flays, if the secretions dependent 
 directly or indirectly on the portal system have been freely solicited, 
 further purging is unnecessary. It will be sufficient that the bowels 
 are moved once gently in the course of twenty-four hours. The 
 effect of the opposite and too common practice is to irritate the 
 mucous membrane, to hurry on and very much aggravate the ady- 
 namic symptoms in protracted cases; and, in recoveries, to leave 
 during the convalescence a deranged condition of the bowels, with 
 a decided proclivity to attacks of dysentery, more especially in the 
 cold season. 
 
 Whether purgatives should be given during the exacerbation or 
 the remission of remittent fever, is an important point to determine. 
 In the Medico-Topographical Report of the Presidency division of 
 the army, published by the Medical Board of Madras, a very de- 
 cided opinion on this point is expressed by the surgeon of the Pre- 
 sidency General Hospital. He is opposed to the use of purgatives 
 in the exacerbation, because they do not act readily, and they tend 
 to perpetuate the exacerbation and interfere with the access of the 
 remission. There is much practical truth in this remark, but it is 
 hardly sufficiently precise and discriminating. 
 
 There can be no doubt that a state of febrile disturbance is ad- 
 verse to the action of all remedies, purgatives included. It is also 
 true that the too free use of purgatives favours the continuance 
 of the exacerbation and interferes with the remission, partly from 
 undue evacuation, and partly from irritation of the intestinal 
 mucous lining. This influence is most likely to be exercised in 
 asthenic constitutions. 
 
 In the fevers of sthenic individuals, however, evacuation by pur- 
 gatives is adopted with the view of moderating the excitement of 
 the exacerbation ; and if this be one of the indications for their use, 
 it is evident that it can only be carried into effect during the exa- 
 cerbation itself. But in following out the other indications for 
 which purgatives are given, as removing constipation, correcting 
 deranged secretions, or eliminating morbid matter from the blood, 
 the remission is the suitable period for their exhibition. They 
 should be administered in moderate doses early in the remission ; 
 and probably there is no better method than by combination with 
 the first doses of quinine in the manner already recommended. 
 
 The imperfect action of purgatives in the exacerbation of fever 
 is partly due to defective secretion and partly to impaired irrita- 
 
140 REMITTENT FBYER. 
 
 bility of the intestinal muscular fibre. This latter condition is 
 sometimes made evident by the retention of enemata when used 
 in the exacerbation : this circumstance is known to me from my 
 own observation; and Gillespie, in his remarks on the diseases 
 of the Leeward Islands station, notes the retention of enemata 
 during the exacerbation, and their action during the remission. * 
 
 The practice of Cleghorn, as explained in his observations on the 
 epidemical diseases in Minorca, was to give purgatives in the 
 morning with the first remission. He attaches importance to their 
 use at this stage, but does not allude to their exhibition in the 
 exacerbation. 
 
 Balfour recommends purgatives at the commencement of the 
 remission, or, when this is not well marked, at the periods when the 
 remissions usually occur. He says : " I have learnt by experience 
 that all laxative and purgative medicines, as well as injections, are 
 very uncertain in their operation, and generally disappoint so long 
 as any degree of fever is present." f 
 
 E nictics. — The occasional utility of emetics in the early stage 
 of fever, and the circumstances for which they are suitable, have 
 been already explained. 
 
 The treatment of fevers by a solution of tartar emetic and 
 Epsom salts in frequentty-repeated doses, to the causing of free 
 vomiting and purging, is unsuited to febrile disease as occurring in 
 Bombay, and as a routine system of practice must always be 
 hazardous. Even in the quotidian and ephemeral fevers of more 
 phlogistic type, in the Deccan, in well-conditioned Europeans, I 
 have witnessed an alarming state of collapse brought on by this 
 mode of treatment. It is not disputed that many cases of fever, 
 thus managed, recover well ; but they must be selected with care, 
 for in every epidemic of tropical fever there occur many cases for 
 which this kind of treatment is not only unsuited, but also very 
 dangerous. 
 
 Blisters applied with the intention of controlling local ca- 
 pillary derangement when the stage appropriate for topical blood- 
 letting has passed have already been adverted to; and I would 
 only here repeat what has already been previously stated, that 
 when blisters are used in remittent fever the stage of remission is 
 the suitable time. 
 
 On the Use of Opiates. — In my remarks on the treatment of 
 
 * Page 73. 
 
 f " Collection of Treatises on the Effects of Sol-lunar Influence in Fevers." By 
 Francis Balfour, M.D., late President Medical Board, Bengal. First Edition, 1816. 
 
USE OF OriATES — TREATMENT. 141 
 
 ordinary remittent fever the circumstances in which an opiate often 
 acts with advantage, and the precautions which should be kept in 
 view, have been explained. At the period when this practice was 
 followed by me in the European General Hospital, I was not aware 
 that Lind * had given opium still more freely and with less pre- 
 caution in the hot stage of intermittent fever. His belief was, that, 
 when administered early in the attack, it shortened the duration 
 of the hot stage, and favoured the access of the third stage and of 
 the intermission. He did not give opium when delirium was pre- 
 sent, but considered that headache was no contra-indication to its 
 use. 
 
 Whether the favourable opinion entertained by this high author- 
 ity on tropical fevers, of the beneficial effects of this free use of 
 opium, be just or not, I am unable to judge from experience. As 
 already explained, I have always, before exhibiting opiates in the 
 hot stage of fever, had recourse to certain precautionary measures 
 for reducing general and cerebral vascular action : these I still think 
 must be very expedient. But, whatever view be taken of Lind's 
 opinions, there are certainly other conditions of fever, in some 
 respects analogous, in which a full dose of opium cannot be 
 given without much hazard. I allude to its use after a lengthened 
 period of restlessness, in which the skin is not steadily warm or 
 rather is coldish, and in which the pulse is frequent and feeble. 
 This state occurs either in cases which have been for some time 
 protracted, or towards the end of a paroxysm. These symptoms 
 indicate that the nervous influence on the organs of circulation is 
 failing, and the sedative action of a full opiate, under these cir- 
 cumstances, is apt f to increase the state of collapse, to mask the 
 degree in which it exists, and to hurry on coma and death. Such 
 cases should be treated by the assiduous use of stimulants. 
 
 Again, when in the remittent fevers of the intemperate, there 
 exist delirium and tremors with slight febrile heat and a pulse fre- 
 quent and compressible, there is — in consequence of the resem- 
 blance of these symptoms to those of delirium tremens, and of the 
 erroneous views entertained on the treatment of this latter disease 
 — often a great temptation to give a full opiate to overcome the 
 delirium and to cause sleep. This is, assuredly, in general, a most 
 hazardous and not unfrequently a fatal proceeding, as is illustrated 
 by cases 23, 24, 25. It is very probable that in the treatment of 
 
 * "Lind's Essay on Diseases incidental to Europeans in Hot Climates," 1777, 
 p. 343. 
 
 f Case No. 9 is an illustration. 
 
142 REMITTENT FEVER. 
 
 such cases the exhibition of quarter -grain doses of tartar-emetic, 
 with five minims of tincture of opium, on the principles advocated 
 by Dr. Graves, in the management of some forms of delirium in 
 European continued fever, may prove appropriate and useful. 
 
 The use of opium in remittent fever demands our careful 
 study, for the cases which have been now specially alluded to 
 are not the only instances of error which I have myself witnessed; 
 and others have been noted by me in the perusal of the diaries of 
 cases -which had not come under nrv own observation. These 
 circumstances have fixed my attention on this question of prac- 
 tice, and after much reflection it has seemed to me that the 
 following are the principles which should be kept in view in giving 
 full opiates in remittent fever. 
 
 1. Opium can be used with safety only in the restlessness of the 
 early stage of remittent fever, when there are not symptoms of 
 marked determination to the brain, and when the pulse is of good 
 volume, and soft, and not much above 100. 
 
 2. When remittent fever has persisted for six or seven daj*s, 
 each recurring exacerbation is attended with increasing frequency 
 and decreasing strength of the pulse. This depression of the 
 heart's action is most observable towards the close of the paroxysm, 
 and is not unfrequently attended with general restlessness, and then 
 the temptation to give an opiate is often great, in the hope that sleep 
 and its consequent advantages may be secured ; but, under these 
 circumstances, the proceeding is always dangerous. A pulse that 
 ranges towards 120, or one not so frequent, but feeble and compres- 
 sible ; or still more, a pulse that has the frequency of 120, and is, 
 at the same time, feeble and compressible, are conditions which 
 may be held to contra-indicate the use of a full opiate — even 
 though they should not be associated with headache, wandering, 
 delirium, or tendency to drowsiness. Nor is it difficult to under- 
 stand why this should be. These conditions of the pulse indicate 
 that the tendency to death is by syncope — a tendency sure to be 
 most marked towards the close of the paroxysm, and to increase 
 with each returning exacerbation of fever. In this depressed state of 
 the heart's action, the functions of the brain also become impaired, 
 and, under the influence of a full opiate, are not unlikely to be sus- 
 pended ; in other words, the opium is apt to induce coma, and its 
 sedative influence on the brain, acting through the nervous system, 
 still further depresses the action of the heart; and thus, under these 
 circumstances, an opiate, injudiciously given, favours death both in 
 Hie way of syncope and coma. 
 
USE OF QUININE — TREATMENT. 143 
 
 3. As yet no derangement of the brain itself has been assumed. 
 But in a great proportion of cases of remittent fever, of six or seven 
 days' duration, the earlier exacerbations are marked by flushing 
 and headache, the later ones by slight wandering or tendency to 
 drowsiness. This condition of the cerebral functions, whatever the 
 state of the pulse may be, contra-indicates the use of opium; for 
 in such cases the tendency to death is by coma. If the opiate be 
 given at the close of the earlier paroxysms, it may only increase the 
 restlessness ; but if it be given at the close of the later paroxysms, 
 when wandering or tendency to drowsiness is present, it will most 
 surely expedite the supervention of coma, and ought to be most 
 scrupulously abstained from. 
 
 4. But in those cases of remittent fever in which the wander- 
 ing delirium, or drowsiness of the later paroxysms shows a ten- 
 dency to death by coma, there is also, most generally speaking, a 
 frequent and failing pulse. Whenever an exacerbation of remittent 
 fever which has been attended with wandering delirium, or a 
 tendency to drowsiness, terminates with a quick and feeble pulse, 
 it may be inferred with tolerable certainty that death by coma is 
 not far distant, is only to be warded off by the most judicious 
 management, and is most certain to be hurried on if we commit the 
 grievous error of attempting to lessen the delirium and restlessness 
 by the exhibition of opium. To conclude, then, whenever in re- 
 mittent fever the pulse is towards 120, feeble and compressible, 
 and whenever there is wandering delirium, or slight drowsiness, 
 the exhibition of a full opiate is a measure of danger, more parti- 
 cularly towards the close of a febrile exacerbation. In other words, 
 whenever in remittent fever the tendency to death by asthenia 
 or by coma is well marked *, a full opiate will expedite the fatal 
 result. 
 
 On the Use of Qui nine. — The manner in which quinine has 
 been used by me in the treatment of intermittent and remittent 
 fever has already been fully detailed. 
 
 On investigation it is evident that the principles inculcated 
 differ little from those of the older writers, chiefly the Linds f, 
 Cleghorn, and Balfour, in respect to bark. 
 
 * I need hardly observe that, in these remarks, I refer exclusively to opiates given 
 with the intention of, and in doses calculated to produce the soporific action of the 
 drug. "Whether opiates given in small doses, with a view to their stimulant effects, 
 may or may not be admissible in some of the states of fever adverted to by me, is a 
 question altogether apart from my present subject, and one in regard to which I am 
 unable to express any opinion from experience. 
 
 f I may here state that there are two Dr. Janres Linds; one of Haslar Hospital, 
 
144 REMITTENT FEYEK. 
 
 Cleghorn remarks : — 
 
 " Inflammations of the abdominal viscera are likewise natural effects of tertian 
 fevers. For we find that they often come on little by little, and increase with 
 every paroxysm till at last they end in a gangrene. "Whereas the cortex, by bringing 
 the fever to a speedy conclusion, impedes the further progress of the inflammation, so 
 that it afterwards goes off gradually of its own accord ; as I have had occasion to 
 observe in a multitude of instances, where acute fixed pains, tension, and other 
 symptoms made the nature of the disease too plain to be doubted." 
 
 Again : — 
 
 " Upon the whole I am convinced that the unhappy metastases, which some have 
 observed to follow the use of the bark, are exceeding rare, and ought rather to be 
 ascribed to other causes than to this medicine. And I will venture to affirm that 
 more bad consequences ensue from giving it too late than too soon. Prostration of the 
 strength, sudden death, or the most obstinate chronic diseases, if the sick recover, 
 being the usual effects of delay. Whereas the worst that commonly happens from the 
 too early use of it is that it does not at once restrain the paroxysms, like a charm 
 without any sensible evacuation as it frequently does when given after the fever has 
 arrived naturally to its height, and begins to decline of its own accord." * 
 
 Balfour's principles, in respect to the use of bark, are, on the 
 whole, practical and sound. He advocates evacuants in the first 
 exacerbation, and then gives bark in powder freely, increasing the 
 retaining power of the stomach by opium. He prefers the inter- 
 mission and remission, but does not scruple to use it under some 
 circumstances in the exacerbation. His words are : " This becomes 
 absolutely necessary when you happen to be called too late, for 
 after the third or fourth day the fits are protracted so long as to 
 run into one another ; and when this is the case, whoever waits for 
 complete remission will find himself wofully disappointed." f He 
 recognises cases, however, in which reaction is high, remissions 
 short, evacuations more required, and bark less. He insists 
 upon bark being of as great importance in remittents as in inter- 
 mittents. " All the arguments," he observes, " I have been 
 advancing in favour of an early exhibition of the bark in inter- 
 mittents are equally applicable in the case of remittents, whether 
 attended or not with symptoms of obstruction. And as these 
 disorders are more rapid in their progress, and more dangerous, 
 so is the necessity of this practice in proportion more urgent." i 
 After stating that a complicating hepatitis, or other inflammation 
 in intermittent and remittent fever, is to be met by venesection, 
 evacuants and blisters, he adds : " If it be not likely to stop 
 
 who writes on Bcurvy and diseases incidental to Europeans in hot climates: the 
 other, Dr. Jam.- Lind, of Windsor, who writes on putrid and remitting marsh fever of 
 I 
 * "Observations on the Epidemical Diseasi in Minorca, from 1714 to 1749." By 
 
 Clegl orn, pp. 223 and 225. 
 , ;;, I Page 39, 
 
USE OF QUININE — TREATMENT. 145 
 
 by prosecuting this plan, the bark is to be given without hesitation, 
 for in all the partial determinations I have met with, I have ever 
 found the fever do much more harm in one fit than all the bark 
 that is necessary to stop its return." 
 
 The following are the rules laid down by Cullen : — ■ * 
 
 " 1. That the bark may be employed with safety at any period of intermittent 
 fevers, providing that, at the same time, there be neither a phlogistic diathesis pre- 
 vailing in the system, nor any considerable or fixed congestion present in the abdo- 
 minal viscera. 
 
 "2. The proper time for exhibiting the bark in intermittent fevers, is during the 
 time of intermission ; and where intermissions are to be expected, it is to be abstained 
 from in the time of paroxysms. 
 
 " 3. In remittents, though uo entire apyrexia occurs, the bark may be given during 
 the remissions; and it shoidd be given, even though the remissions be considerable, 
 if, from the known nature of the epidemic, intermissions or considerable remissions 
 are not to be so soon expected, and that great danger is apprehended from repeated 
 exacerbations. 
 
 " 4. In the case of genuine intermittents, while a due quantity of bark is to be em- 
 ployed, the exhibition of it ought to be brought as near to the time of accession as the 
 condition of the patient's stomach will allow. 
 
 '• 5. In general, in all cases of intermittents, it is not sufficient that the recurrence 
 of paroxysms be stopped for once by the use of the bark ; a relapse is commonly to be 
 expected, and should be prevented by the exhibition of the bark, repeated at proper 
 intervals." 
 
 When we recollect the difficulties with which the older physi- 
 cians had to contend in the exhibition of the crude bark, we cannot 
 sufficiently admire the ingenuity with which they endeavoured to 
 overcome them, and the constancy with which they adhered to 
 those sound principles of therapeutics which the means at their 
 command enabled them so inadequately to apply. The great 
 advantage which the modern physician enjoys, is simply this, that 
 he is able by means of quinine to carry out those same princij^les 
 more easily, completely, and safely. 
 
 Dr. Greddes was, at an early period (1828), instrumental in 
 establishing the use of quinine in India. In his later work 
 published in 1846f, there are valuable practical suggestions on the 
 use of quinine in fever, which well deserve attentive consideration. 
 They are too long for insertion here, but I cannot deny myself the 
 satisfaction of quoting that part of Dr. Geddes' remarks which 
 relates to the exhibition of quinine in complicated cases. 
 
 " The exhibition of quinine," he writes {, " can go on along with that of any remedy 
 for attendant symptoms ; and, inasmuch as the latter may depend upon or be aggra- 
 vated by tlie febrile accession, this medicine must be considered as an auxiliary to any 
 
 * Thomson's Edition, vol. i. p. 673. 
 
 t " Clinical Illustrations of the Diseases of India." By "William Greddes, M.D., 
 p. 175. + Ibid. p. 176. 
 
 L 
 
14G EEMITTENT FEVEK. 
 
 remedial means, even of a supposed discordant nature, which may be employed for 
 the relief of such symptoms. Thus quinine has been combined with the treatment 
 suitable to inflammatory, dysenteric, and other affections; and by preventing the 
 increased febrile action of the paroxysmal disease, it has tended, in a material degree, 
 to the diminution and ultimate removal of all the accompanying morbid phenomena." 
 
 Dr. Haspel *, in his treatise on the diseases of Algeria, inculcates 
 the same principles on the use of quinine in complicated cases of 
 remittent fever. 
 
 In the year 1851 the treatment of Bengal remittent fever with 
 scruple doses of quinine repeated several times during the height 
 of the exacerbation, was advocated by Mr. Hare of the Bengal 
 Z\Iedical Service. The subject attracted considerable attention at 
 the time, and was much discussed. The tendency of the system is 
 to favour superficial clinical observation, as is evident in the follow- 
 ing extract from Mr. Hare's Eeport : — f 
 
 " I thus treated 421 cases in all of Bengal fever, and during the experiment some 
 remarkable facts were observed. My orders to my apothecary in both wards were to 
 give scruple doses of quinine to eTery patient with symptoms of fever, from the 
 very first moment of admission, and they often thus got forty grains of quinine before 
 I saw tkem. During part of the year, viz., March, April, and May, small-pox and 
 measles raged like an epidemic in Calcutta. Numbers of these patients in their 
 early stages, before the appearance of any eruption, were sent to my ward as fever 
 and were treated as the rest with huge doses of quinine, sometimes for 
 thirty-six hours before I coidd detect their disease. Almost all these cases termi- 
 nated fatally. Latterly, however, I was able to avoid these errors, by watching the 
 effect of the first dose of quinine. For in cases not malarious it invariably caused 
 great uneasiness, without any benefit to the general symptoms. Moreover, deafness 
 and singing in the ears were very quickly induced ; whereas in malarious fever, with 
 the same ardent symptoms, the quantity of quinine taken without producing any 
 cinchonism was often extraordinary, and so far from uneasiness, it seemed always to 
 give relief, and the febrile symptoms yielded rapidly under its use." 
 
 We may, with Balfour, admit, that when the exacerbations so 
 run into each another that the remissions are hardly observed, 
 quinine may be given with care at the periods which, in the ordi- 
 nary course of the disease, are those of remission. 
 
 The question of the free use of quinine in the exacerbations of 
 remittent fever is so important, that no apology is necessary for 
 .submitting the reflections which its consideration has suggested 
 to me. 
 
 1. There is no evidence that quinine has the power of dimin- 
 ishing existing febrile excitement in the manner of evacuants and 
 cold. The disturbed action of the heart and nervous system, 
 de n i bed by Briquet $ as resulting from large doses of quinine, 
 
 * " Maladies de l'Algerie," vol. ii. pp. 176, 184. 
 
 f " The Indian Annals of Medical Science," No. 2, p. -17-1. 
 
 | " Mi dical Times and Gazette," .May and June, 18o<5; " Indian Annals of Medical 
 " vol. iii. p, 281 
 
USE OF QUININE — TREATMENT. 147 
 
 resembles that from hydrocyanic acid ; and it cannot he safe in 
 therapeutics to produce" such disturbance of these important 
 organs. 
 
 2. When the action of a remedy is distinct in its nature, and 
 opposed to that of a morbific cause, it is a therapeutic law that 
 such remedy will be more effective before the action of the 
 morbific influence is in full force. For example : an anodyne, in 
 anticipation of pain, an anti-spasmodic in anticipation of a par- 
 oxysm of asthma, a soporific in anticipation of a season of restless- 
 ness, are more certainly effective than when postponed till these 
 several derangements are in full force: in the latter case they 
 often fail. Anti-periodics are so called because their peculiar 
 action is unquestionably of this character. They are comparatively 
 powerless if not given to anticipate derangement, as appears in 
 intermittent fever and neuralgia : why .should it be otherwise in 
 remittent fever? 
 
 3. Admitting that quinine in the exacerbation may be benefi- 
 cial rather than otherwise, still we know that the greater the febrile 
 disturbance, the less likely the action of remedies which require 
 to be previously absorbed and assimilated. The exacerbation must 
 therefore be the period least suited for ensuring their action, and 
 if not then injurious they are at best in a great measure useless, 
 because necessarily inert. 
 
 4. That quinine has no power of directly reducing febrile 
 excitement is clear from its inutility in continued fever, symptoma- 
 tic fever, and the eruptive fevers : why should it be otherwise in 
 the exacerbation of remittent fever ? 
 
 5. Febrile disturbance in zymotic continued fevers may be in- 
 creased by injudicious and moderated by judicious management: 
 increased by stimulants, heat, imperfect ventilation, and mode- 
 rated by evacuants, cool and pure air, sponging, affusion, and the 
 wet sheet. It is of as much, if not more, importance to atteud 
 to this indication in remittent fever, not only on account of 
 the reaction and the immediate danger to important organs, but 
 also because it favours an early and more complete remission — that 
 is, brings about the opportunity of giving with good effect — quinine 
 — the agent most potent in the cure of the disease. 
 
 6. By administering quinine in the exacerbation, we give it at a 
 time least appropriate for its peculiar action, and when its action, 
 if any, is as likely to be injurious as useful. Moreover, attention 
 thus misdirected tends to induce neglect of those means for re- 
 ducing febrile excitement, — applicable to all types of fever, — 
 
 L 2 
 
148 REMITTENT FETEB. 
 
 and which are additionally useful in remittents, because they favour 
 the access of a distinct remission. 
 
 7. Under wavering principles the appropriate treatment of the 
 exacerbation is liable to be neglected. The difficulty seems to be 
 in keeping clearly before the mind, that the principles for the 
 exacerbation are distinct from those for the remission : that both 
 are important, and require to be modified in particular cases, but 
 should never be confounded and transposed. 
 
 8. We cannot, with certainty, distinguish remittent fever, first 
 seen during the exacerbation, from continued fever, or the ini- 
 tiatory stage of an eruptive fever, or that type compounded of 
 remittent and common continued fever — for all of which large 
 doses of quinine are unquestionably unsuitable. 
 
 9. I know, from clinical experience, that there are febrile states 
 in which quinine is injurious, and others in which large doses do 
 harm, and small ones good. All that we practically know of the 
 action of anti-periodics is, that when given, at seasons of subsidence 
 of deranged action, in diseases in which there are remissions and 
 exacerbations, they are efficacious ; that the dose varies, that it 
 ought to be sufficient to prevent the recurrence of the derange- 
 ment, but not to cause its own abnormal actions. If we use these 
 agents at other periods of disease, aud with other views, we are 
 misapplying remedies, and acting with needless empiricism. 
 
 1 0. The indications of treatment in remittent fever are three, 
 and each has its own appropriate means. 1. To control the ex- 
 citement and complications of the exacerbation. 2. To act in 
 the remission so as to prevent a recurrence of the exacerbation. 
 3. To ward off exhaustion by the timely use of stimulants and 
 nourishment.* 
 
 I would, in conclusion, remark, that my opinions respecting 
 quinine are the result of clinical observation, and were formed 
 irrespective of those of other observers. This statement (and a 
 similar one might be made relative to my opinions on the mer- 
 curial treatment of fever) is advanced simply that the authority 
 of my own investigations may be added to that of others who, 
 
 fVa ''.','•- fever drops have at times acquired a reputation in parts of India. 
 
 In L 844, when attached to the European General Hospital, eleven bottles were tried 
 
 In one or two of the cases there was a decided sudorific action from the 
 
 and the febrile paroxysm seemed to 1»' shortened, and did not recur for 
 
 a cure i [n I here \i is no sudorific 
 
 and the fever was in no its use. In 
 
 fever v i becked for (lamination oi the 
 
 Btomach was excited. From I drew the conclusion that "Warburg's drops 
 
 ii addition of very little value to the means which we already possess of con- 
 
THE ITvOPKYLACTIC USE OF QUINIHE. 149 
 
 through the same process, have arrived at similar and independent 
 conclusions. 
 
 On the prophylactic use of Quinine. — The prevention of inter- 
 mittent and remittent fever in malarious districts by the daily use 
 of a small quantity of quinine is an important consideration, but 
 the evidence in its favour is as yet neither extensive nor conclusive. 
 
 There is no want of instances which are supposed to prove this^ 
 prophylactic power, but they are generally deficient in some of the 
 conditions essential in experiments of this nature. For example : 
 detachments of the 18th Eoyal Irish, the 92nd Highlanders, the 
 3rd Dragoon Guards, with the 4th troop Bombay Horse Artillery 
 and native details, were engaged on field service in the latter half 
 of Xovember and beginning of December, 1858, in the jungly 
 tracts along the southern base of the Sautpoora Hills, in localities 
 usually considered to be malarious at that season of the year. The 
 men of the 92nd took two grains of quinine twice daily from the 
 27th Xovember to 6th December, and the immunity from fever 
 which they enjoyed was attributed by the medical officer to this 
 measure. On inquiring into the state of health of the other detach- 
 ments, I found that they had been equally free of fever, though 
 they had not used quinine as a prophylactic. The comparison of 
 the 92nd and Horse Artillery troop was instructive : the men of the 
 92nd had been conveyed to the scene of service by bullock train, 
 but the troop had reached it by forced and fatiguing marches. The 
 men of the latter were consequently more predisposed, yet they did 
 not suffer from fever. The immunity of the 92nd therefore did not 
 depend on the small quantity of quinine consumed daily, but, with 
 that of the other troops engaged, on the circumstance that the 
 malarious season had passed. Further careful investigation is, in 
 my opinion, necessary before the proplrylactic value of quinine 
 can be received as an established fact. 
 
 Diet. — In order to control the undue vascular action of the 
 exacerbation, the regimen must in all resjDects be antiphlogistic. 
 
 trolling the fevers of India ; and that, in some cases, their use is not unattended with 
 risk of injury. 
 
 In 1851 I was asked to see an English merchant in Bombay, who in the month of 
 Julv, from residence in a swampy locality, became affected with remittent fever com- 
 plicated with diarrhoea. He was moved to a better situation. The state of the 
 bowels interfered, it was said, with the use of opainine. I saw this gentleman on the 
 eleventh day of the fever, the third after it had become continued, and one after 
 a Lottie of Warburg's drops had been given. It caused profuse sweating, which con- 
 
 I at the time of my visit ; the adynamic symptoms were well marked. K 
 twenty-four hours aft crvards. Here the profuse 
 have increased the exhaustion. 
 
 J. o 
 
150 REMITTENT FEVER. 
 
 It has, however, been stated, that in remittent fever we must be 
 on the outlook for prostration, and prepared to prevent it by the 
 adequate use of farinacea, milk, and animal broths during the re- 
 mission. The usual error in practice on this point — a very serious 
 one — i s to postpone the use of nutritious food till prostration is 
 urgently present. The judicious physician, however, foresees its 
 •advent, appreciates its earliest signs, and strives to prevent it by 
 the timely and skilful use of nourishment and stimulants. The 
 adjustment of the food and of stimulants to the state of the consti- 
 tution and type and stage of the fever is a very important part of 
 the management, and one on which, in bad cases, success very often 
 mainly depends. 
 
 Change of Air. — To place a fever patient in the most advan- 
 tageous circumstances at our command as respects house and 
 apartment, ought to be an invariable rule. If the situation be 
 decidedly malarious, and that in which the fever has been acquired, 
 then the removal of the patient to a more suitable adjoining 
 locality, where medical treatment and care are also available, is a 
 very necessary measure. But this necessity does not frequently 
 occur in India, for hospital patients, by their removal to hospital, 
 experience the benefit of change from the locality in which the 
 attack has been excited ; and officers do not frequently suffer from 
 fever caused by malaria generated in the neighbourhood of their 
 residences, but from exposure on the occasion of a hunting, 
 shooting, or pic-nic expedition. When remittent fever persists, 
 uncontrolled by remedies, change of air often holds out the pros- 
 pect of benefit, particularly when residence on the sea-coast 
 admits of change to sea, provided the patient can enjoy at the 
 same time the advantages of careful nursing and medical treat- 
 ment. The necessity for a measure of this kind will be frequent 
 or rare, according to the knowledge and skill evinced in the 
 medical treatment. The contingency often occurred in former 
 years, when remittent fever was treated with mercury, without 
 bark or quinine; and the change was so generally carried into 
 effect, without sufficient provision for the essential medical manage- 
 ment of the patient, or reference to fatigue and exposure, that 
 much suffering and increased mortality resulted from it. 
 
 That this evil has really existed, is very evident from the fol- 
 lowing facts: — 
 
 A medical officer, on the 10th October, 1829, was taken ill 
 with fever at Jumbooseer, in Guzcrat. The attack was treated 
 with depletion and mercurials, and was characterised by tendency 
 
CHANGE OF AIR — TREATMENT. 151 
 
 to exhaustion. He went to Tankariabunder, and embarked there 
 for Bombay on the 19th; suffered in the boat from nightly 
 exacerbations, and sense of exhaustion in the day. He reached 
 Bombay on the morning of the 23rd with a thready pulse, and 
 died at 9 p.m. 
 
 A military officer was taken ill with remittent fever at Rajcote 
 on the 18th October, 1834; treated with mercurials and purga- 
 tives; and sent on the 22nd to the coast and Bombay, supplied 
 with fever pills and purgatives. He died on the road on the 
 26th. 
 
 An officer at Ahmudnuggur, in Gruzerat, after ailing for two or 
 three days, became affected with remittent fever on the 13th 
 August, 1835. There were noon and midnight exacerbations and 
 morning remissions. He was bled, used calomel and purgatives, 
 and was sent to Hursole on the 18th. He reached it exhausted on 
 the 19th, and died on the 20th. He was on his way to the sea- 
 coast. 
 
 A military officer, in the month of October, 1839, was ill for a 
 week with fever at Ahmedabad. He was sent to Cambay; was 
 exhausted ; there was wandering delirium, with oppression of 
 breathing. Leeches were applied to the head, a blister to the 
 epigastrium, and several free doses of calomel were given. He 
 was then embarked for Bombay, and died at sea the night of his 
 departure from Cambay. 
 
 The wife of the subject of the last case, also ill with remittent 
 fever, left Cambay at the same time in another boat. I went on 
 board to receive this lady on her arrival at Bombay, and found her 
 suffering from adynamic fever. I attended her for two or three 
 days, when she died. It was this case that first fixed my attention 
 on the evils of this routine and injudicious system. 
 
 An officer ill with remittent fever at Tatta, in Scinde, in De- 
 cember, 1840, was sent to Kurrachee, and was seen there three days 
 afterwards in a state of febrile excitement with delirium and ful- 
 ness of both hypochondria. He was bled, and purgatives were 
 given, also a draught with half a drachm of solution of muriate of 
 morphia. He became comatose, and died twelve hours after his 
 arrival. The head was not examined. The liver and spleen were 
 enlarged, congested, and friable. 
 
 An officer of intemperate habits, and often injudiciously exposing 
 himself to the sun, suffered from two or three attacks of fever at 
 Tatta in December, 1840 ; these were followed by dysentery. He 
 proceeded to Kurrachee, and arrived there in an adynamic state, 
 
 L 4 
 
152 UEMITTENl FEVEE. 
 
 and died the following day. The liver was much enlarged, and 
 there was softening of the gastro-intestinal mucous lining. 
 
 A gentleman had fever at Poona on the 21st of November, and 
 was first seen on the 23rd. The morning remission and noon 
 exacerbation were marked on the 24th, 25th, 26th, 27th, 28th, and 
 29th. He was treated with leeching, mercurials, purgatives ; and 
 general blood-letting on the 28th : no quinine. He was sent from 
 Poona on the morning of the 29th, and was seen at Bombay on 
 the evening of the 30th. There was exacerbation with stupor and 
 asthenia. On the morning of the 1st, a remission; at noon, an 
 exacerbation with increasing stupor. He died comatose at 10 A.M. 
 of the 2nd. 
 
 These cases will suffice*; they show unmistakeably the injurious 
 effects of the excitement and fatigue of travelling, and the neglect 
 of medical treatment. It is not difficult to understand how this 
 system of mismanagement obtained currency. It is very evident 
 that depletory measures and mercury are quite unequal to the cine 
 of remittent fever. In this difficulty medical men and the public 
 clung to the hope of benefit from change of air, and have been 
 slow to interpret rightly the casualties which have resulted from it. 
 
 When treating of splenic cachexia, I pointed out the necessity 
 of change of air with the view of improving the state of the consti- 
 tution. When health has been injured by remittent fever, and 
 convalescence is in progress, then change of air becomes, on the 
 same grounds, a very useful and important measure. 
 
 * To satisfy myself on the question of change of air in remittent fever was a 
 pal objed with me in examining the eases of sick officers. From the ninety 
 fatal cases of which I have notes, I have selected the eight just quoted. On the 
 other hand, of 1,388 successful cases of officers recommended for change of air on dif- 
 ferent accounts, I do no) find that I have noted a single instance of benefit from the 
 are adopted under those circumstances of fever to which these remarks have 
 been directed. 
 
 Note. The principles of treatment of remittent fever have been considered at some- 
 peal T length, and with more precision than iii the tii-st edition of tiiis work. 
 The discussion on the mercurial treatment has been reproduced with a greater conviction 
 of its importance and necessity, because the nature of my duties on my return to 
 India has afforded me the opportunity of becoming acquainted on a more extended 
 scale with the present state of medical practice in thai country, and I have been often 
 astonished at the want of sound principles on the use of mercury, and of fixed princi- 
 ples of any kind on the general treatment of fever. 
 
153 
 
 CHAP VI. 
 
 ON CERTAIN OBSCURE PHENOMENA, PROBABLY RELATED TO MALARIA. 
 
 Intermittent and remittent fever are attributed to malaria as a 
 cause, and the presence of these diseases may be received as evidence 
 that this agency is active. 
 
 The observations made on the symptoms of the cold stage of 
 intermittent fever, and on the diagnosis between remittent and 
 symptomatic fever, have evinced my belief that the influence of 
 malaria may be indicated by phenomena less marked, but still ])ar- 
 taking somewhat of the character of those of intermittent and 
 remittent fever. This subject may be pursued still further, and 
 with much advantage by the practitioner in malarious countries. 
 Careful observation in tropical climates will satisfy the inquirer 
 that there is a tendency in all forms of disease to put on more 
 or less of a periodic character in the malarious months of the year. 
 This feature is more likely to be observed in the natives of India, 
 and in long resident Europeans, than in the recently arrived. It 
 is practically important ; for when observed, it may be viewed as 
 suggesting caution in the use of antiphlogistic means, and indi- 
 cating the expediency of quinine. 
 
 After a period of residence in tropical countries, occurring sooner 
 in some localities and constitutions than in others, an influence 
 becomes operative on the system, produced perhaps by general 
 climatic conditions, but more probably by malaria. There are 
 many phenomena which may be taken as indicating the presence 
 of this influence, — as restless nights, pain of limbs, frequent 
 yawning, depression of spirits, giddiness, booming sounds in the 
 ears, a sense of faintness or chilliness with vomiting, defective 
 secretion of the liver leading to pale alvine discharges without 
 jaundice; defective irritability of muscular fibre giving rise to 
 palpitation, a feeble, sometimes intermitting pulse, constipation 
 and dyspeptic symptoms. In these phenomena, if watched, a 
 
154 EFFECTS OF MALARIA. 
 
 marked periodic tendency may often be observed. They are more 
 apt to occur at times of considerable atmospheric changes, and 
 very frequently about full or new moon.* All these symptoms are 
 distinctly controlled by the use of quinine. The occurrence of night 
 paroxysms of malarious fever is a familiar fact. The phenomena 
 of the lesser influence of malaria may occur at the same diurnal 
 period. In this way restless nights may often be explained : 
 at all events, five or six grains of quinine, given at bed-time under 
 these circumstances, cause sleep more certainly than opium. 
 
 The correct interpretation of these symptoms of deranged health 
 leads to the use of quinine, and, to great caution in local blood- 
 lettings, purgatives, and mercury; but the measure which they 
 most clearly indicate, is change to a suitable temperate climate free 
 from malaria. This is a most necessary step ; for in the state of 
 constitution of which these phenomena are the evidence, there is 
 unquestionably a general tendency to fatty or other degeneration 
 of tissue, which can only be prevented by forethought on our part, 
 in recommending a suitable change of climate. To wait for the 
 occurrence of structural change as the signal for removal from 
 India, is a great practical error, and pathology has been studied to 
 little purpose if its lessons have not taught us when to expect 
 structural lesions, and how best to prevent them. 
 
 * The question of lunar influence on disease in India has been much discussed at 
 different times. In the 2nd and 6th numbers of the " Transactions of the Medical 
 and Physical Society of Bombay,"' the reader will find the latest consideration of 
 this subject with which I am acquainted. The first paper, by 3Ir. Murray, details 
 what the author conceived to be illustrations of lunar agency in chronic disease. The 
 second is by Dr. Peet, and embraces an inquiry into the evidence on which the opinion 
 rests. 
 
 On this question I shall merely observe: 1. To find on the same day several of the 
 asthenic inmates of his wards affected with febrile disease, though all had been free 
 of it for many days previously, is a fact familiar to the hospital physician in India. 
 The days on which this is observed are often coincident with new or full moon. 
 
 2. To find those who have Buffered from malarious fever experiencing recurrences 
 at the periods of new and full moon, is a fact familiar both to patients and to m 
 men in India, 
 
 '.',. When this coincidence of febrile disease and these lunar phases arc noted, there 
 will generally be found to be present an appreciable atmospheric change of ten 
 tore, of moisture, of direction of the winds, &c. Ii is this atmospheric \ '■ 
 apprehend, which is the determining cause of the febrile disturbance. Dr. Balfour, 
 the gn mar inflnem - coincidence of atmospheric 
 
 changes. II -: "I'.ut I ran declare in general thai in India the meridional 
 
 '-. both diurnal and nocturnal, were distinguished by remarkable changes or 
 of the weatherj and that these paroxysms were most remark- 
 al the lunar periods." 
 
155 
 
 CHAP. VII. 
 
 ON ADYNAMIC REMITTENT FETES OF SUSPECTED INFECTIOUS CHABACTEB. 
 
 That malarious fevers are liable, under circumstances favourable 
 to the spread of infection, to become infectious, is an old opinion. 
 Fordvce held this view, and Clark and Lind believed that Bengal 
 remittent was at times invested with this character. 
 
 We shall do well to bear this old doctrine in recollection, 
 because, though with our present greater attention to cleanliness 
 and ventilation, remittent fever is not infectious, it does not follow 
 that it may not become so from overcrowding and neglect. From 
 1815 to 1820 a febrile disease* of very adynamic type prevailed in 
 Katty war, Kutch, and parts of Gruzerat. A similar affection appeared 
 at Pali in Marwar in July, 1836 ; was more or less present there, 
 and extended to the towns in the adjacent districts up to the middle 
 of 1838. Again, we have notices of a like disease in 1849 in 
 Gfurhwal, in Kumaon, and, more lately still (1853), in Eohilcund. 
 
 The fever was remittent in character, with great tendency to 
 become continued, and the adynamic phenomena were well marked. 
 It was attended, in the great majority of instances, with glandular 
 swellings of the groins, axilla?, and neck ; and, in the cold season, 
 there was in some of the fatal cases dyspnoea, with cough and 
 bloody expectoration. In none were carbuncles and petechia? or 
 purple patches present. 
 
 The number of cases seen by Dr. Forbesf at Pali, from January 
 
 * The terms Pali disease and Mahamurree have been given to this fever. It 
 is much to be desired that the too common practice of giving local or native 
 names to diseases in India be altogether abandoned, as tending to lead to careless 
 diagnosis and vague pathology; I allude to such terms as Scinde, Guzerat, Mysore, 
 Bengal, Deccan, Jungle, Pucka fever, Liver, Spleen, Eeri-beri, Hill diarrhoea, and 
 many others. 
 
 t " Transactions, Medical and Physical Society of Boml j ." N 2, p. 14. 
 
156 ADYNAMIC REMITTENT FEYEE. 
 
 29th to February 3rd, 1848, amounted to forty-eight. He thus 
 describes the symptoms : — * 
 
 " Of these many had reached from the tenth to the twentieth day of the disease, 
 with large buboes, no particular degree of fever, parched skin, tenderness of epigas- 
 trium, tongue white and moist, eyes didl and watery, bowels generally very slow, but 
 sometimes loose, and the greater part with more or less cough ; some few complained 
 of little else than the pain of the buboes, with great weakness and loss of appetite. 
 All, without exception, had buboes, but I met with no instance of carbuncle or 
 vibiccs. 
 
 " In the mildest form the buboes make their appearance with little constitutional 
 disturbance, attended only by languor, debility, and a general feeling of indisposition ; 
 they go on slowly to suppuration, and health is very gradually restored. 
 
 " In the most common variety the invasion is sudden, not being preceded by any 
 feelings of disorder or uneasiness sufficient to engage the notice of the patient, gene- 
 rally takes place in the evening, and is rarely attended with rigors. The occurrence 
 of the febrile symptoms, and the pain and swelling of the glands, appear to be in 
 most cases simultaneous ; in many the buboes showed themselves before the fever, 
 while in none were . they developed at a later period than the second day of the 
 disease. The symptoms most generally present are great prostration of strength, 
 giddiness, headache confined to the forehead, excessive thirst, dry burning skin, 
 tongue moist and white, pulse from 110 to 130, small and weak, slight vomiting and 
 tenderness of epigastrium, bowels confined, urine scanty and high coloured, great 
 indifference as to recovery, and disinclination to speak or answer questions. The fever 
 is of the remittent type, with marked tertian exacerbations, often attended with low 
 delirium, but the crises are very imperfect. If uncomplicated with any thoracic or 
 abdominal affection, and if the patient survives the fifth day, it commonly abates in 
 violence after the seventh or eighth, so that in the third week little else remains but 
 extreme debility, and sympathetic evening flushes from the buboes, which by this 
 time have advanced to suppuration. In most of these cases, however, more or less 
 co\igh is present through the height of the disease ; it is generally dry, but sometimes 
 accompanied by white frothy expectoration. 
 
 "In the more violent and malignant forms the attack sets in suddenly, with severe 
 headache, staggering, and giddiness, quickly followed by delirium. The morning 
 remission is scarcely perceptible, except by the abatement of the delirium. No 
 glandular swellings appear, or they remain small, hard, and exquisitely painful ; 
 vomiting of bilious matter, and latterly of dark coffee-coloured fluid, comes on; the 
 bowels are either constipated or the stools black and fetid, the teeth are covered with 
 sordes, and the patient tosses and moans in bed. A dry cough now supervenes, 
 attended with severe pain in the region of the heart, and laboured respiration; 
 partial insensibility passes into profound coma with trismus, and death fakes place 
 early in the morning of the fourth day, or, in cases where the symptoms are less 
 violent, on the morning of the sixth. 
 
 "The most fatal modification of the disease, from which no recovery has been 
 known, sets in without any febrile excitement whatever, if we except a very slight 
 acceleration of the jxilsc. The most prominent symptoms from the commencement 
 are slight cough, and expectoration of blood; the cough appears to an observer more 
 like a voluntary aet t<> relieve oppression or constriction about tlie chest than, to 
 be caused by pain or irritation. The body is covered with frequent clammy sweats; 
 the countenance exceedingly anxious and wild; thirsl urgent, tongue clean, bowels 
 slow; the urine increased in quantity and loaded with Mood, which also oozes from 
 
 * This enterprising of&i t* subsequently lost his life in Central Via while trai 
 
 on bis ict urn from Europe to I ndia, 
 
ADYNAMIC REMITTENT FEVEH. 157 
 
 the gums. The expectoration of blood becomes more copious. To the anxiety and 
 oppression of the chest is added pain in the cardiac region, the pulse becomes quick 
 and thready, the action of the heart tumultuous, faintness and complete exhaustion 
 come on ; and a fatal syncope puts an end to the sufferings of the patient, generally 
 within forty hours from the attack, the intellectual faculties remaining perfect till 
 nearly the last moment. 
 
 " It is, however, by no means rare to see the different forms mixed or merging in 
 each other. The attack may be at first mild and apparently without much danger, the 
 buboes well developed and the fever Blight ; when from the third to the fifth day, and 
 sometimes so late as the seventh, the ocam-ence either of delirium, coma, bloody expec- 
 toration, diarrhoea, retention of urine, or recession of the bubo, point out an unfavour- 
 able change, and the fatal termination soon follows, as in the more aggravated forms." 
 
 Dr. Forbes alludes to the treatment, and points out the inap- 
 plicability of all depressant remedies. 
 
 This fever has been observed at all periods of the year, and has 
 prevailed chiefly amongst the poor, in filthy, badly-ventilated 
 houses and villages, and has been preceded by seasons of famine. 
 The mortality has been very great. Dr. Forbes thinks four-fifths 
 of those attacked died. The circumstances just stated sufficiently 
 explain the occurrence of adynamic fever; but they have been 
 viewed chiefly with reference to the question of the contagious cha- 
 racter of the fever, and its identity, or not, with the plague of Egypt 
 and the Levant. Hence speculations arose relative to the manner of 
 its introduction into India in the course of commerce from the Red 
 Sea or Persian Gulf ; and quarantine measures were on occasions 
 strictly enforced. 
 
 It would be unprofitable, and foreign to the objects of this work, 
 to enter into discussion on a subject of which I have no personal 
 knowledge ; but my impression is in favour of the opinion that it 
 was a fever of endemic origin, of very adynamic type from the 
 state of constitution of the attacked, assuming infectious properties 
 from filth, crowding and imperfect ventilation, and having features 
 in common with the plague of Egypt, — as is more or less the case 
 in every fever in which adynamic symptoms and deteriorated blood 
 are well marked.* 
 
 * The first known reports of this disease are by Messrs. McAdam, YVhyte, and 
 Gilder, in the 1st Number of the " Transactions of the Medical and Physical Society 
 of Bombay." 
 
 The disease, as appearing at Pah and the adjoining districts, has been described 
 by Messrs. McLean, Irvine, Keir, and Eussel, of the Bengal Medical Service ; 
 and the results of their observations have been brought forward in an able memoir, 
 by Dr. James Banken, at the time Secretary to the Medical Board of Bengal. 
 It was also reported on by Mr. Cramond and Dr. Forbes, of the Bombay Medical 
 Service. The latter gentleman published a very interesting report of his observation^ 
 in the 2nd Number of the " Transactions of the Bombay Society," already referred lo 
 in the text. 
 
 The accounts of the disease in Kumaon and Eohilcund are given by Drs. Pearson, 
 
158 ADYNAMIC REMITTENT FEVER. 
 
 The description of jail or hospital fever by Pringle, in the 
 seventh chapter of the third part of his work on the diseases of the 
 army, has considerable resemblance to that of the fever observed at 
 Pali. There were the same kind of adynamic phenomena, with sup- 
 puration of the axillary and parotid glands, with, in addition, the fre- 
 quent presence of petechial spots. The causes were supposed to be 
 crowding, filth, and effluvia from decomposing animal and vegetable 
 matters. In some cases it was attributed to the effluvia from putre- 
 fying marshes ; and in these the type was more remitting. The 
 fever was regarded as infectious, but in no great degree, unless 
 there had been continued exposure to the foul air. 
 
 In a Report on the Medical Topography and Diseases of Aden *, by 
 Mr. Ruttonjee Hormuzjee, it is stated that intermittent fever is not 
 so common there as in India ; but the station is not exempt from 
 the occasional visitation of febrile disease of severe type. During 
 two of the years embraced in the report, 270 cases of remittent 
 fever of adynamic type were treated, and of these 77 proved fatal. 
 It prevailed with greatest severity from February to April, 1856, 
 during which time there were 188 admissions and 60 deaths. The 
 outbreak occurred among the native labourers engaged in the public 
 works, and was attributed to undue crowding in a hot and badly- 
 ventilated valley, in close, badly-constructed huts, in the proximity 
 of sources of foul effluvia from decomposing animal excreta and 
 other matters, coupled with poor living, and especially an in- 
 adequate supply of fresh water. The fever was characterised by 
 evening exacerbations and morning remissions. The complications 
 were various : cerebral disturbance in some indicated by delirium, 
 drowsiness, and coma, attended with adynamic phenomena, as sub- 
 sultus tendinum and dry tongue. Pneumonia, bronchitis, dysen- 
 
 Erancis, Benny, and Stiven, of the Bengal Service, and are noticed in the 2nd and 3rd 
 Numbers of the "Indian Annals of Medical Science." 
 
 The subject is also ably discussed by Dr. Mackinnon, in his treatise on the "Pre- 
 vailing Diseases of Bengal and the North-west Provinces," published in the same 
 journal. 
 
 In the 4th Number of the " Indian Annals of Medical Science." receivedsince these 
 remarks were written, I find a report, by Dr. Farquhar and Mr. Wallick, of an 
 adynamic remittenl fever which prevailed in the valley of Peshawur in 1852 and 
 1853, and was believed to be contagious. The worst cases were complicated with 
 jaundice, and a relapsing tendency would seem to have been well marked in the 
 disease. 
 
 li is important to aote thai this form of fever would seem to be confined to extra- 
 tropical India, or to districts Cnicli, Kattywar — not much to the south of tho 
 tropic. 
 
 * Grant College Medical Society, Retrospective Address for the year 1857, by the 
 
 autlior. 
 
ADYNAMIC REMITTENT FEVER. 159 
 
 tery, diarrhoea, and jaundice were the complicating conditions in 
 other cases. In the general immimity from intermittent fever at 
 Aden, there is evidence that the true ague-malaria is not abundantly 
 generated there, and this view is further supported by the physical 
 characters of the locality — the absence of vegetation and moisture. 
 It is therefore reasonable to conclude that this fever of bad type 
 was due, in great part, to the defective sanitary conditions which 
 existed, and was probably allied to the fever described in this 
 chapter as having occurred at Pali, and other localities in the 
 northern parts of India. The question of infection is not noticed 
 by Mr. Hormuzjee in his report. 
 
160 TYPHOID FETER. 
 
 CHAP. VIII. 
 
 ON TYrHOID FEYEE. 
 
 In the first edition of this work I stated that typhoid fever was 
 unknown in India. Shortly after my return to Bombay a case of 
 fever came under my observation towards the end of November, 
 1856, which led me to doubt the correctness of this opinion. The 
 subject was a European female, and the attack commenced the day 
 after her arrival from England by the overland route. The symp- 
 toms were febrile heat without distinct remissions, much prostration, 
 febrile expression of countenance, tremulous hands, dry lips, the 
 tongue dry and brownish in the centre, and some degree of tym- 
 panites. The bowels were very readily acted on by small doses of 
 laxatives, and on one or two occasions blood was intermixed with 
 the feculent discharges. Quinine was given without effect, and 
 then omitted after two or three days, when the treatment con- 
 sisted of small opiates, and attention to suitable nourishment. The 
 fever persisted for twenty-one days, after which there was slow 
 amendment, but the patient was not able to leave the house till the 
 thirty-fifth day from the commencement of the illness. 
 
 This seemed to me to be a mild case of typhoid fever, and not 
 long after its occurrence the reports* of Dr. Ewart and Mr. Scriven 
 on typhoid fever came under my notice, and, more recently, the 
 doubts which I still entertained were removed by a clinical 
 lecturef by Dr. Edward Goodeve, in which seven cases of un- 
 doubted typhoid fever are detailed. As the object of this work 
 is to record my personal experience, a detailed description of 
 typhoid fever would be misplaced, as it could only be drawn from 
 sources equally open to my readers. 
 
 The investigation which has thus been commenced is of much 
 practical importance, in consequence of the principles of treatment 
 
 * "Indian Annals of Medical Science," vol. iv. pp. Go, 511. 
 t Ibid. No. xi. p. 111. 
 
TYPHOID FEVER. 1C1 
 
 of typhoid fever differing so materially from those of malarious 
 fevers ; and it will require to be prosecuted with much care, in order 
 that the tendency so common in medical research to exaggerate the 
 importance of new subjects of inquiry, to the neglect of established 
 truths, may be sufficiently controlled. With this view I would 
 venture to suggest : - • 
 
 1. That the locality, season and supposed causes be alwa}'s 
 stated, for it is not improbable that typhoid fever will be chiefly 
 found in extra-tropical India, or in inter-tropical provinces, in the 
 near proximity of the tropics and in the winter rather than the 
 autumnal malarious season. 
 
 2. That it be recollected that disease of Peyer's glands, either in 
 the stage of turgescence or ulceration, is not a morbid state peculiar 
 to typhoid fever. It occurs in cholera, in protracted diarrhoea, in 
 acute muco-enteritis, as an occasional complication of remittent 
 fever, and a frequent one of phthisis pulmonalis. 
 
 3. From the last statement it follows, that we are not justified 
 in asserting the existence of typhoid fever from the mere character 
 of the post-mortem appearances. These require to be interpreted 
 by the symptoms which have been present during life, in order 
 that they may be correctly understood. 
 
 4. The observation made by Dr. Jenner, and confirmed by Dr. 
 Watson, that they never saw jaundice in typhus or typhoid fever, 
 is important to remember. 
 
 5. That the so-called t} T phoid (adynamic) symptoms are not 
 peculiar to one form of fever, but may occur in all, is well known, 
 and should not be forgotten. 
 
162 COMMON CONTINUED FEVER — FEBRICULA. 
 
 CHAP. IX. 
 
 ON COMMON CONTINUED FEVER — FEBRICULA — AND ARDENT 
 CONTINUED FEVER. 
 
 Section I. — General Remarks. 
 
 In India and other tropical countries, in addition to intermittent 
 and remittent fevers, there occur forms of idiopathic fever produced 
 by ordinary exciting causes, — as vicissitudes of temperature, great 
 heat, violent exercise, excitement of mind, excesses in eating, 
 intemperate habits, and imperfect excretion. The fevers thus 
 excited differ in degree rather than character. To the milder form, 
 the terms ephemeral fever, Common continued fever and febricula, 
 have been almost indiscriminately applied. To the severer form, 
 the designation ardent fever has been given. 
 
 They are most common in those parts of India which do not 
 experience much of the influence of the monsoon rains, and whose 
 hot season is not tempered by regular breezes from the sea. They 
 are more met with in the central parts of the table land of the 
 Deccan and Mysore, the Ceded districts, the coast of Coromandel, 
 Scinde, and the Punjaub, than in Bengal or Bombay, and the 
 western coast line south of Surat. They chiefly occur in March, 
 April, and May ; but also prevail in June and July in localities 
 where the temperature is elevated, and the conditions of malaria 
 are absent. 
 
 Section II. — Common Continued Fever — Febricula. 
 
 The mildest variety — ephemeral — may proceed from any of the 
 ordinary exciting causes which have been mentioned, and though 
 most common in unseasoned Europeans, may occur in Natives as 
 well as in Europeans who have been some time resident in India. 
 It consists of febrile symptoms without local complication, com- 
 mencing with chills, followed by reactiou, and this by perspiration, 
 
COMMON CONTINUED FEVER — FEBKJCULA. 16:5 
 
 and thus is removed in from twenty-four to thirty-six hours. But 
 the febrile reaction may continue for periods of four or five days ; 
 and then the term common continued fever is more correctly 
 applied. It would be convenient, however, to substitute for these 
 two designations, the single name, febricula. For the treatment of 
 ephemeral and common continued fever, such means as an emetic, 
 purgatives, tepid sponging, diaphoretics, and antiphlogistic regimen 
 are employed. In plethoric individuals, when there is much 
 headache and flushing of the face, a moderate general blood- 
 letting, or leeches to the temples, may be an expedient measure, 
 but they are not often necessary. These are not serious affections, 
 and do not differ from the febricula of the colder climates ; but 
 the degree of reaction has always relation to the state of constitu- 
 tion, whether sthenic or not. 
 
 This form of fever occurred under my observation in the troops 
 at Poona, in 1858 and 1859. In March, April, and May, the 17th 
 Lancers, the 3rd Dragoon Guards, the 18th Koyal Irish, and the 
 D Troop, Horse Artillery — all recently arrived — suffered from 
 febricula, marked by headache, flushed face, coated tongue, and 
 pains of loins and limbs, subsiding and disappearing in from two to 
 four days under moderate treatment. The 3rd Dragoon Guards were 
 affected in greatest degree, consequent, as was supposed, od an im- 
 perfect head-dress, late morning parades, and suspected excesses in 
 drinking. In the D Troop there was in some cases an eruption of 
 roseola, or erythema, about the loins and thighs, which came and 
 disappeared with the fever. The recruits of the Native Eegiments 
 at Poona were also sickly from febricula during the rains — June, 
 July, August — of this year, consequent, in all probability, on too 
 much drill and insufficient protection from cold and wet, owing to 
 the badness of their huts. 
 
 A comparison of the state of health, as respects febricula, of the 
 31st Eegiment and the German Legion, at Poona, from December 
 1858, to April 1859, is interesting, because both regiments arrived 
 from the Cape of Good Hope about the same time, and the differ- 
 ence was doubtless due to the different sanitary conditions of the 
 two bodies of men. 
 
 The 31st was composed of seasoned, well-equipped, and disci- 
 plined soldiers, and not, as was the case with many regiments sent 
 to India to meet the late exigency, in great part of young recruits. 
 They also occupied the best barracks at the station. 
 
 The German Legion consisted of badly-selected volunteers, 
 who had been ill-cared for at the Cape, and a considerable number 
 
164 
 
 ARDENT CONTINUED FEVER. 
 
 of whom left the colony tainted with scurvy and syphilis, and 
 reached India in that condition. They were ill-equipped, occupied 
 the worst barracks at Poona, were, perhaps, too much exposed 
 at drill, but were not intemperate. The Indian ration was mucli 
 more than they bad been accustomed to. The scorbutic taint 
 rapidly disappeared, and the men gained in flesh and strength. 
 In fact, the Indian ration, and the Deccan cold season, so 
 raised the constitution of these men, that it was, at the commence- 
 ment of the hot months, similar to that of troops freshly arrived at 
 that season. They were therefore more predisposed than the men 
 of the 31st, who had not, in the cold months, undergone a change 
 of this kind. 
 
 The general symptoms in the German Legion were considerable 
 febrile excitement, flushing, headache, coated tongue, occasional 
 vomiting, and sometimes cramps of the legs : with recovery in 
 from three to four days. In a small proportion a remittent 
 tendency was noticed. The treatment consisted of an ipeca- 
 cuanha emetic,— which generally acted also on the bowels — acid 
 drinks, and antiphlogistic regimen. There was no fatal case : 
 seldom a readmission. 
 
 Admissions fbom Fever in the 31st Regiment and the Gebman Legion, at 
 Poona, feom Decembeb, 1858, to Apetl, 1859. 
 
 
 31st Regiment. 
 Strength ranged 
 fromseito 1116. 
 
 German Legion. 
 Strength, 1UU7. 
 
 December ....... 
 
 January ....... 
 
 diary ....... 
 
 March 
 
 April ........ 
 
 3 
 
 37 
 25 
 
 S 
 
 65 
 
 127 
 
 283 
 
 65 
 
 103 
 
 548 
 
 During the hot season, a squadron of the 6th Inniskilling Dra- 
 goons (late arrival) suffered from severe febricula at .Sattara, 
 equent ehiefly on insufficient protection in temporary barracks. 
 The 22nd Native Infantry were sickly at Ahmednuggur from 
 febricula at the same time; of a strength of 886, there were 214 
 9 of fever, chiefly febricula, admitted in April. 
 
 Section III. — Ardent Continued Fever. 
 
 Ardent continued fever is almost confined to tropical coun- 
 triesj and is a very serious disease. The exciting causes are 
 
SYMPTOMS AND rATIIOLOGY. IG5 
 
 elevated temperature, exposure to the sun, excessive exercise, 
 mental excitement, excesses in eating, intemperance, defective 
 excretion. There may be several of these causes combined. 
 But in order to produce the disease in its most aggravated form 
 elevated temperature is a necessary condition ; and another is, that 
 there should be present that kind of predisposition peculiar to the 
 robust European lately arrived in a warm climate. This form 
 of fever, then, is almost confined to the hot and dry months of the 
 year in arid localities, and to regiments or recruits recently arrived 
 from Europe. 
 
 Symptoms. — The attack is generally sudden, often without 
 much chilliness. The face becomes flushed, and there is giddiness 
 with much headache, and intolerance of light and of sound. The 
 heat of skin is great, and the pulse frequent, full and firm. There 
 is pain of limbs and of loins. The respiration is anxious. There 
 is a sense of oppression at the epigastrium, with nausea and 
 frequently vomiting of bilious matters. The bowels are sometimes 
 confined ; but, at others, vitiated bilious discharges take place. 
 The tongue is white, often with florid edges. The urine is scanty 
 and high coloured. If the excitement continues unabated, the 
 headache increases, and is often accompanied with delirium. If 
 symptoms such as these persist for from forty-eight to sixty hours, 
 then the febrile phenomena may subside, the skin may become cold, 
 and there will be risk of death from exhaustion and sudden collapse; 
 or in cases in which the cerebral disturbance is great, death may 
 take place at even an earlier period in the way of coma ; or when 
 symptoms of gastritis are very prominent, exhaustion may hasten 
 the fatal result ; or jaundice may appear and increase the danger. 
 
 The continuance for two or three days of excessive vascular 
 action, such as that now described, must necessarily be followed by 
 a corresponding depression ; and in this we have the explanation of 
 the collapse and exhaustion which become developed as the febrile 
 excitement subsides. Again, the excessive action, with the addition 
 of retained excretions, must vitiate the blood ; and in some cases 
 there is evidence of this condition in the dark grumous matters 
 vomited and evacuated from the bowels. When these phenomena 
 are present, exhaustion and collapse become very prominent, and 
 are no doubt in a great measure attributable to the influence of the 
 deteriorated blood. 
 
 The diagnosis between this form of fever and inflammatory 
 remittent has been already considered (p. 57), and the remarks 
 then made should now be referred to. 
 
 M 3 
 
166 ARDENT CONTINUED FEVER. 
 
 Pathology. — In the excessive vascular action of this form of 
 fever there is risk to important organs, as in the stage of exacer- 
 bation of the severer remittents. There is also danger from 
 prostration, after a time, in consequence of continuance of high 
 febrile excitement. 
 
 But between the pathology of ardent and remittent fever there 
 is believed to be this great difference. In the former there is no 
 materies in the blood, as in the latter, exercising a sedative 
 influence on vital actions, and requiring time for its elimination. 
 Therefore, we may hope that by subduing the vascular excitement 
 at the outset of ardent fever we are adopting the most efficient 
 means for shortening the duration of the disease. 
 
 Treatment. — There is much more scope in the treatment of 
 ardent fever for the use of free and repeated general and local 
 blood-letting, cold affusion, tartar emetic when tolerated, and 
 mercurial and other purgatives. It must, however, be borne in 
 mind, that these means are only effective when used promptly in 
 the early periods of the fever, and that, if they be delayed till the 
 third or fourth day, — when in the course of the disease the pheno- 
 mena of prostration may be looked for, — their effect must be to 
 hurry on the fatal result. They must be adopted also in recollec- 
 tion of the difficulties which sometimes beset the diagnosis of this 
 from the remittent form of fever, and of the greater caution 
 required in their use in the latter disease. 
 
 The symptoms of ardent fever, and the success of prompt and 
 active treatment, are well illustrated in Dr. Arnott's Medical 
 History of the Bombay Fusileers in the Puujaub.* The fever 
 prevailed chiefly in the months of June, July and August at 
 Peshawur, when the men were in tents under a temperature 
 ranging from 70° to 114°, described by the author as intense, with 
 hot blasts and thick suffocating clouds of dust, and as fearfully 
 oppressive day and night, and completely breaking and disturbing 
 rest. In these months 884 admissions from fever took place, and 
 not a single death. 
 
 Dr. Arnott thus describes the character of the fever and the 
 nature of the treatment which he followed: — 
 
 " Tlic charai ter of the epidemic fever which prevailed in .Ink and Angusl may be 
 inferred, when I mention thai out of the 798 rases admitted in these two months, no1 
 ; , man died. The symptoms on admission, it i- true, were often very urgent, and 
 
 demanded tin- mosl prompt ami derided measures for their relief. There was pungent 
 
 * "Transactions of the Medical and Physical Soeiety of Bombay," 1st ■ 
 
 loth Number, ]>. 31. 
 
TREATMENT. 107 
 
 heat of skin ; great thirst ; parched, red, and dry tongue ; quick, full, and stron im- 
 pulse ; racking pains in different parts of the hody and acute headache, with flushed 
 countenance ; throbbing of the temples, restlessness, nausea, and vomiting of bilious 
 matter, &e. ; which symptoms, no doubt, were in many instances aggravated by the 
 indifferent shelter the men had from the inclemency of the weather in that hot 
 valley. The autumnal fever, which afterwards appeared, was almost equally mild, as 
 we lost only three men from fever in October, November, and December.* 
 
 " To describe the plan of treatment of a disease having such marked symptoms 
 seems almost superfluous. Evacuants fully and freely employed, with copious and 
 repeated venesection, cupping and leeches (in fact, I never at any former time had 
 occasion to prescribe bleeding, either to the same extent or so frequently), aided by 
 tartar emetic, till all local determination and the chief urgent symptoms were removed, 
 and afterwards quinine, were the means had recourse to." 
 
 It is not to be supposed that all the cases in the Fusileers were 
 of the ardent variety, and presented the symptoms and required the 
 treatment described by Dr. Arnott ; doubtless, the greater number 
 were febricula, and yielded to moderate measures. But as there 
 was a proportion of ardent cases, and no deaths, the statement 
 shows that the active treatment followed in these was appropriate. 
 
 * In these three months the range of the thermometer was from 42° to 91°. 
 
168 FEVER IN CHILDREN. 
 
 CHAP. X. 
 
 ON THE FEBRILE AFFECTIONS OF CHILDREN IN INDIA. FEBRICULA. 
 
 INTERMITTENT AND REMITTENT FEVER. 
 
 The fevers of children in India are best understood by keeping in 
 view the principles which have been stated in respect to adults. 
 
 During the period of infancy — from birth to the end of the 
 second year — attacks of febricula occur from errors in diet or the 
 irritation of teething, just as in the colder climates, and they 
 require the application of the same general principles of treatment. 
 It is also necessary in the management of the febrile affections of 
 early life, in India as elsewhere, to be careful in our diagnosis, and 
 not to mistake the fever sjunptomatic of an internal inflammation 
 for simple febricula. This caution is very necessary in regard to 
 native children in the cold season in Bombay, for I have seen 
 several cases in which pneumonia had been overlooked. 
 
 Intermittent or remittent fevers are, according to my experience, 
 not common in the period of infancy ; they doubtless occur, and 
 probably much more frequently, in very malarious districts, than I 
 have myself witnessed. The most striking instance that I have 
 seen was early in November 1837. On the Bhore Ghaut, midway 
 between Campooly and Khandalla, on the route from Bombay to 
 Poona, there is a small house situated on the margin of a ravine 
 for the accommodation of the gatherer of the tax levied on carts 
 and bullocks passing over the mountain. At the time adverted to 
 it was occupied by an old European pensioner and his wife ; they 
 had both suffered from intermittent fever. In the woman the 
 indications of malarious fever were well marked in her sallow 
 countenance and emaciated frame, and at the time I saw her she 
 was suffering from tertian fever. She had an infant six weeks 
 old, whom she was nursing, and it also experienced regular febrile 
 paroxysms commencing with a well-marked cold stage. I saw the 
 child in the cold stage of one of the attacks. 
 
FEVEK IN CHILDREN. 1G9 
 
 During the period of childhood, from the third to the tenth year 
 and upwards, febricula is met with as in colder climates, proceeding 
 from the same ordinary causes, and exhibiting that feature of re- 
 mittence characteristic more or less of all the febrile affections of 
 early life. These should be treated on the same principles as in 
 other countries. 
 
 But in India, during childhood, just as in the adult, malarious 
 fevers are by far the most frequent idiopathic forms. I have 
 before me the diaries of many cases of intermittent and remittent 
 fever treated by me in the Byculla Schools, while I held medical 
 charge of that institution. They resemble the same affections in 
 the adult, and require the same means of treatment modified to 
 difference of age and peculiarities of constitution. Quinine may 
 be used with the same freedom as in the adult, and it constitutes 
 as essential a part of the treatment. There has been hesitation on 
 this point in the minds of many ; but I can state, on the authority 
 of my own experience, and that of friends in whose judgment I 
 place confidence, that two or three-grain doses may be given with 
 safety, in necessary cases, in a child of three years of age. A 
 European child of about seven years of age, ill for several days with 
 intermittent fever, uninfluenced by a grain and a half dose of 
 quinine, was brought to me. The recurrences were at once pre- 
 vented by five or six-grain doses. 
 
 From the results of recent research, it may be concluded that 
 occasional attacks of typhoid fever may also be looked for in 
 children in India. 
 
170 STATISTICS OF FEVER. 
 
 CHAP. XI. 
 
 STATISTICS OF FEYER IN THE EUROPEAN GENERAL HOSPITAL, THE 
 JAMSETJEE JEJEEBHOY HOSPITAL, AND BYCULLA SCHOOLS, AT BOMBAY. 
 
 Section I. — European General Hospital. — Total Fevers. 
 
 Tables V., VI., VII. represent the total* admissions of fever 
 (4,037) into the European General Hospital at Bombay for the 
 fifteen years from 1838 to 1853, arranged in quinquennial periods. 
 Table V. is for a period during which I was assistant surgeon in 
 the hospital, and includes cases from which a part of the clinical 
 observations recorded in these pages has been drawn. For 
 Tables VI. and VII. I am indebted to Dr. Stovell, when suro-eon 
 of the hospital. 
 
 When we compare the proportion of fever admissions in these 
 three quinquennial periods, we find a remarkable difference be- 
 tween the first and the last. In the former (1838 to 1843J the 
 fevers to the total admissions were 24*2 per cent. In the latter 
 (1849 to 1853) only 13-5. In the middle period (1844 to 1848) 
 they were 20'6. 
 
 In the three tables the greater proportion of admissions in the 
 six months, from June to November, is well shown— it is 24*1 ; 
 whereas that from December to May is 14. And if we omit the 
 last quinquennial period — that in which fever admissions were 
 comparatively few — we find that the proportion differs still more 
 widely. That from June to November the fevers are 28-8 per cent. 
 of the total admissions. From December to May they are 15. 
 The month of October, however, is that of greatest prevalence — 
 they amount to 37*5 per cent. 
 
 When we regard the mortality from fever in this hospital, we 
 find it to be very uniform for these three periods. In the first 
 table it is 3-5 per cent, of the admissions; in the second 3-3; 
 
 * They are chiefly intermittenl and remittent. The proportion of ephemeral i 
 is very small; it is only given for the first quinquennial period, in which they 
 
 amounted to &■) per cent, of the total fever admissions. 
 
EUKOrEAN GENERAL HOSPITAL. 
 
 171 
 
 in the third 3 - l.* From 1838 to 1848 the proportion of fever 
 mortality to total hospital deaths is 12-1 ; but from 1849 to 1853 
 it is only 6*7. 
 Table V. — Admissions and Deaths, ivith Per-centage, from Fever of all 
 
 kinds, in the European General Hospital at Bombay, for the Six Years 
 
 from July 1838 to July 1843. 
 
 
 
 
 July 1838 to July 1813. 
 
 Monthly Average of the Six Years. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 on total 
 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 
 105 
 
 5 
 
 4.7 
 
 191 
 
 115 
 
 February 
 
 
 
 55 
 
 2 
 
 36 
 
 13-3 
 
 6-2 
 
 March . 
 
 
 
 74 
 
 3 
 
 4- 
 
 145 
 
 9- 
 
 April . 
 
 
 
 88 
 
 5 
 
 5-6 
 
 151 
 
 12-1 
 
 May . 
 
 
 
 154 
 
 3 
 
 1-9 
 
 17-9 
 
 3-7 
 
 June 
 
 
 
 219 
 
 6 
 
 27 
 
 28-4 
 
 117 
 
 July . 
 
 
 
 219 
 
 7 
 
 31 
 
 30-5 
 
 18-9 
 
 August . 
 
 
 
 179 
 
 8 
 
 4-4 
 
 29-3 
 
 22-8 
 
 September 
 
 
 
 141 
 
 8 
 
 5-6 
 
 25-8 
 
 153 
 
 October 
 
 
 
 318 
 
 6 
 
 1-8 
 
 44- 
 
 222 
 
 November 
 
 
 
 193 
 
 5 
 
 2-5 
 
 28.1 
 
 10-6 
 
 December 
 
 
 
 94 
 
 8 
 
 8-5 
 
 15-3 
 
 12-1 
 
 Total 
 
 
 
 1839 
 
 66 
 
 3-5 
 
 24-2 
 
 12-1 
 
 Table VI. — Admissions and Deaths, with Per-centage, from Fever of all 
 kinds, in the European General Hospital at Bombay, for the Five Years 
 from 1844 to 1848. 
 
 
 
 
 1844 to 1848. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 on total 
 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 
 February 
 
 March . 
 
 April . 
 
 May . 
 
 June 
 
 July . 
 
 August 
 
 September 
 
 October 
 
 November 
 
 December 
 
 
 
 105 
 
 85 
 
 59 
 
 67 
 
 99 
 
 172 
 
 196 
 
 154 
 
 100 
 
 188 
 
 136 
 
 58 
 
 6 
 4 
 1 
 2 
 4 
 5 
 4 
 4 
 2 
 8 
 5 
 2 
 
 57 
 4-7 
 1-7 
 3-0 
 4-0 
 2-9 
 2-0 
 2-6 
 2-0 
 4-2 
 37 
 3-4 
 
 17-0 
 16-5 
 12-2 
 13-1 
 169 
 24-1 
 28-8 
 28-1 
 21-8 
 311 
 24-3 
 11-1 
 
 13-0 
 11-5 
 
 3-3 
 
 65 
 13-3 
 15-2 
 111 
 26-6 
 
 91 
 21-0 
 16-4 
 
 5-0 
 
 Total 
 
 
 
 1419 
 
 47 
 
 3-3 
 
 20-6 
 
 12-1 
 
 * Dr. Stovell's report (" Statistics of European General Hospitals for Ten Years," 
 " Transactions of Medical and Physical Society, Bombay," New Series, No. 3) extends 
 to March 1856 ; and shows a decreasing mortality from fever, that for the five years 
 from 1851 to 1856, being 0789. 
 
172 
 
 STATISTICS OF FEVER. 
 
 Table VII. — Admissions and Deaths, with Per-centage, from Fever of all 
 kinds, in the European General Hosjyital at Bombay, for the Five Years 
 from 1849 to 1853. 
 
 
 
 
 1849 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total Deaths 
 
 January 
 February 
 March . 
 April . 
 May . 
 June 
 July . 
 August . 
 September 
 October 
 November 
 December 
 
 
 
 48 
 38 
 43 
 45 
 91 
 78 
 87 
 62 
 49 
 52 
 93 
 93 
 
 4 
 3 
 
 3 
 
 1 
 4 
 3 
 
 
 5 
 1 
 
 8-3 
 
 7-8 
 
 6-6 
 
 1-3 
 
 4-6 
 4-8 
 
 5-3 
 1-1 
 
 10-6 
 10-3 
 9-8 
 8-7 
 17-5 
 13-6 
 16-4 
 12-0 
 13-8 
 132 
 17-8 
 15-3 
 
 103 
 16-6 
 
 12-0 
 
 3-4 
 121 
 
 7'8 
 
 16-6 
 2-5 
 
 Total 
 
 
 
 779 
 
 24 
 
 3-1 
 
 13-5 
 
 67 
 
 Section II. — European General Hospital. — Intermittent Fever. 
 
 Tables VII L, IX., X. give the admissions from intermittent 
 fever, from 1838 to 1853, also arranged in three quinquennial 
 periods. They show that the proportion of this type to the total 
 admissions from fever has been 73-6 per cent. 
 
 We found from Tables V., VI., VII. that the proportion of fever 
 admissions from June to November was nearly double that of from 
 December to May ; but the present Tables show that the excess of 
 the first half year is not due to admissions of the intermittent 
 type, for the proportions of intermittents to total fevers is from 
 June to November 72*3, and from December to May 75*1. 
 
 The deaths are 1*1 per cent, of the admissions. It has been 
 stated (p. 24) that we have no data which correctly show the 
 mortality from simple intermittent fever. Much of the mortality 
 stated in these tables (and I may add in hospital returns generally) 
 is, I am satisfied not accurately recorded as directly proceeding 
 from intermittent fever. It occurs from inflammations arising in 
 malaria-tainted constitutions, and should be entered under the 
 I ( :id of the inflammation, whatever it may be. 
 
 Table XI. shows the ephemeral fevers from 1838 to 1843. 
 
EUROPEAN GENERAL HOSPITAL. 
 
 173 
 
 Table VIII. — Admissions and Deaths, with Per-ecntage, from Intermittent 
 Fever, in the European General Hospital at Bombay, for the Five Tears 
 from July 1838 to July 1843. 
 
 
 
 
 July 1838 to July 1843. 
 
 Monthly Averng 
 
 B. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on 
 total Fever 
 Admissions. 
 
 Deaths on 
 
 total Fever 
 
 Deaths. 
 
 January 
 
 77 
 
 1 
 
 1-3 
 
 73-3 
 
 200 
 
 February 
 
 
 
 43 
 
 1 
 
 2-3 
 
 78-2 
 
 50-0 
 
 March . 
 
 
 
 59 
 
 2 
 
 3-4 
 
 797 
 
 66-0 
 
 April . 
 
 
 
 60 
 
 2 
 
 3-4 
 
 .68-2 
 
 40-0 
 
 May . 
 
 
 
 109 
 
 1 
 
 0-9 
 
 64-3 
 
 33-3 
 
 June 
 
 
 
 169 
 
 1 
 
 0-6 
 
 77-2 
 
 167 
 
 July . 
 
 
 
 1^6 
 
 1 
 
 0-8 
 
 62-1 
 
 14-3 
 
 August . 
 
 
 
 113 
 
 
 
 — 
 
 .63-1 
 
 
 
 September 
 
 
 
 92 
 
 2 
 
 22 
 
 65-2 
 
 25-0 
 
 October 
 
 
 
 262 
 
 3 
 
 1-15 
 
 82-4 
 
 50-0 
 
 November 
 
 
 
 151 
 
 
 
 . 
 
 78-2 
 
 
 December 
 
 
 
 73 
 
 4 
 
 O'O 
 
 777 
 
 50-0 
 
 Total 
 
 
 
 1344 
 
 18 
 
 1-3 
 
 72-0 
 
 27-3 
 
 Table IX. — Admissions and Deaths, with Per-centage, from Intermittent 
 Fever, in the European General Hospital at Bombay, for the Five Years 
 from 1844 to 1848, 
 
 
 
 
 1844 to 1848. 
 
 Monthly Averag 
 
 p. 
 
 
 
 
 Deaths 
 
 Admissions 
 
 Deaths 
 
 
 Admissions. 
 
 
 
 on 
 
 on 
 
 
 
 
 Admissions. 
 
 total Fever 
 Admissions. 
 
 total Fever 
 Deaths. 
 
 January 
 
 87 
 
 1 
 
 1-1 
 
 82-9 
 
 16-6 
 
 February 
 
 
 
 69 
 
 1 
 
 1-4 
 
 81-2 
 
 25-0 
 
 March . 
 
 
 
 51 
 
 
 
 — 
 
 86-5 
 
 
 
 April . 
 
 
 
 57 
 
 
 
 — 
 
 85-1 
 
 
 
 May 
 
 
 
 88 
 
 
 
 — 
 
 88-8 
 
 — 
 
 June 
 
 
 
 144 
 
 1 
 
 0-7 
 
 83-7 
 
 20-0 
 
 July . 
 
 
 
 163 
 
 3 
 
 1-8 
 
 83-2 
 
 75-0 
 
 August . 
 
 
 
 116 
 
 
 
 — 
 
 74-0 
 
 
 
 September 
 
 
 
 81 
 
 
 
 — 
 
 81-0 
 
 
 
 October 
 
 
 
 167 
 
 4 
 
 2-4 
 
 88-S 
 
 50-0 
 
 November 
 
 
 
 114 
 
 2 
 
 1-7 
 
 83-8 
 
 40-0 
 
 December 
 
 
 
 44 
 
 
 
 — 
 
 76-0 
 
 — 
 
 Total 
 
 
 
 1181 12 
 
 102 
 
 83-2 
 
 25-0 
 
174 
 
 STATISTICS OF FEVER. 
 
 Table X. — Admissions and Deaths, ivith Per-centage, from Intermittent 
 Fever, in the European General Hospital at Bombay, for the Five Years 
 from 1849 to 1853. 
 
 
 
 
 1849 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths 
 on 
 
 Admissions. 
 
 Admissions 
 
 on 
 total Fever 
 Admissions. 
 
 Deaths 
 
 on 
 
 total Fever 
 
 Deaths. 
 
 January 
 
 32 
 
 2 
 
 6-3 
 
 66-6 
 
 50-0 
 
 February 
 
 
 
 25 
 
 
 
 — 
 
 65-8 
 
 — 
 
 March . 
 
 
 
 32 
 
 
 
 — 
 
 74-4 
 
 — ■ 
 
 April . 
 
 
 
 30 
 
 1 
 
 3-3 
 
 66-6 
 
 33-3 
 
 May . 
 June 
 
 
 
 60 
 46 
 
 
 
 
 — 
 
 65-9 
 58'9 
 
 — 
 
 July 
 
 
 
 53 
 
 1 
 
 1-9 
 
 60-9 
 
 25-0 
 
 August . 
 
 September 
 
 October 
 
 
 
 37 
 30 
 32 
 
 1 
 
 
 
 
 27 
 
 597 
 61-2 
 61-5 
 
 33-3 
 
 November 
 
 
 
 67 
 
 
 
 — 
 
 ■ 72-0 
 
 — 
 
 December 
 
 
 
 67 
 511 
 
 
 
 — 
 
 72-0 
 
 — 
 
 Total 
 
 
 
 5 
 
 0-98 
 
 65-6 
 
 20-8 
 
 Table XI. — Admissions and Deaths, with Per-centage, from Ephemeral 
 Fever, in the European General Hospital at Bombay, for the Five Years 
 from July 1838 to June 1843. 
 
 
 
 
 July 1838 to June 1843. 
 
 w 
 
 onthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 on 
 total Fever 
 Admissions. 
 
 Deaths on 
 
 total Fever 
 
 Deaths. 
 
 January 
 
 13 
 
 
 
 
 
 12-4 
 
 
 
 February 
 
 
 
 5 
 
 
 
 
 
 8-9 
 
 
 
 March . 
 
 
 
 8 
 
 
 
 
 
 10-8 
 
 
 
 April . 
 May . 
 June 
 
 
 
 9 
 21 
 23 
 
 
 
 
 
 
 
 
 
 10-2 
 13-6 
 
 10-5 
 
 
 
 
 
 
 July . 
 August . 
 
 
 
 8 
 17 
 
 
 
 
 
 
 
 
 37 
 9-5 
 
 
 
 
 September 
 
 October 
 
 
 
 15 
 23 
 
 
 
 
 
 
 
 
 10-5 
 
 7-2 
 
 
 
 
 November 
 
 
 
 9 
 
 
 
 
 
 4-6 
 
 
 
 December 
 
 
 
 8 
 
 
 
 
 
 8-5 
 
 
 
 Total 
 
 
 
 159 
 
 
 
 
 
 8-7 
 
 
 
JAMSETJEE JEJEEBHOY nOSPITAL. 175 
 
 Section III. — Jamsetjee JejeebJioy Hospital. — Total Fevers. 
 
 Table XII. gives the total admissions of fever into this hospital 
 from 1848 to 1853, a period of six years ; they amount to 2,473.* 
 Compared with the European Greneral Hospital, it shows a smaller 
 proportion of fevers to total admissions ; it is 9*8, that in the 
 European Greneral Hospital for the same years is 13*5 per cent. In 
 the half year from June to November the excess is also less ; the 
 proportion is 10 - 8 per cent, of the total hospital admissions, while 
 in the half year from December to May it is 8*6. But in compar- 
 ing this proportion with the average of the European General 
 Hospital we must bear in mind that for the years included in this 
 Table (XII.) the difference between the two half years was in the 
 European Greneral Hospital much below that of the ten preceding 
 years. It was from June to November 14*4 ; from December to 
 May 12. 
 
 The mortality from fever in this Hospital has been 12-4 per cent.; 
 that in the European Greneral Hospital was 3*3. 
 
 In this difference we have an illustration of the kind of errors to 
 which statistical statements must inevitably lead when applied to 
 etiology and therapeutics, unless used by those who are familiar 
 with all the circumstances of the individuals to whom the figures 
 relate. 
 
 A statistical inquirer, from a comparison of the mortality in the 
 European Greneral Hospital for Europeans, and the Jamsetjee 
 Jejeebhoy Hospital for Natives, as shown in Tables V., VI., VII. and 
 XII., might infer that fever is a more fatal disease in Natives than 
 in Europeans, and that the treatment of the disease was not so well 
 understood in the one hospital as in the other. 
 
 But I, who have had a lengthened clinical experience in both 
 hospitals, know that these inferences would be altogether erroneous. 
 The high mortality in the Jamsetjee Jejeebhoy Hospital is simply 
 due to the very destitute state of a large proportion of its inmates, 
 and the very advanced stages of disease at which they seek for 
 admission. 
 
 * The clinical eases, so frequently adverted to, were selections from this number. 
 
176 
 
 STATISTICS OF FEVEI\ 
 
 Table XII. — Admissions and Deaths, with Per-centage, from Remittent 
 and Intermittent Fever*, in the Jamsetjee Jejeebhoy Hospital at Bombay, 
 for the Six Years from 1848 to 1853. 
 
 
 
 
 lb-18 to 1853. 
 
 Monthly Avcrag 
 
 e. 
 
 
 
 
 Deaths on 
 
 Admissions 
 
 \ Deaths 
 
 
 Admissions. 
 
 Deaths. 
 
 on total 
 
 on total 
 
 
 
 
 
 Admissions. 
 
 Deaths. 
 
 January 
 
 183 
 
 40 
 
 21-8 
 
 87 
 
 8-9 
 
 February 
 
 
 
 116 
 
 30 
 
 20-6 
 
 7-2 
 
 9-4 
 
 March . 
 
 
 
 139 
 
 23 
 
 16o 
 
 6o 
 
 59 
 
 April . 
 
 
 
 168 
 
 16 
 
 9-5 
 
 7-9 
 
 4-6 
 
 May . 
 
 
 
 218 
 
 20 
 
 9-1 
 
 9-9 
 
 6-9 
 
 June 
 
 
 
 191 
 
 20 
 
 10-3 
 
 9-3 
 
 6-5 
 
 July . 
 
 
 
 210 
 
 19 
 
 9-04 
 
 10-4 
 
 6-2 
 
 August . 
 
 
 
 214 
 
 18 
 
 8-4 
 
 10-8 
 
 5-5 
 
 September 
 
 
 
 202 
 
 26 
 
 12-3 
 
 9-8 
 
 8-3 
 
 October 
 
 
 
 274 
 
 27 
 
 9-9 
 
 12-8 
 
 7-9 
 
 November 
 
 
 
 251 
 
 26 
 
 10-3 
 
 11-6 
 
 7-8 
 
 December 
 
 
 
 274 
 
 43 
 
 15-7 
 
 11-8 
 
 10-8 
 
 Total 
 
 
 
 2,473 
 
 308 
 
 12-4 
 
 9-8 
 
 7o 
 
 Section IV. — Jamsetjee Jejeebhoy Hospital. — Intermittent Fever. 
 
 The proportion of admissions of this type to the total fevers is 
 69*1 ; that for the half year from June to November being 72*5 ; 
 that from December to May 63*9. The mortality is 09. 
 
 In the proportion of intermittents in the two half-yearly periods, 
 we have the converse of what is stated in respect to the European 
 General Hospital : in it the greater proportion is in the half year 
 including the cold months of the year. In the Jamsetjee Jejeeb- 
 hoy Hospital it is in the half year which includes the malarious 
 months. 
 
 Tli is discrepancy is to be explained by the fact, that, in the Eu- 
 ropean General Hospital, a considerable proportion of the admis- 
 sions from intermittent fever are of individuals who have arrived 
 from other malarious countries, and who, reaching Bombay in the 
 cold season, have the disease re-excited, not by the malaria of 
 Bombay as an exciting cause, but by cold or other atmospheric 
 states acting on a tainted system. This is not the case in the 
 Jamsetjee Jejeebhoy Hospital to nearly the same extent. 
 
 * This Table mighl have been entitled " Fevers of all Kinds, 
 under (ho head "Ephemeral" have been vn-y few. 
 
 for the admissions 
 
EUEOrEAN GENERAL HOSPITAL. 
 
 177 
 
 Table XIII. — Admissions and Deaths, with Per-centage, from Intermittent 
 Fever, in the Jeunsetjee Jcjccbhoy Hospital at Bombay, for the Six Years 
 from 1848 to 1853. 
 
 Section V. — European General Hospital. — Remittent Fever. 
 
 Tables XIV., XV., XVI. show that the proportion of this type, 
 to the total fevers, is 16*6 * per cent. 
 
 When we compare the proportion in the half-years, from June to 
 November, and December to May, we find that it was 19-8 per cent, 
 in the former, and 13-6 in the latter. 
 
 The mortality from this type is, for the 15 years f, 15*1 per 
 cent, on the admissions, and 76*1 per cent, of the total deaths 
 from fever. 
 
 In regarding the mortality from remittent fever in this hospital, 
 it must be borne in mind that, from the variety in the inmates, 
 and the not unfrequent advanced periods of admission, it is neces- 
 sarily higher than that of European regimental hospitals. 
 
 * That 166 of this type, with the proportion of Intermittents, does not complete the 
 total admissions, is to be explained by the abstraction of 8 - 7 for Ephemerals in the 
 first qiiinquennial period. 
 
 t Dr. Storell's decennial Report shows a remarkable decrease in the mortality, from 
 1853 to 1856. For the fire years from 1846 to 1851, the ratio keeps up to that in the 
 text it is 15123 ; but for the five years from 1S51 to 1856, it falls to 4-838 per cenl 
 
 N 
 
178 
 
 STATISTICS OF FEVER. 
 
 Table XIV. — Admissions and Deaths, with Per-centage, from Remittent 
 Fever, in the European General Hospital at Bombay, for the Five Years 
 from July 1838 to June 1843. 
 
 
 
 
 July 1838 to June 1843. 
 
 Monthly Average for the Five Years. 
 
 
 
 
 Deaths 
 
 Admissions 
 
 Deaths 
 
 
 Admissions. 
 
 Deaths. 
 
 on 
 
 Admissions. 
 
 total Fever 
 Admissions. 
 
 total Fever 
 Deaths. 
 
 January 
 
 15 
 
 4 
 
 26-6 
 
 14-1 
 
 80-0 
 
 February 
 
 
 
 7 
 
 1 
 
 14-2 
 
 12-7 
 
 50-0 
 
 March . 
 
 
 
 7 
 
 1 
 
 14-2 
 
 9-4 
 
 33-3 
 
 April . 
 
 
 
 19 
 
 3 
 
 157 
 
 215 
 
 60-0 
 
 May . 
 
 
 
 2-4 
 
 2 
 
 8-3 
 
 15-5 
 
 66-6 
 
 June 
 
 
 
 27 
 
 5 
 
 18-5 
 
 12-3 
 
 83-3 
 
 July 
 
 
 
 75 
 
 6 
 
 8-0 
 
 34-7 
 
 857 
 
 August . 
 
 
 
 49 
 
 8 
 
 163 
 
 27-3 
 
 1000 
 
 September 
 
 
 
 34 
 
 6 
 
 17-6 
 
 24-1 
 
 75-0 
 
 October 
 
 
 
 33 
 
 3 
 
 9-0 
 
 10-3 
 
 50-0 
 
 November 
 
 
 
 33 
 
 5 
 
 15-1 
 
 17-0 
 
 100-0 
 
 December 
 
 
 
 13 
 
 4 
 
 30-0 
 
 13-7 
 
 50-0 
 
 Total 
 
 
 
 336 
 
 48 
 
 11-2 
 
 17-6 
 
 72-7 
 
 Table XV. — Admissions and Deaths, with Per-centage, from Remittent 
 Fever, in the European General Hospital at Bombay, for the Five Years 
 from 1844 to 1848. 
 
 
 
 
 1844 to 1848. 
 
 Monthly Averag 
 
 
 
 
 
 Deaths 
 
 Admissions 
 
 Deaths 
 
 
 Admissions. 
 
 Deaths. 
 
 on 
 Admissions. 
 
 total Fever 
 Admissions. 
 
 total Fever 
 Deaths. 
 
 January 
 
 16 
 
 5 
 
 31-3 
 
 15-2 
 
 83-3 
 
 February 
 
 
 
 10 
 
 2 
 
 20-0 
 
 11-7 
 
 50-0 
 
 March . 
 
 
 
 5 
 
 1 
 
 20-0 
 
 8-5 
 
 100-0 
 
 April 
 
 
 
 10 
 
 1 
 
 10-0 
 
 14-9 
 
 .Mill 
 
 May . 
 
 
 
 11 
 
 4 
 
 364 
 
 11-1 
 
 100-0 
 
 June 
 
 
 
 25 
 
 4 
 
 16-0 
 
 14-5 
 
 80-0 
 
 July . 
 
 
 
 25 
 
 3 
 
 120 
 
 12-7 
 
 75-0 
 
 August . 
 
 
 
 36 
 
 4 
 
 11-1 
 
 234 
 
 LOO-0 
 
 September 
 
 
 
 16 
 
 2 
 
 12-5 
 
 160 
 
 LOO-0 
 
 ( Ictober 
 
 
 
 21 
 
 
 
 23-8 
 
 11-2 
 
 62-5 
 
 November 
 
 
 
 20 
 
 3 
 
 15-0 
 
 14 7 
 
 60-0 
 
 ! »i • mber 
 
 
 
 11 
 
 18-2 
 
 18-9 
 
 1(10-0 
 
 Total 
 
 
 
 206 
 
 36 
 
 171 
 
 14o 
 
 766 
 
JAMSETJEE JEJEEBIIOY IIO.SriTAL. 
 
 179 
 
 Table XVI. — Admissions and Deaths, with Per-centage, from Remittent 
 Fever, in the European General Hospital at Bombay, for the Five Years 
 from 1849 to 1853. 
 
 Section VI. — Ja/msetjee Jejeebhoy Hospital. — Remittent Fever. 
 
 The proportion of remittents to intermittents is 32*1 per cent. : 
 double that of the European General Hospital. If the inference 
 be drawn from this statement that the remittent is more frequent 
 in Natives, compared with the intermittent type, than in Europeans, 
 it would be a correct deduction from the tables ; but it would be 
 an application of the figures to a question which they are not 
 calculated to solve. The fact is, that natives do not readily 
 resort to a civil hospital for mild attacks of fever ; therefore the 
 proportion of the severer type is greater than in a Eurojaean hos- 
 pital, partly civil and partly military in its character. 
 
 In the half year from June to November the proportion of 
 this type is 29 ; in the half year from December to May it is 3G 
 per cent. We have found that, from June to November the pro- 
 portion of remittents was greater, but that of intermittents was less, 
 in the European General Hospital ; whereas in the Jamsetjee 
 Jejeebhoy Hospital the proportion of remittents was less, that of 
 intermittents was greater. On the other hand, in the half year 
 from December to May intermittents were proportionally greater, 
 and remittents less, in the European General Hospital ; but in the 
 Jamsetjee Jejeebhoy Hospital the proportion of remittents ex- 
 ceeded that of the intermittents, and fell short of that of the other 
 half year. 
 
 N 2 
 
180 
 
 STATISTICS OF FEVER. 
 
 It may be suggested, in explanation of the greater proportional 
 prevalence of remittent fever in the native inmates of the Jamsetjee 
 Jejeebhoy Hospital, in the half year including the cold months, 
 than in that including the malarious months — that many of 
 them are instances of malarious fever, assuming the remittent 
 character in consequence of inflammatory complication — pneumonia 
 or other — induced by cold, to the influence of which, as an exciting- 
 cause, the badly fed and clothed classes of the native community 
 are very susceptible. 
 
 The greater proportion of fever deaths in natives in Bomba} 7 , 
 in the half year from December to May, also appears in Mr. 
 Leith's Mortuary Eeturns ; it is — for the five years from February 
 1848 to January 1853 — 54-44 of the total mortality; whereas the 
 proportion for the half year from June to November is 45 "55. 
 This fact is also to be explained in the same manner, with the 
 addition that, as a large number of the returns are made from non- 
 professional sources, it is probable that part of the mortality 
 recorded as due to fevers has been caused by inflammations with 
 symptomatic fever. This is Mr. Leith's opinion. 
 
 I have already explained the probable cause of the proportional 
 excess of intermittents in the European General Hospital in the 
 non-malarious half of the year. We have found, however, that the 
 remittent type is in greatest proportion in the malarious six months 
 — for then we have a more fixed community, and more of the 
 influence of the malaria of the island as an exciting cause. 
 
 Table XVII. — Admission and Deaths, with Per-eentage, from Remit hut 
 Fever, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six Years 
 fr.nn 1848 to 1853. 
 
 
 
 
 1818 to 1853. 
 
 Monthly Averag 
 
 e. 
 
 
 
 
 
 Admissions 
 
 Deaths 
 
 
 Admissions. 
 
 Deaths. 
 
 Dpaths on 
 Admissions. 
 
 on 
 total Fever 
 
 on 
 total Fever 
 
 
 
 
 
 Admissions. 
 
 Deaths. 
 
 January 
 
 76 
 
 34 
 
 447 
 
 415 
 
 850 
 
 February 
 
 
 
 57 
 
 27 
 
 473 
 
 39 04 
 
 90-0 
 
 March . 
 
 
 
 GO 
 
 23 
 
 383 
 
 431 
 
 100-0 
 
 April . 
 
 
 
 57 
 
 1G 
 
 28-1 
 
 33-9 
 
 100-0 
 
 May . 
 
 
 
 7<) 
 
 18 
 
 257 
 
 321 
 
 90-0 
 
 June 
 
 
 
 42 
 
 20 
 
 476 
 
 21*6 
 
 1000 
 
 July . 
 
 
 
 51 
 
 16 
 
 31-4 
 
 243 
 
 84-2 
 
 \ ugusl . 
 
 
 
 71 
 
 17 
 
 22-9 
 
 34 6 
 
 94-4 
 
 September 
 
 
 
 71 
 
 26 
 
 36-6 
 
 :?.">• i 
 
 100-0 
 
 October 
 
 
 
 89 
 
 26 
 
 292 
 
 32-5 
 
 93-3 
 
 Novembi c 
 
 
 
 <;.-> 
 
 20 
 
 in ii 
 
 25 9 
 
 100-0 
 
 December 
 
 
 
 72 
 
 12 
 
 58-3 
 
 263 
 
 977 
 
 Total 
 
 
 
 7-1 
 
 201 
 
 371 
 
 321 
 
 94-5 
 
BYCULLA SCHOOLS. 
 
 181 
 
 Section VII. — Bycidla Schools. — Intermittent and Remittent 
 
 Fever. 
 
 The averages are not given in the following table, because the 
 " strength " of the children and the total admissions are not known. 
 The strength has ranged from about 235 to 355. 
 
 It will be observed that there are no deaths from intermittent 
 fever, and that the ratio of mortality from remittent fever is 2*8 
 per cent, of admissions. 
 
 Table XVIII. — Admissions and Deaths, from Intermitent and Remittent 
 Fever, in the Byculla Schools, for the Seventeen Years from 1837 to 
 1853. 
 
 
 
 
 
 
 Intermittent Fever. 
 
 Remittent Fever. 
 
 
 Admissions. 
 
 Deaths. 
 
 Admissions. 
 
 Deaths. 
 
 January ..... 
 
 160 
 
 
 
 16 
 
 1 
 
 February- 
 
 
 
 
 
 149 
 
 
 
 21 
 
 1 
 
 March 
 
 
 
 
 
 153 
 
 
 
 17 
 
 
 
 April 
 
 
 
 
 
 172 
 
 
 
 11 
 
 
 
 May 
 
 
 
 
 
 181 
 
 
 
 9 
 
 
 
 June 
 
 
 
 
 
 214 
 
 
 
 20 
 
 1 
 
 July 
 
 
 
 
 
 284 
 
 
 
 47 
 
 2 
 
 August . 
 
 
 
 
 
 260 
 
 
 
 19 
 
 1 
 
 September 
 
 
 
 
 
 250 
 
 
 
 20 
 
 
 
 October . 
 
 
 
 
 
 226 
 
 
 
 9 
 
 
 
 November 
 
 
 
 
 
 197 
 
 
 
 12 
 
 
 
 December 
 
 
 
 
 
 117 
 
 
 
 12 
 
 
 
 Total 
 
 
 
 
 
 2,366 
 
 
 
 213 
 
 6 
 
 S3 
 
182 
 
 ERUPTIVE FEVERS. 
 
 CHAP. XIL 
 
 ON ERUPTIVE FEVERS. 
 
 Section I. — Prevalence in the Native Army. 
 
 The following statement exhibits the comparative prevalence of the 
 different kinds of eruptive fever in the native army of the Madras 
 and Bombay Presidencies for the five years from 1851-52 to 
 1855-56: — 
 
 
 MADRAS. 
 
 BOMBAY. 
 
 Admissions. 
 
 Deaths. 
 
 22 
 1 
 
 1 
 
 Admissions. 
 
 Deaths. 
 
 Varicella .... 
 Rubeola .... 
 Scarlatina .... 
 
 Total . 
 
 495 
 
 1.229 
 
 114 
 
 1 
 
 310 
 612 
 113 
 
 21 
 
 1,839 
 
 24 
 
 1,035 
 
 21 
 
 The proportion of small-pox in the Bombay Presidency is probably 
 understated, in consequence of cases being returned "varicella," 
 which are in reality modified small-pox. At all events, I observed 
 in the hospitals at Poona, in the early part of 1858, when small pox- 
 prevailed, several cases in which this error of diagnosis had been 
 committed. 
 
 Section II. — Small-pox, as observed in Bombay. — Prevalence. — 
 Prevention by Vaccination. 
 
 During five years of my service in the European General 
 Hospital, from July 1838 to July 1843, 32 cases of small-pox 
 were admitted. Of these 25 took place in the months of January, 
 February, March, and April:! in the month of November, that of 
 1839 ; and 3 — one in each month — in May, June, and July ; and 
 in the months of August, September, October, and December, there 
 
SMALL-POX 
 
 STATISTICS. 
 
 183 
 
 was not, during these five years, a single admission from small- 
 pox. There were 5 deaths, which gives a mortality of 15*6 per 
 cent. 
 
 During the ten succeeding years — from 1844 to 1853 — there 
 were 49 admissions of small-pox into the European General Hos- 
 pital, and of these 44 were in the five months from January to 
 May. The deaths were 12, being a mortality rate of 25*6 per 
 cent. 
 
 In the course of the seventeen years from 1837 to 1853, 23 
 children of the Byculla Schools suffered from small-pox, and 3 of 
 them died, a mortality of 13 per cent ; but the disease did not pre- 
 vail in each year of this period, 1838, 1841, 1843 to 1848 inclusive ; 
 1852 and 1853 were exempt. 
 
 The subjoined tabular statement shows the admissions from 
 .small-pox into the Jamsetjee Jejeebhoy Hospital for the six years 
 from 1848 to 1853 : — 
 
 
 
 
 
 Total. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions .,, ., 
 on total Ad- , deaths on 
 missions. total Deatlls - 
 
 January 
 
 32 
 
 9 
 
 28 
 
 1 
 
 1-5 
 
 2-0 
 
 February 
 
 
 
 59 
 
 18 
 
 30 
 
 5 
 
 3-1 
 
 5-6 
 
 March . 
 
 
 
 74 
 
 29 
 
 38 
 
 8 
 
 3-4 
 
 7'5 
 
 April 
 
 
 
 
 52 
 
 28 
 
 53 
 
 8 
 
 2-4 
 
 8-1 
 
 May 
 
 
 
 
 17 
 
 11 
 
 64 
 
 6 
 
 07 
 
 3-8 
 
 June 
 
 
 
 
 6 
 
 1 
 
 16 
 
 6 
 
 0-2 
 
 0-3 
 
 July 
 
 
 
 
 10 
 
 3 
 
 30-0 
 
 05 
 
 0-9 
 
 August 
 
 
 
 2 
 
 3 
 
 15-0 
 
 01 
 
 0-8 
 
 September 
 
 
 
 1 
 
 — 
 
 — 
 
 0-05 
 
 — 
 
 October 
 
 
 
 — 
 
 ■ — 
 
 — 
 
 — 
 
 — 
 
 November 
 
 
 
 1 
 
 1 
 
 100.0 
 
 0-05 
 
 0-3 
 
 December 
 
 
 
 7 
 
 1 
 
 14.3 
 
 0-3 
 
 0-3 
 
 T 
 
 3tal 
 
 • 
 
 
 261 
 
 104 
 
 39-8 
 
 1-03 
 
 2-5 
 
 Though daily visiting the small-pox ward during the pre- 
 valence of the disease in these six years and the three preceding- 
 ones, it was in the months of December 1845, January, February, 
 and March 1846, that I took immediate charge of the small-pox 
 patients, and made the following notes on the disease, as it occurs 
 in the hospital frequenting classes of the native community of 
 Bombay. 
 
 The number of admissions, and deaths from small-pox, during 
 these four months, are shown in this tabular statement : — 
 
 n4 
 
18i 
 
 ERUPTIVE FEVERS. 
 
 u 
 
 Months. 
 
 •a 
 a> 
 c 
 '« 
 S 
 
 •3 
 
 1 
 
 -3 
 
 "3 
 o 
 H 
 
 ■a 
 
 60 
 0) 
 
 Q 
 
 •a 
 
 n 
 
 be 
 
 'H 
 '3 
 S 
 
 c 
 
 1845 
 1846 
 
 
 3 
 4 
 4 
 
 5 
 
 10 
 
 8 
 
 26 
 
 5 
 13 
 12 
 
 30 
 
 2 
 4 
 
 ? 
 
 5 
 
 6 
 
 12 
 
 23 
 
 3 
 
 4 
 
 4 
 
 11 
 
 Total . . . 
 
 — 
 
 49 
 
 — 
 
 1 
 
 1 15 
 
 — 
 
 It exhibits a mortality of 46 per cent. The fatal cases were, 
 with very few exceptions, markedly confluent, and death took place 
 on the 3rd, 4th, 6th, 7th, 8th, 9th, 10th, and 11th days of the 
 eruption. 
 
 The cases which proved fatal before the seventh day of the erup- 
 tion, were generally instances in which the eruptive fever had been 
 characterised by very urgent symptoms, as delirium, much anxiety, 
 vomiting, pain of loins, badly-developed pulse, and had extended 
 beyond the usual period, having in two instances continued till the 
 fifth day. These symptoms were succeeded by a badly-developed 
 eruption. In these cases the urgent symptoms abated somewhat 
 on the first appearance of the eruption, but they in general re- 
 curred on the second and succeeding days, and proved fatal about 
 the fourth and fifth, with delirium, sinking pulse, and coma. Such 
 form of fatal result is to be accounted for, in a majority of cases, by 
 the circumstance of the febrile state being more or less congestive 
 and adynamic in type. There are, however, cases occasionally 
 to be observed which prove fatal under very much the same train 
 of symptoms, and at the same stage, in consequence of con- 
 gestion taking place in important organs, — as the lungs, — 
 during the eruptive fever, and, by its presence, preventing the 
 free development of the eruption. I have seen more than one 
 case fatal on the third or fourth day of a badly - developed 
 eruption, with complication of pneumonia marked by hurried 
 breathing and rusty sputa, dating back to the period of the erup- 
 tive fever. 
 
 The cases fatal after the seventh day of the eruption (and they 
 constitute the greater number) were generally those in which the 
 eruption had been copious and very confluent, and in which there 
 bad been present hoarseness, with more or less dyspnoea and cough. 
 These signs of laryngeal and tracheal irritation increased towards 
 the eighth day, and proved fatal then, or in the early stage of 
 
SMALL-POX — SYMPTOMS. 
 
 185 
 
 the secondary fever. The eleventh was the latest day of fatal 
 termination. 
 
 In none of the fatal cases were the symptoms usually termed 
 malignant observed, as petechia?, the pustules filling with dark- 
 coloured serum, hematuria or other hemorrhage. In a few of the 
 successful cases, glandular swellings, and the formation of small 
 abscesses, were troublesome during convalescence. In none of them 
 did injured vision take place. 
 
 The admissions from small-pox were, with four exceptions, con- 
 fined to Mussulmans and Portuguese : many of the former were 
 sailors, and probably strangers in Bombay ; several of the latter 
 had recently arrived from Groa. Of the affected with small-pox 
 7 were females, the rest males. The ages of 48 of the number 
 were — 
 
 5 years 
 
 and under 
 
 . 4 
 
 15 „ 
 
 ,, 
 
 . 3 
 
 15 „ 
 
 to 20 
 
 . 6 
 
 20 „ 
 
 to 30 inclusive 
 
 . 29 
 
 30 „ 
 
 to 40 . 
 
 . 4 
 
 40 „ 
 
 to oldest, 55 
 
 . 2 
 
 
 Total . 
 
 . 48 
 
 It is probable that almost all the admissions were of parties 
 unprotected by vaccination or previous small-pox, but on this point 
 it is often impossible to obtain trustworthy information from the 
 inmates of our hospitals ; for they are admitted, not unfrequently, 
 at stages of the disease when incapable of giving a connected history 
 of themselves, and are often unattended by friends able to supply 
 the deficiency. 
 
 Of the admissions which form the subject of these notes, there 
 was only one in which vaccination was undoubted and the marks 
 on the arms distinct. In this case the disease was very modified, 
 and confined to a few vesicles on the face, — and this, though 
 (as is usually observed) the initiatory fever had been very well 
 marked. 
 
 Several interesting cases of the modifying influence of vaccina- 
 tion came under my notice at Poona in 1858, especially one in the 
 hospital of the Bombay Artillery, and another in that of the 18th 
 Eoyal Irish. In both the initiatory fever ran high, and the 
 eruption came out copiously, with confluence on the face, and 
 up to its fifth day there was every indication of a dangerous attack, 
 when the distinct vesicles acuminated, and became turbid. On 
 the sixth day desiccation was in progress on the face, and before 
 
186 ERUPTIVE FEVERS. 
 
 the acme of the natural disease — the eighth day — had arrived, 
 convalescence was well advanced. 
 
 As already stated, I have reason to think that modified 
 small-pox, in its mildest form, is liable to be mistaken for 
 chicken-pox. In chicken-pox there is little initiatory fever. The 
 pellucid vesicles are without central depression ; they come out 
 in successive crops, seldom appear on the face, and their contents 
 become turbid before desiccation begins. In modified small-pox the 
 initiatory fever is alwa}^s well marked, often severe. The eruption 
 first appears on the face, then on the trunk and extremities, and 
 is often very scanty. The vesicles are depressed in the centre at 
 first, but they acuminate on the fifth day, their contents become 
 turbid, and on the sixth day they dry into small dark-coloured 
 crusts. In consequence of the eruption on the face preceding that 
 on the other parts of the body, — the character and development by 
 successive crops is in a measure, simulated. But the liability to err 
 in the diagnosis turns on this point, that the period of depression 
 of the vesicles is of short duration, probably not more than twenty- 
 four hours, and is therefore very apt to be overlooked. When there 
 has been marked initiatory fever, acuminated vesicles, with turbid 
 contents, on the face, on the fourth or fifth day of the eruption, 
 with desiccation on the fifth or sixth, and at the same time (fifth or 
 sixth day) acuminated vesicles on the trunk and extremities, there 
 should be no hesitation in regarding the case as modified small- 
 pox — not varicella. 
 
 Treatment. — In the mild distinct small-pox with a moderate 
 eruption Ave may look for recovery ; and, with the exception of 
 mitigating the febrile disturbance by diaphoretics, aperients, if 
 necessary, and attention to purity of air and cleanliness, further 
 medical interference is unnecessary. 
 
 In the confluent form we have another illustration of the speedy 
 prostration of vital actions from the sedative influence of the 
 morbific cause, often aggravated by complicating derangement of 
 important organs. 
 
 All that can be attempted under these circumstances is to endea- 
 vour, by stimulants, nourishment, and opiates, to sustain the sys- 
 tem till the natural course and processes of poison elimination have 
 been gone through. It need hardly be added that attention to purity 
 of air and cleanliness are most important parts of these arrangements. 
 
 Finally, in respect to the initiatory fever the treatment should 
 always be v< iry guarded, and conducted in recollection that the 
 dangers of prostration are likely soon to arise, 
 
SMALL-POX — PREVALENCE, PREVENTION. 187 
 
 Prevalence and Prevention of Small-pox. — The best means of 
 prevention of this still very prevalent and fatal disease continue to 
 engage the attention of the Indian Government. In the report of 
 the Small-pox Commissioners, apppointed by the Government of 
 Bengal in 1850 ; in Mr. Bedford's Statistical Notes on Small-pox, 
 Vaccination, and Inoculation in India*, and in Dr. Mackinnon's 
 paper on the Epidemics of the Bengal and North- West Presidencies!, 
 we have the latest and fullest consideration of this subject in rela- 
 tion to Bengal and the North-Western Provinces, 
 
 In the following remarks, however, I shall confine myself in a 
 great measure to the island of Bombay ; for I believe that in the 
 published mortuary registers of Bombay, prepared since the year 
 1848 with so much care and ability by Mr. Leith, we have data 
 far more trustworthy than are to be obtained of any other part of 
 India. 
 
 From these we learn that during the five years from 1st Febru- 
 ary 1848, to 31st January 1853, 4,038 deaths took place from 
 small-pox in Bombay, and of these 3,203 occurred in children under 
 seven years of age. The proportion of deaths from this disease 
 to the total deaths was, for the five years, 5-83 per cent., the 
 highest being 7-80, in the year 1848, and the lowest 2-70, in 1849. 
 
 The observation made by me in 1846$ — founded on hospital 
 
 records, and on Dr. Stewart's report of the small-pox epidemics in 
 
 Calcutta of 1833, 1838, 1843 — that small-pox prevailed more in 
 
 some months of the year than in others, is amply confirmed by 
 
 Mr. Leith's registers, for in these we find that the deaths from 
 
 small-pox bear, in the different quarters of the year, the following 
 
 proportions to the total deaths : — 
 
 1st Quarter from 1st February to 30th April 11-15 per cent. 
 2nd „ 1st May to 31st July 6-24 
 3rd „ 1st August to 31st October 1/19 „ 
 4th „ 1st November to 31st January P36 ,, 
 
 The tables enable us to enter into still further details, and to 
 allot the proportion of deaths, from small-pox to the different 
 months of the year. Thus — still taking the average of the five 
 years — the proportion in different months is — 
 
 January . . . . .4-18 
 
 February ..... 11-17 
 
 March ' 20-34 
 
 April 24-24 
 
 * " Indian Annals of Medical Science," No. 2, 1853. 
 
 f Ibid. No. 3, 1854. 
 
 t " Transactions, Medical and Physical Society of Bombay," No. 8, p. 28. 
 
188 
 
 ERUPTIVE FEVERS. 
 
 
 
 May 17-47 
 
 June 
 
 
 
 11-36 
 
 July 
 
 
 
 4-51 
 
 August . 
 
 
 
 2-20 
 
 .September 
 
 
 
 1-21 
 
 October 
 
 
 
 •51 
 
 November 
 
 
 
 •90 
 
 December 
 
 
 
 1-84 
 
 Total 
 
 99-93 
 
 The tabular statement of small-pox in the Jamsetjee Jejeebhoy 
 Hospital (p. 183) illustrates this feature of small-pox, viz. that it 
 prevails most in Bombay in the first half of the year, and more in 
 March and April than in other months. The same general law is also 
 true of Calcutta.* A similar characteristic, but much less marked, 
 may probably be observed of small -pox epidemics in Europe. 
 Sydenham distinctly states that the season about the vernal equinox 
 is that most favourable to epidemic small-pox ; and the same fact 
 may be traced more or less through Huxham's " Observations on 
 Air and Epidemics." In the Second Annual Report by the Regis- 
 trar-General of births, deaths, and marriages in England, there is an 
 account of an epidemic small-pox in England in the years 1838, 
 1839, in which this law may be traced, but not so clearly as in the 
 Bombay and Calcutta records. For example, from 1st January to 
 1st July of 1838, there were 8,631 deaths from small-pox; from 
 1st July to 1st January 7,536 deaths, being a decrease of 1,095 
 iD the last half year. From January to July 1839, there were 
 5,487 deaths; but from July to January 1840, there were 3,263, 
 being a decrease in the summer and autumn of 2,224. f 
 
 * Report of the Small-pox Commissioners, Calcutta, 1850, table A. page 9 ; also the 
 following abstract, taken from p. 24 of the same Eeport. 
 
 Table showing the Total Monthly Mortality by Small-pox during Eighteen succes- 
 sive Years, from 1st May 1832, to 1st May 1850, inclusive : — 
 
 November 
 December 
 January 
 February 
 
 120 | March 
 512 April 
 1,316 May 
 2,372 June 
 
 3,689 I July . 
 2,846 August 
 1,419 September 
 761 1 October . 
 
 551 
 189 
 181 
 134 
 
 t This observation, written in 1846 and published (Transactions, Medical and 
 Physical Society of Bombay, No. 8, p. 29) in 1847, does not altogether accord with 
 flu statement made by Mr. Bedford at page 192 of the able and interesting paper 
 already referred to; nor with that of the Small-pox Commissioners of Calcutta at page 
 24 of their Report I have not at present the opportunity nor the time to mak 
 another and more extensive reference to the Report of the Registrar General. 
 
 In 1846 (Transactions, Bombay, Medical Soeiety, No. 8, p. 29), adverting to these 
 facts, which seem to show that the prevalence of small-pox in particular seasons, so 
 
SMALL-POX — PREVALENCE, TREVENTION. 189 
 
 The question of the degree to which the prevalence of small- 
 pox may be attributed to the practice of inoculation, has been dis- 
 cussed in the Bengal reports ; but as respects the island of Bombay 
 it need not be entertained. The practice of inoculation is not, it 
 is believed, followed by any of the classes of the native community 
 of Bombay ; but a greater mortality from small-pox in some years 
 than in others is very observable in Mr. Leith's reports : for 
 example,— 
 
 In 1848. 1849. 1850. 1851. 1852, 
 7-80 2-70 7-635 3-57 7"45 
 
 We gather, then, from Mr. Leith's registers, that the mortality 
 from small -pox in the island of Bombay is very nearly 60 in 1000. 
 
 Small-pox inoculation is not practised in the island, but it is so 
 to some extent in the adjoining Concans; therefore, though the 
 native population of Bombay is not in general protected by inocu- 
 lation, still, from its fluctuating character, a proportion of it pro- 
 bably is so. 
 
 I am unable to state precisely the number of annual vaccinations 
 in Bombay, but the proportion which it bears to the total native 
 population is very small indeed. The mortality from small-pox in 
 
 remarkable in India, may also be traced in European countries, I remarked," Though, 
 then, this law of epidemic small-pox is not peculiar but only more marked in tropical 
 countries, it is only, as far as I am aware, in this country, that a similar law has been 
 observed in a remarkable way to influence the propagation of the vaccine disease. 
 
 "Now that there is not any longer doubt in regard to the identity of small -pox and 
 cow-pox, the difficulty of propagating the latter in some parts of India during the hot 
 months may be considered as in accordance with the epidemic law, and as additional 
 evidence of the identity of the two diseases. The difficulty which has attended the 
 propagation of the vaccine disease in some months, in some of the Bengal provinces, 
 has been the subject of much discussion, and too much weight has in all probability 
 been attached to it, as an impediment in the way of the diffusion of the protective in- 
 fluence of vaccination in India, While the law of preference of certain seasons has 
 been so much dwelt on with reference to the cow-pox, it has been too much lost sight 
 of in regard to the small-pox. For what is the practical inference ? It is this : if, in 
 the seasons in which there is difficulty, if not impracticability, in propagating the 
 vaccine disease in its perfect form, there is also very seldom prevalence of epidemic 
 small-pox — does it not follow that this obstacle to the diffusion of the vaccine is a 
 matter of no great regret, and speaking generally, the absence of vaccination in these 
 seasons no great evil, because there is no great demand for the exercise of its protec- 
 tive influence ? While, on the contrary, if the seasons, to which epidemic small-pox is 
 almost exclusively confined, are those, or immediately succeed those, in which there is 
 no difficulty in keeping \ip the vaccine disease, — then, does it not follow that vaccina- 
 tion, assiduously and carefully practised in those seasons, will afford to the people almost 
 the full measure of its protection ? " 
 
 Mr. Bedford, at page 194 of his " Notes," shows, that in the Upper Provinces of 
 India, successful vaccinations in July amount only to 10 per cent, and in October to 
 7 per cent. 
 
190 ERUPTIVE FEVERS. 
 
 Bombay represents that of a very partially protected' community. 
 But when we direct our attention to the European residents 
 of Bombay, whose number, according to the census of 1850*, was 
 5,088, we find that, during the five years from 1848 to 1852 
 inclusive, 1,177 deaths are registered, and of these 12 were from 
 small-pox. This is a fraction more than 10 deaths in 1000 ; 
 double that of the average of European countries in which vacci- 
 nation is compulsory, but not half that of England and Wales, 
 and not more than one-fifth of that of the native population of 
 Bombay. There can be no doubt that the instances, if aDy, must 
 be few of inoculated Europeans in Bombay, and that therefore the 
 smaller proportion of mortality from small pox in them can only 
 be attributed to the protective power of vaccination. 
 
 The results deducible from my notes of the fatal cases of Euro- 
 pean officers do not seem so favourable to vaccination. Of 311 
 deaths 7 were from small-pox, which is at about the rate of 22 in 
 1000. The fatal cases f occurred in the years 1834, 1848, 1849, 
 1850, 1851. 
 
 Though the attention of the Indian Government was called to 
 the subject of vaccination very shortly after Jenner's discovery, 
 and notwithstanding the exertions which have been made, it is to 
 be feared that as yet little influence has been exercised on the 
 health of the civil population of India by the systems of vacci- 
 nation which have been adopted. The tabular returns, from the 
 impossibility, owing to the prejudices or fears of the people, of 
 verifying the success of the operation in a large proportion of cases, 
 and from the ignorance, dishonesty, and unskilfulness of much of 
 the native agency employed, are unworthy of being received as 
 evidence for or against a question so important as the prophylactic 
 power of vaccination. 
 
 Nor can it be said that vaccination in the Native army and fol- 
 lowers has been attended with that decree of success which might 
 fairly have been anticipated from the more effective agency of 
 military system. It was, I believe, never enforced in the Bengnl 
 Native army; but the rule both in Madras and Bombay has been 
 to vaccinate all unprotected recruits. 
 
 The prevalence of small-pox at several of the military stations 
 
 * I have not alluded to this census (which make the total population of the island 
 566,119), relative to the Dative population, because ii is considered untrustworthy. 
 Bu1 in reaped in Europeans there is no reason for questioning its accuracy. 
 
 •!• One a1 each of the following stations: Seroor, Nassick, Poona, Mooltan, Mahu- 
 buleshwur, Of two the station is qoI menti I In my notes. 
 
SMALL-rOX — PREVALENCE, PREVENTION. 
 
 191 
 
 in the Poona division of the Bombay army, in the early part of 
 1858, led to the system of vaccination and its results being sub- 
 mitted to close scrutiny. The returns of all kinds were communi- 
 cated to me, as Superintending Surgeon of the division, by Major- 
 General Michel, who at that time commanded ; and the report which 
 was prepared by me from these documents was afterwards published 
 by the Commander-in-chief in the general orders of the army. 
 From this report the following extracts are taken : — 
 
 "1. The tables exhibit a total of 7,189 natives; that is, 58-2 per cent, of the 
 strength who have at some time or other suffered from small-pox. As the returns do 
 not separate those who have been inoculated for small-pox from those who have had 
 the natural disease*, it is impossible to estimate correctly the mortality represented 
 by this number of attacks. If these had been all instances of natural small-pox, and 
 if the average rate of mortality in European countries, viz. 1 in 4, obtains also in 
 India, then 7,189 attacks represents about 1,797 deaths. If, however, the impression 
 entertained by some, though as yet unsubstantiated by statistical data, that small-pox 
 is a less fatal disease in India be correct, and 1 in 7 be assumed as the rate of mor- 
 tality, then the number of attacks in question will have been attended by about 1,027 
 deaths in the communities of which the individuals were members. 
 
 " 2. TI13 same tables show the numbers vaccinated to be 4,299 — that is, 34-8 per 
 cent, of the strength ; and the numbers unprotected to be 85-5 — that is, 7 per cent, of 
 the strength. Of the unprotected, 539 are children under 10 years of age, which gives' 
 a per-centage 20-3 of unprotected children. 
 
 " 3. This proportion of small-pox and unprotection, viz. 65-2 per cent., and of vac- 
 cinated 34-8, exists in a native army in which " every recruit is to be vaccinated, if 
 requisite, on enlistment," and in respect to which medical officers are told " that it is 
 particularly imperative on those serving in the army to fulfil this duty (vaccination) 
 in their respective regiments or other charges, as well as among the women, children, 
 and camp followers belonging to the same." 
 
 "4. Of adtdt male sepoys and followers the following are the general per-centages : 
 
 
 Small-pox. 
 
 Vaccinated. 
 
 Unprotected. 
 
 Sepoys 
 Followers 
 
 61-8 
 68-8 
 
 34-5 
 
 27-1 
 
 35 
 3-4 
 
 " If these be alone regarded, then it may be inferred that the per-centage of small- 
 pox shows the proportion existing at the period of enlistment, and merely indicati i 
 the degree in which vaccination is neglected in the communities of which the indi- 
 viduals in question were originally members. But when the difference exhibited in 
 the several regiments is considered, then the following range becomes apparent:— 
 
 
 Small-pox. 
 
 Vaccinated. 
 
 Unprotected. 
 
 Sepoys 
 Followers 
 
 23- to 86-3 7-1 to 72-9 
 13-8 to 100- JO- to 86.2 
 
 0- to 13-6 
 0- to 20- 
 
 * On this question it may be stated that inoculation is not practise.! in the upper 
 provinces of India, is so in a very limited degree in the Deccan, but in greater de 
 in the Concan. 
 
192 
 
 EHUFTIVE FEVERS. 
 
 " It may be advanced, in explanation of this difference in the proportion of small- 
 pox, that inocidation is probably more practised in the communities from which some 
 regiments are chiefly recruited than in those from which others are ; and to account 
 for the greater proportion of vaccination in some, it may be that it is practised in 
 these more indiscriminately than in others — that is, without regard to the fact of 
 previous small-pox; and that such operations, though unsuccessful, have been errone- 
 ously recorded as vaccinations. Still, making every allowance for these explanations 
 in abatement of the difference in the number of adult males vaccinated in different 
 regiments, it is impossible to avoid the conclusion that vaccination, as respects this 
 class, is more carefully conducted in some regiments than in others. 
 
 "5. Of the wives of sepoys and followers the general per-centages are — 
 
 
 Small Pox. 
 
 Vaccinated. 
 
 Unprotected. 
 
 Sepoys' Wives 
 Followers' ditto . 
 
 69-7 
 73-7 
 
 29-3 
 21-3 
 
 0-9 
 5-7 
 
 The range is as follows : — 
 
 
 Small Pox. 
 
 Vaccinated. 
 
 Unprotected. 
 
 Sepoys' Wives 
 Followers' ditto . 
 
 40-4to 97-3 
 16-6 to 100- 
 
 2-7 to 55- 
 0- to 85-3 
 
 0- to 4-4 
 0- to 17-5 
 
 " The several remarks made in the preceding paragraph on the different proportions 
 of small-pox and vaccinated among the males in different regiments, are, to some 
 extent, also applicable to females. But this further observation may be hazarded — 
 that the differences in the number vaccinated show that scruples and prejudices are 
 more readily overcome in some regiments than in others. 
 
 "6. Of the children of sepoys and followers the general per-centages are — 
 
 
 Small Pox. 
 
 Vaccinated. 
 
 Unprotected. 
 
 Sepoys' Children . 27' 
 Followers' ditto . . 40-6 
 
 57-3 
 34-3 
 
 lo-5 
 25-1 
 
 " The following is the range : — 
 
 
 Small Pox. 
 
 Vaccinated. 
 
 Unprotected. 
 
 Sepoys' Children 
 Followers' ditto . 
 
 17-9 to 54-3 
 4- to 100- 
 
 22-5 to 77-7 
 4-4 to 96- 
 
 0- to 50- 
 
 0- to 71-2 
 
 " The difficulty in determining the number of adults, male and female, affected with 
 small-pox before coming under regimental observation, renders the returns of these 
 classes an imperfect test of the degree of observance or neglect of vaccination. But 
 in respect to children, this uncertainty does not exist; for it may be fairly assumed 
 thai a large proportion of them have been born and reared in the regimental lines, 
 and that 27 +40-6=67-6-i-2 = 38-8 per cent, small-pox, and 15-5 + 25-1 =40-6-i-2 = 
 20-3 percent, unprotected prove a very defective state of vaccination in (lie commu- 
 nity in which they exist. 
 
 "7. The number returned 'vaccinated' is shown in (lie 2nd paragraph to be 
 4,299; that is, 34'8 per cent, of (lie strength. But even this email proportion of 
 'vaccinated' is in excess of the nominally 'vaccinated' under ordinary circumstances, 
 and very considerably in excess of the truly protected by vaccination, (a.) On the 
 
VACCINATION — NATIVE ARMY. 
 
 193 
 
 prevalence of small-pox at Poona being reported, the acting superintending surgeon 
 called the attention of the medical officers in charge of native troops in the division 
 to the subject of vaccination by circular, dated 10th March, and required not only a 
 return of the numbers vaccinated monthly, but also of those who remained unpro- 
 tected. From the 1st March to the 30th June 1,138 vaccinations were returned from 
 native regiments, which is 26 -4 per cent, of the total vaccinated shown in the 2nd 
 paragraph. It is therefore a just conclusion that the proportion of vaccinated shown 
 on the 30th June had been raised above the usual standard by a temporary impulse. 
 (/j.) The native regimental vaccinations for the official year 1857-58 (from 1st April 
 1857, to 31st March 1858) amounted to 1,627, viz. :— Men, regiments, 460; men, 
 followers, 2; woman, 1; children, sepoys, 713; children, followers, 451: total, 1,627. 
 Of these the proportion returned as failed or doubtful is : — Men, regiments, 273 ; 
 men, followers, 2 or 59 - 3 per cent, this class ; children, sepoys, 202 ; children, fol- 
 lowers, 126 or 28 - l per cent, this class. The total of vaccinations in 1857-58, not 
 affording the certainty of protection, was 602, or 37 per cent, of the whole number 
 vaccinated. It may be reasonably assumed, that of the total vaccinations given in 
 the 2nd paragraph, 37 per cent, were failures or doubtful ; and that, in consequence, 
 the proportion of real protection from vaccination is not 34 - 8 per cent, of the strength, 
 but only 22-1. 
 
 " 8. It is of importance to determine the cause of the large proportion of unsuc- 
 cessful vaccinations in the native army. They may be stated as follows : — 1st. The 
 want of general and systematic vaccination leaves the medical officer too often depen- 
 dent on lymph, preserved on glasses, — often sent from a distance, and perhaps care- 
 lessly taken and transmitted. 2nd. Vaccination is too much left to hospital assistants, 
 who, from want of practice, are unskilled in the operation, and, from defective know- 
 ledge, are not well acquainted with the conditions of its success. 3rd. A portion of 
 the failures in adidts is due to protection by previous small-pox. 
 
 " 9. Another table shows the number of European soldiers, with their wives and 
 children, who have had small-pox, been vaccinated, or are unprotected. The per- 
 centage to strength is as follows : — 
 
 
 Small Pox. 
 
 Vaccinated. 
 
 Unprotected. 
 
 Soldiers 
 Ditto Wives 
 Ditto Children 
 
 13-5 
 116 
 
 2-8 
 
 83-5 
 86-2 
 93-0 
 
 34 
 0-5 
 41 
 
 " The contrast between the proportions of vaccinated here shown and that in 
 natives, in paragraphs 4, 5, 6, is striking. Still the proportion of those who have 
 had small-pox illustrates the well-known fact, that in the classes in Great Britain and 
 Ireland, from which recruits for the army are drawn, vaccination is also imperfectly 
 conducted. 
 
 " 10. The information communicated in these returns, relative to the proportion of 
 protected and unprotected in cantonment military bazaars, is quite inadequate for the 
 object in view. The facts recorded amount to this : that the estimated population is, in 
 
 Poona Bazaar 
 
 Kirkee . 
 
 Ahmednuggur 
 
 Malligaum 
 
 Sattara 
 
 Dapoolie 
 
 Total 
 
 56.111 
 
194 EliUrTIVE FEVERS. 
 
 " The number protected in the Poona, Kirkee, and Malligaum bazaars is unknown. 
 In the other, the residents are supposed to be all protected, with the following 
 exceptions : — ■ 
 
 Ahmednuggur . . . .236 
 
 Sattara . . . . . .11 
 
 Dapoolie . . . . . .111 
 
 " If the ratio of the successfully vaccinated in the native army, under the more 
 favourable circumstances of smaller numbers, greater control, and professional agency, 
 is only 22 per cent, of the strength, it may be fairly assumed that the ratio of annual 
 vaccinations in large military bazaars as that of Poona, does not, under ordinary cir- 
 cumstances, exceed that of the general civil population of the Bombay Presidency, 
 which, estimating the population at 15,578,992*, and the successful vaccinations at 
 202,535t, is 1'3| per cent, 
 
 " Though the quarterly returns, from which the several statements in this memo- 
 randum have been deduced, cannot be regarded as statistical data, on which full reli- 
 ance may be placed, yet they safely justify the following conclusions. 1st. Vaccination 
 is very insufficiently carried on in the general communities from which the recruits of 
 the native army are drawn. 2nd. Vaccination is unequally practised in native regi- 
 ments, and though this may in part be explained, as respects adults, by circumstances 
 antecedent to enlistment, yet the great degree of difference, and the facts relative to 
 small-pox and to vaccination in children, prove that this important sanitary measure, 
 inadequate in all regiments, receives much greater attention in some than in others. 
 
 "12. The representations which led to the issue of the Division Order would seem 
 to be amply confirmed by the analysis of these returns, and it is not to be doubted 
 that the imperfect practice of vaccination, thus made apparent, calls for active and 
 sustained efforts on the part of the military and medical officers connected with the 
 native army and with military bazaars. This subject, though of great importance to 
 the interests of the native military population, also involves the welfare, in some 
 degree, of a large body of European troops brought into constant association with the 
 Sepoys of the native army and the residents in the military bazaars. Though it is 
 true that Europeans in India enjoy, for the most part, the advantage of protection 
 from small-pox through a well-organised system of vaccination, still occasional in- 
 stances occur when, from some cause or other, this protection has ceased, and lives, of 
 the highest value to the State, may thus fall a sacrifice to that extensive diffusion of 
 small-pox which the neglect of vaccination permits to exist," § 
 
 Section III. — On Measles in Bombay and the Deccan. 
 
 My clinical knowledge of measles has been chiefly obtained in 
 the sick wards of the Central Schools at Bycnlla.|| This institution 
 is for the maintenance and education of children of the European 
 soldiers of the Bombay Presidency. The children are partly of 
 unmixed European extraction, and partly Indo-Britons. During 
 
 * "Thornton's Gazetteer." 
 
 f " Report on Vaccination, Bombay Presidency, for 1854-55," p. 53. 
 
 | In Agra and Delhi, o-()5l per cent. In Bengal, where inoculation is practised, 
 the annual vaccinations are o-'JS per thousand. Indian Annals Medical Science, vol. i. 
 {Bedford.) 
 
 § This memorandum was written shortly after the lamented death of Sir William 
 Peel, by coiiMnenl sniall-]io\, at Cawnpore, in April 1858. 
 
 || In the Island of lloinbay. 
 
MEASLES. 195 
 
 the last twenty years, their numbers, both sexes included, have 
 ranged from 235 to 355, and their ages from 3 to 16. 
 
 There are two buildings, one for boys, the other for girls ; both 
 situated in the same grounds, with an interval of about 100 yards. 
 About eight years ago, a separate hospital was added to the 
 institution ; for before this period, the sick wards were in the 
 school buildings. 
 
 Measles prevailed in the schools in October 1832*; but no 
 record has been preserved of this visitation. The next occurrence 
 of the disease was in December 1838; it commenced on the 21st 
 of that month, and continued till the 2nd of April 1839. At this 
 time I held medical charge of the institution. The schools, with 
 the exception of a single case in January 1840, remained free of 
 measles till December 18-i6, when it commenced on the 21st of 
 the month and ceased on the 10th March 1847. It reappeared 
 on the 13th March 1852, and prevailed till the 22nd of May. 
 It was again absent till the 10th March 1857, when it returned 
 and continued till the 14th of April. No further notice will be 
 taken of the visitation of 1832 ; and in the subsequent remark?, 
 I shall designate the remaining four the first, second, third, and 
 fourth epidemics. 
 
 The disease commenced in the girls' school in the three first, 
 and in the boys' in the last epidemic, and in the second and third 
 the importation of the infection was traced to a fresh arrival. 
 The period that elapsed between the commencement of the disease 
 in the one school and its appearance in the other was in the first 
 epidemic twenty-six days, in the second twenty-seven, in the third 
 twenty-four, and in the fourth eleven. During the first and second 
 epidemics there was no sejDarate hospital building. During the 
 first epidemic the healthy children were removed to a building at 
 some distancef, and the school-rooms were converted into sick 
 wards. This course was adopted because, in the months of February 
 and March 1837, 74 cases of mumps occurred in the girls' school, 
 but not a single case in the boys' school ; and in the months of 
 March and April 1838, 29 cases of varicella occurred in the boys' 
 school, but not a single case in the girls' school. I had therefore, 
 on the outbreak of measles in the girls' school, some expectation 
 
 * Measles was very prevalent at Calcutta arid the vicinity in March, April, and 
 May 1832, as stated by Mr. Corbyn. — Transactions, Medical and Physical Society of 
 Calcutta, vol. vi. p. 477. 
 
 f The imperfect accommodation for the sick was also a reason for the adoption of 
 this measure. 
 
196 EBUPTIVE FEYEBS. 
 
 that it would not extend to the boys' school, and in consequence 
 did not recommend in the first instance any measures of prevention 
 in addition to those already afforded by the school buildings. 
 
 But the removal of the healthy children, after the disease had 
 showu itself also in the boys' school, had no effect in checking the 
 further spread of the epidemic. 
 
 There have been, in the course of twenty-two years, four visi- 
 tations of measles in these schools, with intervals of five and eight 
 years. The first and second commenced on the 21st December, 
 and the third and fourth on the 13th and 10th of March, and none 
 of them continued later than the 22nd of May. Epidemic measles 
 then, in Bombay, shows a preference for the same months as small- 
 pox and (as has just been shown) mumps and varicella are simi- 
 larly characterised. 
 
 The following is a note of the admissions and deaths in the four 
 epidemics: — 
 
 1838-39 
 
 Admissions. 
 100 
 
 Deaths. 
 5 
 
 Mortality 
 
 per cent. 
 
 5" 
 
 1846-47 
 
 144 
 
 5 
 
 3-4 
 
 1852 
 
 107 
 
 _ * 
 
 54 
 
 1857 
 
 117 
 
 10 
 
 8o 
 
 These four epidemics have been described in the Transactions of 
 the Medical and Physical Society of Bombay. The first f by myself, 
 the second \ by Dr. Coles, and the third and fourth § by Mr. Carter. 
 
 But my information relative to measles is not confined to this 
 single institution or to the island of Bombay. In 1857 it prevailed 
 among the general native population in Bombay. Mr. Moreshwur 
 Junardhun, in a report addressed to the Grant College Medical 
 Society mentions that between January and May of that year he 
 treated 83 cases, of which 15 died — a mortality of 18 per cent. 
 In March and April of the same year the disease visited the infant 
 branch of the Byculla Schools, located at Poona ; 31 children were 
 affected and 7 died, — a mortality of 22 -5 per cent. 
 
 The children of the 1st battalion of Artillery at Ahmednuggur 
 suffered from measles in May, June, and July of 1857, with this 
 result : — 
 
 Indo-Britons 
 
 Europeans .... 
 
 64 18 
 
 This high mortality — 28 per cent. — may in part be accounted 
 
 * The number is not distinctly stated in the Report. 
 
 f 2nd No. + 9th No. § Lsl No. and 4th No. NW Series. 
 
 Admitted. 
 . 12 
 
 Died 
 
 4 
 
 . 52 
 
 14 
 
MEASLES. 
 
 197 
 
 for by the children having come off a long and fatiguing journey 
 from Nusseerabad, and their accommodation at Ahmednuggur 
 being overcrowded. 
 
 Again, as regards the general population of the island of Bom- 
 bay, it appears from Mr. Leith's Eegister that dming the five years 
 from 1st February 1848, to 31st January 1852, 323 deaths from 
 measles are recorded; and of these 212 occurred in children under 
 seven years of age. In the following classification of these deaths, 
 made with reference to the months of their occurrence, the prefe- 
 rence shown by the disease for the first six months of the year is 
 atrain well illustrated : — 
 
 January 
 
 . 32 
 
 July . 
 
 . 15 
 
 February 
 
 . 48 
 
 August 
 
 . 4 
 
 March . 
 
 . 47 
 
 September . 
 
 1 
 
 April 
 
 . 63 
 
 October 
 
 . 7 
 
 May 
 
 . 57 
 
 November . 
 
 . 4 
 
 June 
 
 . 41 
 
 December . 
 
 . 4 
 
 288 35 
 
 Among the children of the better classes of Europeans at Bombay, 
 I do not recollect an instance of its epidemic prevalence. But spo- 
 radic cases have been met with from time to time. I remember, 
 however, only two as coming under my personal observation. They 
 occurred in the month of June 1853. 
 
 In the fatal cases of European officers, from 1829 to 1848, I find 
 only one case of measles. It occurred at Belgaum in February 
 1832, in an officer of the staff. The initiatory febrile symptoms 
 were congestive in character ; they continued from the 9th to the 
 13th, when the eruption came out on the 14th. This officer impru- 
 dently sat up, exposed to cold, and attended to some of the duties 
 of his office. On the evening of that day he complained of sore 
 throat, which had increased on the following day with addition of 
 oppression of the chest and delirium ; symptoms of collapse came on, 
 and he died on the 15th. 
 
 It is unnecessary for me to describe the s} T mptoms and treatment 
 of a disease so well known to medical observers in all countries ; 
 but there is one circumstance in the character of the symptoms, 
 as it has been observed in the Byculla schools, which it is of 
 importance to note. In the accounts of measles as occurring in 
 European countries, paleness of the eruption is stated to be of un- 
 favourable import. This doubtless is true of the more sthenic chil- 
 dren of these countries, and equally so of well-conditioned European 
 children in India. But in all Indian epidemics we may expect 
 frequently to meet with the disease in children more or less 
 
 o 3 
 
103 ERUPTIVE FEVERS. 
 
 anaemic ; and in them the eruption will be found occasionally to 
 present a faintness of tint, which in a sthenic child might excite 
 apprehension, but which in the asthenic is quite compatible with a 
 mild and favourable course. 
 
 In respect to treatment, I would only observe that it is of much 
 importance in the feeble children of India to be very careful not 
 to debilitate, but to watch for a failing pulse and other symptoms 
 of asthenia, and then to give chicken broth or beef tea freely, 
 and wine if necessary ; to omit all depressant medicines, and use 
 squills and carbonate of ammonia with camphor mixture. I am 
 satisfied that several lives were saved in the first epidemic from 
 observance of this principle, and if errors were committed in the 
 general management they were on the side of too much depression. 
 
 Measles in the Byculla schools has been usually followed by 
 troublesome catarrhal oj)hthalmia. 
 
 The fatal cases which I had an opportunity of examining were 
 those of the first epidemic. They were five in number. In all 
 there was pneumonia, which in four had passed on to hepatization, 
 with, in one, gangrenous excavations. In two the pneumonia 
 was general, in two lobular, and in one vesicular. In all there 
 had been muco-enteritis, which in two had led to granular exudation 
 on the mucous lining of the lower part of the ileum and of the 
 colon ; in one to turgescence and ulceration of Peyer's agminated 
 glands; in one to redness of the mucous membrane of the lower 
 part of the ileum and turgescence of Peyer's glands ; and in one 
 merely to vascularity of the end of the ileum. 
 
 When we compare the history of measles in India with that of 
 the disease in colder climates, we find the mortality to be much 
 higher in the former. The rates of mortality stand thus : — 
 
 European countries * . . .3' percent. 
 
 Byculla Schools, Bombay, — 1st Epidemic 5' 
 
 » 2nd „ 3-4 „ 
 
 „ 3rd ,, 5-4 „ 
 
 „ 4th ,, 8-5 „ 
 
 Moreshwur Junardhun's cases . . 18* „ 
 
 Infant Schools, Poona . . . 22 - 5 „ 
 
 1st Battalion, Artillery, Nuggur . 28- 
 
 ■ l and N.W. Provinces f • . 8. „ 
 
 Nor is it difficult to understand how this should be. The prone- 
 
 * "Lectures on Diseases of Infancy and Childhood," by Dr. West. 4th edition, p. 
 712. 
 
 f Dr. Mackinnon, in his remarks on the Epidemics of Bengal and the North- 
 western Provinces, states the mortality from measles in the children of European 
 soldiers to be eight per cent.- Indian Annals of Medicine, No. 3, p. 171. 
 
SCARLATINA. 199 
 
 ness of the asthenic constitution in India to become affected 
 with pneumonia has been already alluded to, and will be more 
 fully illustrated in a subsequent part of this work. It has been 
 also shown that January, February, March are months in which 
 measles is apt to prevail. Though the absolute temperature of 
 these months in India is high compared with that of European 
 countries, yet the daily range is great relatively to other seasons of 
 the year ; and the more or less prevalence of north-easterly winds 
 in these months also increases the heat-abstracting property of the 
 atmosphere. When these facts are considered with the additional 
 one, that the heat-generating power of the animal system has rela- 
 tion to temperature of season and climate, we can be at no loss in 
 understanding how the predisposed become affected with pneumo- 
 nia in India and how cold is an exciting cause. 
 
 There is probably moreover greater danger in measles from 
 gastro-intestinal inflammation in India than in the same disease 
 in more temperate climates. And as an additional cause of 
 high mortality, the greater obscurity of pneumonia in asthenic 
 states, and the less control over its course, are deserving of notice. 
 
 Section IV. — Scarlatina. — Erysipelas. — Varicella. — Hoop- 
 ing Cough. — Cynanche Parotide®. 
 
 Scarlatina. — We have not any satisfactory account * of the 
 occurrence in India of the scarlatina simplex, anginosa, and maligna 
 of European countries. 
 
 A fever, remittent in character and attended with scarlet erup- 
 tion, has prevailed epidemically on several occasions, since 1824 to 
 1853, in Bengal and the North-western Provinces. In some in- 
 stances the mucous membrane of the mouth and fauces has been 
 inflamed ; but in others this feature has not been observed. In 
 the earlier epidemics rheumatic pain of the joints was frequently 
 noticed ; but this has not been the case in the later visitations of 
 the disease. 
 
 I am not acquainted with the occurrence of a similar epidemic 
 in any part of the Bombay Presidency.! I have however met with 
 an occasional case of remittent fever in natives attended with an 
 eruption resembling roseola. The same kind of eruption has also 
 
 * The single ease entered in the Madras return at the commencement of this chapter 
 cannot be received. The fact of a single case of an infectious disease returned of an 
 unprotected community, is of itself proof of inaccurate diagnosis. 
 
 t Dr. Peet reports that it has prevailed at Bombay andPoonain 1859. '-Trans- 
 actions, Medical and Physical Society," New Series, No. 5, p. 211. 
 
 o i 
 
200 ERUPTIVE FEVERS. 
 
 been observed by me in a few instances in the secondary fever of 
 cholera, and I have already stated that it was present in some of 
 the cases of febricula in the D troop, Royal Artillery, at Poona 
 in the hot season of 1858. 
 
 The Bengal epidemics have been described by Drs. Mellis, 
 Twining, Cavell, Mouat, and H. H. Groodeve*; also by Dr. Edward 
 Goodevef, and by Dr. Mackinnon.| Xone of these authors have 
 considered the disease described by them as identical with Euro- 
 pean scarlatina. It is, however, similar to the Dengue of America 
 and the West Indies. 
 
 Erysipelas. — The remark made by Dr. Mackinnon, that 
 " idiopathic erysipelas, as it appears on the face and lower extre- 
 mities unconnected with wounds, is a rare affection in India," § is 
 fully confirmed by observation in Bombay. I have met with very 
 few cases either in Europeans or in natives. 
 
 But traumatic erysipelas is of more common occurrence, and at 
 times evinces almost an epidemic tendency. It was common in 
 the Jamsetjee Jejeebhoy Hospital in November and December 
 1851, after wounds of the scalp and lower extremities, but was 
 easily subdued. It did not in all cases originate in the hospital, 
 but in some was present on the admission of the patient ; thus 
 showing that it was not, at least in all cases, due to the air of the 
 hospital. On one or two occasions I have also noticed the lia- 
 bility to erysipelas after the application of blisters so well marked 
 as to render it expedient to discontinue, for the time, the use of 
 this remedy. 
 
 Varicella. — In my observations on measles, allusion has already 
 been made to the occurrence of twenty-nine cases of varicella in the 
 boys' school at Byculla in March and April 1838, but notes of this 
 epidemic have not been preserved by me. Since then, however, 
 cases of this disease have come under my observation, and I am 
 satisfied that the term varicella has not been applied by me 
 to an affection varioloid in character. The diagnosis of the two 
 diseases has been already explained in the remarks on small-pox. 
 
 Mr. Carter states that, in the year 1849, a varioloid form of vari- 
 cella affected twenty-four boys in the school, but only one girl, iu 
 
 * "Transactions, Medical and Physical Society, Calcutta," vols. i. ii. is. 
 f " Indian Annals of Medical Science, No. 2." 
 
 \ " Treatise on Public Health. Indian Annals of Medical Science," Xo. 3. 
 § "Indian Annals of Medicine," No. 3, p. 177. It may be well to bear in mind im- 
 munity from scarlatina and erysipelas in India, in reference to the question raised by 
 pathologists of relation between these affections. 
 
HOOPING-COUGH. 201 
 
 the months of March, April, and May. I am unable to say whe- 
 ther this epidemic differed from that of 1838, or whether the term 
 varioloid used by Mr. Carter merely indicates a difference of opinion 
 on the part of the observers. 
 
 Hooping-Cough. — In Dr. Coles' Keport on Measles in the 
 Byculla schools, allusion is made to the presence of three cases of 
 hooping-cough at the same time. I do not find any account of 
 the epidemic prevalence of this disease in these schools ; but my 
 impression is that it has occurred, from time to time, dming the 
 last twenty years. 
 
 Cynanche Parotidea attacked the girls' school in February and 
 March 1837. Seventy-four girls were affected, not a single bo}'. 
 Mr. Carter reports that it broke out among the boys in October 
 aud November 1851. Seventy-five boys were affected, but only 
 two girls. 
 
202 
 
 EriDEMIC CHOLERA. 
 
 CHAP. XIII. 
 
 ON EPIDEMIC CHOLERA. 
 
 Section I. — Remarks on the Seasons of Prevalence and on the 
 Causes of Cholera. 
 
 The leading statistical facts of cholera amongst European and 
 native troops in India are * : — 
 
 Presidency . 
 
 
 EUROPEANS. 
 
 
 
 NATIVES. 
 
 
 MO — 
 
 o c JJ 
 
 Per-centage 
 
 of Deaths to 
 
 strength. 
 
 Per-centage 
 of Deaths to 
 
 Admissions. 
 
 Per-centage 
 
 of Admissions 
 to strength. 
 
 Per-centage 
 
 of Deaths to 
 
 strength. 
 
 * o ■ 
 
 fl-i 
 
 S, -a 
 
 Bengal . 
 Bombay . 
 Madras . 
 
 2-87 
 2-64 
 1-98 
 
 0-97 
 086 
 0-69 
 
 33-70 
 32-53 
 34-83 
 
 0-53 
 0-96 
 1-35 
 
 0-16 
 0-32 
 0-58 
 
 30-54 
 33-06 
 42-91 
 
 In the European General Hospital 234 cases of cholera, and in 
 the Jamsetjee Jejeebhoy Hospital 1259, were treated during my 
 periods of service in these institutions. I have also had the oppor- 
 tunity of investigating this disease in other parts of the presidency 
 as well as among the better classes of the community, both Euro- 
 pean and Native, in the island of Bombay, f 
 
 The following remarks on cholera combine the results of my 
 own experience, and of a careful consideration of much that has 
 been written on the subject, both by Indian and European writers. 
 
 My connexion with hospitals in Bombay extends from June 
 
 * "Vital Statistics of the European and Native Armies in India," by Joseph Ewart, 
 M.D., pp. 147, 160. 
 
 f It may be stated here, that during my service in India, from August 1S56 to 
 September 1859, subsequent to the publication of the first edition of this work, I have 
 again had extensive opportunities of observing cholera, both in the Jamsetjee Jejeebhoy 
 Hospital, and the Hospitals of the 01st Regiment and the German Legion, at Poona. 
 Notwithstanding, the text is left very much as originally written, for this further ex- 
 perience has in no respect modified my opinions. 
 
SEASONS OF TEE VALENCE. 203 
 
 1838 to May 1854; and from these sources I learn, that in 
 the years 1841, 1847, and 1848, there was very little cholera 
 in the island. It, however, prevailed extensively in the years 
 1842, 1846, 1849, 1850, 1851, 1853, and 1854. But the partial 
 character of the visitations of cholera is shown by the returns from 
 the Byculla schools, in which 1840, 1844, and 1845 were the 
 years of greatest prevalence, and 1848, 1850, 1852, and 1853 were 
 those of exemption. 
 
 The greater prevaleuce of cholera in some years than in others 
 in Bombay is also apparent in Mr. Leith's Mortuary Register. 
 There we learn that the proportion which the deaths from cholera 
 bore to the total deaths in the island in different years, was as 
 follows : — 
 
 1848 . 
 
 ■63 per cent. 
 
 1851 . 
 
 . 27"75 per cent. 
 
 1849 . 
 
 . 17-40 
 
 1852 . 
 
 8-40 
 
 1850 . 
 
 . 27-850 
 
 
 
 The greater prevalence of cholera in the warmer months of the 
 year in European countries, has been supposed to depend on ele- 
 vated temperature favouring an impure state of the atmosphere by 
 increasing decomposition.* But as the heat of an Indian climate 
 must always be sufficient to cause atmospheric impurity in this 
 manner, it may be inferred, if the view stated in respect to Euro- 
 pean countries be correct, that cholera in India will not show a 
 preference for particular seasons. The admissions into the Euro- 
 pean General Hospital at Bombay, from 1838 to 1853, are, for the 
 half year from April to September, 234, and for that from October 
 to March, 114: those into the Hospital of the Byculla schools, 
 from 1837 to 1853, are, for the first period, 68-, and for the second 
 21. Cholera prevailed extensively in many places in the southern 
 Mahratta country and Deccan from April to June 1859; and the 
 Artillery, the 61st Regiment, and the Grerman Legion at Poona 
 suffered considerably from the 24th May to the 7th June. 
 
 This statement seems to countenance the relation of the disease 
 to the hot and rainy months of the year ; but then this inference is 
 corrected by a reference to the Jamsetjee Jejeebhoy Hospital, 
 in which (from 1848 to 1853)417 admissions took place in the 
 first half year, and 637 in the second. Mr. Leith's Mortuary Re- 
 turns, from 1848 to 1852, also give the greatest number of cholera 
 deaths in the half year which includes the cold season, viz. 7,112 
 for the half year, from October to March, and 5,110 from April to 
 September. 
 
 * "Beport on the Cause and Mode of Diffusion of Epidemic Cholera." By Win, 
 Baly, M.D. 1854. 
 
204 EPIDEMIC CHOLEKA. 
 
 But it may be supposed from these statements, considered in 
 connexion with remarks in Mr. Webb's report on the medical 
 statistics of European troops in the Bombay presidency*, that 
 cholera affects Europeans in greatest degree in the hot and rainy 
 months, but Natives in the cold season. This conclusion is, how- 
 ever, corrected by tabular statements before me, relative to the 
 disease in Calcutta. The first j refers to the general population of 
 the city, from 1832 to 1838, and shows, for the half year from 
 April to September, 9,560 deaths, and for that from October to 
 March, 8,555. The second J relates to the European General 
 Hospital at Calcutta from 1842 to 1853, and gives from April to 
 September 358 admissions, and from October to March 383. 
 
 I conclude, then, that though partial data may suggest that 
 cholera has also in India its seasons of preference, the conclusion is 
 not as yet sustained by general and extensive inquiry. 
 
 The cause of cholera — that is, the nature of the poison — is as 
 yet undetermined. If we regard the various opinions which have 
 been put forth on this subject, the want of precision and complete- 
 ness in many of the statements and the hypothetical character of 
 much of the reasoning on which the opinions rest, it is impossible 
 to avoid the conclusion, that at the present time the records of 
 medical science are inadequate for the solution of this question. 
 
 In the course of three epidemics of cholera in Bombay (from 
 1849 to 1854), 158 inmates of the Jamsetjee Jejeebhoy Hospital, 
 while under treatment for other diseases, have been attacked 
 with cholera, and 73 of them died. At the time of these events, 
 a record was kept, showing the date of the attack, the bed of the 
 patient, the date of admission into hospital, and the disease for 
 which he was under treatment. § I entertained the hope that 
 these facts might throw some light on the etiology of cholera ; but 
 their careful consideration has brought me to this conclusion, — 
 that though a considerable part of them are trustworthy, so far as 
 they go, yet they are defective in so many particulars, necessary to 
 justify positive inferences, in an inquiry so difficult and important, 
 that their detailed statement is not here submitted. This course 
 
 * " Transactions, Medical and Physical Society of Bombay," New Series, No. 1, p. 104. 
 
 t Mr. Martin, "Influence of Tropica] Climates," &c. p. 346. Edition of 1854. 
 
 t. "Notes on Cholera," by John Macpherson, M.D. "Indian Annals of Medical 
 Science, "No. 1, p. 111. 
 
 § This unsatisfactory state of mailers continues. During my absence from India, 
 and also subsequent to my return : viz. from July 1854 to April 1857, there were 84 
 seizures from cholera in Hospital, with 7'. ( deaths, and yet the explanation is no fur- 
 ther advanced. 
 
CAUSES OF CHOLERA. 205 
 
 is adopted, because I am satisfied that nothing so surely impedes 
 the progress of medical science as the irrelevant use made by some 
 inquirers of the observations and statements of others. 
 
 The occurrence, however, of so many attacks of cholera in one 
 institution have seemed to point to the following general in- 
 ferences : — 
 
 1. Cholera prevailed in the divisions of the town adjacent to the 
 hospital, so that the cause may be assumed to have been operative 
 on the residents of both- 
 
 2. A considerable proportion of the seizures was of individuals 
 only a few days resident in the hospital, and who may therefore 
 have been infected before admission. 
 
 3. A considerable proportion was simultaneous with an increase 
 of the disease in the island generally, and therefore justified the 
 inference that a general cause was in operation. 
 
 4. They occurred more or less in all the fourteen wards of the 
 hospital, but in considerably greater number in those in which 
 from position, nature of disease, or number of inmates, atmospheric 
 impurity was most likely, at times, to be present. 
 
 5. The greater number of attacks was in cachectic or debilitated 
 individuals : the influence of predisposition was very apparent. 
 
 6. The cholera sick in the hospital, whether admissions or 
 seizures, were treated in the verandahs of certain wards, and were 
 so arranged as to be widely apart from each other. The ward 
 which adjoined the verandah in which cholera patients were most 
 constantly present, was that in which, in one epidemic, the fewest 
 cholera seizures took place ; and in which, in another epidemic, 
 the seizures were fewer than in several other wards. 
 
 These statements seem to indicate a relation between the cause 
 of cholera and an atmospheric state, external to, as well as in, the 
 hosjjital ; also a relation to impure conditions of the atmosphere 
 and states of individual predisposition. 
 
 The portable or contagious property of the cholera poison is not 
 supported by these statements ; and it is chiefly with reference to 
 this question that facts more complete, precise, and detailed than 
 these, or than any as yet observed and recorded, are required.* 
 
 * In the "Lancet" of the 4th and 11th December 1858, circumstances relative to 
 the arrival of two coolie ships at Mauritius are narrated by Dr. Ayres, the superin- 
 tendent of quarantine at Mauritius, which appear to him convincing proof of the con- 
 veyance of cholera, its communicahility, and the value of strict quarantine. The 
 narrative is very interesting, but the conclusions appear to me in part questionable. 
 The following is a summary of the leading facts. The quarantine station at Mauritius 
 is on two small islands, Gabriol and Flat Islands, separated from each other by a 
 
206 
 
 EPIDEMIC CHOLERA. 
 
 My present impression on this point is, that if any of the spread of 
 cholera be due to human intercourse, the degree is very limited ; 
 but my practice with reference to it has always been to pay great 
 attention to scrupulous cleanliness and ventilation around cholera 
 patients, and to place them widely apart from each other ; for set- 
 ting aside the suspicion of communicability, nothing is so likely, 
 
 coral reef. Flat Island is about one mile in diameter, and it had been inhabited for 
 many months by about 150 persons, Europeans and coolie workmen, and servants of 
 the quarantine estabbshment. On the 16th October 1857 a coolie ship arrived from 
 Madras, after twenty-six days' voyage; thirty-six cases of cholera, with eighteen 
 deaths, the last five days before arrival, had occurred. Shortly afterwards, another 
 cooHe ship, in which there had been cases of cholera during the voyage, arrived from 
 Calcutta. The coolies of both ships numbered between six and seven hundred. Those 
 of the Madras ship were landed on 16th October, and accommodated in Flat Island; 
 and those of the Calcutta ship on the 26th, and placed in huts on Gabriol Island. 
 There had been no trace of cholera in Mauritius or the adjacent islands for upwards of 
 a year. The Madras coolies were in a much better physical condition than those from 
 Calcutta. 
 
 The following cases of cholera, or choleraic diarrhcea, occurred in Flat and Gabriol 
 Islands : — 
 
 Date. 
 
 Madras 
 
 Calcutta 
 
 Quarantine 
 
 Coolies. 
 
 Coolies. 
 
 Servants. 
 
 October 26 
 
 1 
 
 
 
 27 
 
 
 2 
 
 
 29 
 
 
 
 2 
 
 „ 30 
 
 1 
 
 1 
 
 
 31 
 
 
 4 
 
 
 November 1 
 
 1 
 
 1 
 
 
 2 . . . 
 
 
 4 
 
 
 3 
 
 
 4 
 
 
 „ 4 
 
 1 
 
 1 
 
 
 19 
 
 
 1 
 
 
 „ 20 
 
 
 
 1 
 
 Consequent on the greater number of cases in Gabriol island, the Calcutta coolies 
 were removed to Flat Island on the 5th November, and the disease entirely disap- 
 peared after the 20th. 
 
 From these facts, Dr. Ayres concludes : — 1. That cholera was conveyed from India 
 to Mauritius. 2. That the quarantine servants were infected. 3. That the disease 
 woidd have been introduced into Mauritius, which it was not, had rigid quarantine 
 not been enforced. 
 
 I would rather substitute for these conclusions the following suggestions : — 
 1. That the probably tainted with cholera poison, on departure from India, were with 
 the others, placed, from crowding and other defective sanitary conditions on board ship, 
 in circumstances favourable for the development of the disease. 2, That, congregated 
 together in huts on two small islands, the unfavourable conditions of the ship were 
 continued after arrival; the disease was therefore kept n[>. and extended toothers, 
 who had also become exposed to the same adverse local sanitary state. 3. That had the 
 coolies on arrival, instead of being collected together, been distributed, well housed, 
 clothed, washed, and fed. the probabilities are that cholera would not have reappeared 
 amongst them, and would not have affected others. 
 
CAUSES OF CnOLERA. 207 
 
 as exhalation from the discharges and bodies of the sick, to pro- 
 duce that impure state of the atmosphere, which is undoubtedly 
 an efficient condition in favouring the spread of the disease. 
 
 There were circumstances connected with the outbreak of cholera 
 at Aden, in October 1858, and in part of the troops at Poona, in 
 May 1859, which bear evidence on questions involved in the 
 etiology of cholera, and which it may be useful briefly to state. 
 
 In the summer of 1858 *, cholera prevailed to a great degree 
 along the Arabian coast, at Jedda, Loheia, Hodeida, Mocha, and 
 Musawa. Native vessels from these ports were in constant com- 
 munication with Aden ; and in a ship with pilgrims from Mecca it 
 was said that two deaths from cholera occurred as they approached 
 Aden, but none were reported after the vessel came to anchor; 
 but the date of arrival is not stated in the report. Aden had 
 been exempt from cholera, with the exception of an occasional 
 spasmodic case, from the period of its occupation in 1839 to the 
 29th of September 1858, when the first case occurred among the 
 labourers on the public works. The temperature ranged from 80 
 to 98, and dew fell in the early morning. Between the 29th Sep- 
 tember and the 13th October, when it ceased, 136 individuals, 
 partly labourers, partly Sepoys and others, were seized, and 85 
 deaths occurred, a mortality of 62*5. The mortality among 
 the Sepoys was less than amongst the labourers : it was 52*6 in 
 the former and 65'6 in the latter; and the difference was attri- 
 buted to the Sepoys being in better condition, and nearer to their 
 hospitals. The disease became more amenable to treatment after 
 the 8th October. 
 
 Of the number attacked, 108 resided in the Koosaff Valley, in 
 one side of which there was an open privy ground near to the huts, 
 and a source of foul emanations. 
 
 After ceasing at Aden, the disease appeared at Lahadge, a short 
 distance inland, and also at Berbera, on the opposite Somauli 
 coast. Both these places were in free communication with Aden, 
 but the date on which cholera appeared in them is not stated in 
 the report. 
 
 Mr. Hormuzjee was of opinion that the outbreak was caused by 
 the poison imported from affected places acting on people generally 
 predisposed by debility, and favoured by a privy atmosphere and ele- 
 vated temperature ; but the evidence of importation is incomplete. 
 
 In May 1859, cholera, though prevailing in different places of 
 
 * Report by Mr. Kuttonjee Hormuzjee. "Transactions, Medical and Physical 
 Society, Bombay; " New Series, No. 5. 
 
208 EPIDEMIC CHOLERA. 
 
 the Deccan, was, in the military cantonment of Poona, confined to 
 the Artillery, the 61st Regiment, and the German Legion. These 
 troops occupied a consecutive line of barracks, in a direction from 
 east to west. The buildings, with the exception of one block, were 
 the oldest and worst constructed at the station, and had long 
 before been condemned. They were, moreover, overcrowded, but 
 the exigency of the times had continued to render their occupation 
 an unavoidable measure. The 61st Regiment, after distinguished 
 services before Delhi and Lucknow. were marched to Bombay for 
 embarkation to Europe, but an unlooked-for contingency led to their 
 temporary detention, and with this view they were sent to Poona, 
 where they arrived in May, disappointed and depressed. The 
 condition of the Germans, on arrival from the Cape, and their 
 subsequent sickness in March and April, from febricula, have 
 already been described (p. 163). 
 
 The regiments exempt from cholera were the 31st Infantry, and 
 the 6th and 14th Dragoons, situated at considerable distances from 
 the others, in more open positions, and in better barracks. 
 
 The 31st and 6th Dragoons had been healthy throughout the 
 cold and hot seasons, and though the 14th Dragoons had, as the 
 61st, been marched to Bombay for embarkation, and also tem- 
 porarily detained, the circumstances were very different. The 
 14th returned from service to their families and to a favourite sta- 
 tion, which had for many years of their Indian service been their 
 home. The 61st had served exclusively in the Bengal Presidency, 
 and found themselves in a new place and among strangers. 
 
 Before concluding my remarks on the causes of cholera, I would 
 observe, that the occurrence of the disease after exposure to cold or 
 wet, has been occasionally noticed ; and it may be presumed that 
 the relation which subsists between these ordinary exciting causes 
 of disease and the special cause of cholera, is the same as that 
 which obtains between them and malaria in respect to occasional 
 attacks of intermittent fever. They are determinining causes. 
 
 Section II. — Symptoms considered in reference to their degrees 
 of severity. — Diagnosis from Bilious Cholera, Irritant Poison- 
 ing, and Collapse of Remittent Fever. 
 
 It is assumed that the student of clinical medicine is already 
 familiar with the leading features of epidemic cholera — that the 
 disease frequently comes on in the night, often without previous 
 warning, but, at other times, preceded by diarrhoea of longer or 
 
SYMPTOMS. 209 
 
 shorter duration — that the characteristic symptoms are the rice- 
 water-like alvine discharges, the vomiting of watery fluid, spasms 
 of the extremities or muscles of the abdomen, restlessness and 
 anxiety, skin cold, damp and clammy, sunken eyes and shrunken 
 features, a quickly failing, and finally imperceptible pulse, much 
 thirst, suspended secretions, a whispering voice, intelligence lan- 
 guid but not deranged. 
 
 There is considerable range in the degree and rapidity of the 
 collapse ; and neglect of this fact has led to much inaccurate state- 
 ment on the value of different remedial means. 
 
 The characteristic alvine discharges are the pathognomonic 
 symptom of cholera. They may be present in varying amount, 
 associated with more or less — sometimes hardly appreciable — 
 muscular spasm, and with different degrees of collapse. The fol- 
 lowing classification is convenient for practical purposes. 
 
 1. Cases in which, after three or four hours of the characteristic 
 vomiting and purging, with some amount of spasm, the countenance 
 becomes somewhat collapsed ; but the tempe rature of the skin 
 remains still good, and the pulse of tolerable strength. There is 
 generally a varying proportion of this class of cases met with in 
 epidemic visitations in European regiments in India; and if they 
 are judiciously treated, a very considerable number may be ex- 
 pected to recover. This mildest form of the disease occurs very 
 seldom in natives, or in the classes of Europeans who resort to 
 general hospitals in India. 
 
 2. Cases in which, after six or seven hours of more or less 
 characteristic purging, vomiting, and spasm, the countenance 
 becomes sunken, the skin cold and damp ; but the pulse, though 
 small and feeble, is still distinct, and the respiration without hurry 
 or oppression. This degree of the disease is met with both in 
 natives and Europeans. It may be considered the mildest form in 
 natives as well as in Europeans in general hospitals. It does not 
 seem to be merely the first degree aggravated by longer duration ; 
 for it will be found that the greater collapse has been present from 
 the very outset, and little under the control of medical treatment. 
 Still, a considerable proportion of this form of the disease recovers, 
 probably more than one half. 
 
 3. Cases in which, after from one to six hours of characteristic 
 vomiting and purging, with discharges often inconsiderable in quan- 
 tity, the skin becomes cold and clammy, the countenance sunken, 
 the voice almost gone, the restlessness great, the pulse impercep- 
 tible, and the respiration begins to be hurried and anxious. This 
 
 p 
 
210 EPIDEMIC CHOLERA. 
 
 decree of the disease occurs both in Europeans and natives, and 
 recoveries, though occasional, are few in number. The very- 
 speedy collapse, unattended by the usual evacuations mentioned 
 by some writers, has not come under my observation; but I 
 should think it a very possible occurrence, for the scanty watery 
 secretion may take place into, and be retained in, the intestinal 
 canal. 
 
 The two last degrees of the disease are by far the most common, 
 at the present time, in India, and have been so during the whole 
 period of my service in that country. The first degree would seem 
 to have been met with more frequently in the epidemics between 
 1818 and 1824, as suggested by Mr. Martin, and many of the cases 
 detailed by Sir James Annesley confirm this opinion. 
 
 I have not thought it necessary to notice particularly a train of 
 symptoms described as occurring in sthenic Europeans in India, and 
 consisting of urgent cramps, a warm skin, a flushed countenance, 
 and a pulse full and firm. This must be a rare form of disease, for 
 I can bring to my recollection only one instance, and that was in 
 the year 1830, in a soldier of her Majesty's 40th Eegiment, at 
 Vingorla; yet it has been erroneously classed with epidemic 
 cholera, and its successful treatment by general blood-letting 
 was one of the circumstances which led to the adoption of that 
 remedy in the very different form of disease now under consi- 
 deration. 
 
 In following the course of the three degrees under which the 
 symptoms of epidemic cholera have here been classed, we find 
 that in the first, recoveries are numerous, derangements pass 
 away, and the several functions are gradually restored to their 
 normal state ; and that when cases prove fatal this result is brought 
 about by increasing collapse, or by consecutive fever with or with- 
 out the complication of secondary inflammations. I do not, how- 
 ever, enlarge on these milder instances of the disease, because my 
 clinical experience has been chiefly of the severer forms. 
 
 In a large proportion of the second and third degrees, the pulse- 
 less collapse, which has taken place in periods longer or shorter, 
 persists, though the serous discharges from the bowels may have 
 ceased, and the cramps have abated; the respiration becomes 
 hurried, and death follows in from four to thirty-six hours, dating 
 from the commencement of the symptoms. When, however, a 
 fatal result has not occurred in the stage of collapse, then the 
 disease may pursue one of the following courses : — 
 
 1. There is gradual and slow improvement of the pulse; the 
 
SYMPTOMS. 211 
 
 skin loses its dampness, and its heat slowly returns ; the alvine 
 discharges become less frequent and watery, assume first a turbid 
 and milky appearance, then become coloured, and gradually 
 restored to their normal state ; and the secretion of urine, which 
 had been suspended during the stage of collapse, is slowly es- 
 tablished. It is when the colla,pse has not been of long duration 
 — not exceeding seven or eight hours — that we may hope for 
 this favourable course of the disease. It is, on the other hand, 
 when the collapse has endured eighteen hours or upwards (though 
 recoveries may still take place in the manner just described), that 
 we may apprehend one or other of the remaining more unfavour- 
 able terminations. 
 
 2. The restoration of function, and final recovery, may be re- 
 tarded by gastro-enteric irritation, or inflammation, characterised 
 by a florid tongue with central yellow fur, uneasiness at the epigas- 
 trium, vomiting of ingesta, yellow watery, or greenish gelatinous 
 dejections, associated with a dry skin, and often some degree of 
 febrile heat and frequency of pulse. 
 
 3. Whilst the pulse and the heat of the skin have been gra- 
 dually restored, the alvine and renal excretions may continue 
 suppressed, the conjunctivae become gradually injected, and the 
 manner sluggish ; then distinct drowsiness may come on and pass 
 into coma. In these cases the stupor is occasionally preceded by low 
 delirium ; and a preternatural slowness of the pulse is sometimes 
 the first symptom to direct attention to the cerebral functions. This 
 train of symptoms, if not passing beyond the state of drowsiness, is 
 sometimes recovered from. 
 
 4. The stage of collapse may be immediately succeeded by febrile 
 reaction, adynamic in character, sometimes complicated with gas- 
 troenteritis, cerebral or pulmonic symptoms, or suppressed alvine 
 and renal excretion. 
 
 5. In asthenic individuals there may be restoration of function, 
 and yet death from secondary exhaustion, without any very evident 
 local complication. 
 
 Though the favourable import of restored urine and coloured 
 alvine discharges in the course of cholera is not to be doubted, yet, 
 I am certain, that needless alarm is often experienced from their 
 absence, as well as too much hope sometimes entertained from their 
 reappearance. 
 
 So long as the skin continues cold and the pulse imperceptible 
 or very feeble, it is not in accordance with sound physiology to 
 look for restoration of the biliary or urinary secretions. Again : 
 
 p 2 
 
212 EPIDEMIC CHOLERA. 
 
 if the collapse has not exceeded eight or ten hours, the non- 
 appearance of the excretions during the succeeding twelve or 
 eighteen hours of the gradual return of the circulation and of 
 animal heat need not occasion apprehension. 
 
 But if the collapse has endured for eighteen hours and more, 
 then, as already explained, with the return of the circulation and of 
 animal heat, all secondary dangers — those arising from defective 
 excretion included — are increased. The more completely and 
 speedily the circulation becomes restored after this long collapse, 
 the greater is the risk incurred by the continued suppression of 
 urine. 
 
 These statements, derived from clinical observation, are in strict 
 accordance with physiology. While the processes in which the 
 capillary circulation is concerned are suspended during the stage of 
 collapse, metamorphoses of tissue and the formation of products of 
 excretion are necessarily in abeyance ; but the longer the collapse has 
 endured and the more completely it has been removed, the more 
 surely and quickly will effete products be formed and the necessity 
 for their elimination created. 
 
 Though we may admit that there is a probable relation between 
 urasmia and cerebral disturbance, and perhaps other local derange- 
 ments, yet we shall be disappointed if we always expect to find head 
 symptoms removed on the return of the urinary secretion. 
 
 Again, in attributing the cessation of drowsiness to the restoration 
 of the renal secretion, care is necessary in order that the stupor 
 occasionally present in the stage of collapse may not be mistaken 
 for that which is secondary, which occurs after reaction, and which 
 alone can be related to uraemia. 
 
 There is still another clinical remark to be made with reference 
 to the urine. The early observers of cholera confounded sup- 
 pression with retention of urine, and used the catheter ; but there 
 is now an occasional risk of retention being mistaken for a continu- 
 ance of suppression and the use of the catheter being neglected. 
 
 It has been already mentioned that as the profuse watery alvine 
 discharges cease, they become less thin, and assume a milky ap- 
 pearance ; there is, in fact, less of water and more of epithelial 
 debris. This change, in favourable cases, is a state intermediate 
 between the clear watery and the coloured discharges, and 
 may continue for twelve hours and more after reaction has taken 
 place. Nor are we to assume from the continuance of these scanty 
 milk-like discharges that the case is progressing unfavourably. 
 They were present in the intestinal canal as the residue of the 
 
SYMPTOMS — DIAGNOSIS. 213 
 
 transudations of the stage of collapse, antecedent to the commence- 
 ment of reaction, and must necessarily be evacuated before more 
 normal excretions can reappear. Moreover, if during the period of 
 transudation much of the intestinal epithelium has been thrown off, 
 it is reasonable to suppose that its restoration will be amono-st the 
 earliest actions of returning health, and one desirable to accomplish 
 before biliary secretions are brought into relation with the lining 
 membrane. Then, just as in respect to the urine, clinical observa- 
 tion and physiology lead to the practical conclusion that for twelve 
 or eighteen hours after the commencement of reaction, more parti- 
 cularly when the collapse has been of short duration, we need not 
 attach any importance to the alvine discharges not becoming of 
 normal colour. 
 
 In occasional instances dejections during the collapse are of 
 pinkish tint; they may be so, and not profuse, from the com- 
 mencement, or they may present this appearance at a later period 
 when they have ceased to be very watery. Discharges of this kind, 
 caused, no doubt, by partial transudation of the colouring matter 
 of the blood, have been observed by me only in natives. They are 
 of most unfavourable import, for I have never met with an in- 
 stance of recovery. 
 
 Dr. Macpherson* cites two interesting cases of hsematernesis in 
 the course of cholera, which occurred to him in the General Hos- 
 pital at Calcutta ; and it is not improbable, though I am not 
 aware that the observation has been made, that the pink-coloured 
 discharges are of more frequent occurrence in Bengal than in 
 Bombay, because haemorrhage from the bowels is more common in 
 that province. 
 
 The remark, in the report on cholera by the Madras Medical 
 Board, that hiccup is not the unfavourable prognostic in this disease 
 which it is in many others, accords with what I have myself noticed. 
 It occurs generally in cases in which the collapse has been long-, 
 and the reaction slowly established, is coincident with the latter 
 state, and though often, is not necessarily, associated with gastric 
 irritation. 
 
 The diagnosis of epidemic cholera is well marked when the 
 disease is fully formed. The cramps and the prostration co-exist- 
 ing with the peculiar discharges, are sufficiently characteristic to 
 distinguish it from bilious cholera, with its bile-tinged discharges, 
 coated tongue, transient prostration, and occasional cramps. If a 
 
 ■ " Notes on Cholera. Indian Annals of Medical Science," vol. i. p. 120. 
 
 P 3 
 
214 EPIDEMIC CHOLERA. 
 
 conclusion may be drawn from my own field of inquiry, I would 
 say that bilious cholera is a rare form of disease in Indian hospitals, 
 particularly in those for native sick. On referring to the returns 
 of the European General Hospital at Bombay, I find, that of 20,147 
 admissions in fifteen years, only 74 were from bilious cholera, and 52 
 of those were during the six years of my service in that hospital. 
 The deaths recorded under this head were 3, occurring from 1845 to 
 1847 ; and as during this period the admissions amounted only to 4, 
 we have a mortality from bilious cholera of 75 per cent. — a result 
 so contrary to all experience, leads to the conclusion that these were 
 cases of epidemic cholera, and the record therefore further shows 
 that an error in diagnosis is a possible contingency. Then in 
 respect to the Jamsetjee Jejeebhoy Hospital, it appears that out 
 of 25,190 admissions in six years, there were only 2 of bilious 
 cholera. 
 
 These facts justify the statement that bilious cholera is not a 
 common disease in India in numerous classes of the community. 
 
 It is not denied that in sthenic Europeans in India bilious 
 vomiting, a flushed countenance, a coated tongue, and more or less 
 derangement of the bowels after debauch, are sufficiently common ; 
 but this form of disease, even if correctly designated bilious cho- 
 lera, cannot possibly be mistaken for epidemic cholera. 
 
 But another and very important question of diagnosis may present 
 itself in India. 
 
 In one * of the reports of the Bengal charitable dispensaries, it 
 is stated that advantage is sometimes taken of the prevalence of 
 cholera for the perpetration of acts of criminal poisoning, in con- 
 sequence of the lessened chance of detection which exists under 
 such circumstances of the public health. This remark is just ; for 
 my own observation in Bombay enables me to say, that criminal 
 poisoning, chiefly by arsenic, is, unfortunately, not rare, and that 
 the great collapse which speedily comes on after a large quantity 
 of this poison has been taken, sufficiently resembles that of cholera 
 as to render the mistake in cholera seasons, when suspicion has not 
 been aroused, by no means improbable. If we have the oppor- 
 tunity of examining the vomited and dejected matters during life, 
 there should be no difficulty in determining the question. The 
 florid tongue and tender epigastrium of gastritis, will also assist in 
 the diagnosis ; but if in fatal cases doubt still remains, a post mor- 
 tem examination will at once remove it. 
 
 * I regret my inability at the present time to refer particularly to the Report ami 
 its author. 
 
KATE OF MORTALITY. 215 
 
 At a time when cholera prevailed, two children, a brother and 
 sister, were brought to the European General Hospital ill with 
 vomiting and purging. They died shortly afterwards, and there 
 had not been any opportunity, subsequent to their admission into 
 hospital, of observing the character of the evacuations. There were 
 circumstances connected with the commencement of the illness of 
 these children which raised the suspicion that something deleterious 
 had been exhibited. An inquest was held. The parents were un- 
 willing that the post mortem examination should be more minute 
 than was sufficient to remove the doubt. The stomach and the end 
 of the ileum were opened, and in both cases the mucous coat of the 
 former was pale, that of the latter was studded with prominent 
 Peyer's glands. On these appearances, coupled with the circum- 
 stance that cholera was prevalent, I grounded the opinion that death 
 had been caused by cholera, and not by an irritant poison. 
 
 When treating of remittent fever it was explained that the 
 paroxysm sometimes terminates with unlooked-for prostration, 
 thready pulse, cold skin, and death by syncope. I have known 
 such an event viewed as an attack of cholera coming on in the 
 course of fever ; but we must be on our guard against an error of 
 this kind. Cholera may doubtless occur in the course of fever, and 
 lead to a fatal issue ; but there can be no difficulty in distinguishing 
 such cases from prostration at the close of a febrile paroxysm. The 
 diagnosis will turn upon the relation of the prostration to alvine 
 discharges, to the period of the paroxysm, and to the general course 
 of the disease. 
 
 Section III. — The general rate of mortaUfy. — lis relation to 
 age, period of epidemic, and duration before admission con- 
 sidered. — General pathology shortly noticed.. — Morbid ana- 
 tomy described. 
 
 The following statement," with that at p. 202, illustrates the well- 
 known mortality occasioned by this disease : — 
 
 
 Proportion of Mortality from 
 Cholera to total Mortality. 
 
 In European troops, Bombay Presidency . 
 
 European officers, ditto ..... 
 In Population, Bombay, for four years 
 
 European General Hospital, Bombay 
 
 Jamsetjee Jejeebhoy Hospital .... 
 
 10' per cent. 
 7-7 ' „ 
 20-35 
 14-5 
 139 
 
 P 4 
 
216 
 
 EPIDEMIC CHOLERA. 
 
 In regard to the rate of mortality there is a good deal of dis- 
 crepancy in published statements. But this is easily understood, 
 when we recollect that the severity of the disease varies in different 
 epidemics, and at different periods of the same epidemic, and in 
 different classes of individuals. 
 
 As an approximate statement, we may estimate the mortality in 
 India at from 30 to 45 per cent, in regimental hospitals, 50 to 55 in 
 European general hospitals, and 60 to 65 in general hospitals for 
 the civil native population of large towns, as the Jamsetjee Jejee- 
 Lhoy Hospital in Bombay.* 
 
 The only investigations which I have made on the variation of 
 the ratio from age f, the period of the epidemic, and duration 
 of attack, refer to 159 individuals admitted into the Jamsetjee 
 Jejeebhoy Hospital from the 17th August to the 31st December, 
 1849; of these, 94 died, and 5 remained under treatment 
 on the 1st of January. The results are shown in the following 
 tables : — 
 
 A. 
 
 Ages noted. 
 
 Under 10 years 
 Between 10 and 20 
 „ 20 and 40 
 Above 50 
 
 Numbers. 
 
 13 
 
 19 
 
 112 
 
 10 
 
 Rate of Mortality. 
 
 69 per cent. 
 
 63 
 
 58 „ 
 
 50 
 
 These numbers are too limited to be of much value on the 
 question of age. The high mortality shown in the tables in very 
 early life probably accords with the results of the epidemic 
 cholera in England in 1 8494 But in that epidemic the lowest 
 mortality was from five to fifteen years of age : this does not appear 
 to be a feature of cholera in India, judging from the above table 
 and one in Dr. Macpherson's notes. § The low mortality above the 
 age of fifty, in my statement, is opposed to the results obtained by 
 Dr. Gull and Dr. Macpherson, and illustrates the errors into which 
 we may be led by partial statistics. 
 
 * This is a considerably higher rate than appears in the appended return of this 
 hospital for six years, and I so state it because the mortality has been higher in 
 other years and patients occasionally are removed in a precarious state by their 
 friends, but entered discharged in the returns, and rated as recoveries. 
 
 f The rate of mortality in the Kyeulla Schools may also be considered— it has been 
 48-2. 
 
 \ " Report on the Morbid Anatomy, Pathology, and Treatment of Epidemic 
 Cholera." By William W. Gull, M.D. &c. p. 147. 
 
 § " Annals of Indian Medical Science." No. 1, p. 113. 
 
KATE OF MORTALITY. 
 
 217 
 
 The varying ratio at different periods of the epidemic is clearly- 
 exhibited in the following table : — 
 
 B. 
 
 Dates of Admission. 
 
 Rate of Mortality. 
 
 17th August to 3rd September . 
 4th September to 17th September 
 18th September to 1st October. 
 2nd October to 15th October . 
 
 
 
 
 
 84-6 per cent. 
 72-0 
 
 75-0 „ 
 47-0 „ 
 
 16th October to 29th October . 
 
 
 
 
 
 28-0 
 
 30th October to 12th November 
 
 
 
 
 
 50-0 
 
 13th November to 26th November 
 
 
 
 
 
 50-0 
 
 27th November to 10th December 
 
 
 
 
 
 55"5 ,, 
 
 11th December to 31st December 
 
 
 
 
 
 433 
 
 With the view of endeavouring to determine to what extent the 
 mortality was influenced by admission into hospital at early or ad- 
 vanced periods of the attack, I made the following note in respect 
 to 157 cases: — 
 
 C. 
 
 Duration of Disease on Admission. 
 
 Numbers. 
 
 Rate of Mortality. 
 
 
 38 
 49 
 48 
 22 
 
 63-3 
 613 
 45-9 
 59-0 
 
 That the highest mortality should be in those admitted at the 
 earliest period of the disease, and the lowest in those in whom it 
 had been present for upwards of twelve hours, may seem an unex- 
 pected result ; but it is easily explained by those who are acquainted 
 with the habits of the individuals represented by these figures, — 
 with their unwillingness to resort for hospital relief in the early 
 stages of illness. The conclusion to be drawn from the statement 
 is, that the admissions under five hours were cases of great severity, 
 enforcing an early application for relief, hence the high mortality. 
 On the other hand, those between twelve and twenty-four hours 
 were milder, and had not yet entered on the risks of reaction. In 
 the admissions above twenty-four hours there is again a rise in the 
 mortality, depending, no doubt, on the fact that a proportion of 
 these cases had been neglected, and that the secondary dangers 
 had been incurred before admission. 
 
 To determine the proportion of deaths in the stage of collapse, 
 and in that of reaction, is a question of interest, for it probably 
 
218 EriDEMIC CHOLERA. 
 
 differs in India and in European countries ; I have no data bearing 
 on this point. Dr. Grull * estimates the proportion of death from 
 consecutive fever in England at one-tenth. Though the opinion 
 generally entertained, that the proportion of deaths in the stage 
 of collapse in India preponderates over that of the same stage in 
 England, is probably correct ; yet it is an error to suppose that the 
 practitioner in India is not perfectly familiar with all the secondary 
 phenomena and dangers of cholera. 
 
 Pathology. — In considering the pathology of cholera, the first 
 circumstance on which to fix the attention is, that the general and 
 capillary circulation of the blood, and all their dependent actions, 
 are more or less arrested. That this arrest is favoured, but not mainly 
 caused, by the copious watery discharges, is shown by the facts that 
 not unfrequently the collapse is great, and the discharge is small ; 
 and that occasionally the prostration is moderate, and the discharges 
 copious and long continued. 
 
 Whether the morbific cause acts first on the blood or on the 
 ganglionic nervous system, is a question which physiological and 
 pathological science are, in their present state, unequal to deter- 
 mine, and the discussion of which does not come within the scope 
 of a clinical treatise. 
 
 I proceed to notice the morbid anatomy of the disease. Of 
 17 fatal cases now before mej 15 occurred in the stage of collapse, 
 and 2 with secondary complication — one of the head, the other of 
 the lungs and pericardium. These cases show that the morbid ap- 
 pearances which chiefly attract attention after death, in the col- 
 lapsed stage of cholera, are the following : — 
 
 Head. — The vessels of the membranes are congested with dark- 
 coloured blood, and the substance of the brain, when incised, 
 shows numerous bloody points. There is generally increased 
 effusion of serum in the cavity of the cranium, but this state is not 
 necessarily an evidence of drowsiness or other head symptoms 
 having been present during life. 
 
 Chest. — The lungs are usually well collapsed ; the anterior 
 surface is pale, with sometimes an inflated, or emphysematous state 
 of their edges. There is, for the most part, a reddened colour 
 at their posterior aspect, with moderate congestion. The heart 
 is sometimes flaccid, at others not so. The left ventricle is 
 almost invariably empty ; but the right one is more or less rilled 
 with blood, dark-coloured, generally quite fluid, sometimes with 
 co-existing fibrinous coagula. 
 
 * Report, p. 112. 
 
PATHOLOGY. 219 
 
 Abdomen. — Very commonly there is a blush of redness on the 
 visceral peritoneum. The stomach is frequently distended, and its 
 mucous surface, commonly pale, sometimes presents dotted or 
 marbled red patches. The small intestines usually contain some 
 amount of watery or milk -like contents similar to the cholera dis- 
 charges ; and their mucous surface is, for the most part, pale, 
 with the villi very distinct. The isolated and agminated glands 
 of Peyer are very generally prominent ; this has been chiefly ob- 
 served at the lower part of the ileum, where the surface is often 
 studded with pale solitary glands, enlarged to about the size of a 
 mustard seed. The large intestines are often contracted, and the 
 mucous membrane of the colon is pale, and the solitary glands 
 prominent : the mucous follicles, with their dark depressed centres, 
 are frequently distinctly seen. The mesenteric glands are usually 
 enlarged, but pale in colour. There is commonly little to notice in 
 the appearance of the liver; sometimes, when incised, it bleeds more 
 freely than usual. A distended state of the gall-bladder was observed 
 in only one of the cases, and from this it may be inferred that there 
 has not been usually anything in the state ofthis viscus to arrest 
 my attention. In my cases little notice is taken of the condi- 
 tion of the spleen, from which it may be concluded that it was 
 not enlarged ; the free evacuations must tend to cause this organ 
 to shrink, and, indeed, I have had evidence of this in the great 
 decrease of a much enlarged spleen in an individual who became 
 affected with cholera. The kidneys are sometimes healthy in 
 external apppearance, sometimes they are congested. In one 
 case, that of an individual (with abdominal pleuritic effusion, 
 with commencing Bright's disease and old tubercular peritonitis), 
 attacked with cholera, the collapse was incomplete, and the disease 
 protracted for four days — evidently in consequence of the drop- 
 sical effusions, which gradually disappeared, supplying to the blood 
 the water which was being lost by the discharges. In this case 
 absorption took place because the pulse continued distinct till 
 shortly before death. 
 
 In cases of cholera fatal in the secondary stage, the mor- 
 bid appearances found after death are the results of inflam- 
 mation of the structures which have been chiefly affected during 
 life. 
 
 Such is a summary of the morbid appearances in the collapsed 
 stage of cholera, drawn from my own observation, and I am not 
 aware that any important addition can be made to it from the 
 writings of the latest observers, with exception of a minuter de- 
 
220 EPIDEMIC CHOLERA. 
 
 scription of the condition of the kidneys.* I allude to the epithelial 
 debris found in the uriniferous tubes and pelvis of the kidney as 
 explanatory of the albuminous state of the urine f on its re-appear- 
 ance after reaction. 
 
 The chemistry of the alvine discharges and of the blood in 
 cholera has also been investigated ; but as yet the inquiry has 
 done little more than confirm and give precision to inferences 
 already fairly deducible from clinical observation and morbid 
 anatomy* 
 
 According to Dr. Parkes J, there are in 1000 parts of cholera 
 evacuations: water, 987-95 ; organic matter and insoluble salts 
 (earthy phosphates), 3*9; soluble salts (chlorides, phosphates, and 
 sulphates of soda and potash), 8*1. The same careful inquirer has 
 particularly noted the small amount of organic extractives in the 
 discharges of cholera, and he believes that this circumstance indi- 
 cates the suspension during the collapsed stage of cholera of the 
 proper excreting functions of the intestinal mucous membrane. I 
 need hardly remark that this belief is quite in accordance with 
 clinical inferences relative to the general state of the vital actions 
 of the system in this stage of the disease. 
 
 The density of the blood is necessarily much increased in conse- 
 quence of the transudation from the capillaries and discharge from 
 the bowels of so much of its watery constituent. The degree of in- 
 crease of density will have relation to the duration of the attack, the 
 amount of transudation, and the absence of replacement of water. 
 It need hardly be observed, that the loss of the water of the blood 
 does not merely affect the constitution of the liquor sanguinis, but 
 must also, in accordance with the laws of endosmosis and exosmosis, 
 influence that of the contents of the blood corpuscles. The propor- 
 tion of the inorganic salts of the blood would seem to be increased 
 in the early stages of the disease in consequence of the greater pro- 
 portional transudation of the water. But in the more advanced 
 periods the salts gradually sink below their normal ratio. § 
 
 Dr. Cfarrod || thus states the conclusion which may be drawn 
 from his experiments on urea in the blood in cholera : " That 
 urea usually exists in increased quantities in cholera blood, 
 
 * Dr. Gull's Report, p. 32. 
 
 f Of this condition of the urine lam unable to say much from my own observation ; 
 in the few cases in which the urine was tested it was found albuminous. 
 
 \ " Report on the Morbid Anatomy and Pathology of Cholera," pp. 25 and 26, by 
 Dr. Gull. 
 
 § Dr. Gull's Report, p. 45. 
 
 || Dr. Gull's Report, p. 53. 
 
TREATMENT. 221 
 
 but that the amount differs considerably in the different stages of 
 the disease ; being but small in quantity in the intense stage of col- 
 lapse, increasing during re-action, and in excess when consecutive 
 febrile symptoms occur." 
 
 This statement — that urea is present in the blood in small 
 quantity in the intense stage of collapse, increased with reaction, 
 and is in excess when consecutive febrile symptoms occur — quite 
 accords with the general tenour of the remarks, based on clinical 
 observation alone, which I have already made relative to the 
 importance attributable to the absence of the urinary secretion in 
 cholera (pp. 211, 212). 
 
 Section IV. — Treatment in the different degrees and stages of 
 
 the disease. 
 
 My remarks on the treatment of cholera will be restricted to a 
 statement of the conclusions to which I have been led by reflection, 
 and the clinical observation of cases not only immediately under my 
 own care, but also of those treated by others in the same or different 
 hospitals. I place the more confidence in the opinions thus formed, 
 — many years ago in part elsewhere expressed, — because they 
 rest on principles very similar to those entertained by the latest 
 and best writers * on this disease. 
 
 Extensive clinical experience of epidemic cholera leads the 
 unbiassed mind to this conclusion. That there are degrees and 
 stages of cholera, as of other zymotic diseases, beyond the direct 
 resources of medical art, and that in the management of these the 
 physician best consults the interests of humanity and the character 
 of his profession, when he abstains from rash and restless empiri- 
 cism, and is satisfied with placing the patient in the circumstances 
 most favourable for the revival of vital actions, under the influence 
 of their ordinary stimuli. That, on the other hand, there are de- 
 grees and stages of the disease which are frequently readily con- 
 trolled by medicine, and that these demand careful study and 
 attention. Guided by these principles, I proceed to the considera- 
 tion of the treatment of cholera. 
 
 The prevalence of diarrhoea in seasons of epidemic cholera, 
 obtains in India as well as in European countries ; but this event 
 is more common in the latter than in the former. The relation, 
 however, which these two affections bear to each other is the same 
 
 * Chapter on Treatment in Dr. Parkes' " Researches into the Pathology and Treat- 
 ment of Cholera ; " also Dr. GiuTs "Report on the Treatment of Cholera." 
 
222 EPIDEMIC CHOLERA. 
 
 in both countries. The diarrhoea, if neglected, is very apt to pass 
 into cholera ; and, on the other hand, is amenable to ordinary 
 treatment in a large proportion of cases. We may state these facts 
 in other words by saying that cholera is not unfrequently preceded 
 by a premonitory, and often readily curable, diarrhoea. The prac- 
 tical rule of carefully regarding and treating all cases of diarrhoea, 
 and of being very cautious in the use of purgatives, antimonials, or 
 other intestinal irritants, in the general treatment of disease, in 
 cholera seasons, is very familiar to the experienced practitioner in 
 India ; and there can be no doubt that its observance has led to 
 much saving of life. It has for many years been the judicious 
 practice of the authorities in Bombay, in seasons when cholera is 
 epidemic, to station qualified individuals, with suitable remedies, in 
 the different divisions of the native town; and to encourage those 
 affected with diarrhoea to apply for relief. 
 
 The medicines which have been used for this premonitory diar- 
 rhoea are numerous ; but in natives or Europeans who have been 
 long resident in India, a simple opiate is the best means we can 
 adopt. One or two grains of solid opium, or twenty to forty minims 
 of the tincture with peppermint water, and two or three drachms 
 of brandy, may be given. If the diarrhoea has been early noticed, 
 and if at the same time diet and the temperature of the surface of 
 the body have been carefully attended to, a single dose of opium 
 will very generally suffice. Should, however, it prove otherwise, 
 then after a suitable interval a smaller dose may be repeated. 
 
 In sthenic Europeans in India, in whom this premonitory diar- 
 rhoea frequently co-exists with a coated tongue, it is advisable to 
 combine the opium with calomel, in the proportion of two grains 
 of the former to ten of the latter. This course is followed, not so 
 much on account of any direct expected benefit from the calomel, 
 as on the supposition that it modifies or prevents the astringing 
 effect of the opium on the biliary excretion. 
 
 In cases in which the diarrhoea has been neglected, and allowed 
 to continue for some time unchecked, in which the discharges are 
 becoming very watery, and the pulse and countenance beginning to 
 change, then attention to such adjuvants as confinement to bed in 
 the recumbent posture, and warmth by suitable clothing to the sur- 
 face of the body, must at once be enforced ; while at the same time 
 the opiate remedies are given and repeated, combined with a larger 
 proportion of alcoholic or ammoniated stimulant. 
 
 ►Should such means, however, used under these circumstances, 
 fail in speedily checking the diarrhoea, and should the true cholera 
 
TREATMENT. 223 
 
 discbarges not as yet have been established, then we are no longer 
 to trust to opium alone, for it will prove inefficacious in small doses, 
 and injurious in large ones frequently repeated. Recourse must be 
 had to astringent remedies given more or less frequently, either 
 alone or combined with small doses of opium. Acetate of lead, 
 diluted sulphuric acid, preparations of kino or catechu, gallic acid, 
 with many others, may be named. The first * is the astringent of 
 which my experience has been the greatest, but I have no great bias 
 in its favour, and would prefer any of the others, if, as is very pro- 
 bable, they should prove of equal efficacy. 
 
 But should the symptoms still continue, and the diarrhoea pass 
 into cholera, and collapse be more or less established, then the 
 principles for the treatment of this stage of cholera, presently to be 
 explained, ought to be applied. 
 
 After these few remarks on the treatment of, and the importance 
 of attending to, the diarrhoea prevalent at cholera seasons, I next 
 consider the management of the disease after it has become fairly 
 developed. And here it is necessary, in the first instance, to state 
 certain principles which seem to me to be true, and to rest on 
 clinical observation. 
 
 * I have always used the formula recommended by Dr. Graves, from whose writings 
 I adopted this system of treatment, viz. : "A scruple of acetate of lead combined with a 
 grain of opium, and six grains of powdered liquorice made into a mass with mucilage, 
 divided into twelve pills." 
 
 In the year 1839, I published in the second number of the " Transactions of the 
 Medical and Physical Society of Bombay " cases of cholera treated with acetate of lead, 
 after the manner recommended by Dr. Graves. They seemed to me favourable. 
 Further experience led me, in the seventh number of the Transactions of the Society, 
 in 1845, to write in a more qualified manner. Again, after my experience in the 
 Jamsetjee Jejeebhoy Hospital, I expressed myself in the tenth number of the Trans- 
 actions, p. 323, in 1850, to the following effect : — 
 
 " In the "Transactions of the Medical and Physical Society" I have expressed my 
 opinion on the efficacy of the acetate of lead, if given while the pulse is of tolerable 
 strength, also of its inappbcability to those extreme cases of the disease in which 
 great collapse follows trifling discharges ; and I would now add, as the result of my 
 experience in this epidemic, that the acetate of lead has proved altogether powerless 
 in restraining the serous discharges occurring after collapse has fully set in. 
 "Whether an attempt to restrain these discharges after fully formed collapse has taken 
 place is an indication to be kept in view, is probably an open question in the patho- 
 logy of the disease, which need not be discussed here. The acetate of lead, however, 
 has been inefficacious for the purpose, and I should be indisposed again to have 
 recourse to it under the same circumstances of the disease ; the more so, as it is pos- 
 sible enough that the drug lying inert in the alimentary canal during the period of 
 collapse may have an injurious influence by its rapid absorption on the occurrence of 
 reaction." My present opinion, then, is not corroborative of the estimate entertained 
 by Dr. Graves of the value of this medicine in cholera, and the above statement will 
 show that it has not been hastily formed, but is the result of upwards of fifteen years' 
 attention to the question. 
 
224 EPIDEMIC CHOLERA. 
 
 1. In the collapsed stage of cholera, the capillary circulation, 
 and the processes in which it is concerned, are in a great measure 
 suspended ; hence there cannot be absorption or action of medicinal 
 agents. 
 
 2. In cases in which the collapse is recovered from, the re- 
 turn of the general and capillary circulation, and consequent vital 
 processes, is gradual and slow, and more likely to be disturbed than 
 aided by medicines; while, at the same time, the gastro-intestinal 
 mucous membrane is very predisposed, from defective epithelium, 
 to take on inflammatory action. 
 
 3. Medicinal agents given in the stage of collapse and not at 
 that time absorbed, are liable to accumulate in the intestinal canal, 
 to become absorbed as reaction is re-established, and then to inter- 
 fere with the restoration of secretion and other functions ; or they 
 may, by their mere presence, act as irritants on the predisposed 
 mucous surface, and excite gastro-enteritis. 
 
 In the first and milder degree, described at page 209, — in 
 which, though the cholera discharges are present, the pulse is 
 still of moderate strength, — it is not improbable that absorption 
 still may be carried on at the intestinal surface, and that there- 
 fore there may be indication for the use of medicines. It is 
 right to act cautiously on this probability ; but, with every allow- 
 ance for it, my belief still is, that when cholera discharges are 
 fairly established, they are, whatever the state of the circulation 
 may be, very little under the control of astringent or other 
 remedies. 
 
 In my further remarks on treatment, it is assumed that the 
 reader bears in mind not only the statement of principles which has 
 just been made, but also the degrees of the disease as already ex- 
 plained in connection with the symptoms. 
 
 When cases of cholera come under treatment with the pulse dis- 
 tinct, then the remedies recommended for the treatment of the 
 preliminary diarrhoea may be used. We must be careful, however, 
 not to give more than one or two * full doses of opium ; for this 
 will be test sufficient of its efficacy, and more will be likely to prove 
 injurious. If the collapse increases and the pulse becomes indis- 
 tinct, or if, after four or six hours of the use of astringents, the 
 discharges persist unchecked, the discontinuance of these remedies, 
 even though the pulse is still distinct, will be advisable, for under 
 both circumstances a fair trial of them will have been made. The 
 want of success justifies the inference that the state of the system 
 
 * I assume, of course, that opiates have not been previously given at earlier stages. 
 
TREATMENT. 225 
 
 has not been compatible with the action of the medicines, and that 
 their further use may lead to the subsequent risks attendant on 
 their accumulation. 
 
 A considerable proportion of the cases of the first degree of the 
 disease, — those in which, after three or four hours of characteristic 
 vomiting and purging, the temperature of the skin remains still 
 good and the pulse of tolerable strength, — will do well under this 
 treatment without any material augmentation of the collapse. 
 It was in this form of the disease — common in the early epi- 
 demics in India, but rare in later years — that general blood- 
 letting and repeated doses of calomel and opium acquired a thera- 
 peutic fame, which subsequent and more general experience has 
 not confirmed. The truth is simply this, — that when the degree 
 of the disease is such as to stop short of any considerable amount of 
 collapse, then attention to the recumbent posture, to warmth of the 
 surface of the body by suitable coverings, and the exhibition of a 
 full opiate with or without calomel, according to the state of the 
 tongue, are means sufficient for the cure. That more than this is 
 in general not only unnecessary, but likely to be injurious rather 
 than beneficial. 
 
 But, as already stated, a large proportion of the cases in Indian 
 epidemics are of those degrees in which collapse, complete or great, 
 comes on more or less quickly. In these the skin is cold and damp, 
 the pulse thready or imperceptible, and the features shrunken. 
 When these symptoms are present — it matters not whether they 
 have come on quickly or slowly, or whether treatment has been 
 previously followed or neglected, or whether the discharges con- 
 tinue or have ceased — the period for the exhibition of opiates 
 or alteratives or astringents has passed ; the condition of the 
 system is incompatible with their action. This state of the 
 disease is best managed by directing attention to those ordinary 
 stimuli necessary to the maintenance of vital actions in health, 
 and to their restoration when depressed. The patient should 
 be placed in a well-ventilated room ; the surface of the body 
 should be wiped from time to time, lightly covered with two or 
 three blankets, over which warm bricks, or other similar means 
 of imparting external heat, may be applied. Water should be 
 given frequently in small quantities, according to the desire of 
 the patient, if he is alert ; or it should be offered to him if he is 
 sluggish and apathetic. It has been my practice, in addition to 
 these means, to give a drachm of aromatic spirit of ammonia every 
 hour or second hour, and a little wine with thin sago every third 
 
 Q 
 
226 EriDEMIC CHOLERA. 
 
 hour ; for it is well to assume the possibility of some degree of ab- 
 sorption, and to regard it to this extent, A recumbent posture 
 should also be strictly observed. The cramps and restlessness, if 
 distressing, may be palliated by gentle rubbing and shampooing. 
 
 The proportion of recoveries from the stage of complete or great 
 collapse is considerable, certainly not less than 40 per cent. : but I 
 believe that if the attention of the practitioner were more generally 
 confined to assiduously enforcing the simple indications just ex- 
 plained, and not distracted with the vain hope of benefit from rash 
 empirical experiments, the mortality in this stage would be still 
 further reduced. Of the cases in India, which recover from the 
 collapse, the larger proportion is restored to health by a gradual 
 return of the functions to their normal condition ; but the re- 
 mainder is more or less exposed to the risks of secondary fever or 
 inflammation, and a portion of them die. Though my impression, 
 — that by treating the stage of collapse in the manner just recom- 
 mended, an increase in the number of recoveries from that state is 
 probable, — may admit of doubt, still I am very confident that, by 
 abstaining from the use of opiates, astringents, alteratives, and 
 excessive stimulants, we materially lessen the proportion of sub- 
 sequent secondary risks, and, consequently, diminish the absolute 
 mortality of the disease. 
 
 Let us now follow the treatment when collapse is passing 
 away and reaction is taking place, noticing, first, those cases in 
 which there is gradual restoration of function without febrile ex- 
 citement or secondary inflammation. When writing on the treat- 
 ment of cholera in the European General Hospital in 1845, I made 
 the following observations * : — 
 
 " The most satisfactory recoveries which. I have witnessed from states of extreme 
 and almost hopeless collapse — the purging having in great measure ceased — have been 
 under the use of camphor and blue pill, in doses of three grains of the former and two 
 of the latter, given every second or third hour, with effervescing draughts, light 
 nourishment, and occasional stimulants. 
 
 "In successful cases, when the collapse is passing off, and the indication of cure is 
 to restore the secretory functions which have been paralysed, I am clearly of opinion 
 that tins, in most cases, can be most satisfactorily effected by combinations of 
 camphor, or quinine, and blue pill; perhaps calomel in small doses, with or without 
 a small addition of opium, according to circumstances, and accompanied with the occa- 
 sional exhibition of effervescing draughts, or small doses of castor oil. This course 
 Si ems to me Bafer than to attempt the same indication by calomel in large doses and 
 purgatives; it being probablj more in accordance with the operations of nature. For 
 it seems a fair assumption thai functions after having been completely checked, will 
 be more likerj to recover their natural course by degrees; and that, consequently, the 
 indication seems rather gently to guide, than attempt by strong measures to propel." 
 
 * " [Transactions of Medical and Physical Society of Bombay," No. 7. p. 192. 
 
TREATMENT. 227 
 
 In the fifteen years which have elapsed since these remarks were 
 written, my opportunities of treating cholera, and of witnessing the 
 treatment by others, have been extensive ; but my principles have 
 undergone very little change. On considering the diaries of re- 
 covered cases now before me, I observe that not unfrequently 
 twenty-four hours, after return of pulse and warmth of the 
 surface, have elapsed before the urine has been restored, or the 
 alvine discharges become coloured: such facts prove that these 
 processes are restored to their normal condition slowly and gradually, 
 and that, if active alteratives and eliminants are used, harm rather 
 than good is likely to result. Again, some cases show that calomel 
 may, under these circumstances, be given in considerable doses, 
 and yet not exercise any perceptible effect on the biliary secretion ; 
 while, at the same time, its irritant action on the gastro-intestinal 
 surface may be suspected : from these events we may draw the 
 inference, that for some time after the commencement of reaction 
 the secretory processes are not readily susceptible of influence 
 from alteratives or eliminants, and that, therefore, when these re- 
 medies are used, the hazard of gastro-enteric irritation without the 
 counter-balancing advantage of more quickly restored secretions, 
 is incurred. It follows, then, that, in my remarks of 1845, an 
 importance was accorded to the combination of blue pill with 
 camphor and quinine to which it was in all probability not 
 entitled. My present opinion is, that the recoveries would have 
 taken place equally well under the use of occasional effervescing 
 draughts and diluents, light nourishment and occasional stimu- 
 lants ; and that, by the needless use of mercurials and purgatives, 
 restoration is delayed, and gastro-enteric irritation is apt to be 
 excited. In individuals asthenic before the attack, it will some- 
 times be of advantage to give small doses of quinine every third 
 or fourth hour; and it will be very necessary in such cases to 
 pay much attention to frequent and appropriate nourishment, 
 for asthenic individuals recovered from collapse are liable to 
 sink unexpectedly from subsequent exhaustion. Occasionally, 
 after reaction has been established, the alvine discharges continue 
 so frequent as to indicate the expediency of restraining them by 
 small opiates or astringents ; but I believe that this seldom occurs, 
 unless secondary enteric irritation is present, and is chiefly ob- 
 served when irritant remedies have formed a part of the previous 
 treatment. 
 
 Next we have to notice the treatment of cases recovered 
 from collapse, but in which the restoration to health has been 
 
 q 2 
 
228 EPIDEMIC CHOLERA. 
 
 delayed, and risk to life occasioned, by secondary fever or in- 
 flammation. 
 
 The secondary febrile and inflammatory states are more or less 
 adynamic. In India the febrile state is seldom simple, but gene- 
 rally accompanied with gastro-enteric, cerebral, pulmonic, or other 
 inflammation ; but when it does occur in its uncomplicated form, it 
 must be treated on the general principles applicable to adynamic 
 fever, however arising. 
 
 When the injected conj unctivse, delirium, or drowsiness, and slow 
 pulse, indicate cerebral disturbance, and threatening secondary 
 meningitis ; or the florid tongue, the tender epigastrium, the 
 vomiting, the diarrhoea, indicate gastro-enteritis, then general prin- 
 ciples of treatment, by leeches and blisters according to the state of 
 constitution, must be adopted, and cases before me show that 
 success may attend the use of these means. 
 
 But an important practical question remains to be considered. 
 It is the tendency of current pathological theory to relate these 
 secondary inflammations, more particularly the cerebral, to the re- 
 tention of excretions in the blood, and to point to elimination by 
 the usual channels, as an indication in their treatment. Clinical 
 observation is sufficiently in accordance with this theory to justify 
 our acceptance of the therapeutic principle ; but it requires to be 
 carried into effect with much caution. 
 
 Whenever the collapse has been of such duration as to render it 
 probable that secondary dangers may arise, then, with the return- 
 ing pulse and warmth of the surface, we may commence the use 
 of a saline diuretic, and give it every third or fourth hour : the 
 acetate or nitrate of potass in combination with spiritus oetheris 
 nitrici, answers very well, and, at the same time, simple diluents 
 should be given. Should cerebral complication threaten, and there 
 be no symptoms of gastro-enteric irritation present, then recourse 
 may be had to one or two ten-grain doses of calomel, followed, if 
 necessary, by two or three drachms each of castor and turpentine 
 oil. These means, however, must be very cautiously used, because, 
 as already shown, under this state of the secretions calomel is slow 
 to take effect on them, but quick to excite gastro-enteric inflam- 
 mation. When, however, the threatening of cerebral complication 
 co-exists with gastro-enteric irritation, we must abstain from the 
 use of mercurial or other purgatives, for the excitement of gastro- 
 enteritis will more certainly aggravate t he head symptoms and 
 endanger life than the eliminatory action of the mercury effect 
 ■.' I. 
 
TREATMENT. 229 
 
 Ou the whole, there is more scope for the use of mercurial and 
 other purgatives in cerebral complication after cholera in sthenic 
 individuals, than in those debilitated before the attack, because 
 in asthenic constitutions cerebral complication with gastro-enteritis 
 is more common than the simple form, and when this coincidence 
 occurs, the remedial means are restricted to local depletion, counter- 
 irritation, diuretics, and diluents. 
 
 Still, however, another practical question may be asked : May 
 we net endeavour to control the secondary inflammations of cholera, 
 more especially the cerebral, by constitutional mercurial action ? 
 My opinion is distinctly opposed to this proceeding, both because 
 the adynamic state of the system generally contra-indicates it, and 
 the risk of gastro-enteric irritation, from the internal use of mercury, 
 more than counterbalances any advantage likely to arise from its 
 theoretic adoption. 
 
 Before concluding the treatment of cholera, it is desirable that I 
 should state the estimate entertained by me of remedies which at 
 times have been much used, but which, as yet, have not been 
 alluded to in these remarks. 
 
 General Blood-letting, at one time so much used in India in the 
 treatment of cholera, is now nearly abandoned. In the few in- 
 stances in which I have myself adopted it, no good effect was appa- 
 rent, and the recoveries which took place under its use in the early 
 epidemics, were probably generally of the mild form of the disease 
 now seldom seen, and for the cure of which rest and an opiate 
 usually suffice. 
 
 My estimate of opium, calomel, astringents, and stimulants, may 
 be gathered from the observations which have already been made 
 on the general treatment of the disease. 
 
 The Hot bath, with the view of restoring the heat of the body 
 and thus lessening the collapse, has been had recourse to. On 
 this means of treatment Dr. Parkes * thus expresses his opinion : 
 " The depressing effects of the warm bath were sometimes marked 
 and unmistakeable. I have seen a man walk firmly to the bath, 
 with a pulse of tolerable volume, and a cool but not cold surface, 
 and in five or ten minutes have seen the same man carried from the 
 bath with a pulse almost imperceptible, and a cold and clammy 
 skin. I cannot find in my notes a single case in which the warm 
 bath appeared beneficial." In the second number of the " Trans- 
 actions of the Bombay Medical and Physical Society," in 1839, I 
 thus stated the result of my own observation on the effect of the 
 
 * " Treatise on Cholera," p. 209. 
 Q 3 
 
230 EPIDEMIC CHOLERA. 
 
 hot bath in cholera patients. " I used the hot bath in this case, 
 and watched the effect, that I might have an opportunity of satis- 
 fying myself on this point of practice. The bath was plainly 
 injurious."* 
 
 Further, it may be asserted that a reference to the works of 
 authors on Indian cholera will show a very general condemnation 
 of the hot bath in the stage of collapse. This important fact 
 would seem to have been disregarded in the treatment of 
 cholera in London in the epidemic of 1854, for I find f in the 
 metropolitan hospitals it was used in nearly 37 per cent, of the 
 cases treated. 
 
 Emetics have been given in the collapse of cholera in expec- 
 tation that the act of vomiting might favour reaction. In the 
 cholera epidemic of 1849, in Bombay, a Cholera Infirmary was 
 temporarily established by Dr. Mosgrove, for the treatment 
 of the disease chiefly by the plentiful imbibition of cold water 
 and the application of external heat. When this institution 
 passed under the care of the late Dr. Larkworthy, I visited, 
 through his kind permission, the patients almost daily, and some- 
 times twice a day, for the period of a month. One of the objects 
 in giving large draughts of water was, that the act of vomiting, 
 and its assumed stimulant action on the pulse, might be from 
 time to time induced. As I had never exhibited emetics in my 
 own practice, I gladly availed myself of the opportunity of testing 
 the accuracy of the principle on which they have been recom- 
 mended ; and the result of my observation was, that in a 
 large majority of cases in which collapse was fairly present, the 
 draughts of water and the vomiting were not followed by any sen- 
 sible effect on the pulse. I witnessed many cases of ultimate re- 
 covery, in which the state of pulseless collapse continued from six 
 to twenty-four hours after the commencement of the exhibition of 
 the cold water ; and it may be further remarked, that in some in- 
 stances the frequent imbibition of water in large quantity seemed to 
 keep up an irritable state of the stomach, which it was afterwards 
 troublesome to subdue. \ 
 
 Hot Saline Enemata were used by me in the European General 
 
 * " Transactions of Medical and Physical Society of Bombay," No. 2, p. 240. 
 
 f " Report mi the Results of the Different Methods ofTreatmenl pursued in Epidemic 
 Cholera, addressed to the President of the General Board of Health." By the Treat- 
 ment Committee of the Medical Council. 
 
 \ At p. 321, No. 10, "Transactions, Medical and Physical Society of Bombay," there 
 will !"■ found a letter on the treatment followed in the Cholera Infirmary, addressed 
 by me to the Superintending Surgeon. 
 
TREATMENT. 231 
 
 Hospital, but without any effect in lessening the state of 
 collapse. 
 
 Rubefacient Liniments, Turpentine, and Sincqiisms have been 
 generally applied in the stage of collapse, but I have no faith in 
 their utility ; and there is a disadvantage in the disagreeable odours 
 which arise from some of them, and in their probable interference 
 with the functions of the skin. 
 
 Of Saline Injections into the Veins I have no experience ; but it 
 may be taken for granted that the experiments which have been 
 already recorded are conclusive against them. 
 
 The Inhalation of Vapours seems to be a therapeutic means to 
 which some still incline with hope. I have not had any oppor- 
 tunity of witnessing this mode of treatment, nor am I of those 
 who see in it the prospect of good. If it be that the pulmonary 
 is obstructed as well as the general capillary circulation, then 
 the pulmonary channel of absorption into the blood is as much 
 closed as the intestinal one: and when it begins to be re-esta- 
 blished, can there be a doubt that pure atmospheric air will 
 more surely minister to the restoration of depressed vital actions 
 than medicated vapours ? 
 
 Galvanism has been applied with the view of exciting the action 
 of the heart and the respiratory function in the stage of collapse, 
 but without any results calculated to inspire hope. The coil 
 machine has also, to my knowledge, been used after reaction with 
 the view of re-exciting the secretory function of the kidney. In 
 this therapeutic theory I have no belief. The statements which 
 have been made to me of urine having been passed shortly after 
 the transmission of the electric current in the course of the kidneys 
 and ureters are not called in question ; but it may be suggested 
 that the action has been on the muscular fibre of the bladder, into 
 which the urine for hours previously had been slowly trickling, and 
 not on the secretory structure of the kidney. 
 
 Cold Affusion and Wet Sheet. — Of these I cannot speak from 
 personal knowledge ; but I quote * Dr. Gull's summary : — 
 
 " On the continent, in the former and in the last epidemic, cold affusion 'was highly 
 spoken of as a means of producing reaction. The patient was placed in a warm hip 
 bath, and cold water poured or thrown over the head, back, and chest. This was done 
 quickly, and the patient then placed between warm blankets. If the first application 
 was followed by any improvement, the operation was repeated every three or four 
 hours. The results appear to have been on the whole more satisfactory than from the 
 hot bath. 
 
 " The ' wet-sheet envelope ' was more commonly used in this country. The effects 
 
 * Report, p. 206. 
 Q 4 
 
232 EPIDEMIC CHOLERA. 
 
 varied according to the state of the patient ; in the milder eases it favoured reaction, 
 but when the disease was severe it was useless or injurious. The sweating caused by 
 it added to the exhaustion, and had no influence in arresting the intestinal discharges. 
 In none of the cases, which were many, in which we saw it tried, did it produce any 
 good effect." 
 
 Eesults such as these are surely sufficient to induce medical men 
 henceforth to abstain from a restless and too often injurious em- 
 piricism in the management of this disease. 
 
 RECAPITULATION. 
 
 My practical conclusions may be shortly re-stated under the 
 following heads : — 
 
 1. In cholera epidemics there is a proportion of cases ushered in 
 by premonitory diarrhoea, which if early treated by simple means 
 are frequently cm-able, and the cholera attack is prevented. In 
 some instances, however, the diarrhoea is not checked by treatment, 
 and cholera becomes developed. 
 
 2. Cases of cholera occur — common in the early Indian 
 epidemics, but rare in the later ones — in which the state of col- 
 lapse is moderate in degree. In these the tendency is to recovery, 
 not to death ; but restoration is materially favoured by judicious 
 moderate medical treatment. 
 
 3. When collapse is considerable, then we have a condition 
 somewhat analogous to the cold stage of ague, or the initiatory 
 fever of small-pox, — a state which cannot be checked, but which 
 must run on a certain course, varying in intensity and duration 
 in different instances — in which all that we can pretend to 
 attempt, is to place the patient in circumstances as favourable as 
 possible for enabling the system to outlive this stage of the disease 
 while we at the same time carefully abstain from the use of means 
 which may be injurious, not only then, but in subsequent stages of 
 the attack. 
 
 5. When reaction from collapse is taking place, the restoration 
 of the various functions is a slow process requiring careful watching, 
 mild assistance, and avoidance of officious interference. This 
 expectant course is more certainly correct when the stage of col- 
 lapse has not exceeded eight hours ; but when it has been 
 longer, the probability of secondary danger is increased; and 
 when this arises it must be met, or when it threatens it may be 
 modified, by cautious judicious medical treatment, directed with 
 the fact constantly before us, that in this state of the disease gastro- 
 enteritis is readily excited. 
 
STATISTICS. 
 
 233 
 
 5. The secondary dangers of cholera are to be treated, on gene- 
 ral principles, with that care and cantion which it is always neces- 
 sary to observe^in all forms of disease present in states of constitution 
 which tend to be adynamic. 
 
 6. In a disease amenable in its milder degrees to ordinary medi- 
 cal treatment — and in its severer ones, though beyond the influence 
 of medicines, still often recovered from — the value of remedies can- 
 not be tested by statistical data as hitherto recorded. Therapeutic 
 principles drawn from this source are very likely to be erroneous. 
 
 7. It is to be feared that cholera — as some other zymotic dis- 
 eases in their severer forms, for example, plague, yellow fever, 
 small-pox — will, in its severer forms, always prove little under 
 the control of medical treatment ; and that therefore in it, as in 
 these others, the chief hope of lessening the mortality rests on our 
 being able to understand its causes, and to prevent their action. 
 To these important objects the attention of the medical profession 
 should be earnestly given. 
 
 Section V. — Statistical Tables relative to Epidemic Cholera in 
 the European General Hospital, the Jamsetjee Jejeebhoy Hos- 
 pital and the Byculla Schools at Bombay. 
 
 Table XIX. — Admissions and Deaths, with Per-centaye, from Epidemic 
 Cholera in the European General Hospital at Bombay, for the Six years 
 from 1838 to 1843. 
 
 
 
 
 1838 to 1843. 
 
 M 
 
 mthly Average 
 
 
 
 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 Deaths on 
 
 
 Admissions. 
 
 Deaths. 
 
 on total Ad- 
 missions. 
 
 total 
 Deaths. 
 
 January 
 
 
 1 
 
 1 
 
 100-0 
 
 0-18 
 
 2-3 
 
 February 
 
 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 March . 
 
 
 
 13 
 
 4 
 
 30-8 
 
 25 
 
 12-1 
 
 April . 
 
 
 
 11 
 
 9 
 
 81-8 
 
 1-8 
 
 21-9 
 
 May . 
 
 
 
 56 
 
 28 
 
 50-0 
 
 65 
 
 35-0 
 
 June 
 
 
 
 23 
 
 13 
 
 56-5 
 
 2-9 
 
 25-5 
 
 July 
 
 
 
 19 
 
 9 
 
 47-4 
 
 26 
 
 24-3 
 
 August . 
 
 
 
 11 
 
 
 
 45'5 
 
 1-8 
 
 14-3 
 
 September 
 
 
 
 14 
 
 
 
 357 
 
 2-5 
 
 96 
 
 October 
 
 
 
 10 
 
 6 
 
 60-0 
 
 1-3 
 
 22-2 
 
 November 
 
 
 
 14 
 
 8 
 
 57-1 
 
 2 04 
 
 1702 
 
 December 
 
 
 
 31 
 
 18 
 
 58-06 
 
 5-05 
 
 27-3 
 
 Total 
 
 
 
 203 
 
 106 
 
 52.2 
 
 2-7 
 
 19-5 
 
234 
 
 EPIDEMIC CH0LE11A. 
 
 Table XX. — Admissions and Deaths, with Per-centage, from Epidemic 
 Cholera, in the European General Hospital at Bombay, for the Fire years 
 from 1844 to 1848. 
 
 
 
 
 1844 to 1848. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 
 total 
 Deaths. 
 
 January 
 
 February 
 
 March. 
 
 April . 
 
 May . 
 
 June 
 
 July . 
 
 August 
 
 September 
 
 October 
 
 November 
 
 December 
 
 
 
 4 
 6 
 5 
 3 
 11 
 29 
 7 
 1 
 1 
 
 4 
 3 
 4 
 4 
 8 
 12 
 5 
 
 100-0 
 50-9 
 80-0 
 
 133-3 
 72-5 
 41-4 
 71-4 
 
 0-6 
 
 11 
 
 1-03 
 
 0-5 
 
 1-9 
 
 4-6 
 
 1-03 
 
 0-18 
 
 2-2 
 
 8-7 
 8-6 
 13-3 
 12-8 
 26-6 
 36-7 
 13-9 
 
 Total ■ 
 
 
 
 67 
 
 40 
 
 59-6 0-98 
 
 10-3 
 
 Table XXI. — Admissions and Deaths, with Per-centage, from Epidemic 
 Cholera, in the European General Hospital at Bombay, for the Five years, 
 from 1849 to 1853. 
 
 
 
 
 1849 to 1853. 
 
 Monthly Average. 
 
 
 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 Deaths on 
 
 
 Admissions. 
 
 Deaths. 
 
 on total 
 Admissions. 
 
 total 
 Deaths. 
 
 January 
 
 7 
 
 6 
 
 85-7 
 
 1-5 
 
 154 
 
 February 
 
 
 
 2 
 
 1 
 
 50-0 
 
 0-5 
 
 OO 
 
 March . 
 
 
 
 4 
 
 2 
 
 50-6 
 
 0-9 
 
 5-9 
 
 April . 
 
 
 
 3 
 
 2 
 
 60-6 
 
 0-5 
 
 8-3 
 
 May . 
 
 
 
 5 
 
 3 
 
 60-0 
 
 0-9 
 
 12-5 
 
 June 
 
 
 
 9 
 
 7 
 
 777 
 
 1-5 
 
 241 
 
 July . 
 
 
 
 5 
 
 5 
 
 100-0 
 
 0-9 
 
 15-1 
 
 August 
 
 
 
 16 
 
 9 
 
 56-2 
 
 3-2 
 
 23-7 
 
 September 
 
 
 
 10 
 
 7 
 
 70-0 
 
 2-8 
 
 28-0 
 
 October 
 
 
 
 1 
 
 — . 
 
 — 
 
 0-25 
 
 
 
 November 
 
 
 
 7 
 
 3 
 
 42-8 
 
 1-3 
 
 10-0 
 
 December 
 
 
 
 9 
 
 5 
 
 55-5 
 
 1-5 
 
 12-5 
 
 Total 
 
 
 
 78 
 
 50 
 
 61 1 
 
 1-3 
 
 13-9 
 
STATISTICS. 
 
 235 
 
 Table XXII. — Admissions and Deaths, with Per-cmtage, from Epidemic 
 Cholera, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six years, 
 from 1848 to 1853. 
 
 
 
 
 1848 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions 
 on total 
 
 Deaths on 
 
 total 
 
 
 
 
 
 Admissions. 
 
 Deaths. 
 
 January 
 
 158 
 
 95 
 
 60 
 
 2 
 
 7-5 
 
 21-1 
 
 February 
 
 
 
 69 
 
 36 
 
 52 
 
 2 
 
 37 
 
 11-3 
 
 March . 
 
 
 
 141 
 
 71 
 
 50 
 
 3 
 
 6-6 
 
 18-4 
 
 April . 
 
 
 
 138 
 
 73 
 
 52 
 
 9 
 
 6-5 
 
 21-3 
 
 May . 
 
 
 
 84 
 
 41 
 
 48 
 
 8 
 
 3-8 
 
 14-3 
 
 June 
 
 
 
 50 
 
 30 
 
 60 
 
 
 
 2-4 
 
 9-8 
 
 July . 
 
 
 
 37 
 
 20 
 
 54 
 
 1 
 
 1-8 
 
 6-5 
 
 August . 
 
 
 
 41 
 
 27 
 
 65 
 
 9 
 
 2-05 
 
 8-2 
 
 September 
 
 
 
 66 
 
 43 
 
 65 
 
 1 
 
 3-3 
 
 138 
 
 October 
 
 
 
 65 
 
 31 
 
 47 
 
 7 
 
 3-04 
 
 91 
 
 November 
 
 
 
 94 
 
 45 
 
 47 
 
 8 
 
 4-3 
 
 13-6 
 
 December 
 
 
 
 110 
 
 62 
 
 56-3 
 
 4-7 
 
 15-6 
 
 Total 
 
 
 
 1053 
 
 574 
 
 54-5 
 
 41 
 
 13-9 
 
 Table XXIII. — Admissions and Deaths, with Per-centage, from Epidemic 
 Cholera in the Byculla Schools, at Bombay, for the Seventeen years from 
 1837 to 1853. 
 
 
 
 
 1837 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths per 
 cent, of 
 
 Admissions. 
 
 
 
 January 
 February 
 March . 
 
 
 
 2 
 
 3 
 
 14 
 
 1 
 
 1 
 6 
 
 50 
 33 
 
 42 
 
 
 3 
 
 8 
 
 
 
 April . 
 May . 
 June 
 
 
 
 6 
 15 
 31 
 
 4 
 
 5 
 
 17 
 
 66 
 33 
 54 
 
 6 
 3 
 
 8 
 
 
 
 July . 
 
 August . 
 
 September 
 
 October 
 
 
 
 14 
 2 
 
 8 
 1 
 
 571 
 
 50-0 
 
 
 
 November 
 
 
 
 1 
 
 — 
 
 — 
 
 
 
 December. 
 
 
 
 1 
 
 — 
 
 — 
 
 
 
 Total 
 
 
 
 89 
 
 43 
 
 48-2 
 
 
 
236 
 
 DYSENTERY 
 
 CHAP. XIV. 
 
 ON DYSENTERY. 
 
 Section I. — The Importance of Dysentery hi India — Order in 
 which the subject ivill be treated. 
 
 The following facts relative to the sickness and mortality, from 
 dysentery and diarrhoea, amongst European and Native troops in 
 India, are extracted from Dr. Ewart's very instructive work : — * 
 
 « 
 
 EUROPEANS. 
 
 NATIVES. 
 
 CD c . 
 
 e.2 = 
 
 T-si 
 
 >-< o «* 
 
 &3S 
 
 C a V 
 4, O O 
 
 Per-eentage 
 of Deaths to 
 Admissions. 
 
 Per-eentage 
 of Admissions 
 
 to strength. 
 
 ex 2~ 
 5=T3 to 
 = gg 
 
 |-| 
 III 
 
 Bengal . 
 Bombay 
 Madras . 
 
 30-41 
 27-13 
 23-43 
 
 2-02 
 1-71 
 1-24 
 
 6-65 
 6-30 
 5-30 
 
 6-18 
 6-57 
 3-08 
 
 •173 
 •196 
 •190 
 
 2-SO 
 2-98 
 6-17 
 
 During the six years of my service in the European General 
 Hospital, 736 cases of dysentery were treated ; and during nine of 
 the years of my charge of the Jamsetjee Jejeebhoy Hospital, 1642 
 cases were admitted. To these latter may be added f 1470 cases of 
 diarrhoea treated during the same period ; making an aggregate of 
 3112 affections of the bowels. 
 
 This disease also came under my observation in its severest form 
 in the hospital of Her Majesty's 40th Eegiment at Belgaum, in 
 1830; also in Her Majesty's 4th Light Dragoons at Kirkee, in 
 1832, as well as more or less in all the other fields of practice in 
 which I have been engaged in India. 
 
 * " Vital Statistics of the European and Native Annies in India," pp. 86, 121. 
 t My reason for classing diarrhoea with dysentery will appear in the sequel of this 
 chapter. 
 
ITS PREVALENCE. 
 
 237 
 
 The importance of this disease is at once shown by the facts just 
 quoted from Dr. Ewart's work, as well as by those exhibited in the 
 following tabular statement : 
 
 
 Per-centage 
 
 of Deaths from 
 
 Dysentery and 
 
 Diarrhoea on 
 
 treated. 
 
 Per-centage 
 of Deaths from 
 Dysentery and 
 Diarrhoea on 
 aggregate Mor- 
 tality. 
 
 European General Hospital, Bombay (Dysentery) 
 * Do. Officers, Bombay Presidency 
 Jamsetjee Jejeebhoy Hospital .... 
 f General Population of Bombay 
 
 18-3 
 38-9 
 
 24-1 
 
 ol 
 
 21-8 
 
 13-50 
 
 The ratio of deaths to treated varies according to the class of 
 the sick, and the stage of the disease when submitted to treatment : 
 it is therefore less in regimental than in general hospitals. It is 
 very high in the Jamsetjee Jejeebhoy Hospital, because, as has 
 been explained in respect to other forms of disease, the admissions 
 often take place in hopeless states and stages of disease. The rate 
 of mortality from these affections would seem to be greater in 
 native than in European troops, more particularly those of the 
 Madras Presidency ; but the reason is not apparent. 
 
 My remarks on dysentery will be arranged in the following 
 order: 1st. Pathology; 2nd. Causes; 3rd. Symptoms; 4th. Treat- 
 ment. 
 
 Section II. — Pathology. — Detailed Statement of the Morbid 
 
 Anatomy. 
 
 Dysentery is inflammation of varying extent and degree, of 
 more or less of the constituent parts of the mucous membrane, 
 — sometimes also of the other tissues, — of the large intestine.^ 
 
 * My own Notes. 
 
 f Mr. Leith's Deaths in Bombay. 
 
 J "When -we consider the structural analogy of cutaneous and mucous tissue, it 
 is reasonable to anticipate more or less resemblance in their pathological phenomena, 
 which future research may establish. 
 
 Inflammation of the skin exists in various forms, (a.) General redness with or 
 without desquamation of the cuticle — the orders exanthemata and papula. (/>.) 
 The cutis may become thickened in patches of greater or less extent, with an exco- 
 riated surface, and excessive development and shedding of epidermal scales — the 
 order squama, (c.) The upper layer of the cutis, inflamed at points more or less 
 numerous, more or less aggregated together, may lead to serous or puriform effusion. 
 confined by the superimposed epidermis, in collections of variotis size, and termi- 
 
238 DYSENTERY. 
 
 In describing the morbid anatomy of the disease, I shall, 
 though occasionally referring to the writings of others, chiefly 
 follow my own observations. 
 
 The subject may be appropriately arranged under the following 
 heads : — 
 
 I. The morbid appearances presented by the mucous membrane 
 of the large intestine. 
 
 II. The complication of inflammation, or its results, of the 
 mucous membrane of the large intestine, with peritonitis, general 
 or partial. 
 
 III. Tumefaction in the region of the ccecum, or sigmoid flexure 
 of the colon. 
 
 IV. Displacements of the colon. 
 
 V. Complication of ulceration of the mucous lining of the large 
 intestine, with abscess in the liver. 
 
 VI. Complication of dysentery with morbid lesions of the sto- 
 mach or small intestine. 
 
 VII. The co-existence of enlargement of the mesenteric glands. 
 
 I. — The morbid appearances of the Mucous Membrane of the 
 large Intestine may be classed under the following heads : — 1. 
 Changes of colour and texture of the membrane ; 2. Exudation on 
 the free surface and into the interstices of the membrane ; 3. Impli- 
 cation of the ordinary mucous follicles, or of the solitary glands ; 
 4. Different forms of ulceration of the mucous membrane ; 5. The 
 
 nating in desiccation, incrustation, and desquamation — the orders vcsiculce, bulla, and 
 pustules, (d.) Inflammation of the skin may extend to the subcutaneous tissue, and 
 end in serous or puriform effusion, or gangrene and sloughing — erysipelas, carbuncle, 
 furuncuhis. Consequent on these various forms of inflammation, there may be 
 solution of continuity — destruction — of portions of the skin, more or less extensive, 
 by processes of ulceration or sloughing. 
 
 The several orders of cutaneous inflammations have been further subdivided into 
 genera and species. The opportunity of observing inflammation of the skin from its 
 earliest appearance to its close has enabled us to determine these facts of its patho- 
 logy. Similar processes may fairly be assumed to occur in some degree in the mucous 
 membrane of the large intestine ; but, for very evident reasons, they are, and must 
 always be, insusceptible of proof, except in a very limited degree. 
 
 If the skin during life were removed from the cognizance of our senses, and all that 
 we know of its inflammations were derived from symptoms caused by deranged 
 function or constitutional sympathy, desquamated products, and post mortem appear- 
 ances, we should be, in respect to the pathology of the skin, hi a position analogous to 
 that in which we now stand in respect to the pathology of the mucous membrane of 
 the large intestine. In this hypothetical stale of ignorance of cutaneous inflammation, 
 our positive knowledge would probably bo fully expressed by a single term — as 
 dermitis — just as our presenl positive knowledge of inflammation of the mucous mem- 
 brane of the large intestine is expressed by the single term — dysentery. 
 
PATHOLOGY DISCOLORATION. 239 
 
 cicatrisation of ulcers ; 6. The separation of parts of the mucous 
 coat in patches, shreds, or tubular portions. 
 
 1. Changes of Colour and Texture of the Membrane. — A 
 bright red and turgid state of the mucous membrane must be the 
 earliest change produced by acute inflammation ; but death takes 
 place so seldom in this stage that the appearance is very rarely 
 observed. Occasionally in cases of disease which have proved fatal 
 with the symptoms of chronic dysentery, the only morbid appear- 
 ance found after death is dark red or grey, sometimes black 
 (melanosis), discoloration of the mucous coat of the large intes- 
 tine. This state may be attended with softening, thinning, or 
 thickening of the tissue. Hypertrophy is more common than the 
 other alterations of texture, and sometimes in consequence of its 
 having taken place unequally, the surface of the membrane pre- 
 sents an irregular mammillated or tubercular appearance. I have 
 not satisfied myself that there are any particular symptoms 
 which enable us to determine during life, that these only, and not 
 other morbid changes, have taken place. It is not improbable 
 that they exist most generally in cases in which dysentery has 
 alternated with other diseases — as rheumatism — and in which it 
 is reasonable to infer that there may be something special in the 
 character of the inflammatory action. 
 
 The following three cases are illustrative : — 
 
 46. Under treatment nine months. — Dysentery alternating with rheumatism, probably 
 
 syphilitic ; terminating hi general cachexia with febrile symptoms. — Charles , 
 
 aged twenty-eight, after ten days' illness with dysentery, was admitted into the Gene- 
 ral Hospital on the 3rd November, 1841. The symptoms were for some time urgent, 
 and considerable abdominal tenderness was complained of. He remained under treat- 
 ment with alternation of dysentery, swelling and pain of joints, with thickening in the 
 course of the tibiae and increasing cachexia, and died on the 1st August, 1842. 
 
 Inspection fourteen hours after death made and reported by Mr. J. Peet. — Body 
 emaciated, crude tubercles interspersed through the substance of both lungs. Kather 
 more fluid than usual in the pericardium ; heart healthy. Abdomen. — The stomach 
 and duodenum contained a quantity of dark chocolate-looking fluid, and the mucous 
 membrane of both presented distinct patches of injected vessels ; these were most 
 distinctly seen near the pyloric extremity of the stomach. The mucous membrane of 
 ccecuni of a dark, nearly approaching to a black, colour, but without thickening or 
 ulceration. The transverse portion of the colon upon its inner surface was in a state 
 of excessive congestion, but there were no distinct ulcers, although in some parts 
 the mucoiis membrane was soft and pulpy ; the mucous surface of sigmoid flexure 
 healthy. Coats of the ileum at its termination in the colon thickened, in other re- 
 spects, as well as the jejunum, healthy. Other viscera presented no abnormal ap- 
 pearance. — Head not examined. 
 
 47. Chronic dysentery, discoloration with thickening of parts of the mucous mem- 
 brane of the large intestines. — Antone de Cost, of African extraction, but brought up 
 at Goa, of twenty years of age, and following the occupation of cook on board a ship. 
 For about two months before his admission, on the 28th June, 1849, he had been 
 
240 DYSENTERY. 
 
 affected with bowel complaint. He was much emaciated, and the pulse was very- 
 feeble. The tongue was moist and florid. He was purged from six to ten times in the 
 twenty-four hours. The discharges were of slimy feculence, sometimes pale, at others 
 of various tints of gray. He improved somewhat from the 2nd to the 10th July, then 
 the purging increased, the discharges being more copious and watery. He died on 
 the 21st. 
 
 Inspection. — Chest. — The lower part of the second lobe of the left lung was in a 
 state of red hepatisation, the upper lobe was somewhat cedematous. The right lung 
 adhered by r old adhesions to the costal pleura, but was crepitating in its structure. 
 Abdomen. — The liver was undiseased ; the small intestine was somewhat attenuated. 
 About three feet of the lower end of the ileum were laid open, but no morbid changes 
 of the mucous membrane were observed. The mucous lining of the ececum, colon, and 
 rectum was in many places discoloured, of dark red, of brownish and of greyish tints, 
 and in parts seemed somewhat thickened ; in the sigmoid flexure and at the upper 
 part of the rectum there were well-marked cicatrices of former ulcers. Kidneys. — In 
 the central part of both there was commencement of yellow degeneration. 
 
 48. Melanosis of the colon. — No ulceration. — Tubercles in the liver. — Private P. L., 
 aged forty-five, of the Bombay European Regiment. Had frequently been a patient 
 in hospital, with symptoms of dyspepsia. He was admitted for the last time at 
 Bombay on the 13th April, 1829. He then complained principally of flatulence and 
 debility. Seldom had pain of abdomen, but when present it was generally removed by 
 carminatives and remedies of that description. He gradually became emaciated, 
 without the symptoms becoming more distinct. Finally diarrhoea came on, and the 
 dejections were of dark colour. He sunk slowly, and died October 29th, 1829. 
 
 Inspection. — The transverse colon was much distended, except at the middle portion, 
 where it was a good deal contracted. The peritoneal surface was of dark colour. 
 The coats of the large intestine throughout its whole course were much thickened and 
 indurated. The mucoxis membrane was of dark colour, in some places almost black, 
 and presented a very irregular surface, which was caused by numerous small globular 
 bodies, each about the size of a pea, apparently situated in the sub-mucous tissue. 
 There were not any traces of ideeration throughout the whole course of the large 
 intestine. The stomach was small, and owing to the distension of the colon, was 
 forced upwards ; but its coats were free from disease. The small intestine was healthy. 
 The liver was of light colour externally, with tubercles the size of cherry stones in the 
 substance of the left lobe. With the exception of old costal adhesions the thoracic 
 viscera were healthy. 
 
 2. Exudation on the Free Surface and into the Tissue of the 
 Membrane. — The uniform effusion of lymph for some extent over 
 the surface of the mucous coat, in such manner as to lead to its 
 separation in shreds or tubular portions, as obtains in the croupous 
 forms of inflammation of the mucous membrane of the air passages, 
 has been noticed by several writers on this disease. The occasional 
 occurrence of this exudation in tropical dysentery may probably be 
 admitted, but the following is the only instance of this morbid 
 state which has come under my own observation, and it was not a 
 case of dysentery : — 
 
 49. Mviiibritiiiwx iiiKcmts exxilation on th\ inner surf act of the large intestine. — Private 
 "William Todd, aged 29, admitted into the hospital of the Bombay European Regiment, 
 October 28th, 1829, ill with fever. There was niueh headache, with full and frequent 
 pulse. He became drowsy, the skin assumed a yellow tint ; he sunk and died Novem- 
 ber 1st. On the 29th he shrunk on the abdomen being pressed ; but there was no 
 
rATIIOLOGY — EXUDATION. 241 
 
 purging except from the use of medicine. About one hundred grains of calomel were 
 given during the three days preceding death. 
 
 Inspection. — Vascularity of the membranes of the brain and effusion of patches of 
 lymph. The greater part of the mucous surface of the large intestine was covered 
 with a dark red effusion, in some places loosely attached to the membrane, and having 
 the appearance of red currant jelly ; in other places the effusion was firmer in consis- 
 tence, and could be peeled from the mucous tunic in an almost membranous form. In 
 the coecum the effusion was evidently of longer standing from its firmer consistence, 
 and from its being connected with the subjacent mucous tissue, through the medium 
 of what appeared to be small capillary vessels. The mucous membrane underneath 
 the effusion was vascidar. 
 
 A yellow or greyish granular exudation — sometimes small, like 
 grains of sand, at others larger and thicker — not unfrequently 
 occurs on the mucous surface of some part of the colon or rectum, 
 as well as of the ileum in cases of disease which have proved 
 fatal with symptoms of chronic dysentery. It presents itself in 
 patches more or less extensive, frequently coursing round the in- 
 testine in transverse bands, and preferring the elevated part of the 
 rugae of the membrane. The granules are generally found adherent 
 to the surface of the membrane, which is commonly of a red tint 
 more or less dark. The mucous membrane and the sub-mucous 
 tissue are also usually thickened, sometimes to a considerable de- 
 gree, and when cut, the edges of the incision present a fleshy 
 appearance. 
 
 The granular exudation and the thickening are, however, dis- 
 tinctly preceded by a state of simply increased redness ; whence it 
 follows that the appearance adverted to under the first head — 
 discoloration — may be merely the earlier stage of that now 
 under consideration. 
 
 This granular deposit, which probably consists partly of modified 
 epithelial debris, and partly of amorphous lymph exudation, is 
 noticed by Eokitansky, Baly*, and other pathologists. 
 
 It has been observed by me most commonly in dysentery in 
 persons whose constitutions have been in some degree cachectic, 
 and an analogy between it and the squamous order of cutaneous 
 inflammation may be suggested. The two cases which follow are 
 instances of this appearance : — f 
 
 50. Chronic dysentery in an opium eater. — The mucous coat of the colon covered with 
 a firm granular layer. — The lungs tubercular. — Cartilaginous contraction of the 
 pyloric orifice of the stomach. — Wm. C, aged about thirty-five, of dissipated habits, an 
 acknowledged opium eater, of spare habit, with narrow chest, came to Bombay as the 
 surgeon of a ship from Australia, and was under treatment in the General Hospital for 
 delirium tremens. He was discharged cured, and remained out of hospital for about 
 
 * Gulstonian Lectures, Medical Gazette, 
 t Also 34, 36, 42, 95, 98, 99. 
 B 
 
242 DYSENTERY. 
 
 a fortnight or three weeks, when he was again admitted on the 10th of July, 1840, with 
 dysentery, which had attacked him four or five days previously. It heeame chronic, 
 and he gradually sunk and died on the 3rd September. The treatment consisted of 
 free opiates with bismuth, quinine and blue pill, wine and brandy. 
 
 Inspection seven hours after death. — Body much emaciated. Head. — There was a 
 veil of serum below the arachnoid membrane on the convex surface of the brain. 
 Chest. — The lungs partially collapsed, adhered here and there to the costal pleurae. A 
 considerable part of the upper lobe of the left lung was condensed from tubercular 
 infiltration, and at its apex there was a cavity the size of an almond. In the lower 
 lobe of the left lung there were many scattered miliary tubercles. There were numer- 
 ous miliar}' tubercles in the right lung, but nowhere condensation of any considerable 
 portion of the pulmonary tissue. Abdomen. — The intestines were collapsed. The liver 
 was of dark red coloiu\ The mesenteric glands were not enlarged. Four feet of the 
 end of the ileum and the large intestine were laid open. The contents of the end of 
 the ileum were mucous and tenacious. The lining membrane was of dark red colour 
 without alteration of texture. The mucoxis coat of the coecum was dark red, the surface 
 slightly roughened, as if sprinkled with sand, but the texture was natural. The 
 inner surface of the colon was of dark red colour throughout, and granular. But 
 in the rectum the gramilar exudation was greatest, and most firmly adherent to 
 the mucous coat, which was somewhat thickened, and when cut, had a fleshy ap- 
 pearance. There was one ulcer in the colon. The mucous coat of the stomach was 
 of dark brown colour towards the cardiac end. The pylorus was much contracted 
 from a cartilaginous ring in the sub-mucous tissue. The mucous coat of the 
 duodenum was dark red in colour, but healthy in texture. The kidneys were healthy. 
 
 51. Diarrhoea ted 'ions. — Granular yellow exudation on the mucous surf ace of the 
 large intestine with thickening of the tunic. — James Grady, aged twenty-three, private 
 in Her Majesty's 15th Hussars, admitted on the 12th October, 1839, with febrile 
 symptoms. Diarrhoea followed and continued troublesome. The dejections were 
 generally of pale yellow colour and thin. There was frequently irritability of stomach, 
 with fulness and tenseness of the abdomen, and florid tongue. Under these symptoms 
 he became much emaciated and sallow, and died on the 13th January. 
 
 Inspection. — Abdomen. — The chief disease was a yellow warty granular layer on the 
 mucous coat of the large intestine, closely adherent to, and attended with thickening, 
 and a thickened state of the mucous, and subjacent tunics. Where this granular 
 exudation was still thin and only formed here and there, the mucous coat had not 
 become thickened; thus proving that the granular state preceded the thickening of 
 the tissue. 
 
 3. Implication of the Mucous Follicles and of Hie Solitari/ 
 Glands of the Colon. — In the normal state of the lining mem- 
 brane of the colon, the mucous follicles are hardly apparent to the 
 linked eye, but on the occurrence of increased secretion consequent 
 on active or passive congestion, they become more or less prominent, 
 and their orifices — dark coloured, slightly depressed points — are 
 \ciy distinct. This condition of these follicles is very generally 
 observed in the examination of fatal eases of cholera ; also oc- 
 casionally after death from remittent fever (26); and it is very 
 provable thai if always occurs in cases of transient diarrhoea, as 
 well as during and immediately after Hie action of an active ca- 
 ll lartic: it merely indicates an excess of the ordinary secretion 
 of Mir mucous crypts. 
 
PATHOLOGY — FOLLICLES. 243 
 
 The enlargement of the follicles in these several circumstances 
 has as yet been unaccompanied by inflammatory action ; but there 
 is reason to believe that inflammation very readily takes place, and 
 that its early stage is marked by general redness of the mucous 
 membrane, or merely by a circle of vascularity around the orifice 
 of the follicle, associated in some cases with thickening of the 
 tissue, in others with ulceration. These conditions of the ordinary 
 follicles of the colon, though not frequently noticed in fatal cases 
 of dysentery, are very important with reference to that disease, 
 because they are the early stages of morbid changes, which, in 
 their advanced states, are often observed. 
 
 The solitary glands of the colon are also often implicated in this 
 disease. In cholera, they, as well as the ordinary follicles of the 
 colon, and Peyer's solitary and agminated glands of the ileum 
 become distinct, pale in colour, about the size of a mustard seed, 
 and are scattered here and there over the inner surface of the 
 bowel. Under continued irritation, these glandular structures are 
 liable, consequent on an increase of their secretion, to become 
 larger and more elevated, sometimes attaining the size of a split 
 pea. On the occurrence of inflammation of the mucous mem- 
 brane, that part of it which is placed over the swollen solitary 
 glands must, consequent on the pressure from within, readily 
 give way, partly by an ulcerative process, partly by simple rupture. 
 So frequently are these glands engaged in dysentery, that some 
 observers, as Dr. Parkes, are of opinion that the disease always 
 originates in them ; but it seems to me that the utmost that can 
 be said is, that they share with the other constituent tissues of the 
 bowel in the morbid action. There has been much obscurity in 
 the descriptions of the morbid appearances presented by the glan- 
 dular structures of the large intestine, partly in consequence of the 
 ordinary follicles and the solitary glands being confounded, and 
 partly from the terms used by some observers. It may be useful 
 to explain this statement more fully. Rokitansky uses the term 
 mucous follicles, and it is not always clear, whether in his descrip- 
 tions he speaks of the ordinary crypts or of the solitary glands. 
 Pringle*, in describing the morbid appearances in dysentery, men- 
 tions certain protuberances of light colour, roundish, the twelfth of 
 an inch in elevation, closely set, and resembling the small-pox at 
 the height of the disease. Dr. Murray, of the Bengal Service, 
 many years ago| drew attention to appearances similar to those 
 
 * " Diseases of the Army," p. 215. 
 
 t '• Transactions, Medical and Physical Society of Calcutta," 7th volume. 
 
 R 2 
 
244 DYSENTERY. 
 
 attributed by me to enlarged follicles; but he uses the term vesicles, 
 and loses sight of the fact that they were probably more related to 
 the cholera of which his patients died, than to the dysenteric 
 symptoms under which they had previously suffered : he hence 
 conceived — on erroneous grounds, as seems to me — an analogy 
 between dysentery and small-pox. Whether it is the follicular 
 development, or the enlargement of solitary glands, which Dr. 
 Bleeker describes imder the term "Lenticular exudation*/' I am 
 unable to determine. 
 
 Kokitansky also alludes to vesicles formed by the epithelium 
 raised by clear serum, and this in connection with the granular 
 deposit of which I have already treated. Kokitansky implies that 
 both appearances are different stages of the same process ; that, 
 after the discharge of the serum the epithelium subsides in the 
 form of branny scales. It does not, however, clearly appear whether 
 this statement refers to what has been actually observed, or to a 
 hypothetical explanation of the commencement of morbid changes 
 witnessed only in their after stages. The elevation of the epithe- 
 lium in the form of vesicles by small collections of clear serum, has 
 never been seen by me ; and yet I have had the opportunity of 
 frequently observing the different stages of the process connected 
 with this granular exudation: 1, as reddened mucous membrane 
 without thickening or exudation ; 2, some slight degree of thick- 
 ening and samty-looking deposit ; 3, increased thickening of the 
 membrane and increased exudation — morbid processes more re- 
 lated, it seems to me, to the order Squamae than Vesiculse. 
 
 The term pustular appearance has been used by Mr. Twining in 
 reference to the early stages of dysentery; but he does not explain 
 to what altered anatomical condition of the membrane it is applied: 
 small puriform collections in the sub-mucous tissue, not elevations 
 of the mere epithelium, are probably referred to. Though in- 
 flammation of the mucous membrane of the large intestine, analo- 
 g( ius to vesicula' and pustulae of the skin, is a reasonable kypot' 
 
 * "Indian Annals of Medical Science,!' No. 1. p. 4. IhavereadDr. Meeker's very able 
 paper with much interest and care, but I cannot satisfy myself that I rightly under- 
 stand his description of the morbid appearances of dysentery. When I compare it 
 with my own observations I find a sufficient resemblance to give me the impn 
 that we have l>"tli Looked upon the same objects; but I cannot avoid the suspicion 
 that Mr. Bleeker has marred the distinctness <>f hi- pictures by a too exclusive gene- 
 ralisation and by tin' onappn dated Lnflui ace of a preconceived theory. This remark 
 I make with great diffidence, being very sensible that the error may lie with myself 
 and not with the acute Batavian pathologist, whose co-operation [, equally with the 
 ditore of the •• Indian Annals of Medical Science," have hailed with much and 
 sincere pleasure. 
 
TATHOLOGY ULCERATION. 245 
 
 yet, in determining its probability, we must not forget the physical 
 difference of the epithelium in the two situations.* 
 
 4. Different Forms of Ulcer of the Mucous Membrane. — The 
 term nicer is here used to express destruction, more or less exten- 
 sive, of the mucous membrane, irrespective of whether it has been 
 caused by a true process of ulceration, or by one of more rapid . 
 fusion of tissue, or by a process of gangrene and sloughing. 
 
 Ulcers of the mucous membrane of the large intestine may be 
 conveniently classed under the heads transverse, and circular, as 
 elementary types. These two forms, however, though often dis- 
 tinct, are not unfrequently combined ; and in their advanced stages 
 they may coalesce, and thus form extensive irregular surfaces of 
 ulceration. The transverse form, — either in separate bands, or in 
 several bands coalescing and occupying a greater or less extent of 
 the inner surface of the large intestine, — is generally found after 
 acute attacks of dysentery, and is most commonly associated with 
 more or less thickening of the walls of the intestine. The appear- 
 ance of the ulcer varies according to its stage, and the state of the 
 contiguous tissues. Its bed may be occupied by a greyish slough ; 
 or the slough having been thrown off, the muscular coat may be 
 exposed, and the edges of the ulcer may be irregular and thick- 
 ened, or thinner and more rounded, with commencing cicatrisa- 
 tion. On the mucous membrane surrounding the ulcer granular 
 exudation is sometimes observed. 
 
 In regard to the manner of formation of these transverse ulcers, 
 it may in the first place be remarked, that one of the early effects 
 of inflammation of the mucous lining of the large intestine is to 
 stimulate the muscular coat to increased contraction ; and, in con- 
 sequence, to dispose part of the free mucous surface to arrange 
 itself in transverse folds, as well as in rugae in other directions. 
 This fact has, I am satisfied, not been sufficiently taken into ac- 
 count in the explanation of the irregularity of surface frequently 
 presented by the mucous membrane in its morbid conditions, f 
 
 * Since this passage was written the translation of the Eucliments of Pathological 
 Histology, by Carl. Weill, M.D. by the Sydenham Society, has come into my hands, 
 and I observe at page 213 the following observation : — 
 
 " When the delicacy of the epithelial layer of the mucous membranes in general, 
 except in the mouth, oesophagus, vagina, and palpebrce, is considered, it is easy to 
 comprehend that exudations poured out from the corium cannot produce any vesicular 
 elevation of the epithelium. The single layer of epithelial cells is easily detached by 
 the exudation collected beneath it ; and the elements newly formed from the exuda- 
 tion, are seen upon the exposed surface of the mucous membrane, and often become 
 the subject of observation when eliminated from the living organism." 
 
 t I called attention to this in a paper published in the 7th volume of the "Transac- 
 tions of the Medical and Physical Society of Calcutta," in 1S3<3. 
 
 r 3 
 
246 DYSENTERY. 
 
 It has been stated that the granular exudation is frequently 
 found on the summit of the transverse folds of the membrane. 
 This is true of the ileum as well as of the large intestine. Why 
 inflammatory action should show this preference for these situa- 
 tions I do not pretend to explain ; but the fact is undoubted. 
 
 Let it be further remembered that, in the advanced stages of the 
 granular exudation, there is always considerable thickening of the 
 mucous membrane and sub-mucous tissue ; and that the transverse 
 ulcers are most commonly associated with thickening of the intes- 
 tinal coats. 
 
 These facts justify the inference that transverse ulcers, co-exist- 
 ing with thickening, are merely the last stage of that morbid pro- 
 cess which, commencing with redness, terminates, in its chronic 
 form, in thickening and granular exudation; but which, under 
 acuter inflammatory action, either original or superadded, passes 
 on to gangrene and sloughing, and the formation of the kind of 
 ulcer of which I now treat, as well as of others of different forms, 
 also associated with thickening of tissue. 
 
 Under this view, then, it is assumed that when the morbid pro- 
 cess — which going on slowly, gives rise to the symptoms of chronic 
 dysentery, and does not pass beyond a state of thickening of the 
 mucous membrane with granular exudation on the free surface — ■ 
 runs a more rapid course, it gives rise to the symptoms of acute 
 dysentery, and ends in gangrene and sloughing. This view also 
 explains how it is that we not unfrequently meet with cases of 
 dysentery in which, after two or three days of apparently a simple 
 diarrhcea, acute symptoms rapidly evolve themselves. In such we 
 may suppose that the first stage — that of redness — of the process 
 has gone on mildly, but that, from some cause or other, exacerba- 
 fcion has arisen, and that then the morbid action has rapidly gone 
 through its full course. 
 
 But there is still further evidence of this relation between trans- 
 verse; ulcers and granular exudation in the fact, that cases of 
 dysentery are not unfrequently met with in which we find sloughy 
 ulceration of the mucous membrane, and granular exudation on the 
 free Burface immediately adjoining. 
 
 The following thirteen cases Illustrate this last statement: — 
 
 52. /> ■ ntery with adynamic febrile symptoms. Granular exudation on the n, 
 c ni at the end of the ill 'ceration of the large intestine.— John Thomp- 
 
 son, aged thirteeD, of the Garrison Band, ;t delicate boy, frequently in hospital with 
 intermittent fever, was admitted on the 27th November, L840, stating thai he had 
 I from bowel complaint for two or three days. The tongue was without fur, the 
 yellowish, thin, and the iliac regions tender. Ee was 
 freelj ! I treated with ipecacuanha, gentian, and blue pill withoul purgatives. 
 
TAUTOLOGY — ULCERATION. 247 
 
 On the 29th pyrexial symptoms came on. The dejections thin and partly fecnlent. 
 Abdomen tender. He was again leeched and the ipecacuanha and bine pill treatment 
 continued. The purging became more urgent, the pidse rose to 120, the skin became 
 dry and the tongue brownish. He lost flesh and continued to pass light yellow dejec- 
 tions sometimes with streaks of blood. Euemata, opiates, a blister, &c. were used. He 
 died on the 10th December. 
 
 Inspection twelve hours after death. — Body considerably emaciated. Head. — The 
 membranes of the brain rather vascular and there were more bloody points than usual 
 on incising the brain. There was an ounce of serum at the base of the skull. Chest. 
 ■ — The lungs collapsed and were health)-. Heart healthy. Abdomen. — Liver healthy. 
 The omentum was matted over the transverse colon and the coecum, and adhered to 
 folds of the small intestine. The descending colon adhered to the lateral parietes, and 
 the sigmoid flexure, by tender bands, to the walls of the pelvis. The mesenteric glands 
 were enlarged, and reddened. The small intestine contained much thin yellow adhesive 
 feculence. For three feet of the end of the ileum a layer of granular lymph adhered 
 closely to the mucous coat, in transverse bands, following the summit of the valvular 
 conniventes. There was little of the mucous coat of the large intestines left except 
 in the form of sloughy transverse patches ; the muscular coat was distinct and denuded. 
 The stomach was healthy. 
 
 53. Granular exudation on mucous surface of Ut wm and colon, with irregular ulcera- 
 tion of the latter. — No disease of the liver. — Displacement of the colon. — Henry Green, 
 aged thirty-six, private 4th Light Dragoons, ten years resident in India, suffered from 
 •fever twice at Kaira, but never from hepatitis, was admitted into the hospital at 
 Kirkee, on the 21st April, 1832, with diarrhoea, was discharged on April the 25th. Ee- 
 admitted on June 1st, with mild dysentery, and was discharged on the 26th. 
 Re-admitted on the 15th July, affected with frequent purging. The evacuations 
 contained blood and mucus and were passed with griping and straining. There Mas 
 constant pain around the umbilicus increased by pressure. The disease progressed, 
 and by the 21st the discharges were reddish brown, watery, with clots of blood and 
 shreddy matter. The pulse was frequent and small, the countenance collapsed, and 
 hiccup present. He died on the 30th July. 
 
 Inspection five hours after death. — The omentum was vascular, and adhered firmly 
 to the surface of the transverse colon, to the left side of the pelvis, and to the sigmoid 
 flexure of the colon. The large intestine throughout was thickened. The upper portion 
 of the ascending colon adhered to the under surface of the liver. The commencement 
 of the transverse portion doubled down towards the umbilicus, thence ascended 
 obliquely upwards towards the left side, passed to the left of the great arch of the 
 stomach to which it was closely united, reached the diaphragm, and thence, after an 
 acute duplieature, descended closely adherent to the left side of the abdominal parietes. 
 The mucous coat of the ileum for about three inches from its termination was of dark 
 red colour, and covered with granular lymph. The inner coat of the large intestine 
 was irregular, and in many places fungus-like from granular lymph. There were many 
 large transverse ideers, some covered with thick pus, and others with black sloughs in 
 the centre. Surrounding the ulcers, and in most part of the inner coat not occupied 
 by ulceration, there was tenacious red transparent mucus effused ; and here and there 
 on its surface there was granular lymph. The stomach was displaced to accom- 
 modate itself to the displacement of the transverse colon ; its inner surface was not 
 examined. Liver healthy. Gall-bladder not distended. Lungs healthy. Heart healthy. 
 There were one or two small points of deposit at the commencement of the aorta. 
 
 54. Di/senti ry altt mating with febrile accessions. — Bands of granular deposit at the 
 end of the ileum. — Sloughy via ration of the colon. — Goolab Poorie, a Hindoo beggar, of 
 twenty-seven years of age, was admitted into hospital on the 17th June, 1851. He had 
 suffered for about two months from quotidian liver, which commenced with chills in 
 
 r 4 
 
248 DYSENTERY. 
 
 the evening. For fifteen days he had heen affected with diarrhoea. From the time 
 of admission to the 1st July, frequent thin feculent evacuations were passed with 
 griping and straining. The tongue was florid and glazed, and there was occasional 
 vomiting. The pulse was feeble, but febrile accessions were absent. He was treated 
 with astringents, opium, diluted hydrocyanic acid, opiate enemata, and small blisters. 
 From the 1st to the 16th July, the bowels were composed, the vomiting ceased, the 
 tongue lost its florid appearance, but the febrile accessions recurred and were tertian 
 in type. He was now treated with hydrocyanic acid and quinine in small doses. 
 From the 14th to his death on the 20th July, dysenteric symptoms recurred and the 
 discharges contained blood-tinged mucus, and the febrile accessions ceased. 
 
 Inspection five hours after death. — The body generally was much emaciated, but 
 there was a thick layer of fat in the parietes of the abdomen as well as in the omentum. 
 The peritoneal covering of the small intestine was in some places slightly vascular, 
 and siime of the convolutions adhered to each other by tender lymph. A part of the 
 great omentum (that covering the ascending and the transverse colon) was fleshy 
 looking and of rose-red colour. Intestines. — The mucous lining at the end of the 
 ileum presented red transverse streaks, the surface of which was studded with granu- 
 lar deposit. The ascending and the transverse colon were much thickened through- 
 out, and presented internally almost a continuous surface of ulceration covered with 
 greyish sloughs. In the mucous membrane of the descending colon and of the sigmoid 
 flexure the ulcers were not so continuous. They were circular in character, each 
 about the size of quarter of a rupee. The liver was of natural size and texture, 
 but of pale yellow colour, both externally and internally. The mucous membrane 
 of the stomach was pale-looking and soft, chiefly towards the cardiac end. Both 
 the kidneys were healthy but ex-sanguine. Chest. — The lungs collapsed, were of 
 spongy texture and free from adhesion. The heart was of natural size, and its surface 
 covered with fat, chiefly towards the margin of the right ventricle. 
 
 55. Dysentery. — Sloughy ulceration of large intestine. — Granular deposit in trans- 
 verse bands in the ileum. — Peritonitis and matting of the omentum. — An opium eat r. 
 ■ — Dhyam, a Mussulman ■water-carrier, of forty years of age, emaciated and addicted to 
 the habitual use of opium, a native of Delhi, and not long resident in Bombay, was 
 admitted into hospital on the 10th December, 1848. He had been ill with bowel com- 
 plaint and febrile symptoms for twenty days. On admission, the abdomen was soft 
 and collapsed, but uneasy on pressure at the umbilical region. During his stay in 
 hospital the alvine discharges were frequent, consisted of slimy mucus tinged with 
 blood, and were passed with griping, tenesmus, and occasional prolapsus. Febrile 
 heal was frequently observed, and the pulse was feeble; the tongue was moist and 
 without fur. He died on the 24th December. He was treated first with ipecacuanha 
 and full opiates : then acetate of lead or sulphate of copper or trisnitrate of bismuth 
 were substituted for the ipecacuanha. A small blister was applied to the pained pari 
 of the abdomen. 
 
 Inspection six hours after death.- Chest. -Lungs extremely collapsed, crepitating 
 and healthy. Pericardium and heart healthy. Abdomen. The liver was healthy. 
 
 The greal omentum, red. and thickened, was matted over the transverse colon, and 
 
 adhered by friable lymph to folds of intestine (small and great) and to parts of the 
 abdominal parietes. The convolutions of the intestines adhered by flakes of lymph to 
 one another, to the viscera of the pelvis, and the parietes of the abdomen ; and there 
 
 w:is a blush of redness over them. The c am, the ascending colon, and the righl half 
 
 of the transverse colon were internally in a state of sloughy ulceration, and all the 
 were tender, of greyish colour, and pultaceous consistence, and tore readily on 
 
 ,;:: " the adhesion-: the ( tents of the gut were thin and of greyish colour. 
 
 1 flexure of the colon was in a similar sloughy condition. The rest 
 of the colon was somewhal thickened with the mucous lining softened, but without 
 any distinct ulceration. The ileum was laid open for about three feet of its length; 
 
FATIIOLOGY — ULCERATION. 249 
 
 there was general redness of the mucous coat ranged in transverse streaks, correspond- 
 ing to the valvulne conniventes ; and at the lower part of the intestine, the reddened 
 surface was covered with a layer of firm, granular lymph, and the mucous coat under- 
 neath was thickened. This effusion of granular lymph lessened as the coeeum was 
 receded from, and ceased two and a half feet from the ccecum, but the redness in 
 transverse streaks without the granular deposit extended somewhat higher. The 
 kidneys appeared tolerably healthy. Head not examined. 
 
 56. Probable scorbutic taint. — Dark, irregular, ragged, internal surface of the colon, 
 with thickening. — Granular deposit on mucous membrane of ileum, with thickening. — 
 Dhondoo Essew, a Maratha labourer, twenty-one years of age, recently returned 
 from Aden, where he had been employed for two years, was admitted into hospital on 
 the 16th October, 1848, after ten days' illness from diarrhoea and febrile symptoms. 
 He was reduced in strength. He died on the 8th of November. The symptoms ob- 
 served were frequent alvine discharges, scanty, passed with griping, and consisting of 
 adhesive pasty or slimy feculence of palish colour, and frequently streaked with blood. 
 There was no fulness or induration of abdomeu, and seldom uneasiness on pressure. 
 The tongue was sometimes coated in the centre, but was not florid. There was frequently 
 an evening febrile exacerbation noted. The skin was always dry ; the pulse feeble, some- 
 times irritable, and it ranged from 80 to 94. There was no sponginess of the gums, yet 
 residence at Aden is well known to engender a scorbutic taint. The urine showed no traces 
 of albumen. He was treated first with acetate of lead and opium, then with quinine and 
 full opiates, and a small blister was applied to the abdomen. Diet, milk , sago, port wine. 
 
 Inspection thirteen hours after death. — The body much emaciated. Chest. — The 
 lungs collapsed freely. Abdomen. — The intestines collapsed. No peritoneal adhesions. 
 The large intestine was rather contracted, and very much thickened. The inner 
 surface presented a dark green, very irregular and ragged surface, and the dark tint 
 extended into the interstices of the tissues, and gave the cut edges of the thickened 
 walls an almost black colour, in places. The inner surface of the ileum, for about two 
 feet above the deo-colic valve, was diseased ; the mucous membrane red, thickened, and 
 covered with a layer, more or less thick, of gramdar, closely adherent lymph. The 
 kidneys were healthy. The liver was healthy. 
 
 57. Thickening and sloughy ulceration of large intestine, with here and there a small 
 encystt d abscess in the thickened tissue. — Granular deposit on inner surface of ileum. — 
 Peritonitis. — Old pericarditis and heart disease. — Corporal C. W., aged thirty-one, of 
 Her Majesty's 40th Regiment, after four days' illness, was admitted into the hospital 
 at Belgaum, on the 8th July, 1830. There was tenderness of abdomen, and frequent 
 purging, attended with tenesmus. The skin was hot and dry. The tenderness of 
 abdomen, never entirely removed, was much aggravated on the 14th. The purging 
 continued frequent, and he died July 16th. No ptyalism induced. 
 
 Inspection. — The peritoneal covering of all the intestines and of the convex surface 
 of the liver was vascular and covered with flakes of effused lymph. The caput coeeuni 
 had formed firni adhesions, and in endeavouring to separate it from the iliac fossa, its 
 coats readily gave way. The disease of the mucous membrane commenced at the 
 termination of the ileum, where there where several vascular patches covered with a 
 slight effusion of granular lymph, but unattended with ulceration. In the ccecum and 
 ascending colon the whole mucous coat was ulcerated and broken down, and the 
 subjacent coats were much thickened, with here and there a small encysted secretion 
 of pus in their tissue. In the transverse and descending colon the ulcers were large, 
 but circumscribed, of an olive green colour in their centre, surrounded by a blush of 
 redness, and uniformly attended with thickening of the other tunics. The paren- 
 chyma of the liver was of lighter colour than natural. The gall-bladder contained little 
 bile. Chest. — The pericardium adhered firmly to the whole surface of the heart, 
 from which it could not be separated without the knife. The heart was natural in 
 size, but of darker colour. The mitral valve was thickened and cartilaginous ; the 
 
250 DYSEXTEEY. 
 
 aortic valves were in a similar state, and instead of being applied to the sides of the 
 vessel projected into its cavity, leaving dilated pouches behind them. 
 
 58. Dysentery. — Sloughy ulceration in transverse bands, and the follicles of the colon in 
 difft rent stages of disease. — Insensibility f<r an how before death. — Two ounces of serum 
 at the base of the skull. — Edward Clark, aged twenty-four, a seaman of slight frame and 
 dark complexion, was under treatment in the General Hospital from May 26th to 31st, 
 1839, ill with rheumatism, chiefly marked by rigidity of the muscles of the back of the 
 neck, and of the masseter muscles. He was discharged well, and joined the Indian Navy. 
 On the 6th June he was re-admitted into the hospital, ill with dysentery. It was the fifth 
 day of the disease. There was considerable fulness and pain of the abdomen, -with tenes- 
 mus and pain at the anus. The countenance was anxious, the pulse frequent, and feeble, 
 the tongue white, but not coated, and the evacuations were yellow, slimy, and streaked 
 with blood. Five dozen leeches were applied to the abdomen, a warm bath used at bed- 
 time, and pills of calomel seven grains, ipecacuanha and opium, each one grain and a half, 
 were given, and followed on the succeeding morning by four drachms of castor oil. Daring 
 the night he was several times disturbed; the evacuations were watery, and tinged red. 
 On the morning of the 17th, the abdomen continued full, and was somewhat tense and 
 tender at the umbilicus. There was also considerable pain at the anus ; the countenance 
 was anxious; the pulse 116, of moderate strength, and the tongue pretty clean. Five 
 dozen leeches were again applied to the abdomen, and fomentations directed to be used 
 every second hour, and an anodyne enema to be exhibited at noon. The evacuations 
 continued frequent, watery, and tinged with blood. The tenderness and fulness of the 
 abdomen persisted, the skin was above natural temperature, the pulse 120, and 
 irritable. At the evening visit the fomentations were continued, and calomel six 
 grains, with opium and ipecacuanha two grains, given at bed-time. The purging con- 
 tinued during the night, and on the morning of the 18th the skin was dampish, pulse 
 92, and feeble. There was less fulness of the abdomen, and less straining. A large blister 
 was applied to the abdomen, and the anodyne enema was repeated, and three ounces 
 of port wine ordered. At the evening visit the blister was found to have acted well ; 
 the purging, however, persisted, and the evacuations consisted of bloody serum with 
 flocculi of blood. Pulse frequent and small, skin hot, much thirst, but the tongue not 
 furred. There had also been frequent vomiting. Calomel and opium each two grains and 
 ipecacuanha one grain, in the form of a pill, were ordered every four hours. The purging 
 was unchecked, and he died at 7 P.M., having become comatose half an hour before death. 
 
 Inspection twelvt hows after death. — The abdomen was moderately distended. 
 Head. -There was about two ounces of serum in the cavity, chiefly at the base of the 
 skull. Chest. — The lungs were emphysematous and not collasped ; but the thoracic 
 viscera were otherwise heslthy.— Abdomen. The omentum adhered to the cceeura, 
 and to the colon; and many of the mesenteric glands were enlarged. At the hepatic 
 flexure of the colon, an ulcer was patched by the opposing side of the angle. The 
 whole of the inner surface of the large intestine was more or less diseased. There 
 were slonghly ulcerations and elevated transverse ridges coated with a layer of 
 granular lymph. The mucous follicles were also in different stages of disease; in 
 some the orifice was merely apparent, in other- it was enlarged by ulceration, and 
 ranged from a mustard seed to the size of a sixpence. The mucous coat of the 
 : i was mammillated. The liver was pale in texture, and in the left lube there 
 was a small abscess, the size of a walnut. The kidneys were healthy. 
 
 59. Dysentery neglected for thirteen days, attended with abscess in the liver. — 
 ration of th mucous coat of the colon, with fringe of granular exudation. 
 —Charles Mitchell, aged twenty-four, of stout habit, four years resident in India. 
 After thirteen day-' illness, was admitted into th< Gh I Bospital on the llth 
 December, ill with dysentery. There was a good deal of uneasiness of the abdomen, 
 and much tenesmus, and the dejections contained much blood mixed with mucus or 
 serum. II ie 3rd January. 
 
PATHOLOGY — ULCERATION. 251 
 
 Inspection, — Abdomen. — In the right lobe of the liver there was an abscess the size 
 of an orange, and in the left lobe there was one the size of a walnut. The large 
 intestine was thickened, and there were large patches of sloughy ulceration of the 
 mucous surface fringed with a layer of granular lymph. This layer of lymph was 
 plainly secreted by the inflamed surrounding mucous coat, and not by the surface of 
 the ulcer. 
 
 60. — Acute dysentery. — The large intestine ulcerated in transverse ridges. — 
 The mucous follicles enlarged. — Considerable effusion of serum in the head without 
 symptoms. — John Billing, aged twenty-three, a stout muscular man, a seaman of Her 
 Majesty's ship Volage was admitted into the European General Hospital, on the 28th 
 December, 1838. On the 22nd he had been affected with slight diarrhoea, from which 
 it was stated he, had recovered. He was allowed to go on shore on leave, and re- 
 turned to the ship complaining of inability to void his urine, and of pain and tender- 
 ness of the hypogastrium. A catheter was introduced, and the bladder was found 
 empty. Subsequently, after the exhibition of diuretics, the urine was voided 
 naturally. On the morning of the 28th there was griping and purging, pain and ten- 
 derness of the abdomen on pressm-e, a small and rapid pulse, cold perspiration, and a 
 dark brown fur on the tongue. He was bled to twenty ounces, a blister was applied 
 to the abdomen, some castor oil exhibited, and he was sent to the European General 
 Hospital. On admission, at 5 p.m., the pulse was very feeble, the skin was cold, the 
 respiration was somewhat hurried, the tongue had a thin brown coat in its centre, 
 and the chief complaint was of debility, faintness, and frequent ineffectual calls to 
 stool. The blister on the abdomen had risen well. An ounce of camphor mixture, 
 with a drachm of aromatic spirit of ammonia and five grains of the sesquicarbonate 
 of ammonia, was given on admission, and ten grains of calomel and two of opium at 
 bed-time. The respiration became more hurried, the pulse thready, the skin cold and 
 damp. Mulled wine was given every hour. He died at 2 a.m. of the 29th. 
 
 Inspt ction eh. ven hours after death. — Head. — The vessels of the pia mater were moder- 
 ately congested. On the convex surface of the brain between the pia mater and the 
 arachnoid membrane, there was considerable effusion of serum, and the latter mem- 
 brane was somewhat thickened and opaque. There were about six drachms of serum 
 in each lateral ventricle, and about two ounces at the base of the skull. Chest. — The 
 lungs with exception of emphysema of the upper lobes were healthy. Abdomen. — The 
 omentum adhered by fleshy points to the ccecum, the iliac fossa, and different parts of 
 the ascending and descending colon. The sigmoid flexiu-e of the colon was doubled 
 down, and adhered to the fundus of the bladder, and to the rectum. The inner 
 sm-face of the ceacum and colon was much ulcerated, under the form of closely set 
 transverse elevated indurated ridges, with an ulcerated suface fringed by a layer of 
 granular gritty yellow lymph, or red gelatinous mucus. In many places, when the 
 layer of lymph was removed, the ulcer was found in process of cicatrisation. Many 
 of the mucous follicles in the colon were enlarged, and some were ulcerated. Through- 
 out the greater part of the large intestine, the sub-mucous tissue was thickened. 
 The liver was healthy, and the gall-bladder full of bile. The small intestine was 
 healthy. The mucous membrane of the stomach was somewhat softened, with 
 marbled dark redness at its cardiac end, and in some places it was mammillated and 
 thickened. The spleen, the kidneys, and bladder, were healthy. 
 
 61. Acute dysentery. — The ideeration in transverse ridges. — Consielcrable effusion of 
 serum in the head, tvithout symptoms. — John Gale, aged fifty-two, a tall man of 
 sallow complexion, who had served for forty-two years in India, had generally en- 
 joyed good health, but had led an intemperate life. After six days' illness, he was 
 admitted into the European General Hospital on the 12th December, affected with 
 frequent purging and pain of the abdomen. He described the evacuations to have 
 been of various appearance, and frequently to have contained much blood. On the 
 
252 DTSENTEltT. 
 
 ni"ht before admission he had been constantly purged, and much blood had been 
 dejected. There was acute tenderness in the course of the colon and over the ececum. 
 Pulse 120, feeble. Skin of natural temperature ; tongue furred. He was ordered 
 four grains of acetate of lead with two grains of opium, at bed-time, and to be repeated 
 the following morning ; port wine was also given in small quantities. During the 
 night there was much purging, the evacuations being red and watery, and on the 
 morning of the 13th the pulse was almost imperceptible. The purging continued, the 
 sinking increased, and he died at micbiight. 
 
 Inspection eight hours after death. — Head. — The vessels of the pia mater were turgid. 
 There was considerable effusion of serum between the arachnoid tunic and the pia 
 mater on the convex surface of the brain, and there was also considerable effusion at 
 the base of the skull. Chest. — The lungs were of dark colour and emphysematous, bnt 
 otherwise healthy. The heart was healthy. Abdomen. — The liver was of natural 
 size, externally of pale colour, with an irregular surface. When incised the texture 
 was found to be indurated, was of a pale buff colour, and mottled. The mucous lining 
 of the middle of the great arch of the stomach was mammillated ; at the cardiac end it 
 was thin, and in places almost removed. The end of the ileum was natural. The 
 colon from beginning to end presented internally an irregidar sm'face of sloughy 
 ulceration, chiefly ranged in dark red fungous, closely set transverse ridges, some of 
 which were half an inch thick, and fleshy when cut across. The free surface of these 
 ridges presented either a foul ulceration or a granular gritty surface from effused 
 lymph. The small intestine was contracted. In the right kidney there was a serous 
 cyst of the size of a walnut, and the parenchyma of the organ was congested. The 
 spleen was healthy. 
 
 62. Dysentery in an advanced state obscured by secondary peritonitis. — Granular 
 
 deposit on the mucous surface of the large intestine. — Shawah, a Hindoo washerman, 
 of thirty years of age, was admitted into the Jamsetjee Jejeebhoy Hospital on the 25th 
 December, 1851. He was emaciated, had been ill for a month, and could not give a 
 connected history of his illness. He complained chiefly of uneasiness of abdomen, 
 which was somewhat full and resisting. The bowels were open sometimes two or 
 three times in the day, and the evacuations were thin and feculent; at other times 
 they were not opened. The pulse was feeble. The case was looked upon as one of 
 subacute peritonitis, and was treated with leeches, opium, ipecacuanha, and castor and 
 turpentine oils in small doses. He died on 1st January. 
 
 Inspection. — The small intestine was full of air, and its convolutions were adherent 
 tn each other by bauds of finable lymph. The transverse colon was displaced down- 
 wards at its central part. The omentum was matted over it. and was also closely 
 adherent to the larger curvature of the stomach. There was a pouch-like dilatation of 
 the upper part of tin- ascending colon. The coats of the large intestine were generally 
 thickened; the mucous coat was pulpy, and generally softened, and studded over 
 with large patches of ulceration and granular deposit. The other viscera were 
 healthy, with the exception of slighl encroachment on the tubular part of the kidney. 
 
 63. Several attacks. — Colon thickened. - Sloughy ulceration, with granular deposit 
 <m i ih, r farts of the raucous surfuce of the colon. - Slighl pi ritonitis. Private J. A., 
 aged thirty-five, of Eer Majesty's loth Regiment, was admitted into hospital at 
 
 Belgi on the 8th .Inly, 1830, ill with dysentery. The attack was acute, but he 
 
 was discharged well on the :;im .inly. Re-admitted lfifh August with tender abdomen, 
 and other dysenteric symptoms. Ptyalism not induced. lie was discharged on 
 the 18th September, after having been in hospital a Long time convalescent. Re- 
 admitted September 23rd with tender abdomen ami frequenl purging. He complained 
 
 lor the first ti nt' pain of the righl hypochondrium. AVas subjected to the usual 
 
 treatment. No ptyalism. Died on the 1st October. 
 
 Inspection. There was much fa1 in the omentum and about the mesentery. The 
 
TATIIOLOGY — ULCERATION. 253 
 
 omentum adhered slightly to the intestines. The small intestine had a blush of 
 redness on its peritoneal surface. The caput ccecum was drawn upwards from its usual 
 situation in the iliac fossa. The colon was thickened, covered with fat, and firmly 
 adherent to the fundus of the gall-bladder, which latter organ adhered also to the 
 pyloric portion of the duodenum. The transverse arch was closely connected to the 
 stomach. The sigmoid flexure formed several folds in the hypogastrium, and the 
 sides of the folds adhered to each other. The mucous membrane of the large intestine 
 was discoloured and ulcerated, and when floated in water exhibited a flocculent 
 surface. Where less diseased there was a granular white effusion on the vascular 
 mucous surface. The liver was rather enlarged, and of lighter colour than natural ; 
 no adhesion. The viscera of the chest were healthy. 
 
 64:. Dysentery admitted in the last stage. — PeritoniUo inflammation. — Sloughy ulcera- 
 tion of the mucous coat of the colon. — Robert Hunter, aged thirty-eight, a seaman of 
 Her Majesty's ship Endymion, was admitted into the European General Hospital 
 on the 21st August, 1841. He stated that he had suffered from dysenteric symptoms 
 for five weeks, but had not reported himself sick till ten days previously. On admis- 
 sion the countenance was sallow, reduced, and anxious. The skin dry, and above 
 the natural temperature. The pulse 116, feeble and easily compressed. The abdomen 
 was rather full and tender on pressure at the right iliac region. The tongue was 
 florid at the tip. dryish in the centre, and without fur. He had been frequently 
 purged during the previous night, but the straining, formerly great, had considerably 
 decreased. Thirty-six leeches were applied to the right iliac region, a warm bath was 
 used, and the ipecacuanha pills with opium given. During the night, there were 
 frequent dejections of ochreous red colour, with intermixed sloughy shreds. On the 
 morning of the 22nd pulse 88 feeble. The other symptoms as on the previous day. 
 Two grains of opium, with an equal quantity of blue pill and ipecacuanha, were given 
 every four hours. On the 23rd, the frequent purging continued, the dejections being 
 of claret-red colour, attended with hiccup and sinking pulse. Acetate of lead and 
 opium were given every four hours, two grains of each. The purging contimied 
 unchecked, and on the 24th, the opium was combined with sulphate of copper, instead 
 of the acetate of lead, without benefit. He died on the morning of the 25th. 
 
 Inspection six hours after death. — The omentum, vascular and fleshy, extended over 
 the intestines, adhered to the ccecum and to the abdominal parietes. There was dark 
 vascularity, with exudation of lymph and tender adhesions of the peritoneal surface 
 of the small intestine. The ccecum, ascending and transverse colon were thickened and 
 tender, tearing readily and showing an inner surface of irregular ulceration, covered 
 with dark-coloured adhesive secretion. Liver healthy. Thoracic viscera healthy. 
 
 Transverse ulceration may also exist with thickening of the 
 coats of the intestine, but without granular exudation. It may 
 occur also, though rarely, without thickening, and then the morbid 
 process is of a different nature — it is one of serous and lymph 
 exudation and suppuration in the sub-mucous tissue of the trans- 
 verse fold, followed by gangrene and sloughing of the mucous 
 layer. But this lesion will be more fully considered in connection 
 with the second form of ulcer — the circular. 
 
 Circular ulcers are generally found in dysentery of long duration, 
 in which the symptoms have never at any time been very acute. 
 
 According to Drs. Parkes and Baly they originate in the solitary 
 glands. The latter author has described well the process of 
 
254 DYSENTERY. 
 
 sloughing by which the gland is thrown off and the circular ulcer 
 is formed. That some circular ulcers of the large intestine are 
 formed in this manner is not to be disputed. They, however, con- 
 stitute, probably, but a small proportion of the circular ulcers 
 which are met with in that situation ; for many of them have 
 seemed to me to originate in the ordinary follicles. It has been 
 already explained that when these structures are irritated to 
 increased secretion they become turgid and their orifices distinct ; 
 then a vascular ring surrounds them and exudation of serum and 
 lymph in small quantity takes place into the mucous membrane 
 of the follicle and the areolar tissue around it, soon to be fol- 
 lowed hj destruction of these tissues, through a process of fusion 
 or sloughing. 
 
 Circular ulcers may probably also be formed by the same process 
 as transverse ones, viz. by thickening of and granular exudation 
 on circular patches of the membrane followed by grangrene and 
 sloughing. But this mode is suggested rather hypothetieally than 
 stated as an observed fact. 
 
 Circular and other forms of ulcer may originate in circumscribed 
 sub-mucous suppuration, of greater or less extent, followed by 
 sloughing of the superimposed mucous layer ; or, to express it 
 otherwise, exudation of circumscribed portions of lymph takes 
 place into the sub-mucous tissue, degenerates into pus, and is 
 succeeded by gangrene and sloughing of the mucous coat which 
 covers it. This manner of ulceration in dysentery has been 
 described by Haspel* ; and if I comprehend Dr. Bleekerf rightly, 
 it is the explanation of destruction of tissue in dysenteiy, 
 which he exclusively adopts. That ulcers are thus formed does 
 not admit of doubt. The process is analogous to that by which 
 some kinds of cutaneous ulcer are caused, viz. by small circum- 
 scribed sub-cutaneous abscesses with sloughing or ulceration of the 
 superimposed cutis. But in the writings of Haspel and Bleeker it 
 does not distinctly appear whether these observers have met with 
 the small sub-mucous abscesses frequently or only very occasionally. 
 If the latter, — which would be in accordance with my own ex- 
 perienced-then their opinion that intestinal ulcers are frequently 
 formed in this way is in great measure hypothetical. If, however, 
 mi the other hand, they have frequently observed this morbid pro- 
 cess in the s1a<fc of sub-mucous abscess, then the inference is, 
 either thai this process is rare in India compared with Algeria and 
 
 * " Maladies de L'Algerie," tome ii. p. 71. 
 i " [ndian Annals of Rledical Science," No. 1. 
 
PATHOLOGY — ULCERATION. 255 
 
 Batavia, or that death in these latter countries takes place more 
 frequently at an earlier period of the disease. 
 
 I have met with only one instance of sub-mucous abscess in my 
 own researches ; for this state is not to be confounded with that of 
 intestinal thickening from lymph deposit with subsequent de- 
 struction, partly by sloughing, partly by suppuration.* 
 
 The following is my only case of sub-mucous abscess : — 
 
 65. Patches of sub-mucous puriform infiltration in colon. — A Hindoo, -with febrile 
 symptoms, abnormal dulness of the lower part of right chest, with crepitus, was con- 
 sidered to be affected with pneumonia, and was treated in part with tartar emetic. 
 He died, and a large abscess was found in the upper and central part of the right lobe 
 of the liver, approaching the diaphragm ; its walls were ragged and shreddy. On the 
 inner surface of the coseum, ascending and transverse colon, there were sloughy ele- 
 vated dark grey patches, of the size of a rupee, not separating, but pulpy, and chiefly 
 remarkable for the distinct puriform infiltration into the sub-mucous tissue beneath. 
 The kidneys were in a state of granular degeneration. Diarrhoea had not been present 
 as a prominent symptom. 
 
 Circular ulcers of the mucous membrane in cachectic individuals 
 may be caused in still another manner — by gangrenous patches con- 
 sequent on sub-mucous oedema, just as in similar states of constitu- 
 tion cutaneous ulcers may be formed by a like process. 
 
 The following is an illustrative case : — 
 
 66. Sloughy -patches of mucous membrane of colon, with sub-mucous oedema. — Earn 
 Dial, treated in the clinical ward, in February 1852, for emphysema, dropsy, and 
 dysentery. The surface of the mucous membrane of the large intestine was elevated 
 from sub-mucous oedema. The elevated patches were grey, circular, and gangrenous in 
 the centre, and ranged in size from a rupee "to a quarter of a rupee. In none had 
 separation of the slough taken place. 
 
 There is then, it seems to me, still considerable uncertainty, in 
 regard to the precise mode of formation of ulcers in dysentery, 
 more particularly of those which are circular in form. 
 
 Pathologists in India will do well to direct their attention to this 
 subject, and to pursue it with minuteness and care. The questions 
 to be determined are, — the relative proportion of these ulcers which 
 originate: 1, in the solitary glands; 2, in the ordinary mucous 
 follicles ; 3, in patches of mucous membrane thickened by exu- 
 dation process ; 4, in sub-mucous abscess ; and perhaps, we may 
 add, in vesicular and pustular processes of the superficial parts of 
 the membrane. The circumstance of surrounding thickening- of 
 the mucous membrane, or sub-mucous tissue, or of both, should 
 also be carefully noted. My expectation is that it will be found 
 that circular ulcers are associated with surrounding thickening:, 
 chiefly when they are formed in the third manner. 
 
 I now quote four cases illustrative of circular ulceration: — 
 * Cases 57 and 75. 
 
 »> 
 
256 DYSENTERY. 
 
 67. Numerous small circular ulcerations of the colon. — Kuneem Khajee, a Mussul- 
 man pilgrim, of twenty years of age, on his way from Lahore to Bombay, with the 
 view of proceeding to Mecca, was exposed to vicissitudes of weather, and three months 
 before admission into hospital, on the 28th September, 1852, became affected with 
 bowel complaint. When he came under observation, he was a good deal emaciated. 
 The face was puffed, the feet were cedeinatous, and the abdomen full, with indistinct 
 sense of fluctuation and uneasiness in the course of the transverse colon. The bowels 
 were opened eight or ten times in the twenty-four hours, and the evacuations, passed 
 with griping and straining, were thin, slimy, and sometimes streaked with blood. The 
 urine not scanty, had generally a specific gravity of 1020, and showed no traces of 
 albumen. He died on the 4th October. 
 
 Inspection Jive hours after death. — The body was much emaciated. Chest. — There 
 were about six ounces of serous fluid in the sac of the left pleura. Both luno-s were 
 pale, crepitating, and without adhesion. The sac of the pericardium contained about 
 four ounces of serous fluid. The heart was of natural size, and the valves healthy ; 
 but there was more than usual quantity of adipose tissue, both over the base and 
 apex of the organ. Abdomen. — The sac of the peritoneum contained about ten ounces 
 of clear serum. The liver was smaller than natural, and the external surface and sub- 
 stance were of pale yellow colour. The gall-bladder and the gall-ducts were quite 
 pervious. .Stomach and small intestines collapsed, their peritoneal surface was pale. 
 The large intestine was not collapsed ; its coats were thickened apparently from 
 cedema ; the mucous membrane was mottled red and white, and numerous small cir- 
 cidar ulcers — some about the size of a pin's head, and others that of a split-pea — ■ 
 were seen scattered throughout the whole inner surface. They were most numerous 
 about the sigmoid flexure of the colon, and many of them presented an appearance of 
 cicatrisation. The mucous membrane of the ileum was healthy, except close to the 
 ileo-colic valve, where several circular ulcers were also observed. The kidneys were 
 healthy. 
 
 68. Chronic dysentery in a person of broken constitution. Numerous circular ulcers 
 in the large intestine, many of them cicatrising. Serous effusion in the head without 
 symptoms. — Henry Heming, aged forty-seven, an Indo-Briton, broken in constitution, 
 feeble in mind, and subject to dysentery for many months, was admitted into hospital 
 on the 2nd November, 1840. Both legs were cedematous, and the surface of the right 
 one was of dark red colour. The diarrhoea continued notwithstanding the different 
 remedies used, which were chiefly bismuth, sulphate of copper, and quinine in combi- 
 nation with opium. The dejections were generally pale in colour and thin. He died 
 on the 14th November. 
 
 Inspection thirteen hours after death. — Head. — There was a thin veil of serum be- 
 tween the arachnoid and pia mater on the convex surface of the brain, and about an 
 ounce at the base of the skull. Chest. — The lungs were fully collapsed. The right 
 auricle of the heart was distended with blood. Abdomen. — The liver, not enlarged, 
 was mottled red and white, and blood flowed from it when incised. The sigmoid 
 flexure of the colon was much dilated, and filled the space between the pelvis and um- 
 bilicus, and overlaid the ccecum. The end of the ileum and the large intestine were 
 laid open. The mucous coat of the end of the ileum was of natural appearance, and 
 contained lijrlit yellow formed feculence. The coats of the colon were not thickened, 
 except, in places, the mucous coat itself. The inner surface throughout was very 
 closely studded with circular ulcers ranging from a silver penny to a small split pea m 
 si/e. In some places the ulcers ran together, and formed irregular longitudinal vertical 
 hands. For the most part the edges of the ulcers were rounded and cicatrised, and tin- 
 bed of the ulcers presented a dark grey cicatrised Burface somewhal fleshy when incised. 
 
 txrfi generally had very much the appearance of deep small-pox pits, shortly 
 
 after desquamation. The mucous coal between the ulcers presented generally a dark 
 reddish tint, bul was qq| The ulcers were most crowded in that pari of the 
 
TATIIOLOGY- -ULCERATION. 257 
 
 sigmoid flexure which was dilated. The mucous coat of the stomach, the kidneys, 
 spleen, and mesenteric glands were healthy. 
 
 69. Dark grey discoloration, with some degree of thickening of mucous membrane of 
 colon, with numerous circular ulcers. — Luximan, a Hindoo beggar, of twenty-five years 
 of age, after eighteen days' illness, was admitted into hospital on the 30th November, 
 1850. He was frequently purged ; the evacuations consisted partly of thin feculence, 
 blood, and mucus, and were passed with much griping and tenesmus. The abdomen 
 was full, and tender on pressure, chiefly at the iliac regions. He suffered from febrile 
 disturbance also. The symptoms continued with occasional alleviation, but at times 
 hiccup was present, with a gradually failing pulse, till 23rd December, when he died. 
 Leeches were used at the commencement, followed by small blisters. Quinine and 
 opium and then acetate of lead were given, and towards the end opium alone. Milk, 
 sago, wine, and chicken-broth as diet. 
 
 Inspection eleven hours after death. — Chest. — The lungs did not collapse readily , and 
 adhered closely to the costal pleura. The upper lobe of the right lung was crepitating, 
 the middle and inferior lobes were cedematous, as was also the inferior lobe of the left 
 lung. The heart was healthy. Abdomen. — The cavity contained about three pints of 
 clear serum. The mucous membrane of the large intestine was of dark grey coloiu*, 
 was somewhat thickened, and did not move freely on the subjacent tissue. There were 
 many round superficial ulcers, several of which were in process of cicatrisation. The 
 ulceration, in its most active state, was in the ccecum and ascending colon. The 
 glands at the end of the ileum were more developed than natural. The mucous mem- 
 brane of the small intestine was healthy. The mesenteric glands were somewhat 
 enlarged, but free from tubercular deposit. The liver somewhat congested. Kidneys' 
 normal. 
 
 70. Circular and transverse ulcers of the large intestine. — Matting of the omentum 
 over the colon, with displacement. — Liver healthy. — Distention of the urinary bladder. — ■ 
 Antonio Ignatio, of twenty-two years of age, and of spare habit, a native of Lisbon, a 
 sailor by occupation, and once the subject of yellow fever at Rio de Janeiro, was 
 admitted into hospital on the 25th July, 1851. He suffered from tertian fever for 
 eighteen days, and some degree of enlargement of the spleen was noted. Dysenteric 
 symptoms had been present for five days before admission, and there was pain of the 
 abdomen on pressure at the umbilicus. While under treatment, the alvine discharges 
 — from six to twelve in the twenty-four hours — are described as thin and feculent, 
 passed with tenesmus, and occasionally with prolapsus. The tongue was coated, and 
 latterly florid at the top. The febrile accessions occasionally recurred. He died on 
 the 10th August. He was treated with opium and ipecacuanha, anodyne enemata, 
 and the application of a small blister to the pained part of the abdomen. 
 
 Insptction ten hours after death. — Chest. — Both lungs collapsed freely. They were 
 soft and crepitating, but pale, and adhered firmly to the walls of the chest. The 
 pericardium contained about two ounces of clear serum. The valves and structure of 
 the heart were natural. Abdomen. — The liver was of normal size ; its structure healthy. 
 The spleen was somewhat enlarged. A small portion of the omentum matted over the 
 ccecum, dragged the transverse colon downwards, to the right side. The ccecum ad- 
 hered to the anterior parietes of the abdomen by tolerably firm bands. The whole of 
 the colon was distended by flatus. The mucous membrane of the large intestine 
 throxighout presented numerous ulcers of various sizes. The smallest was the size of a 
 split pea, others — the largest — that of a dollar. Some were circular, others oval or 
 transverse, and others were rendered very large and irregular, by the coalescence of 
 several smaller ones. The base of all these ideers was formed by the muscular coat. 
 The mucous coat presented here and there a bhish of redness chiefly around the mar- 
 gins of the ulcers. The sub-mucous coat of the ccecum was swollen by serous infiltra- 
 tion. The kidneys were slightly enlarged, bnt their structure was healthy. The bladder 
 
 g 
 
258 DYSENTERY. 
 
 was much distended by urine, and reached above the pelvis.""" The ureters were also 
 distended up to the kidneys. The mucous membrane of the anterior wall of the stomach 
 presented a blush of redness. 
 
 5. The separation of Parts of the Mucous Coat in Shreds 
 and Tubular Portions. — The description of the processes by 
 which destruction and sloughing of the intestinal mucous mem- 
 brane are effected in dj^sentery is not yet completed. The mucous 
 membrane of the large intestine is liable to be affected with a form 
 of inflammation, acute and generally extensive, which, from the 
 course it follows, and the appearances it presents after death, may 
 reasonably be regarded as analogous in character to erysipela- 
 tous inflammation of the skin. It is commonly, but not exclusively, 
 met with in Europeans who have not been long resident in India, 
 and whose constitutions have been deteriorated by debauch and 
 climatic influences. The mucous membrane is discoloured and 
 swollen from exudation of serum and badly plastic lymph, which, also 
 diffusively infiltrated into the sub-mucous tissue, quickly degenerates 
 into sero-pus, and leads to gangrene of this tissue as well as of the 
 mucous membrane itself. Hence the separation of patches and 
 shreds of sloughy mucous tissue — often seen in the dejections 
 during life, and found after death in various states and stages of 
 separation. Cases 71 to 76 illustrate this condition of the intes- 
 tinal structures. 
 
 71. Dysentery. — Death in eeirly stage by cholera. — Gangrenous patches of mucous 
 tin in h rune of large intestine, but no separation. — A soldier of the German Legion at Poona, 
 Under treatment for affection of the bowels with bloody discharges, mistaken for haemor- 
 rhoids, was seized on the 4th June, 1859, with cholera, at the time prevailing, and died. 
 
 In ipection. — The mucous membrane of the colon and rectum was somewhat edema- 
 tous; there were numerous large, grey-black, tumid, chiefly transverse, patches; none 
 had separated, but some were very easily lacerable and gave out sero-pus, others were 
 firmer. The intervening mucous membrane was pale, with enlarged solitary glands 
 ami follicles. 
 
 72. Dysentery. — Sloughs of ' thr mucous coat 'passed before death. — Much displacement 
 of the colon to the left side. Abscess in the Liver. — Joseph Slayman, aged thirty-two, 
 a seaman, was admitted into hospital on the 20th August, 18-10. He had been ill with 
 dysentery for fourteen days. On admission the abdomen was tender, the skin and 
 tongue were dry, and the pulse moderately full. On the 22nd there was tenderness of 
 the left iliac region, with perceptiMo hardness. Throughout ids illness there was a 
 | ood deal of tenesmus. The abdomen was moderately full, and there was more or less 
 dysuria. Dejections watery, brown, and with dysenteric fu>tor. On the 1th, .5th, and 
 'iili September, considerable patches of sloughed mucous coal were passed. There, 
 were do peritonitic symptoms during the last days. lie died on the 10th September. 
 Treatment. Ee was once bled at the arm, was leeched several times on the abdo- 
 
 * The distention of the Madder would seem not to have been detected before death. 
 This is an oversight which oughl never to occur in the treatment of dysentery, as 
 attention to the Btate of this viscus should be a rule of practice. 
 
TATIIOLOGY — SLOUGHING. 259 
 
 men, and around the amis. The abdomen was blistered. At first two or three doses 
 of calomel with opium and ipecacuanha were given, then ipecacuanha, gentian, and 
 blue pill, without purgatives; afterwards free opiates frequently repeated in combina- 
 tion with blue pill and ipecacuanha, or quinine and bismuth, according to the state of 
 the pulse and skin. For two or three days acetate of lead and opium were freely used 
 with partial alleviation of the symptoms. Light nourishment and wine. 
 
 Inspection eight hours after death. Bod}- emaciated. — Chest. — Old adhesions of the 
 right pleura; no emphysema. Viscera healthy. Abdomen. — The omentum adhered 
 to the left lateral parietes, and had so dragged the colon from its natural situation 
 that the cceeuni was lodged in the pelvis and adhered to the bladder. The right iliac 
 fossa and all the right, side of the abdominal region were occupied by the small intes- 
 tine. The ascending and transverse portions of the colon passed vertically in the 
 mesial line, extended under the stomach, and formed various turns before passing into 
 the descending colon ; these duplicatures adhered to each other, and the intestine was 
 lacerated in many places, in separating them. The mucous coat of the end of the 
 ileum was healthy. In the ccecum there were hanging loose dark sloughed patches of 
 the mucous tmiic. Lower down the mucous coat had separated and been thrown off, 
 and a pearly ghstening surface was left, with here and there bands and isolated 
 patches of the mucous coat tolerably healthy, and standing out in relief. The liver 
 was enlarged, and extended into the left hypochondrium. It was mottled red and 
 white ; and in the right lobe towards the diaphragm there was an abscess about the 
 size of a large orange, and about half an inch from the surface. The pyloric end of 
 the mucous coat of the stomach was mammillated. The kidneys were healthy. 
 
 73. Acute Dysentery. — Extensive sloughy uUn ration of the inner surface of the large, 
 intestine. — Dark red grumous discharges. — Charles Thompson, aged forty-two, a sailor 
 of intemperate habits, who had been five years in the Indian Navy, and who had 
 made frequent voyages to China during the twelve previous years, was admitted into 
 the European General Hospital on the 17th July, 1838, after he had been ill with 
 dysentery for five days. On admission the symptoms were not urgent. The skin, 
 pidse, and tongue were natural. There was no distention or pain of the abdomen, or 
 straining, when he was purged. The discharges varied in frequency ; they were gene- 
 rally tinged deeply with bile, and contained mucus. As the disease advanced, the 
 purging became more urgent, and tenesmus more complained of. The dejections were 
 more mucous and scanty; latterly they became dark red and serous, and contained 
 clots of blood. The pulse became frequent and feeble, and the skin damp. He died 
 on the 11th August. It would be tedious to detail the varied and ineffective treat- 
 ment that was pursued. 
 
 Inspection five hours after death. — Body not very emaciated. Abdomen. — The 
 omentum extended over all the intestines, and in the hypogastrium and iliac regions 
 adhered to the walls of the pelvis by fleshy vascular fringes. The intestines generally 
 were of dark grey colour, and more distended than natural. The ccecum adhered by tender 
 dark-coloured layers of lymph to the lateral parietes, and in these places the coats of 
 the bowel were black, and tore readily. The tunics of the ascending and transverse 
 portions of the colon were also tender, and the latter part of the gut passed the left 
 side of the stomach, was applied to the diaphragm, and united by adhesions to the 
 spleen. The descending colon adhered to the left lateral parietes, and, on attempting 
 to separate it, the coats readily gave way, and dark grumous blood escaped. The sig- 
 moid flexure of the colon, before turning to reach the top of the sacrum, had dipped 
 more into the pelvis than is natural ; it adhered to the peritoneal lining of the pelvis, 
 and its coats also tore readily. The same lacerable condition characterised the tissues 
 of the rectum ; so much so that it was only separable in fragments. The whole of 
 the large intestine was filled with dark grumous blood. The inner surface of the last 
 two feet of the ileum was dark and red, vascular and softened. The coats of the 
 ccecum were much thickened, and the lining membrane completely disorganised, wad 
 
 s 2 
 
260 DYSENTERY. 
 
 replaced by large dark purple sloughy shreds. In the transverse colon the ideers were 
 more defined, and where there was no ulceration, there the mucous coat was dark red, 
 and softened. The condition of part of the internal surface of the descending colon, 
 the sigmoid flexure and rectum, was similar to that of the coecum. The lining mem- 
 brane along the small curvature of the stomach presented marbled, red, extravasated 
 patches, and was softer than natural. The liver was healthy. The kidneys were 
 paler than natural. The thoracic viscera were healthy. 
 
 74. Dysentery. — General peritonitis before the fatal termination. — Serous effusion 
 in thi- head; no head symptoms. — The mucous coat of the colon in process of separation 
 from the other tunics. — William Anderson, aged twenty-one, stout, seaman of the ship 
 Lord Auckland, after ailing more or less with dysentery for a fortnight, but much 
 aggravated during the last two or three days before admission into the General Hos- 
 pital on the 25th July, 1840, when the abdomen was full, tender, and resisting; pulse 
 frequent and slightly sharp, but compressible. He was once bled from the arm, and 
 leeches in considerable numbers were applied to the abdomen, so long as any tender- 
 ness remained. He was also blistered twice. Calomel in free doses with opium and 
 ipecacuanha was given at the commencement at bed-time, followed during the day 
 with pills of ipecacuanha blue pill and extract of gentian. The dejections were, for 
 the most part, of light yellow colour streaked with blood, aud generally passed without 
 much tenesmus. The disease not yielding, mercury was exhibited, partly by the 
 mouth, partly by inunction, with the view of affecting the system. On the 17th August 
 he was under the influence of mercury, and an abscess formed at the right angle of the 
 lower jaw. The purging, however, continued. Free opiates, in combination with bis- 
 muth, sulphate of copper, or acetate of lead, were given, and opiate enemata were used. 
 On the 29th August the abdomen became tender, continued so, and became full and 
 somewhat tense. The sinking increased rapidly, the purging continued, and he died 
 on the 1st September. 
 
 Inspect ion five hours after death. — Head. — The vessels of the membranes were defi- 
 cient in blood, and the substance of the brain was pale. Between the arachnoid mem- 
 brane and pia mater, at the posterior part of the hemisphere, there was a thin veil of 
 serum, and there was also about an ounce at the base of the skull. Chest. — The viscera 
 were healthy; Abdomen. — The omentum thickened was spread over the intestines and 
 adhered to them, and to parts of the abdominal parietes by a red-coloured fringe. The 
 convolutions of the intestines, great and small, adhered to each other by flakes of 
 lymph, and, on separating these, sero-pUrulent effusion oozed from among them. The 
 end of the ileum and the large intestine were laid open. The mucous coat of the end 
 of the ileum was healthy, and its contents were feculent and partly formed. The 
 toUCOUS coat of the large intestine was of dark grey colour and pulpy aspect, and 
 throughoul almosl the entire extent of the bowel large patches were detached from 
 the muscular coat. Between the mucous and muscular reals there was a yellow lymph- 
 like lacerable layer. The stomach was healthy. The kidneys were healthy. Blood 
 flowed from the liver where it was incised, and the Bubstance of the viscus was in 
 pari mottled buff. 
 
 75. Sloughy state of mucous membrane of the colon. - Sub-mucous puriform infiltra- 
 tion forming little cavities. Gt m ral p< ritonitis> Matti: g <>/ omt ntum.— ffi /. ntvon of 
 urine Malidoo Snggujec, a Eindoo labourer, aged fiftj years of age, and of feeble 
 constitution, was admitted into hospital on the 2nd July, is is. There was retention 
 of urine, the abdomen was painful, and the pain was increased by pressure. lie had 
 also frequent calls to stool, and the discharges consisted of blood-tinged scrum ; he 
 had been ill four days: he died on the 11th July. During the time he was under 
 treatmenl the alvine discharges were frequent, consisted of blood-tinged mucus or 
 scrum, mixed with more or Less feculence. The abdomen was full, doughy, or tense, 
 with some d< gree of hardness in the right iliac region; was tender on pressure, and a 
 
PATnOLOGY— SLOUGHING. 261 
 
 sense of burning was at times complained of. The catheter had frequently to be used. 
 From the 4th the countenance was anxious, and dysenteric fuetor was observed. 
 The tongue was more or less coated, the pulse was never above 92, at first well 
 developed, latterly becoming small. Leeches were several times applied. The treat- 
 ment was commenced with grains ten of calomel and two of opium, followed by castor 
 oil; then ipecacuanha and blue pill were given at intervals, latterly combined with 
 quinine. Turpentine stupes were applied to the abdomen. 
 
 Inspection twelve hours after death. — The abdomen distended, the body emaciated. 
 Abdomen. — The small intestine was much distended from the duodenum downwards, 
 and adhered to the abdominal parietes, and the convolutions to each other by flakes 
 of lymph. The chief adhesions were to the pelvic walls and pelvic viscera, and over 
 the descending colon. In the pelvis and in the lumbar regions there was a good deal 
 of pus effused. The peritoneal surface under" the flakes of lymph had a dotted red 
 appearance. The large intestine was contracted. The omentum was matted over the 
 transverse colon. The inner surface of the large intestine, throughout its entire 
 extent, was of a grey black colour, pulpy, thickened, softened from disorganisation ; 
 and here and there apparently in the sub-mucous tissue were little cavities with ragged 
 sides, containing grey fcetid, sero-puriform fluid. 
 
 76. Mucous membrane of colon sloughy and separating in shreds. — -General perito- 
 nitis and matting of the omentum. — Enam Khan, a Mussulman water-carrier, of 
 twenty-five years of age, was admitted into hospital on the 6th August, 1850. He 
 was reduced in flesh. The abdomen was tense and generally tender on pressure, but 
 more particularly so in the right Uiac, epigastric, and left iliac regions. There was no 
 dulness or induration. The skin was above the natural temperature. The puke was 
 frequent and somewhat irritable. The tongue was coated with a thin dark brown fur, 
 ami was florid at the tip and edges, but moist. The lungs and heart showed no signs 
 of disease. He stated that he had been ill for a month with relaxed bowels, that at 
 first the evacuations were thin and feculent, but after a few days consisted chiefly of 
 scanty discharges of blood and mucus, passed with griping and straining ; that for 
 fifteen days there had been febrile symptoms, with tender abdomen. At the time of 
 admission he was purged from fifteen to twenty times daily, and the urine was scanty 
 and high coloured. On the 7th the scanty bloody mucus discharges continued, the 
 pulse became more irritable, and there was hiccup. On the 8th the abdomen was 
 more tense, full, and tympanitic, and he died at noon of that day. He was treated 
 with quinine, opium, and ipecacuanha. 
 
 Inspection twenty-one hours after death. — Chest. — There were firm adhesions between 
 the greater part of the pleural surfaces of both lungs. The substance of the lungs was 
 soft and crepitating. The heart was healthy. Abdomen tense and tympanitic. On 
 opening the cavity of the peritoneum, some gas escaped. The great omentum was 
 contracted, and matted over the colon, and was also attached by tender lymph to the 
 adjoining convolutions of the small intestine. The small intestines were somewhat 
 distended, and at points of their contact with one another there were continuous stripes 
 of redness, about one-third of an inch broad. There was also slight effusion of lymph 
 between the uppermost convolutions of the small intestine and the transverse colon 
 and stomach. There were five or six ounces of sero-puriform effusion in the pelvic 
 cavity. The mucous membrane, throughout the whole extent of the large intestine, 
 was in a sloughy state. It was detached from the subjacent tunic, and in some places 
 hung in loose shreds. There was some mottled redness of the mucous membrane near 
 the pyloric extremity of the stomach, but this tissue was otherwise healthy. Head. - 
 The vessels of the membranes of the brain were a good deal congested. The substance 
 of the brain was apparently healthy. 
 
 There is one form in which these sloughs of mucous memhrane 
 
 S 3 
 
262 DYSENTERY. 
 
 are separated, which has given rise to some discussion among 
 pathologists, and which therefore calls for more particular notice, 
 viz. : the separation of tubular portions of several inches in extent. 
 Of this lesion eight cases have come under my observation : — 1. 
 In a soldier of the 15th Hussars in the European General Hospital 
 in 1839. The slough, of about one foot in length, was perfectly 
 tubular, and evidently consisted of the mucous coat of part of the 
 intestine. Eecovery took place. 2. Four in the Jamsetjee Jejee- 
 bhoy Hospital, with one death, and the result in the other three not 
 known. 3. A gentleman, at Poona, in August 1859. The slough 
 was tubular, nine inches in length, and death took place by 
 haemorrhage eighteen hours after its separation. 4. One in the 
 practice of Mr. Sebastian Carvalho, the wife of a European pen- 
 sioner, fatal ; one with Mr. Bhawoo Dhajee, a Parsee female, preg- 
 nant four months. She miscarried, but ultimately recovered. 
 Dr. Stovell * thus records his experience : — 
 
 " In four cases there was separation and expulsion per anum of some portion of 
 the mucous lining of the large intestines. In each of these cases the portion was 
 about six inches in length, and in one of them it retained its tubular form. It occurred 
 in the case of a seaman belonging to the ship Euterpe. He died two days afterwards. 
 In a second case, the patient, a sergeant in the Ordnance Department, lived three months 
 after the separated portion came away. The third case recovered. The fourth case 
 was more remarkable. It occurred in a boatswain of the Indian Navy. The separated 
 portion was twenty inches in length, the greater part retaining its tabular form. The 
 membrane was passed on the 29th January, 1852; yet he lived till June 28th — five 
 months. This was the largest portion of membrane which was ever passed in my care." 
 
 Of the twelve cases observed by Dr. Stovell and myself, there 
 have been three recoveries, six deaths, and of three the result 
 was unknown. In two of the fatal cases the result was postponed 
 for three and five months after the separation of the slough. In 
 only one haemorrhage was present, and caused death. 
 
 The nature of the sloughs has been considered at great length 
 by Haspel.f He adopts the view that they consist of mucous 
 tissue, and quotes confirmatory cases strengthened by microscopic 
 observation. Auuesley was acquainted with this morbid process, 
 hut Twining would seem not to have been familiar with it ; indeed, 
 he almost doubts its occurrence. 
 
 [ntus-susception, — strangulation, sloughing, and discharge — of 
 pari of the end of the ileum, consequent, probably, on previous 
 destruction of fche ileo-colic valve, may be confounded with the 
 morbid lesion which has just been described. I have never seen 
 an instance of it. Twining, in the course of eight years, met with 
 
 * " Transactions, Medical and Physical Society, Bombay." New Scries, No. 3, p. 29. 
 ■'• •■ Maladies de I'Algerie," tome ii. p. 78. 
 
PATHOLOGY— CICATRISATION OF ULCERS. 263 
 
 five cases ; and in two of them recovery took place. Dr. Stovell * 
 reports an interesting case of intus-susception in its early stage. 
 
 6. The cicatrisation of ulcers.— The cicatrisation of intestinal 
 ulcers has heen mentioned, by several late writers, as a process with 
 which Indian pathologists are not well acquainted, hut I cannot 
 bring to my recollection the time when it was not as familiar to 
 me as any other fact of the morbid anatomy of dysentery. It is 
 distinctly noticed by me in papers published in 1832 f, 1833 $, and 
 1845.§ 
 
 The stage of the disease when this healthy action may be expected 
 to commence, and its duration, are points which it is impossible 
 to foretell in any given case, because they are dependent more or 
 less on coincident circumstances — as the state of constitution, the 
 degree in which the process of repair has been promoted by judi- 
 cious management, or counteracted by too active interference. It 
 doubtless may be assumed that the less the constitution has 
 been impaired, the more kindly cicatrisation will progress after 
 it has commenced. Moreover, it is evident from some of the cases 
 to which reference will presently be made — and it is a satisfactory 
 fact, — that the repair of intestinal ulcers may go on under very 
 adverse circumstances, such as the co-existence of abscess in the 
 liver. The process of cicatrisation has been minutely and well 
 described by Drs. Parkes and Baly. It consists of exudation and 
 organisation of lymph with contraction of the edges of the ulcer. 
 The appearances which it presents are illustrated by the following 
 cases, 77 to 79. Also in 80, 81. 
 
 77. Dysentery attended by general peritonitis. — The ulcers in different stages of 
 progress, some cicatrised, one perforating, but patched up. — John Murphy, aged eight, 
 was admitted into the sick ward of the Byculla Schools on the 25th September, 1837, 
 ill with dysentery. After ten days he had recovered, the gums having become affected 
 from the moderate use of hydrargyrum c. creta. Shortly afterwards, however, the 
 dysenteric symptoms recurred, but were slight. On the 17th November they had 
 increased, and were attended with tenderness to the left of the umbilicus. The gums 
 were still affected with mercury. From this time to the period of his death, on the 
 28th November, the symptoms were more or less urgent. There were frequent calls to 
 stool, attended by tenesmus, and scanty discharges of blood-tinged mucus or serum. 
 There was more or less tenderness of the abdomen, though never very acute ; it was 
 sometimes of the right iliac region, at others of the left, and unattended at any time 
 with much distention. The skin was often hot and dry. The pulse ranged from 120 
 to 130, and was occasionally sharp and irritable. The tongue was generally clean and 
 lm list, but towards the end of his illness it became florid at the edges and tip. The 
 
 * " Transactions, Medical and Physical Society of Bombay." No. 10, p. 312, First Series, 
 f " Edinburgh Medical and Surgical Journal," April, 1832. 
 J " Transactions, Medical and Physical Society of Calcutta," vol. vii. 
 § " Transactions, Medical and Physical Society of Bombay." No. 7. 
 
 s 4 
 
264 DYSENTERY. 
 
 treatment consisted of leeching and blistering, opiate enemata, opium combined with 
 ipecacuanha, and with acetate of lead, &c. 
 
 Inspection six hours after death. — Abdomen. — There -were three or four ounces of 
 sero-purulent fluid in the cavity. The omentum was vascular, spread over the small 
 intestines, and adherent to them. The peritoneal surface of the anterior parietes, 
 that of the ileum, the sigmoid flexure of the colon, and the rectum, was clotted red, 
 and the convolutions of the ileum adhered to each other by flakes of lymph. The 
 sigmoid flexure of the colon and the rectum adhered in a similar manner to their 
 opposing serous surfaces. The coecum was thickened, and perforated by a small ulcer- 
 ation, which had been patched up by one of the convolutions of the ileum. On the 
 inner surface of the ccecum there were large sloughy ulcerations, with much thick- 
 ening of the subjacent coat, except where the perforating xdcer existed ; and its bed 
 was a portion of sloughy-looking lymph, lying immediately upon the peritoneal coat. 
 The perforation existed at one corner of the ulcer. On the inner surface of the trans- 
 verse colon there were puckered dark grey cicatrices, and also others, round, depressed, 
 the size of a sixpence. Cicatrisation had commenced at the edges and the centre, but 
 the mucous layer had not been replaced in these situations. About two inches above 
 the sphincter of the anus there was thickening of the mucous coat ; and for about an 
 inch in breadth, and throughout the whole circumference of the gut, a portion of that 
 tunic had been removed, and the muscular coat was exposed, and presented a shreddy 
 surface. There was no idceration of the ileum. The other abdominal and the thoracic 
 viscera were healthy. 
 
 78. Chronic dysentery. — Enlarged mesenteric glands. — Mucous coat of the colon 
 firm and thickened. The cicatrices of ulcers. — Abraham Johnson, aged twenty-eight, a 
 seaman of the ship Triumph, suffered from chronic dysentery from July 12th to 
 January 22nd, when he died, much emaciated. 
 
 Inspection. — Abdomen. — Many of the mesenteric glands were as large as an almond 
 without the shell. The intestines were generally contracted. At the end of the ileum 
 there was vascularity in transverse streaks, but the tunics were sound. The colon was 
 in many places contracted; the mucous surface was in parts white, in others dark 
 grey, and slightly roughened ; it was firm, and adhered closely to the sub-mucous 
 tissue. There were the cicatrices of several ulcers in the upper part of the colon. 
 
 79. Tl< uritis cured, succeeded by hydrocele radically cured ; followed by rh wmatism, 
 succeeded by dysentery, cachexia, and recurrence of dysentery. — Colon ulcerated. — 
 Philbp Steer, aged twenty-five, a marine on board Her Majesty's ship Endymion. 
 On the 25th June, 1841. suffered from an attack of pleuritis, for which he was bled 
 largely. On the 22ml July he was admitted into the European General Hospital with 
 swelling of the left testicle and hydrocele of the same side of ten days' standing. On 
 the 2nd Augusl the hydrocele was tapped ami port wine injection was used. On the 
 2:5rd August the testiele was nearly well, and the fluid had not re-accumulated; hut 
 swelling, pain, ami heal of the left knee (to which he hail formerly been subject) came 
 ..ii and continued at times vi ry acute, and with much febrile excitement; treated with 
 Leeching, colchicum, and mercurials. After a few days' steady improvement, on the 
 21st September dysenteric symptoms came on, and the knee-joint improved more 
 rapidly; ami he was discharged, free of complaint, though weak, on the 11th October. 
 On board the Eastings he became affected with dysentery on the 25th October, 
 ami continued under treatment there till the 30th, when he was sent again to the 
 General Hospital. He was reduced in flesh and strength, pulse L20 and very feeble. 
 The tongue aphthous at the edges and coated in the centre ; the abdomen collapsed, 
 I. nt without tenderness. There had been no return of the pain or swelling of the knee- 
 joint. Sago and porl wine were ordered, an.) an anodyne enema at bed-time. During 
 the nighl he was purged frequently, Hie dejections being feculent ami lumpy, and 
 passed without griping or straining. Subnitrate of bismuth, four grains, opium one grain, 
 
PATHOLOGY —COMPLICATIONS. 265 
 
 were ordered every four hours. On the morning of the 31st the purging continued; 
 drowsiness came on with a febrile evening accession. The quantity of opium in each 
 dose of the pills was reduced to half a grain, hut the drowsiness increased to coma, 
 and he died at 8 p.m. of the 31st. 
 
 Inspection twelve hours after death. — The body was much emaciated. The left knee 
 in every respect similar to the right. The left testicle much wasted ; no effusion into 
 the tunica vaginalis of that side. Chest. — There were firm adhesions of the right lung 
 to the costal pleura. The serous covering of the heart presented a general pearly ap- 
 pearance, with here and there opaque spots very slightly thickened ; no enlargement of 
 the heart. Abdomen. — The liver was pale and bound to the side by partial peritonitic 
 adhesions. The intestines generally pale and washy-looking ; and there were a few 
 ounces of serous effusion in the cavity of the abdomen. The colon presented on its 
 inner surface numerous puckered ulcerations, many of them in process of cicatrisation. 
 
 In cases of frequently recurring attacks of dysentery, appearances 
 are sometimes observed which are best explained on the supposition 
 that under the fatal recurrence the cicatrices of former ulcers have 
 lost their vitality, and assumed the appearance of dark-coloured thin 
 pellicles, some attached, some separating, and some detached, and 
 exhibiting underneath a dark red or black, moist, infiltrated surface, 
 with a layer of pale condensed areolar tissue interposed between 
 it and the muscular tissue. 
 
 II. The Complication of Inflammation, or its Results, of the 
 Mucous Membrane of the Large Intestine, with Peritonitic In- 
 flammation, general or partial. — Under this head are included, 
 1st, those cases of general peritonitis terminating in vascularity of 
 the membrane, deposit of flakes of lymph on its suface, or sero- 
 purulent effusion, traceable, perhaps, in some cases, though cer- 
 tainly only in a small proportion, to rupture of an ulcer and 
 consequent escape of part of the contents of the intestine into the 
 sac of the peritoneum. It is remarkable how very generally per- 
 foration of the intestinal wall, from sloughy or other ulceration, is 
 patched by adhesions, and effusion in this manner prevented.* 
 
 2nd. Those very frequent instances of partial peritonitis which 
 cause adhesions of the omentum over the transverse colon or the 
 coecum, to the margin of the liver or to different parts of the peri- 
 toneal lining of the abdominal walls, — the most common being over 
 the transverse colon and in the neighbourhood of the ccecum.f 
 
 The first complication, when not dependent on effusion into the 
 peritoneal sac, will be found generally to occur in persons who have 
 suffered for some time from dysentery, have been previously in 
 indifferent health, or who, not having had the advantage of appro- 
 priate treatment at its commencement, have experienced an exacer- 
 
 * Cases 58, 72, 73, 77, 80, 81, 82, 87, 96, 135, 178, 179. 
 t Do. 52, 54, 55, 60, 72, 96. 
 
266 DYSENTERY. 
 
 bation of inflammatory action terminating in gangrene of the 
 mucous membrane. The second complication most frequently 
 takes place in acute attacks, and is generally associated with 
 thickening of the walls of the intestine, and sloughy ulceration of 
 the mucous coat in transverse bands. Sometimes, as a result of 
 omental adhesion, a tight band passing over the ccecum, and ad- 
 herent to the iliac fossa, is found calculated by its pressure to 
 obstruct the passage through the gut. 
 
 The following cases from 80 to 86 illustrate these observa- 
 tions ; as do also 52, 54, 5*5, 60, 72. 
 
 80. Sloughy ulceration of colon. — General peritonitis and matting of the omentum. — 
 Shaik Abdoolla, a Mussulman sailor of twenty-two years of age, using spirituous 
 liquors moderately, but not opium, was, after four months' illness with bowel com- 
 plaint, admitted into hospital on the 23rd August, 1850. He was much reduced. The 
 abdomen was full and soft, and painful on pressure at the umbilicus. The tongue was 
 moist and slightly florid. The pulse was 76, small, and easily compressed. He con- 
 tinued under observation till the 21st September, when he died. During that time 
 the bowels were opened from six to ten times in the twenty-four hours. The evacu- 
 ations were scanty, thin, yellowish, greyish, or greenish feculence tinged with mucus 
 and blood, and passed with griping and straining. There was occasional evening 
 febrile exacerbation. The countenance became pinched, the feet cedematous. The 
 urine was of low density, but showed no traces of albumen. He was treated with 
 opiates, astringents, and the application of small blisters, sago, milk, and wine. 
 
 Inspection seven hours after death. — Chest. — On opening the chest, both lungs were 
 found fully collapsed. No effusion into the sacs of the pleura, nor any adhesion ob- 
 served. There was some degree of emphysema of both lungs at their thin edges. The 
 lungs were spongy in every part. Some degree of redness of the mucous membrane of 
 the bronchial tubes was observed, but no dilatation. Heart. — There were opaque 
 points of deposit on the inner surface of the aorta ; also on the aortic valves, but not 
 to the extent of injuring their pliability. Abdomen. — About eight or ten ounces of 
 serum were effused into the cavity of the abdomen. There was a blush of di itted red- 
 ■ i the peritoneal surface of several of the convolutions of the small intestine, 
 with effusion of flakes of Lymph. The omentum, vascular and matted over the trans- 
 verse colon, bad a sloughy appearance at one part — that over the hepatic flexure of 
 tlie colon ; and under this sloughy part there was an ulcerated opening into the intes- 
 tine. About the omentum, and also over part of the mesentery, there were greyish 
 Hakes of lymph deposited. Pelvis.— There were five or six ounces of serum in the 
 of the pelvis. Its peritoneal lining, including thai covering the fundus of the 
 bladler. was covi red with thick yellowish flakes of lymph. The mucous membrane of 
 the Large intestine presented numerous ulcerations, some of them with soft and gra- 
 nular surfaces, in others more or less cicatrisation had taken place. The opening at 
 the hepatie flexure of the colon was about the size of half a rupee. The kidneys were 
 healthy. Liver of natural consistence and structure, bul rather pale. The spleen was 
 not enlarged. The brain was healthy. 
 
 81. Sloughy ulceration of large intestint without thick bscesses 
 in liver. Peritonitis. Private YV. II., aged thirty-eight, of Her Majesty's -loth I 
 incut, alter two day-' illness, was admitted into hospital at Belgaum, on the 14th July, 
 L830. There was purging, with much pain and tenderness in the course of the colon. 
 Pulse full, frequent, and sharp. He was freely bled and Leeched, and was free of pain 
 for some days; bul the purging continued, attended with tenesmus. The deje 
 
PATHOLOGY — COMPLICATIONS. 267 
 
 contained neither mucus nor blood, but were watery, light-coloured, foetid, and filmy. 
 On the 23rd there was again tenderness of abdomen. The symptoms continued un- 
 altered. He died July 27th. No ptyalism induced. 
 
 Inspection. — The omentum adhered to both iliac fossae. The peritoneal covering of 
 all the intestines was vascular, and in some places covered with effused lymph. The 
 ascending colon and commencement of the transverse arch adhered to the concave 
 surface of the liver. The mucous membrane of the large intestine was ulcerated in 
 many places. In the ccecum one ulcer had perforated the coats of the bowel, but 
 effusion was prevented by adhesion to the abdominal parietes. Some of the ulcers 
 had the appearance of commencing cicatrisation, and were covered with firmly adher- 
 ing yellowish shreds. In no situation were the coats of the intestine thickened; on 
 the contrary, they were generally thinner than natural. The liver, more compact and 
 tougher than in the healthy state, was externally of olive colour, and in its substance 
 some points of purulent effusion were observed. The gall-bladder was shrivelled and 
 nearly empty. 
 
 82. Sloughy ulceration and thickening of large intestine. — Matting of omentum. 
 Dysuria. — Peritonitis of bladder. — Private J. T., of Her Majesty's 40th Regiment, 
 twenty-six years of age, and of slight make, was, after two days' illness, admitted into 
 the hospital at Belgaum on the 30th May, 1830. He complained of tenesmus, and 
 passed frequent scanty dejections, which contained blood and mucus. There was not 
 any febrile excitement or tenderness of abdomen. He gradually improved, and was 
 discharged free of complaint on the 14th June. He was readmitted on the 18th June 
 with a return of his former symptoms. Still neither pain nor tenderness of abdomen. 
 On the 22nd, however, slight tenderness of the right iliac region was present, but it 
 was removed by the application of a few leeches. On the 26th he complained of dy- 
 suria. On the 27th the dejections were brown and watery. He gradually sank with- 
 out return of pain of abdomen, and died on the 30th June. Ptyalism had not been 
 induced. 
 
 Inspection. — There was evidence that extensive inflammation of the peritoneum had 
 existed. The colon and rectum adhered to every organ in contact with them, the 
 former to the under surface of the right lobe of the liver, the latter by more recent 
 adhesions to the urinary bladder, and to the pelvic wall at the symphysis pubis. The 
 large intestine throughout its whole course was thickened. The mucous membrane 
 was much ulcerated, and in many places gangrenous. The omentum was drawn down 
 like a cord of small vessels, and adhered firmly to the ccecum. 
 
 83. Much sloughy destruction of the colon. — Peritonitis and matting of the OTnentum. 
 Former attack of hepatitis. — Puckered fibrous bands in liver. — Private B. M., aged 
 twenty-seven, of Her Majesty's 40th Regiment, was admitted into hospital at Bel- 
 gaum on the 22ud July, 1830. He had been ill in hospital with hepatitis from January 
 16th to January 24th. Had been webl ever since, till three or four days before admis- 
 sion, when he became affected with purging of mucous and bloody dejections, and 
 with tender abdomen. He died on the 6th August. No ptyalism. Tender gums. 
 
 Inspection. — The whole omentum, vascular, thick, and fleshy, embraced firmly the 
 colon from the ccecum to the sigmoid flexure; and on attempts being made to separate 
 it, the contents of the bowel escaped. In some places, where covered by the omentum, 
 the natural coats of the intestine were entirely destroyed. All the intestines, great 
 and small, were connected together in one mass, and adhered to the parietes of the 
 abdomen. The liver was smaller than natural. Its whole surface, both convex and 
 concave, was covered with depressed and puckered cicatrices, which, when cut into, 
 were found to be firm and membranous. The liver adhered slightly to the diaphragm. 
 
 84. Thickening of the colon. — Numerous deep ulcers. — Matting of the omentum. 
 Liver with fibrous puckered bands. — Private J. P., aged thirty-one, of leuco-phlegmatio 
 habit, was admitted into hospital at Belgaum, on the 27th June, 1830, with ophthal- 
 
268 DYSENTERY. 
 
 mia, which terminated in obstinate opacity of the cornea with interstitial ulceration. 
 While under treatment for ophthalmia, he complained for the first time of dysentery on 
 the 9th October; but it was ascertained that he had been ill during the two days 
 preceding. The symptoms were urgent. The dejections very frequent, mucous, and 
 bloody, were passed with griping and tenesmus, and there was tenderness in the 
 course of the colon. The skin was hot and dry, and the pulse frequent. He was 
 treated in the usual way. Ptyalism was not induced. He died on the loth October. 
 Inspection. — The omentum spread over the intestines adhered firmly to the coecum, 
 where that intestine was united by unnatural adhesions to the iliac fossa. At the 
 points of adhesion the coats of the ccecum were black and tender. The walls of the 
 large intestine, which were in general thickened, were at the upper portion of the 
 ascending colon quite cartilaginous. The mucoiis membrane was ulcerated. The 
 ulcers were numerous, defined, and deep. The liver was natural in size, but hard and 
 much mottled ; there were few adhesions, but the peritoneal covering of the organ 
 was thickened and of pearly colour. Old firm adhesions attached the gall-bladder to 
 the colon. Around the situation of the gall-bladder and elsewhere the liver had a 
 puckered depressed appearance, as if from the adhesion of the surfaces of the cyst of 
 an abscess. In these situations the structure of the liver was almost cartilaginous. 
 The gall-bladder contained numerous concretions. In the chest the costal and pul- 
 monary pleura were connected by old adhesions. 
 
 85. Tliickening and sloughy ulceration of large intestine. — Matting of omentum. 
 Congestion of the liver. — Private M. C, Her Majesty's 40th Regiment, aged twenty- 
 eight, after suffering for thirteen days from pain in the epigastrium and right hypo- 
 ehondrium, on motion and pressure, was admitted into hospital at Belgaum on the 
 26th June, 1830. His bowels had generally been confined, but he had been purged 
 the day before admission. The purging became more frequent. The dejections con- 
 tained mucus and blood, then finally became watery and of a reddish brown colour. 
 He sunk and (bed July 5th. No ptyalism induced. 
 
 Inspection. — The colon was distended, and its peritoneal covering was vascular, and 
 had contracted adhesions. Those between the coecum and right iliac fossa were pale 
 and firmly organised. The omentum was very vascular, and adhered by one corner 
 to the caput coecum and right iliac fossa, so that the commencement of the transverse 
 arch of the colon was drawn down towards the right ibac region, and a beud was pro- 
 duced in the course of that intestine. The ascending colon was more diseased than 
 the rest of the intestine, and it adhered to the gall-Madder. The mucous membrane 
 of the co-ruin, ascending colon, and transverse arch, was not vascular, but thickened, 
 and presented an irregular and softened surface, resembling the walls of a tubercular 
 excavation. The liver was much enlarged, and contained much blood, but was free 
 from adhesion or abscess. The gall-bladder was full of bile. 
 
 86. Habitual constipation. Colon contracted in parts and strictured by a band if 
 the omentum. Tubercular inf. <ftht lungs.— Ulceration of the ileum and c& u n, 
 probably from softening of tubercles. A lady of strumous habil and feeble conforma- 
 tion, aged about twenty-two, had whilst in England, for some years before her depar- 
 ture for India, suffered habitually from constipation, sometimes urgent, attended with 
 fulness and pain in the righl iliac region, supposed i.. be caused bj foecal accumula- 
 tions, In January is:! I, after -\ year's residence in Bombay, in the enjoymenl of 
 c unparatively good health, this lady became the subject of a severe attack of dysen- 
 tery, for which, aboul the end of February, she was sent to the Mahubuleshwur Hills. 
 she was pale, weak, and very much reduced; the bowels acted irregularly, sometimes 
 
 1 !| id i rii i ;d ile, the dejections 1 icing watery and containing mucus, — at other times 
 
 confined tor two or three days in succession, and then relieved by sudden and copious 
 
 evacuation. The i »oon was passed :i t Poona, where her bowels were more irritable 
 
 and relaxed, and where she latterly experienced frequent attacks of dyspnoea. .Much 
 
 
TAUTOLOGY — COMPLICATIONS. 269 
 
 emaciated, she returned to the Mahubuleshwiu' Hills on the 31st October, and died 
 on the 24th November. 
 
 Inspection seven hours after death. — The body was much emaciated and the abdo- 
 men collapsed. Abdomen. — The stomach was small and contracted. A band of the 
 omentum reached from the first third of the transverse colon, passed across the cce- 
 cum, and adhered to the hollow of the os ilium. Underneath the peritoneal coat of 
 the end of the ilium there were small miliary tubercles, and underneath that of the 
 ccecum the tubercles were mimerous, and of the size of a pea. The coats of the coecum 
 were much thickened, and there was adhesion to the hollow of the os ilium. At the 
 hepatic flexure the colon was contracted, and formed a double angle ; it then passed 
 oblicpiely upwards to the left, became applied to the cardiac end of the stomacb. and 
 to the diaphragm ; thence it doubled acutely downwards, and formed the descending 
 colon, considerably contracted, but without thickening. The rectum and the sigmoid 
 flexure of the colon were dilated. On the inner surface of the ileum, close to the ileo- 
 colic valve, there was a ragged vdceration the size of half a crown, with edges dark red, 
 elevated, rounded, and centre irregular. The inner surface of the coacum presented 
 an irregular hard fungoid surface, the elevated parts coursing in transverse bands 
 witli an occasional intersection of longitudinal ones ; their colour was dark red, grey 
 black, in parts ink black; the colouring matter infiltrating deeply the thickened 
 tissues. The mucous coat of the ascending colon was of dark red colour, and much 
 softened. The mesenteric glands were enlarged, and had undergone tubercular de- 
 generation. Chest. — Both lungs contained tubercular masses in a crude state, and 
 adhered to the costal pleura at the points of tubercular deposition. Around the tuber- 
 cles the substance of the lung was quite healthy, and collapsed, so that the tubercles 
 stood in relief from the surface of the lung. 
 
 III. Tumefaction in the Region of the Cozcum or Sigmoid 
 Flexure of the Colon. — The first is the more common, and is 
 caused by matting of the omentum over the ccecum, with more or 
 less thickening of the coats of the latter, or by thickening of the 
 coats of the ccecum without adhesions of the omentum.* It may 
 be caused also by intus-susception of the ileum. In case 88, per- 
 foration of the coecum and effusion of its contents into the cellular 
 tissue surrounding the gut, followed by gangrene of the abdominal 
 walls, took place. 
 
 The opinion that the tumefaction is frequently caused by fcecal 
 accumulation does not accord with my experience in India ; and 
 belief in the frequent occurrence of this morbid condition has, to 
 my knowledge, led to serious errors in practice. 
 
 87. Chronic dysentery. — A palpable tumour of the caeum. — The lungs studded with 
 tubercles not suspected during life. — Considt ruble effusion of serum in the head. — 
 Patrick Fox, aged forty-two, a pensioner, emaciated and of broken constitution, was 
 admitted into the European General Hospital on the 8th March, 1839. He had 
 served twenty-three years in India, had been pensioned two years and a half, and 
 had, he said, generally enjoyed good health. On admission he stated that since the 
 10th of January he had been affected with purging ; that at first the evacuations 
 were scanty and slimy, but that latterly they had become watery ; and that he had 
 not used any remedies. The abdomen was not distended, but it was somewhat tense ; 
 
 * Oases 87. 133. 
 
270 DYSENTERY. 
 
 and on pressure in the course of the colon there was tenderness, and over the 
 coecum a distinct defined hardness. The pulse was 92 and small ; the skin cool ; the 
 tongue, coated yellow, was rough in the centre and florid at the edges and tip. There 
 were in general eight or ten pale, yellow, watery, sometimes frothy, evacuations passed 
 in the twenty-four hours, with dysenteric foetor, but unattended by either griping or 
 straining. At no time was there cough or other pectoral symptoms complained of. 
 He died on the 22nd. 
 
 Inspection sixteen hours after death. Head. — About three ounces of serum in the 
 cavity. Chest. — The lungs collapsed partially. There were old adhesions of the 
 upper lobes of botli sides, and a good deal of puckered irregularity of the external 
 surface of the lung at the site of these adhesions. Both lungs and all the lobes were 
 more or less studded with small grey tul lercles, the size of a mustard-seed. At the 
 posterior part of both lungs, these tubercles had become so numerous and aggregated 
 that the tissue was almost impermeable. On the anterior part of the lungs they were 
 scattered with considerable intervals. Here and there there was a small cavity, the 
 size of a pea ; and there were one or two nodules wdiich, when cut, presented a pearly 
 cartilaginous appearance. Abdomen. — The coats of the coecum were about half an 
 inch thick, firm and cartilaginous, with round tubercular deposition, intermixed ; the 
 inner surface ragged and ulcerated, and a perforation on the anterior aspect was 
 patched up by the omentum. The rest of the colon was little diseased. The liver 
 was pale, mottled, and softened. The stomach was healthy ; so were the kidneys. 
 
 88. Dysentery. — Perforation of the coecum, with consequent formation of a circum- 
 scribed sac, with gangrene of the muscles and integuments. Walker, private of 
 
 Her Majesty's 6th Eegiment, aged 28, after six days' illness, was admitted into hos- 
 pital with dysentery, and died after a month. The bowels were generally very loose, 
 and the dejections frequently contained clots of blood with dysenteric foetor. The 
 pulse was feeble and the skin damp. Latterly there was much defined fulness over 
 the coecum. 
 
 Inspection. — There was fidness of the right iliac region, with a dark gangrenous 
 patch of the integuments about three inches in diameter ; and underneath the muscles 
 were found in a gangrenous state. Over the ccecum there was a circumscribed sac, 
 about the size of an ostrich egg ; the inner surface dark olive green, foetid, and sloughy. 
 The contents of the sac were dark olive green, watery, fectid, — the evident contents of 
 the ccecum which communicated with the sac by an opening of an inch and a half in 
 diameter. 
 
 IV. Displacements of the Colon — are, 1st, of the commencement 
 of the transverse arch. This is very frequent, and is produced by 
 adhesion of the omentum to the ccecum or iliac fossa, causing that 
 portion of the intestine to double down parallel to the ascending 
 colon. 2nd. The transverse colon passing in the line of the great 
 arch of the stomach, adherent to the left side of the diaphragm, and 
 then doubling acutely down to form the descending colon, is a form 
 of displacement occasionally observed, but not nearly so frequently 
 as the one first described. I have witnessed it in four cases. 3rd. 
 The sigmoid flexure dragged to the right, and adherent to the brim 
 of the pelvis or to the bladder, is a displacement, also caused by 
 adhesions, but it is not very common. 
 
 I would refer to cases 53, 60, 63, 68, 70, 72, 178, 179, as afford- 
 ing illustrations of various displacements of the colon. 
 
rATHOLOGY — COMPLICATIONS. 271 
 
 V. Complication of Ulceration of the Mucous Lining of the 
 Large Intestine, with Abscess in the Liver. — This is very com- 
 mon; but the subject will be more appropriately considered in a sub- 
 sequent chapter in connection with hepatitis and hepatic abscess. 
 
 VI. Complication of Dysentery, with Morbid Lesions of the 
 Small Intestine or of the Stomach. — When the small intestine 
 is affected, the morbid changes will be generally found at the end 
 of the ileum. They consist of ulcers more or less circular, originat- 
 ing in Peyer's glands ; or in increased redness, with granular exuda- 
 tion, as already stated.* 
 
 In the following cases circular ulcers of the stomach were 
 associated with similar ulcers of the colon: — 
 
 89. Circular ulcers with sloughs in mucous membrane of colon and stomach. — No 
 thickening. — Mahadoo Mallee, a Hindoo flower-seller, of thirty-fire years of age, of 
 feeble constitution, in destitute circumstances, and often exposed to vicissitudes of 
 ■weather, and occasionally indulging in the moderate use of spirits, was, after twelve 
 days' illness, admitted into hospital on the 22nd June, 1850. During that time he 
 had suffered from relaxed bowels ; the evacuations at first had been thin and feculent, 
 but latterly had shown traces of blood and mucus, and were attended with tenesmus 
 and sometimes with prolapsus. Such continued to be their character during the time 
 the patient was iinder observation. On admission, the lungs and heart were found to 
 be healthy. There was some fidness of abdomen, but no induration. There was no 
 febrile disturbance. The pulse was small, feeble, and easily compressed. The tongue 
 was clean, moLst, and pale. These symptoms continued with little change till the 
 25th, when the bowels became more relaxed ; he sank rapidly, and died at 9 p. m. of 
 that day. He was treated with quinine, in three-grain doses, combined with a grain 
 each of ipecacuanha and blue pill, and latterly half a grain of opium, every fourth 
 hour ; and had milk, sago, and wine as diet. 
 
 Inspection seventeen hours after death. — Chest. — The lungs were collapsed and cre- 
 pitating, but in parts old adhesions united the costal and pulmonary pleurae of both 
 sides. The heart was of healthy size and structure. Abdomen. — There was a small 
 quantity of serous fluid in the peritoneal cavity. The liver was healthy in size and 
 structure. The spleen was healthy. There were five or six patches of ulceration in 
 the mucous membrane of the stomach ; one or two of them were quite circular, with 
 dark yellow or brownish sloughs in the centre ; the others were larger, and more or 
 less irregular, but also had central sloughs attached to them. The mucous membrane 
 at the cardiac extremity of the stomach had a dark brown marbled appearance, but its 
 substance was not soft. The mucous membrane of the large intestine, from the rectum 
 to the ccecum, was studded with ulcers, with dark grey sloughy surfaces of different 
 sizes, — the smallest being circular, and the larger irregular. There was no thickening 
 of the coats of the intestine, and the mucous membrane was not more firmly adherent 
 to the subjacent coat than natural. Xo liberation of the mucous membrane of the end 
 of the ileum. The kidneys were apparently healthy. 
 
 90. Gray softening, with a fw ulcers of the mucous lining of the stomach and colon. 
 — Cicatrices of ulcers in the former. — John Knapp, a private of the 4th Light Dragoons, 
 aged twenty-two, who had suffered twice from dysentery in the year 1830, was. after 
 two days* illness, admitted into the Hospital at Kirkee, on the 17th April, 1832. The 
 evacuations were scanty, frequent, of light colour, tinged with blood, and passed with 
 
 * Cases 46, 52, 55, and 56. 
 
272 DYSENTERY. 
 
 griping and tenesmus. The iliac regions were tender on pressure. The tongue was 
 coated in the centre and florid at the edges. There was occasional retching and 
 vomiting, and frequency of pulse. He died on the 22nd. He had been bled; a 
 blister was applied to the epigastrium ; mercury with opiates was given. The mouth 
 was sore, but there was no salivation. 
 
 Inspection. — There were not any traces of peritoneal inflammation, and no disten- 
 tion of the bowels. The mucous membrane at the end of the ileum was somewhat 
 vascidar, perhaps thinner, and peeled easily off with the nail. There was one ideer in 
 the coecum about the size of a silver penny, not deep, and unsurrounded by thickening 
 or vascularity. The mucous lining of the great intestine throughout, perhaps thicker 
 than natural, of a light ash-grey colour, was here and there dotted red, and peeled off 
 readily with the nail in shreds. The contents of the large intestine were green and 
 fecident. The mucous membrane of the stomach, thickened and somewhat softened, 
 presented there and here an ash-grey dotted red appearance, with the marks of one or 
 two small cicatrising ulcers. The small intestine was not opened, with exception of 
 the end of the ileum. The liver was healthy. The gall-bladder was full of bile. The 
 thoracic viscera were healthy. 
 
 VII. Co-existence of Enlargement of the Mesenteric Glands 
 with Dysentery. — An enlarged, reddened, and somewhat sero- 
 infiltrated state of the mesenteric glands is not unusual in dysen- 
 tery, depending, it may be supposed, on the increased flow of 
 blood through the mesenteric arteries, which is probably present 
 in this disease. These glands were enlarged in cases 52, 69, 101. 
 
 Part of the intestine chiefly affected. — On this point observers 
 have somewhat differed in their statements. The tendency of 
 the inflammation is to affect the entire mucous surface of the 
 large intestine. In some cases it is general ; in others present in 
 greater degree in one portion than another, but very seldom ex- 
 clusively limited to a particular part. The situation of the disease 
 is noticed distinctly in forty-six of my fatal cases. Of these it is 
 described as general in twenty-four ; as predominant in the coecum 
 and ascending colon in fifteen ; in the coecum and transverse colon 
 in three ; in the coecum and rectum in oue ; in the coecum and 
 sigmoid flexure in one ; and in the transverse colon in two. 
 
 Concluding remarks. — My observations on the morbid ana- 
 tomy of this important disease do not include any results of 
 microscopic inquiry, for I have not any information from this source 
 to communicate. A careful use of the microscope will, doubtless, 
 give precision to descriptions of the discharges and of the exudation 
 matter on the surface and in the interstices of the membrane, and 
 serve to distinguish the tissues and structures affected in different 
 forms of the disease. Still, making full allowance for this, 
 and not estimating lightly the addition of positive facts to our 
 knowledge, however unimportant they at first sight may appear, I 
 must frankly avow that I do not anticipate much increase to our 
 
CAUSES — EXCITING. 273 
 
 practical acquaintance with dysentery from this method of investiga- 
 tion ; and I would venture to caution the young pathologist, when 
 engaged with microscopic details, to take care that his mind does 
 not lose the grasp of large principles of Pathology, Etiology, and 
 Therapeutics. 
 
 Section III. — Etiology of Dysentery. — Importance of distin- 
 guishing exciting and predisposing Causes. — Exciting Causes. 
 — Cold, Food. — Predisposing Causes. — Cachectic States. — 
 Action of Malaria discussed. 
 
 In explaining the etiology of dysentery it is necessary carefully 
 to distinguish between exciting and predisposing causes, for neglect 
 of this distinction has led to much of the confusion which exists in 
 the descriptions of this disease. I shall treat first of the exciting, 
 then of the predisposing causes ; and lastly state my reasons for 
 dissenting from the common opinion that malaria is an exciting 
 cause, and for believing that the important influence which it 
 undoubtedly exercises in the causation of dysentery, is predis- 
 posing.* 
 
 Exciting causes. — The atmospheric states which unduly or 
 suddenly depress the temperature of the surface of the body are 
 the most common exciting cause. They consist of absolute lowness 
 of temperature, of considerable diurnal ranges, of much atmospheric 
 moisture, and of currents of dry or humid air. The action of these 
 conditions is often favoured by imprudent exposure of the body 
 deficient in resisting power in consequence of that lowered capa- 
 city of generating animal heat which is its physiological state in 
 tropical climates. 
 
 My hospital experience shows that the proportion of admissions 
 
 * In a note on tke~pathology of dysentery, p. 237, reference is made to certain 
 theoretic analogies between inflammation of the skin and that of the intestinal mucous 
 membrane ; and. in considering the causes of dysentery, these analogies are again 
 suggested to the mind. Some inflammations of the skin — the eruptions of - 
 scarlatina, small-pox — are cause! by the reception of specific poisons into the blood. 
 To apply a similar principle of causation to some forms of dysentery, and to suspect 
 contagious or infectious properties, is within the limits of rational speculation. But 
 it may be safely affirmed that such conclusions are as yet altogether without proof. 
 
 Again, it is sufficiently probable that the blood, vitiated by a specific poison, or by 
 retained or altered excretions, may give rise to other forms of cutaneous inflammation — 
 as erysipelas — or some of the squamous, vesicular, and pustular eruptions ; and that 
 this theory may also be reasonably applied to some forms of dysentery. 
 - But, as it is not pretended that every inflammation of the skin is caused by the 
 blood being vitiated in one or other of these ways, it is contrary to analogy to propose 
 an etiological theory of this kind in respect to all forms of dysentery. 
 
 T 
 
274 
 
 DYSENTERY. 
 
 from dysentery is greatest in those months of the year in which the 
 atmospheric state is most likely to be one or other of those which 
 have just been mentioned ; and in this category I am careful to in- 
 clude June and November, — months in which marked atmospheric 
 changes occur in Bombay. In June the hot season terminates, the 
 rains begin to fall, and damp winds to blow. In November the 
 sultry heat of October ends, and north-easterly winds set in. 
 
 The following statement gives the proportion of admissions from 
 dysentery per cent, of the total admissions in the European 
 General Hospital, and the Jamsetjee Jejeebhoy Hospital at 
 Bombay, in different seasons of the year : — 
 
 
 European General 
 Hospital. 
 
 Jamsetjee Jejeeb- 
 Hospital.* 
 
 Cold ?no?itks. — November, December, January 
 Wet months. — June, July, August . 
 Transition from cold months. — February, 
 
 Transition from rains. — September, October . 
 
 Hot months. — April and May 
 
 Annual proportion 
 
 10-8 
 7-0 
 
 6-3 
 5-4 
 51 
 7-4 
 
 10-2 
 10-7 
 
 6-4 
 8-9 
 
 7-2 
 9-1 
 
 The same result is shown by the per-centage of monthly admis- 
 sions, from dysentery and diarrhoea, to the total annual admissions 
 from these diseases in the European General Hospital for the ten 
 years from 1846 to 1856, and in the Byculla Schools for the seven- 
 teen years from 1837 to 1853. Thus : — f 
 
 
 
 
 
 
 
 European General Hospital. 
 
 Byculla Schools. 
 
 
 
 
 Dysentery 
 
 
 Dysenteiy. 
 
 Diarrhoea. 
 
 and 
 Diarrhoea. 
 
 January 
 
 12-170 
 
 8-172 
 
 5-634 
 
 February 
 
 
 
 
 
 
 5-827 
 
 5-836 
 
 6-933 
 
 March . 
 
 
 
 
 
 
 6-177 
 
 8-300 
 
 8-422 
 
 April 
 
 
 
 
 
 
 7-266 
 
 7 652 
 
 7-769 
 
 May . 
 
 
 
 
 
 
 7-266 
 
 6-485 
 
 8-956 
 
 June 
 
 
 
 
 
 
 7-312 
 
 9-597 
 
 12-633 
 
 July . 
 
 
 
 
 
 
 10-839 
 
 12-840 
 
 16-903 
 
 August . 
 
 
 
 
 
 
 7-459 
 
 9-987 
 
 11-565 
 
 September 
 
 
 
 
 
 
 5-827 
 
 5-966 
 
 0-7-33 
 
 October 
 
 
 
 
 
 
 5-447 
 
 6 - 255 
 
 4-922 
 
 November 
 
 
 
 
 
 
 9-440 
 
 8-819 
 
 5-634 
 
 December 
 
 
 
 
 
 14-685 
 
 10-116 
 
 4-863 
 
 * This column gives (lie proportion of dysentery and diarrhoea combined. 
 
 t The figures relative to the European General Hospital, are taken from Dr. 
 
CAUSES — PREDISPOSING. 275 
 
 Unsuitable food — impure water included — may excite dysen- 
 tery ; but it is not a common cause. 
 
 Fgecal accumulation, and what are usually termed vitiated ex- 
 cretions, in the large intestine, may act as exciting causes of 
 dysentery; but my experience on this point is not confirmatory 
 of the doctrines of Annesley and others on the frequency and 
 importance of these conditions : it is more in accordance with the 
 opinion of Dr. Mackinnon, that faecal accumulation is not a 
 common pathological state in India.* The question is practically 
 important, from its evident bearing on the use of calomel and 
 purgatives, not only in the treatment of dysentery, but of disease 
 in general. 
 
 Predisposing causes. — The exciting causes of dysentery cannot 
 be justly appreciated unless we carefully note those predisposing 
 states of the system which very generally determine their action. 
 Therefore, in order to discover the causes of dysentery, it is not 
 sufficient merely to regard the atmospheric states to which the 
 affected have just been exposed, or the food, clothing, and bouses 
 with which they have been supplied. It is fully as necessary that 
 we should be informed whether or not, and in what degree, they 
 have been previously subjected to those various well-known influ- 
 ences designated predisposing causes, which are as essential to the 
 development of the disease as the application of the exciting cause 
 itself. 
 
 The chief predisposing conditions of dysentery may be thus 
 briefly stated. 
 
 The European lately arrived in India, consequent on the exhaust- 
 ing effects of elevated temperature, or on the want of adaptation of 
 food and habits to the altered assimilation and elimination induced 
 by climate, has a state of constitution engendered favourable to 
 the occurrence of dysentery, under the influence of exciting atmo- 
 spheric conditions, and which is often still further favoured by 
 imprudent exposure of the perspiring surface of the body. It is in 
 
 Stovell's report. " Transactions, Medical and Physical Society," No. 3, New Series, 
 pp. 22 — 34. Those of the Byculla Schools, from my own notes, Table XXIX., p. 322. 
 There is a striking contrast in the ratios of the General Hospital and of the Schools for 
 December and January ; but as respects the schools, the necessary data are incomplete. 
 It is not improbable that a " strength," greatly reduced by absence in the Christmas 
 holidays, may explain the low ratio in December and January. When we compare 
 the column diarrhoea of the hospital with the conjoint column of the schools, the in- 
 ference may be drawn that the high ratio of June, July, August, in the latter — is due 
 to diarrhoea rather than dysentery. 
 
 * Treatise on Public Health, by Dr. Mackinnon, p. 314. 
 
 T 2 
 
276 DYSENTEKY. 
 
 these circumstances that the erysipelatous form of dysentery is 
 usually produced in Europeans in India. 
 
 All cachectic states of the system, however developed, are very 
 jn-edispouent of dysentery. So much so, that when they are pre- 
 sent in considerable degree, a very slight exciting cause is suf- 
 ficient; and when present in great degree, inflammation of the 
 intestinal mucous lining is apt to arise, almost without appreciable 
 exciting cause, — being, as it were, the closing act of the cachexia. 
 Let me point to some illustrations of this position. 
 
 1. There is no more common cause of cachexia in India than 
 malaria, and recurrences of malarious fever. It consequently 
 happens that whenever persons cachectic from malaria are exposed 
 to atmospheric states, which depress the temperature of the sur- 
 face of the body, dysentery becomes prevalent and very fatal. 
 Evidences of this etiological law, which have passed under my own 
 observation, have been already brought forward in reference to the 
 mortality from intermittent fever (p. 24), and it would be easy to 
 add to their number. For example, the experience of the Hima- 
 layan Hill Sanitaria, as se.t forth by Mr. Grant and Mr. Green in 
 their papers * on Hill Diarrhoea and Dysentery may be instanced. 
 
 2. Again, continued elevation of temperature, habitual residence 
 in an atmosphere vitiated by excess of carbonic acid, or emana- 
 tions from decaying vegetable or animal matter, or too much 
 moisture, will induce cachexia; so will the habitual use of food 
 defective in quantity or quality (scurvy), intemperance of all kinds, 
 too much bodily fatigue, and the influence of depressing passions, 
 as anxiety, fear, &c. A cachectic state may also arise from long- 
 continued disease, from injudicious and too-prolonged antiphlo- 
 gistic medical treatment, from mercury, and the poison of 
 syphilis, &c. 
 
 3. The occurrence of dysentery in crowded barracks, transport 
 ships, jails, standing camps, besieged garrisons, beaten and retreat- 
 ing armies, are illustrations of the importance of considering 
 cachectic conditions in explaining the causes of dysentery. And, if 
 the history of events of this kind be rightly investigated, the in- 
 fluence of cold or wet, from undue exposure, defective clothing, and 
 li<>uses, or of unsuitable food, or impure water, will always be 
 evident, and prove the preventible character of both the predispos- 
 ing and exciting causes. 
 
 The opinion that malaria is an exciting cause of dysentery may 
 now be considered. I do not pretend to name all the able writers 
 
 * " Imlian Annals of Medical Science," Nos. 1 and 2. 
 
MALARIA NOT AN EXCITING CAUSE. 277 
 
 who have advocated this doctrine ; but, amongst later authors, 
 Dr. Ii. Williams, Dr. Baly, Haspel, Mr. Hare, and Mr. Grant 
 may be mentioned. 
 
 The circumstances in which dysentery have occurred in my own 
 field of observation have never justified the supposition that 
 malaria was the exciting cause * ; and the facts usually ad- 
 duced in support of the contrary opinion have seemed to me to 
 admit of a more ready explanation, either in the predisposing 
 influence of malaria, or the exciting influence of the cold, damp 
 air, which in marshy tracts frequently co-exists with malaria. 
 It was to the cold, damp condition of the atmosphere that Pringle 
 attributed both remittent fever and dysentery. He does not allude 
 to malaria, to which since his time both fever and dysentery have 
 been referred. When intermittent and remittent fever co-exist 
 with dysentery, it will probably always appear that the conditions 
 of malaria co-exist with a damp and variable atmosphere. But 
 according to my belief malaria causes the fever f, and the cold damp 
 air the dysentery : hence we can understand why the two affec- 
 tions may sometimes be associated, but also be frequently distinct. 
 
 It would be foreign to the objects of this work to enter into a 
 critical examination of the arguments of those who consider malaria 
 to be an exciting cause of dysentery. Indeed, the assumed facts 
 are so generally wanting in precision, that it may be doubted 
 whether practical profit could arise from engaging in the in- 
 quiry. Yet allusion may be made to some points which fail to 
 make that impression upon me which they seem to effect upon 
 others. 
 
 1. The fact that fevers and dysentery prevail in the same divisions 
 of the Indian army, is not necessarily confirmatory of identity of 
 cause. They who think otherwise forget that a " division " may 
 refer to an extensive tract of country, and may present in different 
 localities considerable variety of climate and of physical feature. 
 
 * On the contrary, the 4th Dragoons, who suffered much at Kaira from malarious 
 fever, were little affected with dysentery there. At Belgaum, dysentery is a frequent 
 and fatal disease; malarious fevers not so. Of the dockyard peons, so frequently 
 tinder treatment in my clinical ward with malarious fevers, only two were received ill 
 with dysentery. 
 
 f To prevent misapprehension, I would suggest a reference to Section I., and that 
 part of Section II. which refers to mortality — of the Chapter on Intermittent Fever. 
 It will there appear that full importance is attached to cold and wet as a determining 
 cause of re-attacks in the previously tainted with malaria. My present observation 
 relates to the previously healthy, and expresses the belief that in these malaria alone 
 excites the fever, but that the co-existing cold and wet, not the malaria, excite the 
 dysentery. 
 
278 DYSENTERY. 
 
 Moreover, in the kind of statements now referred to, mention is 
 not generally made of the months or seasons of the year in which 
 the two diseases have respectively prevailed ; hence we are left in 
 ignorance whether the occurrence has been in the same or in a dif- 
 ferent season. Again, the character of the fever is frequently not 
 stated; for example, Dr. E. Williams, in his work on Morbid 
 Poisons*, places the Presidency division of the Madras army 
 first in his list of instances of the prevalence and identity of cause 
 of paludal fever and dysentery in the same district. Whereas, the 
 fact is, that this division of the Madras army is singnlarly free from 
 malaria ; and of the fevers registered in it, the larger proportion is 
 febricula, and not paludal. 
 
 2. Complication of intermittent or remittent fever with dysen- 
 tery, has been of rare occurrence in my own experience, but it 
 would seem not unfrequently to exist in other provinces of India 
 and in other countries, and is then accepted as evidence that 
 idiopathic dysentery is caused by malaria. In this conclusion, how- 
 ever, I am unable to concur. Elsewhere in this work it will be 
 shown that remittent fever in the natives of Bombay is often com- 
 plicated with pneumonia, but it has never on this account been 
 inferred that malaria is an exciting cause of idiopathic pneumonia ; 
 yet the conclusion would be quite as logical as that which 
 has been drawn with reference to dysentery from analogous 
 premises. 
 
 3. When a person, tainted with malaria, becomes affected with 
 dysentery, sometimes the symptomatic febrile phenomena evince a 
 periodic character, and occasionally the dysenteric symptoms show a 
 similar tendency ; but in this we have no proof that malaria has been 
 the exciting cause of the dysentery. A similar order of events has 
 been observed in other inflammatioDS, as well as in injuries, in 
 the same kind of constitution. Though a staunch advocate might 
 still insist that malaria may be the exciting cause of these other 
 inflammations also, yet he will hardly maintain that the contused 
 wound or fractured limb — which, equally with dysentery, may be 
 accompanied by symptomatic fever of periodic character — can be 
 thus accounted for. 
 
 4. Nor does the alternation of febrile accessions with symptoms 
 of dysentery or diarrhoea — occasionally observed in persons tainted 
 with malaria, and previously affected with intermittent fever — 
 imply that malaria has been the exciting cause of the dysentery. 
 The alternation of dysenteric symptoms with those of chronic 
 
 * Volume ii. p. •') in. 
 
MALARIA NOT AN EXCITING CAUSE. 279 
 
 laryngitis, of pulmonary affections, and of rheumatism, has from 
 time to time come under my observation ; but such facts have not 
 been held necessarily to indicate identity of cause of these several 
 affections. 
 
 5. Mr. Grant, in his interesting report * on the prevalence of 
 dysentery and diarrhoea in the Himalayan Hill Sanitaria, while he 
 attributes much to the cold moist atmosphere of these stations, yet 
 believes that malaria is also influential as an exciting cause. The 
 chief argument which he adduces in favour of this opinion is, that 
 in other hill stations possessing analogous climates, as regards tem- 
 perature and moisture, this tendency to dysentery has not been 
 observed. Nainee Tal, Murree, Darjeeling, the Neilgherries, and 
 Mahubuleshwur, are instanced as hill localities which enjoy this 
 immunity. In respect to the four first stations I am not aware 
 whether the experiment has been made of exposing cachectic per- 
 sons to the influence of their cold, moist atmosphere ; but in respect 
 to Mahubuleswhur I know that the result has been similar to that 
 so ably detailed by Mr. Grant, relating to Kussowlie, Subathoo, 
 Simla, and Dugshai. 
 
 The sanitary station on the Mahubuleshwur hills was established 
 with the view of benefiting the health of the sick European soldiers 
 of Poona and Bombay. The experiment was made in 1829. 
 Badly selected invalids were sent to the hills at the end of 
 October, or commencement of November, with the following 
 result : — The tendency of dysenteric and hepatic affections to 
 relapse, and of soldiers cachectic from fever, mercury, syphilis, 
 rheumatism, to become affected with dysentery or hepatitis, was so 
 well marked that the scheme was very properly speedily abandoned 
 and has not since been revived. 
 
 These facts were necessarily unknown to Mr. Grant, because they 
 are not stated in Mr. Murray's interesting Eeports f on the climate 
 of Mahubuleshwur. These reports relate to an after period and to 
 other sanitary objects. My information has been derived from Mr. 
 Walker's official reports, or rather, I should say, that such are the 
 deductions to be drawn from these reports. Mr. Walker was at the 
 time medical officer in charge of the station. When myself acting 
 in that situation from 1833 to 1835, I had an opportunity of con- 
 sulting the records of the station, and have again very recently en- 
 joyed this privilege through the courtesy of the Medical Board. 
 It is not improbable that my conclusions may be met by statements 
 
 * " Indian Annals of Medical Science," No. 1, p. 311. 
 
 f " Transactions. Medical and Physical Society of Bombay," Nos. 1, 2, 5, and 7. 
 
 T 4 
 
280 DYSENTERY. 
 
 of an opposite tendency, but "on this point I venture to suggest a 
 caution. It is often forgotten that the characteristics of hill cli- 
 mates vary much at different seasons. The results which I have 
 stated to have occurred at Mahubuleshwur, in November, Decem- 
 ber, and January, would no doubt have been observed in much less 
 degree in March, April, and May. 
 
 In thus venturing to differ m part from the opinions expressed 
 by Mr. Grant, I have not overlooked his remark, that attacks of 
 dysentery or diarrhoea were not confined to persons in broken-down 
 health ; but this is merely to say that the exciting cause was 
 adequate to produce the disease, irrespective of peculiar predis- 
 position. 
 
 This discussion has been prolonged further than I at first intended 
 or than its practical importance may seem to require. For it may 
 be objected that when so much importance has been attached to 
 malaria as a predisposing cause, the difference is rather of words 
 than of facts. But there is surely more than this. The ojainion 
 that malaria, in common with many other causes, induces cachexia, 
 and that this state gives a susceptibility to dysentery, enforces the 
 importance, with the view of preventing the disease, of protection 
 from the influence of such predisposing causes. While, on the 
 other hand, the opinion that conditions of the atmosphere which 
 abstract heat are the common exciting cause, enforces the import- 
 ance of protection from their influence by avoiding exposure to 
 them, and by attention to clothing, houses, &c, and this the more 
 especially when we have to deal with cachectic individuals. To 
 state the difference in still more practical terms, the just infer- 
 ence from the principles which have been here advocated is, that 
 the cold season of all hill climates in India is liable to excite dysen- 
 tery in cachectic individuals irrespective of the presence of the con- 
 ditions of malaria ; whereas the view that malaria is itself the 
 exciting cause of the dysentery must tend to condemn only those 
 hill climates in which the conditions of malaria are apparent. 
 
 Section IV. — Symptoms of Dysentery. 
 
 The division of dysentery into several varieties, the allotment of 
 a particular name to each, and the attempt to distinguish the one 
 from the other by symptoms, are not calculated to advance our 
 clinical knowledge of this disease, or to strengthen our hands in its 
 treatment. Et is sufficient that, in respectto each case of dysentery, 
 we propose to ourselves the following questions: — Is it recent or 
 
SYMPTOMS. 281 
 
 advanced ? Does it engage much or little, and what part of the 
 mucous membrane of the large intestine? Is it idiopathic, or 
 co-existing with remittent fever ? Is it simple, or combined with 
 hepatitis, peritonitis, or other disease ? What is the state of con- 
 stitution ; is it sthenic, or likely to be the subject of erysipelatous 
 inflammation ; is it asthenic from former disease, deficient food, or 
 elevated temperature ; or is it tainted with malaria, scorbutus, 
 struma, syphilis, mercury, or retained excretions? What is the 
 condition of the mucous membrane, — simply reddened, or thick- 
 ened, or ulcerated, or sloughing ? 
 
 I must assume that the clinical student of dysentery understands 
 how, by inquiry into the history and by observation, he is to make 
 himself acquainted with the diathesis of his patient ; and I shall, 
 therefore, in my description of the symptoms, keep in view chiefly 
 the other practical points to which his attention has just been 
 directed. 
 
 Variation in Symptoms. — The severity of the disease in a 
 measure depends on the extent of surface of the mucous membrane 
 of the large intestine, which is involved. The symptoms will also 
 somewhat vary, according as the inflammation is in one part or 
 other of the intestine. It may be chiefly in the ccecuni or ascend- 
 ing colon, in the transverse colon, in the descending colon, or in the 
 sigmoid flexure and the rectum. But in the severer acute forms of 
 the disease the greater part of the surface is generally implicated. 
 
 Acute form in stlienic Europeans. — The symptoms of acute 
 dysentery as it occurs in sthenic European troops shortly after their 
 arrival in India will first be noticed. The disease in them fre- 
 quently commences with a relaxed state of the bowels ; thin fecu- 
 lent evacuations being passed with some degree of griping and 
 general uneasiness of abdomen. The fact that serious dysentery 
 in India may begin with symptoms differing little from those of an 
 ordinary feculent diarrhoea is practically most important. It incul- 
 cates both on patient and physician the lesson of carefully watching 
 such cases, with a view to the prevention of the disease *, or the 
 detection of its earliest symptoms. Not a few instances have come 
 to my knowledge of fatal dysentery having been permitted to 
 develop itself from oversight of this simple rule. 
 
 It is probable that at this early stage there is merely increased 
 vascularity of a limited portion of the mucous surface ; and that as 
 this extends, and passes into the more advanced stages of thick- 
 
 * The importance of watching these symptoms of diarrhoea with reference to cholera 
 has been enforced elsewhere, p. 221. 
 
282 DYSENTERY. 
 
 ening, exudation, and sloughing, the characteristic symptoms of 
 acute dysentery gradually evolve themselves. Thus the feculent 
 diarrhoea may continue for two or three days ; then the discharges 
 become more scanty, but the calls to evacuate are more frequent, and 
 attended with more griping pain and some degree of tenesmus. Now 
 the dejections consist sometimes merely of portions of clear mucus 
 more or less tinged with blood ; at other times there is mixed with 
 these bloody mucous discharges more or less feculence, generally thin, 
 of various colours, sometimes natural in appearance, at others green- 
 ish and gelatinous. Or, instead of clear blood-tinged mucus alone 
 or intermixed with feculence, the evacuations may have a slimy 
 appearance like oil paint of various colours, yellowish, greenish, 
 streaked, or speckled with little patches of blood : such evacuations 
 are in general passed without much tenesmus. 
 
 In regard to the diagnostic value of these different kinds of dis- 
 charges, they all indicate that the inflammation has not passed on to 
 its advanced stages. When the evacuations consist of mucus clear 
 or tinged with blood, passed unmixed, in small quantity, and with 
 much tenesmus, it may be inferred that the secretions proceed from 
 the inflamed mucous lining of the rectum and lower part of the 
 colon, and are uncombined with those of the liver and small intes- 
 tine ; and that probably the disease is as yet chiefly confined to the 
 lower part of the bowel. 
 
 When, however, the evacuations are more copious, partly of 
 mucus tinged or not with blood, and intermixed with more or less 
 thin feculence, — generally passed with some degree of tenesmus, 
 — the case differs from the first, inasmuch as the secretions from 
 the inflamed mucous lining of the large intestine are accompanied 
 by more or less of the natural contents of the small intestine ; and 
 all — in consequence of the increased peristaltic action resulting from 
 the more extensive inflammation of the mucous membrane of the 
 large intestine — ■ are passed rapidly through with tormina, and dis- 
 charged. We may infer, then, that when the evacuations are of 
 this latter character, a greater extent of the colon has become 
 involved ; and if such discharges take place with little or no 
 tenesmus, we may further conclude that as yet the lower part of 
 the bowel is little engaged. 
 
 But in applying these suggestions to clinical diagnosis it is neces- 
 sary to caution the practitioner not to lose sight of the nature of 
 the remedies which have been previously used. It is very evident 
 that in the first supposed case — that in which the disease is 
 cl i iefly confined to the lower part of the bowel — the action of a 
 
SYMPTOMS. 283 
 
 purgative will give to the discharges the character related to the 
 second supposed case — that in which the disease has affected a 
 more extensive and higher part of the large intestine. Again, a 
 too free use of opium may give to the discharges of the second the 
 character of those of the first. 
 
 In reference to the diagnostic value of the intestinal excreta, one 
 general remark may be prefaced, viz., that I entertain a strono- 
 suspicion that much of the dark green, gelatinous, and other varie- 
 ties of discharges which have been described by various authors, 
 and to which much pathological importance has been attached, are 
 the products of the excessive use of calomel and purgatives and not 
 true symptoms of the disease. 
 
 Dysentery in Bombay and Bengal very generally commences 
 with diarrhoea in the manner which has just been described, but 
 sometimes it is otherwise* In the disease, as observed by me in 
 Her Majesty's 40th Eegiment, at Belgaum, the bowels were often 
 rather constipated at the commencement, than relaxed, and there 
 was a sense of fulness and uneasiness experienced in the course of 
 the colon, followed after a time by mucous and scanty dejec- 
 tions. It is when the disease originates in this manner that the 
 intermixed feculence may occasionally exhibit a scybalous cha- 
 racter. 
 
 The further description of the symptoms will equally apply, 
 whether the disease has commenced with diarrhoea or in the man- 
 ner last alluded to. 
 
 Abdominal pain. — Associated with the frequent and morbid dis- 
 charges, the tormina and tenesmus, there is a sense of uneasiness 
 experienced in some part of the colon ; and therefore in all cases 
 of dysentery the abdomen should be carefully examined with the 
 view of ascertaining in what situation this uneasiness is chiefly 
 present. We must not expect to find the acute tenderness of 
 idiopathic peritonitis, but rather a sense of soreness which is how- 
 ever distinctly aggravated by pressure. The extent and situation 
 of this discomfort will indicate the extent and parts of the intestine 
 affected. The degree of the pain will suggest the complication, or 
 not, of general or partial peritonitis, and our suspicion of this will 
 receive confirmation from the co-existence of tenseness or indura- 
 tion* in the neighbourhood of some part of the large intestine. 
 
 * In respect to a feeling of induration in some part of the course of the colon, it is 
 necessary to offer this caution. If the abdominal parietes be thin, we may frequently 
 feel the intestine indurated merely from being in a state of contraction. We must be 
 careful not to confound this with induration depending on thickening or other organic 
 
284 DYSENTERY. 
 
 The clinical observer will readily appreciate the importance of 
 symptoms of peritonitis appearing in the course of dysentery when 
 he recollects that this serious complication attends only the 
 worst forms and the advanced stages of this disease, — those in 
 which there is sloughy ulceration of the mucous membrane with 
 threatened perforation of the intestine. (P. 265.) 
 
 But in respect to the import of tenderness in the course of the 
 colon as a symptom of dysentery, I must guard myself against being- 
 misunderstood. That degree of tenderness, tenseness, and indura- 
 tion related to peritonitis is a condition of an advanced and gene- 
 rally hopeless stage of the disease. In those early stages, however, 
 when precise diagnosis is practically so important, a careful 
 observer will be able to discover some uneasy part of the large 
 intestine — caused by inflammation of the other tissues — to which 
 his remedial means may be more particularly applied ; but should 
 he fail in detecting this symptom, he is not on that account to 
 attach the less importance to the evidence of presence or severity 
 of the inflammatory action derivable from the character and man- 
 ner of the discharges alone. 
 
 Dysuria and retention of urine are occasional occurrences in 
 the course of acute dysentery. They have been generally attributed 
 to extension of irritation from the rectum to the neck of the bladder. 
 Without denying that this may be the explanation of these sym- 
 ptoms (more particularly of mere irritability of the bladder), in 
 occasional cases, yet the tendency of my own observation has been 
 to regard them in a much more serious light. Eetention of urine 
 will very frequently be found co-existing with inflammation of the 
 peritoneal covering of the bladder, — to be, in fact, an illustration 
 of paralysis of the muscular fibre of a hollow organ, consequent on 
 inflammation of its serous covering. (Cases 60, 82.) 
 
 Tenesmus. — In the account of the symptoms of dysentery 
 usually given in systematic works, the straining, the frequent calls 
 to evacuate, and the scanty mucous, blood-tinged discharges, are 
 dwelt upon as the very characteristic phenomena of the disease. 
 It is true that when the sigmoid flexure and rectum are the parts 
 chiefly affected these are prominent symptoms. But in Indian 
 dysentery the inflammation is very often principally in parts of 
 the large intestine above the sigmoid flexure, and then, as 
 already explained, the discharges may be more copious, and 
 
 change. The state to which I now allude is not morbid, and with careful examina- 
 tion ami under this caution oughl ao1 to be mistaken tor disease. 1 have observed it 
 mo I frequently in the lefl iliac region. 
 
SYMPTOMS. 285 
 
 scantiness and tenesmus be symptoms which attract little atten- 
 tion. All the best writers on tropical dysentery confirm this truth, 
 and yet it often fails to correct the contrary erroneous general im- 
 pression. It is because the fact that inflammation of the mucous 
 membrane of the large intestine — dysentery — may be present 
 without tenesmus or scanty mucous discharges, is so constantly 
 overlooked, that cases of dysentery are very frequently returned 
 as diarrhoea, and thus our statistical data vitiated at their very 
 source. 
 
 General symptoms do not assist much in the diagnosis of this 
 disease. The tongue is often white at the commencement, but it 
 exhibits no characteristic appearance and is seldom much coated 
 except in sthenic lately arrived Europeans in whom biliary derange- 
 ment is also present. In the advanced stages it may become florid 
 and glazed, or present other features related to the state and degree 
 of constitutional disturbance. Symptomatic fever is generally 
 absent at the outset of dysentery, and is often very slight even 
 when a considerable degree of inflammation is present. The 
 co-existence of well-marked febrile phenomena with the early stage 
 of dysentery should ahvays suggest the suspicion that the disease is 
 not simple, but a complication of remittent fever. Then the course 
 of the affection should be very carefully watched with the view of 
 determining this question — a most important one as respects the 
 system of treatment. 
 
 SymjAoms of advanced stages. — Hitherto in my remarks on 
 the symptoms — with exception of those relating to a co-existing 
 peritonitis — I have had in view those periods of the disease in 
 which the inflammation has not as yet passed on to ulceration or 
 sloughing. The course of dysentery to these more advanced stages 
 and to a fatal issue has now to be traced. 
 
 The frequent discharges continue, but they become more watery, 
 brown in colour, streaked with blood, or they contain small floating 
 clots of blood, or white shreddy-looking films, or patches of sloughy 
 tissue. Then the watery fluid becomes still more tinged red, and 
 the foetor peculiar and very offensive. Febrile exacerbations now 
 become distinct — the skin may be hot and dry, and the pulse 
 irritable, or the skin may be covered with perspiration, and the 
 pulse small and compressible. The tongue becomes coated in the 
 centre and dry, the abdomen not unfrequently full and tense, and 
 before the fatal issue some degree of muttering delirium is some- 
 times present. 
 
 When the dejections are serous, more or less tinged red, contain 
 
286 DYSENTERY. 
 
 floating clots and shreds, and possess a strong dysenteric foetor, we 
 may infer that they have proceeded from an ulcerated and sloughy 
 surface of the mucous coat of the large intestine : they also may 
 be more or less intermixed with the secretions from the mucous 
 lining of the small intestine and the liver. 
 
 The disease, as just described, may run its fatal course in from 
 nine to fifteen days. In those cases in which death takes place 
 most quickly it may be assumed that the inflammation has been 
 erysipelatous in character, and has led to extensive gangrene of the 
 mucous membrane. While, on the other hand, in those in which 
 the several stages have been passed through more slowly, we 
 may infer that the morbid state has been thickening, exudation, 
 gangrene, and sloughing of transverse or other shaped patches of 
 the membrane. 
 
 Haemorrhage. ■ — There are still, in relation to the severer and 
 frequently fatal forms of dysentery, other symptoms to allude to. 
 The discharges may contain dark-coloured blood in considerable 
 quantity, constituting that form of the disease to which the name 
 haemorrhagic has been given. A reference to the detailed cases 
 will show that in some (73, 128,) a considerable quantity of 
 blood has been found in the intestine after death, associated with 
 a state of sloughy ulceration. But the occurrence of considerable 
 haemorrhage from the bowels in dysentery, is a rare event in 
 Bombay compared with what the experience of Mr. Twining, Dr. 
 Kaleigh, Dr. Mouat, and Mr. Hare shows it to be in Bengal. In 
 some cases it would seem to be related to a state of ulceration, to 
 the diathesis, — scorbutic or other, — perhaps to the co-existence 
 of hepatic disease, as cirrhosis ; but in others, the haemorrhage 
 would appear to present itself in the early stages before the advent 
 of ulceration, and to be a transudation dependent on congestion 
 of the mucous membrane, and an altered state of the blood : 
 this state, I apprehend, genei-ally complicates forms of remittent 
 fever, caused by intense malaria, and is probably pathologically 
 distinct from dysentery. It is not an inflammation, but passive 
 congestion tending to haemorrhage. This distinction is clini- 
 cally important, for cases with red-tinged serous discharges (that is 
 discharges which in dysentery proceed from a sloughy ulcerated 
 surface, and are of most unfavourable prognosis), are sometimes 
 unexpectedly recovered from. Close inquiry will, however, gene- 
 rally prove that these have not been of dysentery, but simply 
 of congestion ; and the diagnosis will chiefly rest on the fact, 
 that in the latter the discharges occur early in the illness, and 
 
STMrTOMs. 287 
 
 are associated with more or less of the symptoms of congestive 
 fever. 
 
 The dangers of dysentery may further be enhanced by a compli- 
 cation of hepatic disease. But this subject, as already observed, 
 will be treated of, with more advantage, in connection with 
 Hepatitis. 
 
 I have traced the course of acute dysentery in its more formida- 
 ble aspects, and must now follow that of the great majority of 
 cases, to their more favourable termination. 
 
 The frequent calls to stool, the blood-tinged mucus intermixed 
 with feculence, passed with griping and more or less tenesmus, and 
 attended with abdominal uneasiness, may, under appropriate treat- 
 ment, progressively decline, and health be restored. Under these 
 circumstances we may infer that the inflammation of the mucous 
 membrane had not advanced beyond the state of redness and tur- 
 gescence, and that its texture had escaped uninjured. 
 
 Chronic form. — Instead of progressive recovery in this manner, 
 the symptoms may continue with, perhaps, alternations of allevia- 
 tion and exacerbation. The discharges, still frequent, may become 
 gradually more copious, and consist of thin feculence, frequently of 
 pale colour, and frothy, streaked with mucus and blood, or reddish 
 serum, or speckled with small blood clots, films, and shreds, and be 
 passed with some degree of griping, but very generally with little 
 tenesmus. This change is attended with increasing emaciation, and 
 the tongue becomes florid at the tip and edges, with sometimes a 
 glazed appearance. The acute dysentery has passed into a chronic 
 state. Or this chronic condition may take place without having 
 been preceded by the symptoms of the acute degree — the diarrhoea 
 with which I have said dysentery frequently commences, may con- 
 tinue and gradually merge into this chronic form. The reader, 
 with these facts before him, will at once understand that long- 
 standing diarrhoea and chronic dysentery are generally one patho- 
 logical condition ; and that, therefore, a large proportion of hos - 
 pital disease, returned under the head diarrhoea, is in fact d}*sentery. 
 
 The pathological condition of the mucous membrane in chronic 
 d} r sentery may consist merely of a state of increased redness of the 
 membrane ; or the tissue may also be thickened, and have granular 
 exudation on its free surface. There may be various states and 
 stages of ulceration, more generally, however, of the circular form, 
 and with cicatrisation in different degrees of progress. 
 
 It is observed by an able writer *, " The second stage is said to 
 * "Elements of Medicine." By B. Williams, M.D., vol. ii. p. 553. 
 
288 DYSENTERY. 
 
 commence when pus appears in the stools, but it must be admitted 
 there are cases in which the disease pursues a chronic course, and 
 terminates fatally without any such appearance." When we con- 
 sider the morbid changes that have taken place in chronic d} T sen- 
 tery, the probability of the presence of pus in the intestinal canal, 
 and its ready detection by the microscope, in the evacuations, 
 may be admitted. But that the presence of pus in the discharges 
 of Indian chronic dysentery is frequently suggested to the naked 
 eye of the clinical observer, is at variance with my experience. 
 Indeed, I am certain that in the numerous diaries of dysenteric 
 cases written by me in Bombay hospitals, European and native, 
 such terms as pus, puriform, purulent, applied to the intestinal 
 excreta, will seldom be found. 
 
 In Natives. — In describing the symptoms of dysentery, I have 
 not thought it necessary to distinguish the disease as occurring in 
 natives of India from that of Europeans. Cases 54, 55, 56, 67, 
 69, 70, 75, 76, 80, 89, show that it occurs in the former in forms 
 as severe as in the latter. The general description is equally ap- 
 plicable to both. 
 
 Section V. — Treatment — General Principles and Indications. 
 — Detailed Remarks on Blood-letting ', general and local, Calo- 
 mel, Mercurial Influence, Ipecacuanha, Purgatives, Diapho- 
 retics, Opium, Chloroform, Astringents, Tonics, Fomentations, 
 Blisters, Enemata, Diet, and Change of Climate in Dysentery. 
 
 General Principles. — The treatment of dysentery must neces- 
 sarily vary, according to the stage of the inflammation, and the 
 state of the constitution ; and neglect of this simple therapeutic 
 principle, has led to needless confusion and uncertainty. Success 
 in the treatment of dysentery depends on the recency of the attack, 
 and the judgment displayed in adjusting the remedies to the state 
 of the constitution. 
 
 Early stage. —The indication in the early stage is to prevent 
 the simply reddened and swollen membrane from passing into a 
 state of thickening, ulceration, or gangrene. In effecting this it 
 must be remembered that the amount of antiphlogistic means, 
 which in some states of constitution may be required to prevent 
 disorganisation, will in others be the most certain method of en- 
 suring it. Nor are we to expect in inflammation of the intestinal 
 mucous membrane the speedy and marked effects from remedies 
 which sometimes occur at the commencement of the inflammation 
 
TREATMENT —GENERAL rRINCIFLES. 
 
 289 
 
 of other tissues, but must rest satisfied with steady, progressive 
 amendment; for the contrary expectation is apt to lead to fre- 
 quent change, and to the continuance of medicines after benefit 
 from them has ceased and injury begun. 
 
 Advanced Stages. — After the early stage has passed, and dis- 
 organisation of tissue has taken place, it must be borne in mind 
 that restoration to health can only be effected by processes of 
 repair ; and that the indication with this view is simply to place 
 and to maintain the affected part, and the system generally, in the 
 conditions most favourable for growth and nutrition. The means 
 used for this purpose differ from those which it is often necessary to 
 adopt at the commencement of the attack, in order to prevent lesion. 
 Hence we cannot safely enter on the treatment of dysentery, unless 
 we regard the period of the disease, and determine whether dis- 
 organisation has to be prevented or repaired. But these two con- 
 ditions do not comprise all the contingencies of practice ; for there 
 is a transition stage, in which disorganisation, though in progress, 
 has not yet been completed, and the period of repair has consequently 
 not yet arrived. In this the treatment must partake of the transi- 
 tion character of the morbid action, and consist of a gradual change 
 from the principles of the early to those of the more advanced 
 period of the disease. 
 
 In my remarks on the causes of dysentery, much importance was 
 attached to predisposing states of the constitution. It has also 
 been stated that we may not hope to conduct the treatment of the 
 early stages successfully unless we rightly appreciate these conditions 
 of the system ; and now I would advert to their importance in that 
 period of the disease when recovery can only be effected through 
 processes of repair. With a view to the restoration of disorganised 
 structures generally, two leading principles command our attention : 
 — 1. Asthenic or cachectic states of the system are to be cor- 
 rected; 2. The parts must not be unduly disturbed. It is true 
 that in the instance of the external surface of the body various local 
 appliances may also be used, but these are of trivial consequence, 
 compared with the two leading indications ; and in respect to parts 
 removed from the sphere of our senses, the accurate application of 
 local means becomes impracticable, and the attempt to use them 
 is often of questionable expediency. 
 
 These considerations lead to the conclusion that the successful 
 treatment of dysentery must always depend on a just discrimination 
 of its stage, and of the state of the constitution. In the early stage 
 the remedies for inflammation are regulated with reference to the 
 
 u 
 
290 DYSENTERY. 
 
 diathesis. In the advanced stage the means conducive to repair are 
 also selected with reference to the diathesis, and in recollection 
 that the time required for effecting restoration — generally con- 
 siderable — will vary according to the reparative power of the 
 general system.* 
 
 When we reflect on the details involved in applying these prin- 
 ciples, we can be at no loss in understanding how the treatment of 
 dysentery is often complicated and confused, how it must always be 
 unsatisfactory, and frequently injurious, unless these principles are 
 kept steadily before us, and unless the further doctrine be admitted 
 that in all inflammations of mucous tissue and in all chronic dis- 
 eases^time is a necessary condition of restoration to health. 
 
 What are the remedies which, if used with discrimination in the 
 early periods of dysentery, are efficacious, but most of which, if 
 used in the stage of repair, are injurious ? Blood-letting, general 
 and local ; mercury ; purgatives ; ipecacuanha ; opinm. 
 
 What are the remedies which, if used with discrimination in the 
 stage of repair, are more or less efficacious, but most f of which, if 
 used at the outset of the disease, are injurious? Astringents; 
 tonics ; alteratives ; opium. 
 
 Then what are the states of constitution which demand consider- 
 ation, and modification of the details of treatment? The constitu- 
 tion may be sthenic, or in that condition favourable to erysipelatous 
 inflammation ; it may be asthenic or cachectic from malaria, scor- 
 
 * On the pathology and etiology of dysentery, pp. 237, 273, allusion has been made 
 to a theoretic analogy between inflammation of the skin and of the mucous membrane 
 of the large intestine. The question may be put in respect to treatment. Should 
 future research demonstrate that inflammation of the intestinal mucous lining is 
 various as regards its course arid causes — as inflammation of the skin — will it not 
 follow that the principles of treatment now inculcated for dysentery will become in- 
 applicable and require complete revision? The true answer to this question will 
 be found in a reference to the treatment of diseases of the skin. What are the prin- 
 ciples applied to these ? (a.) The prevention of disorganisation in the early stages by 
 sedative means, (b.) The favouring of processes of repair in the advanced stages, (c.) 
 Above all, the correction of the diathesis on general principles ; for it is but in very 
 few instances that we can pretend to a knowledge of means special to particular affec- 
 tions. True, local applications are of subsidiary use, and generally had recourse to 
 with more or less advantage. But it is evident that whatever advances may be made 
 in the pathology of intestinal inflammation, the safe and effective use of local remedies 
 must always be very limited, for the simple reason that the great extent of the struc- 
 ture must always be hid from our sense of sight. The statement of such self-evident 
 propositions woidd call for some apology to the reader were it not that I am desirous 
 of guarding the practice of medicine in India on all sides from the rash and dreamy 
 therapeutics of which I have seen much and read more. 
 
 t I use this qualifying term in reference to opium and ipecacuanha, which may be 
 used under both circumstances, 
 
TREATMENT— GENERAL PRINCIPLES. 291 
 
 butus, vitiated atmosphere, struma, syphilis, &c. Asthenic and 
 cachectic states — always difficult to correct — are necessarily more 
 so when an important part of the intestinal canal is the seat of 
 disease; but in order to effect good and to avoid injury in medical 
 practice, we must always keep before the mind a clear view of the 
 whole subject, with all its attendant difficulties. 
 
 Having premised these observations on the principles of treat- 
 ment in dysentery, I proceed to explain the clinical details. 
 
 The leading indications of cure may be stated as follows : — 
 
 1. To subdue increased general and local vascular action by 
 blood-letting, general and local. To sustain vascular action, when 
 too depressed, by tonics and stimulants. 
 
 2. To favour — by preserving unembarrassed the capillary 
 circulation of all the organs included in the portal circle — the free 
 circulation of the blood in the mucous membrane of the large in- 
 testine, with the view of maintaining the integrity of that tissue 
 before inflammatory action has led to organic change ; or of favour- 
 ing the repair of lesions when they have taken place. This is to 
 be chiefly effected by rest * ; also by, in the early stages and in 
 robust subjects, increasing the secretions from the liver and the 
 entire tract of the mucous lining of the small intestine ; and by, 
 in the advanced stages, checking these very secretions when too 
 profuse. 
 
 3. After ulceration or other organic change has resulted, to 
 favour the processes of repair by attention to the state of the 
 tissues implicated, and of the general constitution of the individual 
 affected. 
 
 The first question which arises in the treatment of a case of dysen- 
 tery is, whether the inflammation has terminated in disorganisation, 
 and if so, whether the disorganisation has ceased to extend, and 
 left recovery, if practicable, to be effected only by repair of tissue. 
 In deciding this question, we must, in a great measure, be guided 
 by the duration of the attack, and the character of the symptoms 
 and of the diathesis. 
 
 If the disease be of a few days' duration, and the constitution of 
 the patient not broken by previous disease, or long residence in 
 India ; if the abdomen be full, but not tense, the dejections frequent 
 and scanty, consisting of mucus more or less tinged with blood and 
 passed with tenesmus ; if the tenderness of abdomen be not acute, 
 the tongue white but not much coated, and little, if any, febrile 
 
 * The importance of the recumbent position in 'the treatment of dysentery cannot be 
 too strongly inculcated. 
 
 U 2 
 
292 DYSENTEKY. 
 
 excitement jwesent, then we may hope that disorganisation has not 
 taken place, and may be prevented, and that a cure may soon be 
 effected by appropriate antiphlogistic remedies. In the application 
 of these means, however, we must remember that inflammatory 
 action, once established in a mucous membrane, does not admit of 
 being checked in the speedy manner of which it is susceptible in 
 serous and other tissues. 
 
 If, on the other hand, the disease has existed for some time*, it 
 is probable that ulceration or other organic change has taken place, 
 and that recovery cannot be effected unless time be allowed, and 
 the patient be placed in the circumstances most favourable to 
 reparative action. In the treatment of these cases there is much 
 room for discrimination, because there is often difficulty in deter- 
 mining the precise pathological condition, and, consequently, the 
 indication of cure. 
 
 I shall attempt to point out the leading distinctive features. 
 
 (a. ) Cases in which the abdomen is distended, tender, and tense ; 
 the dejections frequent, scanty, passed with little tenesmus, and 
 consisting of turbid serous fluid, more or less tinged red and of 
 offensive foetor ; the skin coldish and washy, the pulse frequent and 
 compressible ; or the skin hot and pungent, the pulse thrilling and 
 irritable, but still compressible, with the tongue moist or dry accord- 
 ing as the first or second state of the skin and pulse is present. 
 In such cases, generally of from ten to twenty days' duration, the 
 disease will be found to have already occupied the greater extent 
 of the mucous lining of the large intestine, and to have terminated 
 in sloughing, extensive ulceration, and matting of the omentum 
 over the colon and caecum. Persons admitted into the European 
 General Hospital in this stage and condition of the disease, have 
 generally been sailors or others of dissipated habits, the residents 
 in low taverns, either altogether neglecting the disease, or still 
 more frequently adopting the vain and delusive course of attempt- 
 ing to check its symptoms by the use of ardent spirits. Cases such 
 as these must, I fear, generally be regarded as hopeless. But 
 though we may regret our inability of being permanently useful, 
 we ought to recollect our ability to do harm. The kind of treat- 
 ment — antiphlogistic — which, at an earlier stage, would have 
 been beneficial, will under these circumstances, be positively 
 injurious, and must expedite the fatal termination. 
 
 (6.) Under this head may be included all the variety of cases, 
 
 * It is impossible to be more definite because the stale of the constitution influences 
 the result. 
 
TREATMENT — USE OF BLOOD-LETTING. 293 
 
 usually classed as chronic dysentery, of duration from one to two 
 months and upwards, in which ulceration of varying character and 
 extent exists ; or, instead of ulceration, thickening of the tissue with 
 or without granular exudation, generally existing in states of con- 
 stitution more or less deteriorated. It may be that the tone of the 
 constitution has been sufficiently preserved, to make the chief indi- 
 cation of cure the mere removal of sources of irritation, and the 
 placing thereby the injured structures in circumstances most favour- 
 able to restoration by the natural actions of the system. In such 
 cases a tonic plan of treatment should be avoided, and a mild 
 antiphlogistic course pursued. 
 
 (c.) But when the ulceration or other organic change exists in 
 deteriorated states of the constitution, from whatever cause arising, 
 then the cachexia must be chiefly considered under the certainty 
 that, if it can be removed or lessened, the reparation of the dis- 
 organised tissues will thereby be most effectually advanced. Just 
 as in external ulcers in similar circumstances it is vain to attempt 
 to heal them by any other means than those which effect an 
 improvement in the general system. When the cachexia, how- 
 ever, has been brought about mainly by the long continuance of 
 the local disease, — the patient having been, in ether respects, 
 situated favourably, — then the chances of recovery are small. 
 But in a great many instances other causes of general cachexia 
 will be found to have aided the influence of the disease. For 
 example, medical treatment may have been neglected, or too 
 depressing, the patient may have been badly clothed, housed, or 
 fed, or exposed to unsuitable air or climate : in these circum- 
 stances it is reasonable to expect benefit from treatment judiciously 
 tonic, and from the removal of the influences which have operated 
 injuriously. 
 
 The remedial means which have been chiefly used with the view 
 of effecting these several indications will now be noticed. 
 
 Blood-letting, general and local. — The degree to which increased 
 vascular action, general and local, maybe subdued by blood-letting > 
 general and local, must be determined in each particular instance 
 by the judgment of the practitioner. The tone of the constitution, 
 the state of the skin and pulse, the degree of abdominal tenderness, 
 the duration of the attack, and the consequent probable condition 
 of the mucous coat, — whether ulcerated or not, and whether 
 complicated with peritonic inflammation, — must be carefully con- 
 sidered. 
 
 General blood-letting may be used with advantage within the 
 
 v ;* 
 
294 DYSENTERY. 
 
 first two or three days of the attack in Europeans of good 
 constitution, not long resident in India, and unaffected by the 
 depressing influences of heat, moisture, or malaria, provided the 
 pulse be of good volume and strength, the skin without coldness 
 and moisture, the dejections frequent, scanty, and mucous, and 
 the abdomen more or less uneasy on pressure. The benefit thus 
 likely to result may be maintained and increased by the subsequent 
 application of leeches, and the use of the other means presently to 
 be noticed. 
 
 General blood-letting is seldom, if ever, expedient in the treat- 
 ment of dysentery in natives of India. When the disease occurs 
 in states of constitution asthenic or cachectic, whether in Euro- 
 peans or natives, and has existed for several days, the proceeding 
 is altogether inadmissible. 
 
 In cases in which, from the state of the system, general blood- 
 letting is contra-indicated at the commencement of the attack, 
 recourse may be had to the application of leeches, in numbers of 
 from two * to six dozen, repeated more or less frequently accord- 
 ing to circumstances. With the view of determining the part 
 of the abdomen f on which they may be best applied, the situation 
 in which uneasiness on pressure is chiefly experienced should be 
 carefully ascertained. It has been already said that asthenic and 
 cachectic conditions of the system are contra-indications of general 
 blood-letting ; and when present in great degree they are equally 
 so of local blood-letting. 
 
 Though the benefit derived from the abstraction of blood will 
 generally be proportionate to the recency of the attack, and the 
 consequent probable absence of ulceration or other organic change, 
 still it is not to be inferred that the utility of the measure is ex- 
 clusively confined to these circumstances. Though, from the dura- 
 tion of the attack and the character of the dejections, there is reason 
 for suspecting the commencement of ulceration ; still, if there be 
 abdominal tenderness and much tenesmus, — the state of the pulse, 
 the skin, and general system not distinctly contra-indicating, — we 
 may have recourse to cautious local depletion in the belief, that 
 
 * These numbers relate to the Bombay leech, which is small ; one dozen not ab- 
 stract ing more than about an ounce ami a half of blood. The size of the leech varies 
 much in different parts of India, and must of course always be regarded by the practi- 
 tioner. In respect to proportioning the local abstraction of blood to stage of disease, 
 and state of constitution, clinical experience and observation can alone teach this. 
 
 t On the comparative efficacy of the application of leeches to the abdomen or to the 
 anus, 1 am unable to offer an opinion. I have been always sufficiently satisfied with 
 their efficacy when applied to the abdomen. 
 
TREATMENT USE OF BLOOD-LETTING. 295 
 
 though lesion of the mucous coat exists, there is also present an 
 amount of vascular obstruction of the surrounding portions of the 
 tunic, incompatible with repair, and favourable to an extension of 
 the ulcerative action. 
 
 Though important in suitable circumstances, it is not to be sup- 
 posed that blood-letting is always requisite in the early stage of 
 dysentery in persons of good constitution. Cases frequently occur 
 in which, from the recency of the attack and the mildness of the 
 symptoms, the disease may be readily cured by rest, the removal 
 of lsedentia, a mild laxative, an opiate, and abstinence. These will 
 be met with more frequently in natives of India than in Europeans ; 
 and in respect to the latter, the caution of not permitting the 
 patient himself to be the judge of the mildness or severity of the 
 attack cannot be too earnestly inculcated. The symptoms should 
 invariably be carefully investigated, and the character of the alvine 
 discharges particularly noted. This is a most important rule of 
 practice, for the mortality from dysentery in India is increased by 
 the patient's ignorance often leading him to make light of his 
 illness, and by the physician's credulity favouring neglect of that 
 complete examination of the case, without which there can be no 
 safety in the management of this serious disease. 
 
 The second indication of cure, viz., to favour the free circulation 
 of blood in the mucous membrane of the large intestine, by main- 
 taining unembarrassed the capillary circulation of all the organs in- 
 cluded in the portal circle, is most important, and to be held in view 
 in succession to the abstraction of blood. It is the indication which 
 constitutes the chief object of treatment in the majority of cases. 
 
 It may be assumed that when the capillary vessels of any portion 
 of the portal vascular system are congested, and when in conse- 
 quence the blood does not pass readily through them, then an 
 important step in the removal of this state is to free the entire 
 portal circulation, by augmenting the secretions which proceed 
 from the arterial capillaries of the mucous coat of the whole 
 tract of the intestine, as well as those which depend on the 
 capillary terminations of the portal vein itself. In other words, 
 to increase the secretions from the small intestine and from 
 the liver, is the second indication of cure in the early stages of 
 dysentery. 
 
 This principle of treatment is observed in the management of 
 many affections of the lower part of the bowel, arising from de- 
 ranged circulation, as in haemorrhoids, and in fistula in ano. It 
 is surely equally applicable in the treatment of dysentery — a 
 
 u 4 
 
296 DYSENTERY. 
 
 deranged state of the circulation of the tissues of a higher portion 
 of the same intestine. 
 
 How is this indication to be effected ? Many of the remedies 
 generally found efficacious in dysentery, as calomel, blue pill, 
 ipecacuanha, and purgatives, act in this manner ; but their influence 
 has often been otherwise explained. By some (Sydenham) they are 
 considered useful, because they eliminate a morbid material from 
 the blood ; by others because they assist the discharge of vitiated 
 and acrid intestinal contents. But whichever theory be preferred, 
 this practical fact remains, that the efficacy of these means is re- 
 lated to the recency of the attack and the state of the constitution, 
 
 — that is, to the inflammation being as yet in great part in the 
 stage of capillary stagnation, and to the quantity of blood in the 
 general system being still sufficient. 
 
 On the use of calomel. — In persons whose constitutions are un- 
 injured by former disease or other cause, it forms an important 
 part of the treatment of the early days of the attack, after adequate 
 general or local blood-letting, to give, at bed-time, a ten-grain dose 
 of calomel combined with a grain and a half or two grains of ipe- 
 cacuanha, and the same quantity of opium, with on the following 
 morning from four drachms to an ounce of castor oil. The state of 
 the tongue — whether coated or not; the character of the dejections 
 
 — whether scanty or free; and the condition of the abdomen — 
 whether full and resisting, or supple and soft — will indicate the 
 expediency of repeating these means, or abstaining from their 
 further use. When the abdomen is supple and soft, there seldom 
 can be any necessity for full doses of calomel. 
 
 Though calomel in these doses is generally only applicable to 
 the first few days of the attack, it occasionally happens that it 
 may be given with advantage in more advanced stages, when the 
 tongue is coated, the discharges pale and scanty, the abdomen full, 
 and the general condition and strength of the patient not much 
 impaired. In fact, in circumstances in which it is reasonable to 
 conclude that the excretions are not free, and the portal circulation 
 in consequence embarrassed. 
 
 The object in exhibiting calomel is to increase the secretion of 
 the liver and of the mucous lining of the small intestine, but at 
 the same time to be careful that it does not aggravate the existing 
 inflammation of the large intestine. This latter injurious effect is 
 to be guarded against by avoiding the frequent repetition of the 
 calomel, and by combining it, when used, with opium. This 
 caution is the more necessary when there is good reason for believ- 
 
TREATMENT — USE OF MERCURY. 297 
 
 ing that ulceration has taken place ; because the irritant action 
 of the calomel is then more certain, and there is, moreover, in a 
 lesion requiring time for its restoration less necessity for attempt- 
 ing to influence the abnormal circulation of the large intestine by 
 a decided and speedy effect on the upper part of the portal circu- 
 lation. 
 
 The treatment of dysenteiy by large doses of calomel repeated 
 and continued for some time, on the supposition that they exercise 
 a sedative effect * on the inflamed mucous coat, is, I trust, now 
 obsolete in India. It may be assumed that this system, at one 
 time strongly advocated, and generally followed, would not have 
 fallen into universal disuse, unless it had signally failed of success. 
 My own conviction is, that as a general method of treatment it is 
 irrational and injurious.! 
 
 Calomel is seldom required in the treatment of dysenteiy in the 
 natives of India. 
 
 Mercurial influence. — Though not related to the indication 
 of cure now under discussion, yet the present is the most ap- 
 propriate place in which to notice the treatment of dysentery by 
 inducing the constitutional effect of mercury. The use of calomel, 
 with this view, must be kept distinct from the cholagogue action, 
 which has just been considered. It is unnecessary to discuss in 
 detail the mercurial treatment of dysentery, for as a rule of prac- 
 tice, it has been generally and justly abandoned in India. 
 
 In theory, perhaps, it may be admitted that deposits of lymph 
 in the sub-mucous tissue of sthenic individuals might be appro- 
 priately controlled by mercurial influence. Yet when we reflect, 
 that ulceration and sloughing, consecutive on thickening, are sure 
 to be aggravated by mercury, and further that the disease very 
 often exists in states of constitution in which mercury is hurtful, we 
 must acknowledge that the reasons for not applying this therapeutic 
 principle in dysentery are just and convincing. I can further state, 
 from repeated observation of the fact that individuals under the 
 influence of mercury are very predisposed to dysentery: this is 
 particularly true of the natives of India. 
 
 Doubtless the records of medicine abound with reports of dysen- 
 tery cured after salivation. My earliest clinical acquaintance with 
 
 * This question has been already alluded to in my remarks on the use of calomel in 
 remittent fever, p. 136. 
 
 f I regret to observe in Haspel's Diseases of Algeria, a distinct leaning to the 
 treatment of disease by scruple doses of calomel, which as a routine system has 
 proved so injurious in India, and in consequence fallen into general and complete 
 disuse. 
 
298 DYSENTERY. 
 
 this disease was in the hospital of Her Majesty's 40th Regiment at 
 Belo-aum in the year 1830. The chief means of cure were free 
 blood-letting and mercury. Many recoveries, of course, took place, 
 and, to my inexperience, the treatment seemed efficacious. But 
 the opportunities which have been afforded me, during the thirty 
 years which have since elapsed, have enabled me to correct these 
 erroneous early impressions, and to justify the adverse opinion 
 which I now entertain on the mercurial treatment of dysentery. 
 
 On the use of Ipecacuanha. — Of the various remedies recom- 
 mended in this disease, there is none so generally efficacious and 
 applicable as ipecacuanha alone or combined with blue pill, or, in 
 some cases, with opium, provided it be fairly tried and steadily 
 continued. 
 
 This medicine, brought from the Brazils by Piso *, towards the 
 end of the 17th century, was given by him in dysentery in drachm 
 doses in the form of infusion. It was in more or less use through- 
 out the 18th century, and about the middle of the century was 
 much esteemed by Sir John Pringle, who gave it sometimes in 
 scruple doses, at other times in five-grain doses, three or four times 
 at intervals of two or three hours. Mr. Mortimer and other medi- 
 cal officers of the Madras army, upwards of thirty years ago, 
 thought highly of it, and used it freely in scruple doses, combined 
 with powdered gum arabic. Still more lately Mr. Twining advo- 
 cated its use in doses similar to the smaller ones given by Sir John 
 Pringle. Haspel also combines ipecacuanha in full doses with 
 calomel in the early stages of the disease, f 
 
 The efficacy of ipecacuanha in dysentery has been attributed by 
 some to its nauseant action, by others to its diaphoretic effect, 
 and by others, among whom is Sir J. Pringle, to its laxative or 
 purgative effect. It is to this last property that its efficacy seems 
 to me to be due; and it is with this view that I have always 
 used it. 
 
 * Wiring's Manual of Therapeutics, p. 298. 
 
 t Since the publication of the first edition of this work, the use of ipecacuanha, in 
 doses of from ten to ninety grains, has been advocated by Mr. Docker, surgeon of the 
 7th Fusiliers — (Land, July 31st, August 14th, 1858) — but he does not seem to have 
 been aware of the extent to which the remedy had been previously used in large doses, 
 both in India and elsewhere. Subsequent to the publication of Mr. Docker's reports, 
 rumours used to reach me at Poona, from Central India, of the wonderful success 
 attending the new method of treating dysentery by large doses of ipecacuanha. After 
 vii.'it I have at different times written od tin's subject, I cannot well be charged with 
 undervaluing ipecacuanha in dysentery, in doses related to the severity and stage of the 
 att.iek; l'ut 1 regret t h is returning cycle of indiscriminate use and praise which is sure to 
 lead to injurious reaction, — that invariable result of extreme opinions in medical practice. 
 
TREATMENT — USE OF IPECACUANHA. 299 
 
 In the early stages of acute dysentery, after blood-letting general 
 or local, calomel, ipecacuanha, and opium with laxatives, have been 
 used on the principles already laid down, — then the most satis- 
 factory course is to give ipecacuanha in the doses and combinations 
 recommended by the late Mr. Twining, viz., from six to three 
 grains combined with blue pill from five to two grains, and extract 
 of gentian from four to two grains, every third, fourth, sixth, or 
 eighth hour, and to continue it steadily till amendment takes 
 place. The proportion of the ipecacuanha and the frequency of 
 its repetition must depend on the acuteness of the symptoms. The 
 duration of the treatment and the gradual diminution of the dose 
 and of the frequency of its repetition, must be contingent on the 
 rapidity and permanency of the amendment. It must also be kept 
 distinctly in view that, whilst the treatment by ipecacuanha is 
 being pursued, it is often necessary — according as the state of the 
 pulse, or the uneasiness of the abdomen on pressure, may indicate 
 the necessity — to apply leeches ; and also — according to the 
 character and scantiness of the evacuations, and the greater or less 
 fulness of the abdomen — to give castor oil, occasionally, in 
 moderate doses. 
 
 In dysentery in the natives of India,, or in Europeans, when the 
 disease comes under treatment at a more advanced stage or in a 
 cachectic diathesis, it is often necessary at once to commence the 
 treatment in the manner just described, omitting the preliminary 
 exhibition of calomel and opium, and castor oil, as recommended 
 for the earlier stages in good constitutions. We must be careful 
 not to continue the blue pill, in combination, sufficiently long to 
 run any risk of inducing the constitutional effect of mercury : in 
 determining this risk we must be chiefly guided by the state of 
 the constitution. In cachectic individuals the ipecacuanha and 
 extract of gentian should be used without the blue pill from the 
 commencement of the attack. 
 
 The addition of opium to the ipecacuanha, blue pill, and extract 
 of gentian, will be considered in my subsequent remarks on the 
 use of opium in this disease. 
 
 It is not often that it is necessary to omit the ipecacuanha in 
 consequence of nausea and vomiting. Whether this immunity 
 from the emetic action of the drug proceeds from the effect of the 
 extract of gentian, as supposed by Mr. Twining, or whether from 
 a tolerance induced b}^ the disease, analogous to that of tartar 
 emetic in pneumonia and of opium in tetanus, is of little prac- 
 tical importance. My own impression is that it depends on the 
 
300 DYSENTERY. 
 
 latter cause, and that it will generally be found in practice, that 
 when ipecacuanha disagrees, it is either because the disease is 
 very mild — rather threatens than exists — or has been already 
 removed by treatment ; or because the dysentery is complicated 
 with, and secondary to, some other serious disease, as abscess in 
 the liver. 
 
 The principle on which the efficacy of ipecacuanha and blue 
 pill depends, is, I believe analogous, but less in degTee to that 
 assumed of calomel and purgatives. They cause a moderately 
 free secretion from the liver and small intestine, and thus tend 
 to place the mucous coat of the large intestine in the state most 
 favourable for the return of its deranged capillary circulation to a 
 normal condition. 
 
 Though approving the use of ipecacuanha in these doses and 
 combinations, the practice here recommended differs in one very 
 essential feature from that advocated by Mr. Twining. I mean the 
 absence of the daily exhibition of a dose of compound powder of 
 jalap. My objection to this system of treatment will be more appro- 
 priately stated under the subsequent head. 
 
 On the use of purgatives. — To follow the exhibition of calomel 
 and opium, as already advised at the commencement of attacks of 
 acute dysentery, with a dose of from one ounce to six drachms of 
 castor oil, is a necessary part of the treatment ; and during the use 
 of ipecacuanha and blue pill, to give occasionally smaller doses of 
 castor oil, is also important. The chief indications, under both 
 circumstances, are a scantiness of the dejections, and at the same 
 time a full and puffy abdomen. 
 
 There is, however, room for the exercise of considerable discretion 
 in the use of laxatives and purgatives in the treatment of dysentery. 
 Given occasionally in moderate doses in suitable stages of the 
 disease and states of the constitution, they assist very materially — 
 perhaps are absolutely necessary — in keeping up a free exercise 
 of the secretory functions of the upper part of the portal circula- 
 tion. But, when carried beyond this limit, or when given in 
 advanced periods, or cachectic habits, they not unfrequently in- 
 crease the inflammation of the mucous coat of the large intestine, 
 and thereby prolong and aggravate the disease. This error is very 
 frequently committed. 
 
 At the same time it ought not to be forgotten that injury may 
 result from neglecting the use of purgatives when required, and 
 thereby allowing the contents «»l' the small intestine to accumulate. 
 The following case is an illustration of this : — 
 
TREATMENT — USE OF rURGATIVES. 301 
 
 91. Dysentery. — The use of purgatives too much, abstained .from. — The lower end of 
 the ileum distended from thm feculence. — John Smith, aged sixteen, admitted on the 
 23rd April, 1842, ill with dysentery of a few weeks' duration, tender abdomen and fre- 
 quent scanty stools. Treated by moderate leeching, blister, ipecacuanha, blue pill, and 
 gentian, and opiate enemata; no purgative. Pulse 120. For two days before death, 
 considerable distention of abdomen. Died on the night of the 30th. 
 
 Inspection. — Matting of the omentum, ulceration and friable state of the colon. 
 Small intestine distended with air, and the lower part of the ileum full of thin yellow 
 feculence, and somewhat distended thereby.. 
 
 By regarding fulness of the abdomen in connection with the 
 character of the discharges, and taking care not to confound the 
 former with the state of tension and distention, not unfrequent 
 in the latter stages of bad attacks, and related to peritonitic in- 
 flammation or hepatic abscess, little difficulty will be experienced 
 in deciding on the expediency of giving or withholding purgatives 
 in dysentery. 
 
 These remarks have had reference chiefly to castor oil, for it is 
 the purgative best suited for the disease. Still, I believe, that the 
 course of treatment recommended by the late Mr. Twining, of a 
 daily dose of compound powder of jalap in association with ipecacu- 
 anha, blue pill, and gentian, is applicable during the three or four 
 first days, in some forms of acute dysentery ; but that its longer 
 continuance is under any circumstances a very doubtful measure, 
 and under some, as when the tenesmus is very urgent or the secre- 
 tions not scanty, an inj urious one. 
 
 This caution in respect to purgatives in dysentery is unques- 
 tionably necessary in Bombay, and I believe that it is equally appli- 
 cable to Bengal. Still it may be useful to remark that the treat- 
 ment by purgatives, in the manner advocated by Mr. Twining, has 
 appeared to me more useful in dysentery in European troops in 
 the monsoon season in the Deccan than in the island of Bombay. 
 I have also, in former times, used the same treatment with advan- 
 tage in well-conditioned native troops in the cold season in the 
 Deccan; and more recently (Febniary 1844) at Grharra in Scinde. 
 The latter instance was the more instructive, because this method 
 had proved inapplicable to the disease in the same body of men at 
 Hydrabad in the previous month. 
 
 It is important to keep these facts in mind, because in all proba- 
 bility difference of season and of climate may call for modifications 
 in the treatment of dysentery, as in that of other forms of disease. 
 It is not improbable that purgatives ought to be given more freely 
 in drier and colder, than in moister and warmer, climates ; but the 
 state and amount of the excretions, and the habit of body ought 
 
302 DYSENTERY. 
 
 always to suffice for determining this point of practice in individual 
 cases. 
 
 It should, moreover, be remembered that benefit from laxa- 
 tives is chiefly confined to the outset of the disease, and that 
 nothing can be more faulty than the too frequent system of giving 
 castor oil to every patient admitted with dysentery, as a matter 
 of course, irrespective of his state or the stage of the disease. This 
 routine practice is often hurtful and is altogether at variance with 
 rational therapeutics. 
 
 Diaphoretics. — The maintenance of sufficient warmth of the 
 surface of the body, and the avoidance of all risk of its depression, 
 must be carefully attended to in the management of dysentery. 
 But general diaphoresis either caused by internal remedies, or 
 external appliances, as the warm bath, does not, in my opinion, 
 constitute any part of the treatment of dysentery in India. Even 
 were a perspiring state of the skin a positive benefit in this disease, 
 which I very much doubt, still the practical disadvantage would 
 more than counteract the gain ; for free perspiration is apt to inter- 
 fere with the thorough ventilation of the sick room, and to increase 
 the chance of exposure to chills, when the patient is disturbed by 
 the frequent alvine discharges characteristic of the disease. 
 
 On the use of opium. — Opium in appropriate combinations and 
 doses is useful in almost every condition of the disease. It may be 
 given with advantage combined with calomel at the commencement, 
 with ipecacuanha, and blue pill in the more advanced stages, and 
 alone or in union with tonics and astringents after the disease has 
 become chronic. 
 
 The doubt in regard to the efficacy of opium in dysentery which 
 was partially entertained by Pringle, and more distinctly avowed 
 by Twining and Haspel, may be readily removed by attention to 
 combination and to other points of treatment, as Sydenham well 
 knew and explained. 
 
 The mode of action is probably the same under all the circum- 
 stances of the disease for which opium is suitable. It controls the 
 increased peristaltic action of the intestine, and allays the distress- 
 ing sensations caused by it and by the other effects of the inflam- 
 mation. But, it may be objected, that opium given frequently in 
 free doses represses secretion ; and that therefore its use is opposed 
 to an important indication of cure in the early and middle stages 
 of the disease — the maintenance of a moderately free secretion 
 from the small intestine and the liver. To the practice of oivino- 
 opium alone in these stages this objection is just ; but it may 
 
TREATMENT — USE OF OPIUM. 303 
 
 be obviated by, in the early stages, combination with calomel, and, 
 afterwards with ipecacuanha and blue pill. Thus two important 
 objects are effected. The irritation of the large intestine is miti- 
 gated by opium, whilst secretion is favoured by calomel, ipecacuanha 
 and blue pill ; and we lean to one indication or the other by 
 varying the proportions of the ingredients according to the circum- 
 stances of particular cases. For example if, in the treatment with 
 ipecacuanha and blue pill, the discharges are free and frequent, the 
 tenesmus distressing, and the abdomen soft and supple, improve- 
 ment will follow the addition of a grain or a grain and a half of 
 opium to each dose. But, after a time, the adverse action of the 
 opium may begin to appear, the secretions may become scanty, the 
 abdomen rather full, and the tongue somewhat coated. Under 
 these circumstances it will generally be better to omit the opium 
 for a time and continue the ipecacuanha and blue pill, than to give 
 a purgative, and then immediately resume the opium. For the 
 better illustration of this principle extreme cases have been sup- 
 posed; but between 'these there are many degrees which must 
 be met by corresponding modifications in the treatment, such 
 as by lessening the quantity of opium rather than by omitting it 
 altogether. 
 
 When opium is given alone, or in union with tonics or astrin- 
 gents, in chronic dysentery, with the view of favouring the repara- 
 tion of ulcers, or repressing excessive secretion, then its efficacy is 
 still more evident, because both the sedative and astringent 
 actions assist in fulfilling the indications of cure. Under these 
 circumstances ojrium may be used in two or three-grain doses every 
 third, fourth, or sixth hour with great advantage. It alleviates 
 suffering and diminishes evacuation, and thus places the patient 
 in the condition most conducive to his cure. The following case 
 illustrates the good effects of full opiates : — 
 
 92. Good effects of opium in the treatment of some states of dysentery illustrated. 
 — George Peniball, aged nineteen, of strumous habit, and slight frame, after eight days' 
 illness with dysentery, was admitted into the General Hospital, on the 30th June, 
 1840. He was leeched two or three times, and blistered. Ipecacuanha, blue pill, 
 and gentian, and anodyne enemata were vised. He improved for a few days, and then 
 fell off. About the loth July he was in a very precarious state. There was much emacia- 
 tion, the pvdse was frequent and small, the tongue was florid, sometimes dry, and 
 sometimes coated. The dejections were frequent and scanty, consisted of mucus and 
 blood, were sometimes yeasty and offensive, and were passed with much tenesmus. 
 From this time the treatment consisted of large opiates, combined with quinine, blue 
 pill, or trisnitrate of bismuth. On the 28th July he began to take three grains of 
 opium, with one each of quinine and blue pill, every third hour. The amendment was 
 now tolerably steady and progressive, and the quantity and frequency of the opiate 
 
304 DYSENTERY. 
 
 was gradually reduced. On the 30th there was slight relapse, when four grains of 
 bismuth and one and a half of opium was used every fourth hour with excellent effect. 
 On 22nd August all medicine was omitted, and he left the hospital on the 24th in 
 tolerable flesh, and with regular bowels. From the 15th he had chicken for dinner. 
 
 My remarks on opium have had reference to its exhibition in 
 the form of pill, but I by no means undervalue its use by enema, 
 in the manner usually employed. 
 
 Chloroform. — Dr. Lownds* has pointed out the good effect of 
 chloroform, taken internally in a twenty-minim dose, in relieving 
 severe tenesmus in dysentery. Dr. Stovell f also bears testimony 
 to its utility. I have used it in several cases, and its power in 
 allaying the pain consequent on intestinal spasm is undoubted ; 
 but I have observed that when repeated several times it is apt to 
 create gastric irritation, indicated by a sense of heat at the epigas- 
 trium, and a florid tongue. Chloroform should, therefore, be only 
 used occasionally, to relieve tenesmus or other symptoms of spasm 
 of the muscular fibre of the intestine, when urgent. % 
 
 We have hitherto been engaged in considering the two first indi- 
 cations of cure (p. 291). The third remains to be noticed. 
 
 3. The third indication of cure has in view the repair of ulcers 
 of the mucous coat. This, after increased vascular action of the 
 mucous lining has been subdued, must be effected by tonic treat- 
 ment in its most extensive sense — medicinal, dietetic, climatic — 
 and by restraining the excessive discharges which are apt to exist 
 in old cases in reduced subjects. 
 
 On the use of astring&rds and tonics. — In the advanced stages 
 of dysentery, when ulceration exists, when recovery is only possible 
 by processes of repair, and when the lesion is attended with free 
 discharges from the bowels and a deteriorated state of the consti- 
 tution, then as already stated the efficacy of opium is very appa- 
 rent. Under the same circumstances, astringent and tonic reme- 
 dies are often very beneficial. Of these the most common are 
 acetate of lead, nitrate of bismuth, sulphate of quinine, sulphate 
 of copper, preparations of iron, nitrate of silver, catechu, kino 
 
 * " Transactions Medical and Physical Society of Bombay," New Series, No. 3, 
 Appendix, p. iii. 
 
 t Ditto, p. 32. 
 
 I The vapour of chloroform introduced into the rectum, is probably deserving of a 
 more extensive trial than it lias yet had in the circumstances for which opiate enemata 
 are usually employed. It might be conveniently applied by means of the simple caout- 
 chouc cylinder and tube, used by Dr. Simpson, for. conveying the vapour to the os uteri. 
 
 If it be a therapeutic fact a.- stated by Dr. Simpson, that carbonic acid is anaesthetic 
 and curative of foul ulcers, then applied by the same simple means it may be worthy 
 of trial in chronic dysentery. 
 
TREATMENT — ASTRINGENTS AND TONICS. 305 
 
 hasmatoxylon, pomegranate, Bael fruit, gallic and tannic acids. 
 The metallic salts are, in general given, with varying quantities of 
 opium, and on this combination much of the benefit doubtless 
 depends. 
 
 Astringents and tonics, however, have hitherto been used with 
 little discrimination, and further careful observation is necessary to 
 determine the circumstances of the disease for which they are re- 
 spectively applicable. All that I can attempt on this point is to 
 offer some suggestions on principles and then to state the result of 
 my own experience of particular agents. 
 
 Astringents are indicated only in chronic dysentery, and in the 
 hemorrhagic form of the acute disease. In chronic dysentery, 
 ulcers or other lesions require to be repaired ; and, for this, some 
 degree of tone of constitution is favourable. Increased intesti- 
 nal discharges debilitate the system ; therefore we endeavour to 
 restrain them by astringents. This is the simplest and probably 
 the truest explanation of the action of this class of remedies in 
 chronic dysentery; and should the astringent principle be in 
 combination with a tonic principle, then the efficacy of the re- 
 medy will be enhanced. 
 
 A condition of the body fit for the reparation of lesions can only 
 be brought about and maintained by suitable arrangements of the 
 vital stimuli — food, air, &c. Medicines which favour the action 
 of these stimuli, are named tonics ; but they are very subsidiary 
 to the vital stimuli themselves, and must always be used with much 
 care, lest they operate adversely instead of favourably. This cau- 
 tion is especially necessary, in diseases of the alimentary canal; 
 hence in the treatment of chronic dysentery there is risk of 
 injury in unskilful hands from astringents and tonics. 
 
 The cachectic states associated with chronic dysentery are various. 
 The special means at our command for the correction of special 
 cachexias are limited, but they should be carefully studied with a 
 view to their increase ; for it is in this direction that the resources 
 of medical art are most susceptible of improvement in the treat- 
 ment of chronic dysentery. In illustration of this statement it 
 may be observed that when dysentery is related to malarious cachexia, 
 we may expect the greatest benefit from astringent and tonic pre- 
 parations of iron, from quinine, and from a combination of vege- 
 table bitter and astringent principles. When there is reason to 
 think that the cachexia is scorbutic, we may turn with confi- 
 dence to vegetable acids, and to astringent, tonic, and mucilaginous 
 principles in combination with them. It is in this diathesis 
 
 x 
 
306 DYSENTERY. 
 
 that the Bael fruit, lately again favourably reported of in Bengal, 
 by Mr. Grant and others*, is probably useful. 
 
 My experience of the Bael fruit is limited, yet I may venture to 
 entertain the apprehension that unless the states of the disease for 
 which it is appropriate be carefully determined, the good which it 
 is doubtless capable of effecting in suitable cases will be lost to 
 medical practice. I do not suppose that physicians expect to find 
 in the Bael, or any other article of the Materia Medica, a 
 universal remedy for dysentery; but I have had opportunities of 
 learning something of the state of popular credulity in the instance 
 of the Bael, and of noting its tendency to exercise an injurious 
 influence on rational treatment. 
 
 Still another remark may be made on such remedies, as pome- 
 granate, Bael fruit, and others whose positive therapeutic proper- 
 ties cannot be great. There is reason to believe that sometimes 
 the benefit is negative. The fact may be lost sight of that 
 these kind of remedies are usually had recourse to after many 
 others have been previously tried, and not unfrequently injuriously 
 continued ; and that, therefore, the benefit from the change may pro- 
 ceed from the removal of lsedentia, not the application of juvantia. 
 That this suggestion is not fanciful I know from experience. In 
 dysentery in children it often happens that if opiates be unduly 
 continued, the discharges become pasty and scanty, and the general 
 state of the child deteriorates. If under these circumstances the 
 opiates be omitted, and a weak decoction of pomegranate be substi- 
 tuted, speedy improvement maybe anticipated. But in these facts, 
 there is not proof of the therapeutic virtue of the pomegranate, 
 but merely evidence of a want of skill in the previous use of the 
 opiates. It is well observed by Cullen that the physician shows as 
 much skill in determining when to leave off a remedy as when to 
 prescribe it. There can be no doubt that a want of appreciation of 
 the injurious effects of previous remedies is a great source of fallac}', 
 in judging the true effects of subsequent ones ; and to no disease 
 does this principle apply more forcibly than to dysentery. 
 
 Acetate of lead has been little used by me in the treatment of 
 dysentery, because the trials which I have from time to time made 
 have failed to inspire me with confidence. To improve the gene- 
 ral state of the constitution is an indication in chronic dysentery, 
 but this result is not to be looked for from a salt of lead, and 
 therefore the continued use of this agent must generally be inexpe- 
 dient. Acetate of lead has, with a sad want of discrimination, been 
 
 * " Indian Annals of Medical Science," No. 3. 
 
TREATMENT — ASTRINGENTS AND TONICS. 307 
 
 occasionally given in the early stage of acute dysentery with inju- 
 rious consequences.* 
 
 Trisnitrate of bismuth, and quinine, have been frequently used 
 by me, and often with advantage. But sulphate of copper is the 
 remedy of this class which is most immediately and generally useful. 
 It has been given by me in doses of from a grain to two and a half 
 grains, with an equal quantity of opium, every sixth, fourth, or 
 third hour, according to the urgency of the symptoms. The 
 cases for which it has seemed most applicable, are those in which 
 the dejections are very frequent, copious, often frothy, showing 
 that the secretions from the small intestine are in excess, and not 
 retained, for any time, in the large intestine. In the advanced 
 stage of acute attacks with sanious blood-stained discharges — the 
 evident exudation from an extensive, irritable, probably sloughy 
 ulcerated surface — it is very proper to" try either the acetate of 
 lead or sulphate of copper, or any other astringent which may 
 hold out the prospect of benefit ; — but with a knowledge of 
 the existing pathological conditions, it is vain to expect much 
 advantage from their use. 
 
 Nitrate of silver, in closes of one to three grains, combined with 
 opium, has been occasionally tried by me, both in Europeans and 
 natives, but without evidence of its efficacy. 
 
 In respect both to the salts of copper and of silver, it may be 
 said that as we cannot point to any particular cachectic state for 
 the correction of which they are appropriate, their use must at 
 present be regarded as empirical, and attended with the occasional 
 risk of harm. 
 
 Of the preparations of iron, the solution of the persesquinitrate 
 has been the most efficacious in my hands. With the sulphate of 
 iron combined with opium I have been disappointed. 
 
 Of the vegetable astringents, gallic and tannic acids are the most 
 deserving of confidence in chronic dysentery. 
 
 It is very doubtful whether any astringent can be used with much 
 prospect of advantage, unless the tongue be moist and tolerably 
 clean ; and though in cases in which the tongue is florid, chapped, 
 and dryish, it may be proper to give them cautiously, — because 
 no other course is open to us, — still it should be done with 
 much watching, and with no sanguine expectation of a good result. 
 
 * Opportunities of observation after my return to India have convinced me that this 
 error in practice is much more common than I supposed, when I first expressed 
 this opinion. It is difficult to understand how a system of treatment which evinces 
 both ignorance of the therapeutic action of acetate of lead and of the pathology of 
 acute dysentery can have originated. 
 
 x 2 
 
308 DYSENTERY. 
 
 In chronic dysentery the evacuations are often pale, sometimes 
 almost of chalky appearance ; but this is not an indication of the 
 expediency of mercury, and not a contra-indication of astringents ; 
 for it not unfrequently happens that as the dejections decrease in 
 frequency, their colour gradually assumes a more healthy aspect. 
 
 Should the bowels show a tendency to become confined under 
 the use of astringent remedies, it is always better to intermit them, 
 and thus avoid the exhibition of a laxative or purgative, which, 
 under these circumstances, is apt to aggravate the disease. 
 
 The astringents which have been used with the view of restrain- 
 ing hsemorrhage in the hsernorrhagic form of dysentery, are chiefly 
 the acetate of lead and the vegetable astringents. The most strik- 
 ing effects of this kind which I have witnessed were in the practice 
 of Dr. Leith, from gallic acid and tincture of catechu — eight 
 grains of the former and two drachms of the latter were given every 
 hour and a half alternately, and port wine was at the same time 
 freely used. The case was one of haemorrhagic dysentery, with ady- 
 namic phenomena, in a European officer, and recovery was complete. 
 
 Fomentations to the abdomen, carefully used, are often 
 useful in the early stages of acute dysentery, and materially aid 
 the more important measures. The ivet compress of the hydro- 
 pathic system frequently proves a convenient mode of applying heat 
 and moisture to the surface of the abdomen. In chronic dysentery 
 the maintenance of an equable temperature of the surface of the 
 abdomen by appropriate clothing, flannel bandages, &c, is an 
 essential part of the treatment. 
 
 Blisters. — When symptoms of inflammation continue after local 
 detraction of blood has been sufficiently employed, a large blister 
 is not unfrequently applied to the abdomen ; but my belief is, that 
 blisters under these circumstances do little good, and, as they occa- 
 sion considerable discomfort, I am averse to their use. 
 
 When, however, the inflammatory action is limited to particular 
 parts of the intestine, as the caecum or sigmoid flexure, — indicated 
 by tenderness or induration, — and when, from the stage of the 
 disease, it is probable that ulceration is associated with that 
 inflammatory condition of the surrounding tissue which is favour- 
 able to disorganisation, and adverse to repair, — then a blister, of 
 two to three inches square, is often useful in succession to adequate 
 leeching. By this course the derivative advantages of the blister 
 are obtained without the risk of constitutional disturbance. 
 
 The liquor lyttoe has seemed to me the most convenient epispastic. 
 
 Enematu. — When tenesmus is urgent, and pain at the lower 
 
TREATMENT — USE OF ENEMATA. 309 
 
 part of the rectum distressing, the local application of opium by 
 enema, or suppository, often affords great relief. The addition of 
 acetate of lead has not in my experience seemed to increase the 
 efficacy of the opiate enema. 
 
 To these uses, and to the occasional exhibition of cold water 
 enemata, my experience of this class of remedies is restricted. 
 
 The exhibition of large enemata in the treatment of dysentery, 
 acute and chronic, has been lately urged upon the attention of the 
 profession by Mr. Hare *, of the Bengal Medical Service. In acute 
 dysentery a flexible tube is passed above the sigmoid flexure, and 
 warm water, without limit in quantity, is then slowly injected by 
 a powerful pump, till the patient complains of the distention, and 
 the abdomen becomes visibly enlarged. 
 
 In chronic dysentery large enemata (six or seven pints) are used 
 daily, witli the view of removing acrid secretions, softly stretching 
 the strictured parts, and applying emollient, astringent, or stimulant 
 lotions to the diseased surface of the intestine. 
 
 Though unable to offer an opinion on this system of practice 
 from my own observation, still it is incumbent on me to state the 
 convictions left on my mind from a consideration of the subject. 
 
 In respect to large warm water enemata in acute dysentery, I 
 would remark : — 1. That, should a case of dysentery present 
 itself in which there is good reason for believing that the large in- 
 testine is loaded with scybalous or other feculence, the advantage 
 of removing these contents by a sufficient enema of warm water 
 may not be called in question. But a case of dysentery answering 
 to this description I have never seen, and, if a possible occurrence, 
 it must be certainly so rare as not to call for notice in laying down 
 a method of treatment of this disease. 2. That many cases of 
 dysentery may recover well under rest, abstinence, and large 
 warm water enemata, is not to be doubted ; but such cases 
 will recover equally well under rest, abstinence, three or four 
 drachms of castor oil and an opiate, or even without these latter 
 means. Therefore in such the enemata are unnecessary. 3. 
 That the treatment of the severer forms of dysentery, in which 
 thickening soon takes place, or the inflammation is erysipelatous — 
 passing on to gangrene and sloughing, and secondary peritonitis, 
 — can be much advanced by the application of fomentations to the 
 affected mucous surface, is to invest this remedy, in respect to the 
 intestinal tissues, with a therapeutic value which it certainly does 
 not possess, when used in the same degrees and kinds of inflamma- 
 * " Indian Annals of Medical Science," No. 2, p. 485 and 495. 
 x 3 
 
310 DYSENTERY. 
 
 tion in other textures of the body. 4. That dysentery is caused 
 or kept up mainly by the acrid nature of the secretions is a patho- 
 logical doctrine from which I altogether dissent. Surely it is not 
 when the secretions from the small intestine are passing copiously 
 into the large intestine, and being discharged, that the symptoms 
 of the disease are most distressing. Is it not rather when the dis- 
 charges are scanty, and consist of little else than the mucous, 
 bloody, or serous exudations proceeding from the inflamed membrane 
 itself that we are chiefly called upon to palliate pain ? and though 
 it may be admitted, that under these circumstances the application 
 of warm water to the intestinal surface may have a soothing effect, 
 yet it cannot, on this account, be advanced to any other than a 
 very subsidiary and occasional place in the treatment of this serious 
 disease. 5. Under any circumstances of dysentery, to distend 
 the intestine, — thus alter the relation of the mucous to the other 
 coats, and do away with the advantage of rest, — is, I apprehend, 
 a proceeding of very doubtful expediency. But when we recollect 
 what pathology teaches us, that there comes a stage, often quickly, 
 and not marked by characteristic symptoms, in which the coats of 
 the intestine become friable, and sloughy apertures" are closed up 
 by tender patches of. lymph, I would ask, what is likely to be the 
 effect on such an intestine of water injected into it without limit by 
 a powerful pump, till the patient complains of distention and the 
 abdomen becomes visibly enlarged ? 
 
 In respect to the use of large enemata in chronic dysentery : — 
 1. All that has been said in relation to the acute form on the 
 removal of acrid secretions and the distention of the gut, applies 
 also to the chronic form. 2. In the treatment of cutaneous 
 ulcers, or those of visible mucous membranes, local applications are 
 undoubtedly useful ; yet they are subsidiary to general and consti- 
 tutional treatment, and to the rest, position, and support, by which 
 the local circulation of the part is favoured. Moreover, the degree 
 of utility accorded to topical remedies is contingent on the ulcera- 
 tion being visible, — that is, on our ability to vary the applications 
 according to circumstances, and to apply them with precision. 
 Keeping these facts in view, and recollecting that ulcers of the 
 large intestine are out of sight, I would ask whether the repeated 
 use of large injections of solutions of sulphate of copper, alum, 
 nitrate of silver, &c, are not as likely to be injurious as beneficial ? 
 It may not, I admit, be justifiable on these grounds, to dissuade al- 
 together from the use of these means in chronic dysentery, because 
 in the weakness of our art we must act at times on probabilities; 
 
TREATMENT — ON DIET. 311 
 
 but I can have no hesitation in recording my opinion that they 
 must at best be very subsidiary, always require to be used with 
 caution and discrimination, and under a full appreciation of the 
 leading importance of constitutional treatment and rest of the 
 affected structure in the management of chronic dysentery.* 
 
 On Diet. — The principles which direct the medical treatment of 
 dysentery must guide us in determining the diet appropriate in 
 particular cases and different stages. 
 
 So long as the indication of cure is, by antiphlogistic remedies, 
 to prevent disorganisation of the mucous coat, or to check its ex- 
 tension, the diet, as a matter of course, must be very restricted. 
 When, on the other hand, the indication of cure is to favour the 
 reparation of lesions, it must be recollected that the debilitated 
 or deteriorated system cannot effect this without suitable nutriment. 
 It must be supplied of that kind and in that quantity which the 
 digestive organs, in part impaired by disease, are capable of fit- 
 ting for assimilation. I need hardly observe that with neglect 
 of this essential part of treatment, medicine must be utterly 
 useless. 
 
 In arranging the diet for acute cases, in which antiphlogistic 
 
 * In medical writing I am most anxious to avoid the semblance of a controversial 
 spirit, from the tendency which it has to obstruct inqiiiry and true progress, yet I 
 cannot avoid noticing the subjoined passage with which Mr. Hare concludes his paper. 
 To use the vague statistical data of Indian or other hospitals for the determination of 
 questions in therapeutics, is an error which has exercised, and does still exercise, an 
 injurious influence on the practice of medicine. The statistics of disease adequate for 
 this important end do not as yet exist in India, or in any other country, except on a 
 most limited scale, and they will require to be of a nature very different from that of 
 ordinary hospital records. 
 
 To base on data altogether insufficient for the purpose an argument for returning to 
 the treatment of dysentery by salivation, is, I think, very much to be deplored. It is 
 advocating, on unsound reasoning, an injurious system of practice. Mr. Hare thus 
 writes : — 
 
 " I must remark, in conclusion, on malarious dysentery, that if the above treatment 
 by injections be not adopted, statistical facts of the most undoubted kind prove the 
 necessity of our returning without delay to the salivating system. For the returns of 
 the largest and longest established dysenteric hosjnital in the world, show, that since 
 mercury has been avoided, the mortality has been double, for many years' continuance, 
 what it was when salivation was sought for, as the first and only object of treatment ; 
 and to complete the remarkable proof of the importance of mercury (if my system by 
 quinine and injections be not received), these statistics clearly show, that as mercury 
 has gradually been disused, so the mortality has correspondingly increased. If statis- 
 tics then, are, as they ought to be, our only guide to rational practice, our path is clear, 
 — we must return to salivation till some more successful method be discovered. But 
 the fact that in treating 346 cases in Calcutta, I had but -±3 per cent, deaths, will, I 
 hope, induce a trial of large injections by others, and thus prevent the necessity of 
 resorting to the more injurious remedy — mercury." 
 
 x 1 
 
312 DYSENTERY. 
 
 remedies are indicated by the stage of the disease and the state of 
 the constitution, there is no difficult}-. Thin farinaceous solutions 
 in small quantity from time to time are the only food that is 
 necessary or safe : and as recovery advances, the change to more 
 nutritive food must be cautiously made. 
 
 But when the constitution is asthenic or cachectic, and organic 
 lesion exists, then the adjustment of the diet will require all the 
 judgment and skill of the physician : and, in regulating it, he must 
 be guided by his knowledge of the principles of physiology and 
 pathology, and of the digestibility and nutritive value of different 
 articles of food. Those from which selection may be made are 
 farinaceous solutions and jellies, milk, animal broths and jellies, 
 solid farinacea and animal food. "When a scorbutic diathesis is 
 suspected *, then the usual special modification of diet will be 
 necessary : it is in such states that ripe grapes have been given at 
 the Cape of Good Hope and elsewhere with advantage. In the use 
 of wine we must be also regulated by general principles : it will be 
 sometimes useful ; but, on the whole, the error of undue use is 
 more frequent than that of abstinence. 
 
 The affectation and empiricism of regarding particular articles 
 of food as of universal application must be avoided, and we should 
 keep always before us the golden rule, — when the indication is 
 to restore injured structures by nutrition, — not to overtask the 
 digestive and assimilating powers of the weakened system ; and 
 further we must recollect that, in dysentery it is a part of the 
 organs of digestion that is structurally impaired. 
 
 On Change of Air and of Climate. — In considering the causes 
 of dysentery, importance was attached to conditions of the atmo- 
 sphere as predisposing or exciting causes. 
 
 If an atmosphere, loaded with moisture, or vitiated b} T malaria or 
 emanations from decomposing vegetable and animal matter or 
 excess of carbonic acid, favours the onset of the disease, then re- 
 moval from these influences is essential to success in treatment. 
 But the physician, in applying this principle, will sometimes have 
 to exercise much judgment and discretion, in balancing the advan- 
 tages of rest and medical care and the disadvantages of local in- 
 fluences, against the evils of the excitement of motion and less 
 careful treatment. On the whole, however, this difficulty will not 
 often arise ; for the benefit from rest and careful medical treatment 
 
 * I use the term " suspected " because there can lie no question that the scorbutic 
 diathesis exists long before its presence is made certain by spongy gums and subcu- 
 taneous extravasations. 
 
TREATMENT — CHANGE OF AIR AND CLIMATE. 313 
 
 at the commencement of acute ctysentery is so unquestionable, 
 that we are not justified in withholding it unless the evidence 
 of injurious conditions of the locality be very clear. This 
 remark applies to such change of air as involves a journey and 
 the interruption of medical treatment, — not to that merely from 
 one house or room to another ; for in this, as in all other diseases, 
 the removal of the sick from confined houses and ground-floor 
 apartments to those that are well ventilated and elevated, is an 
 advantage which should be secured whenever practicable. 
 
 It may be laid down, then, as a rule subject to very few excep- 
 tions, that, in the management of acute dysentery, rest and watch- 
 ful medical treatment are to be enjoined; and the excitement and 
 disturbance of travelling and the interruption of medical care 
 strongly dissuaded from. 
 
 But to what extent are we to expect benefit from change of 
 climate in chronic dysentery ? If the climate, in which the patient 
 resides, is adverse to processes of repair — is not tonic iu its 
 general influence — but from malaria, moisture, or continued eleva- 
 tion of temperature, exercises a depressant influence on the vital 
 actions, then removal from such climate is a leading indication of 
 cure. 
 
 In selecting a climate suitable for such cases, we must be careful, 
 while we aim at securing a temperate and pure atmosphere, to 
 avoid considerable and sudden reductions of heat, by absolute 
 lowness of temperature, winds, or varying states of atmospheric 
 moisture. Eesort to the Hill Sanitaria in India, more particularly 
 in the cold season of the year, is, on these accounts, generally un- 
 suitable in this disease. In removing to other countries, the season 
 of the year and the character of their climate, in respect to these 
 atmospheric conditions, must be carefully considered ; and if they 
 cannot be altogether avoided, the risk of injury must, as far as 
 practicable, be obviated by great attention to clothing and avoid- 
 ance of exposure. A cold moist air is the most injurious. 
 
 The means by which the change is to be effected are also very 
 important, for exposure to the excitement of motion, unsuitable 
 food, confined and vitiated air, in the passage from one country to 
 another, are injurious influences, often overlooked, but which the 
 physician must never neglect in recommending change of climate. 
 For example, the efficacy in chronic dysentery of a sea voyage in 
 temperate latitudes, in a comfortable roomy ship, is undoubted. 
 From the diminished alvine and urinary excretion, observed in 
 persons at sea, we may infer that there is a corresponding increase 
 
314 DYSENTERY IN CHILDREN. 
 
 of pulmonary and cutaneous elimination; and that the benefit 
 derivable from a sea voyage, in affections of the bowels, is perhaps 
 in part to be explained by this altered relation of the eliminatory 
 processes, and the fuller influence of oxygen which is involved in 
 it. But this advantage of sea air is in a great measure neutralised 
 in the overland journey from India as now conducted. The invalid 
 has to contend with the adverse influences of the discomfort of the 
 coaling stations, the fatigue and excitement of the journey through 
 Egyp^ the unsuitable dietaries, and the overcrowded and badly 
 ventilated cabins. These are all serious evils *, and are sure to 
 operate injuriously on those who journey from India by this route, 
 in any but a state of advanced convalescence. 
 
 Section VI. — Dysentery in Children in India. 
 
 My opportunities of studying the morbid anatomy of dysentery 
 in young children have been limited, and I am unable to say to 
 what extent the sloughy disorganisation, common in the adult, 
 occurs in the early periods of life. 
 
 The general description of the symptoms, and the principles laid 
 down in respect to the causes and the treatment, apply equally to 
 all ages. 
 
 In regard to the treatment, it may be further observed, that in 
 the child the abstraction of blood is inexpedient, and the necessity 
 of it is best obviated by early and careful watching, and by such 
 judicious use of other means as shall prevent the disease passing 
 to that degree of severity which may require the application of 
 leeches. 
 
 Caution in the use of calomel is as applicable to the child as to 
 the adult. It can only be requisite in sthenic children, and then 
 merely at the commencement of the attack, in small doses, com- 
 bined with ipecacuanha, and not repeated above two or three 
 times. Fomentations or the wet compress are very useful in the 
 acute dysentery of children. The indication for the use of castor 
 oil, in small doses, and the cautions against its abuse, are the same 
 as those laid down in respect to the adult ; with perhaps this modi- 
 fication, that a greater degree of alvine excretion is physiological 
 
 * I venture on this statement from haying been a passenger in 1853, in three of the 
 vessels of the Peninsular and Oriental Company, on the Suez and Calcutta line, and in 
 two between Bombay and Ceylon. Also in 1854 from Bombay to Suez, in one of the 
 Hon. Easl India Company's vessels: in this the adverse influences complained ofwere 
 still more apparent. Again from Suez to Bombay in 1856, and Bombay to Suez in 
 1859, in the Peninsular and Oriental Company's vessels. 
 
TREATMENT. 315 
 
 during the season of growth, and that this fact should not be lost 
 sight of in using laxatives. 
 
 Dpecacuanha, given in the manner already recommended, is fully 
 as valuable a remedy in the treatment of dysentery in the child as 
 in the adult. It may be combined with blue pill and extract of 
 gentian, and be given, rubbed up with a little aromatic water ; or 
 the extract of gentian may be dried, and chalk and mercury sub- 
 stituted for the blue pill, and the compound prescribed in the form 
 of powder. If opium be indicated, a suitable proportion of Dover's 
 powder may be added. For a child between two and three years 
 of age, two grains of ipecacuanha will be a suitable dose in the 
 acute disease. It may be increased or lessened according to the 
 constitution of the child, the acuteness of the symptoms, and the 
 tolerance of the remedy. The following case illustrates the effi- 
 cacy of the ipecacuanha in the treatment of dysentery in childhood: — 
 
 93. Acute dysentery in a child. — Treated with ipecacuanha ami blue pill. — Charles 
 Bowen, a European child, of three years of age, after suffering from dysenteric sym- 
 ptoms for fifteen days, was received into hospital on the 9th December, 1851. The calls 
 to stool were Yery frequent ; the evacuations were scanty, consisted of blood-tinged 
 mucus, and were passed with straining and prolapsus. The skin was dry, and above 
 the natural temperature ; the tongue was white ; there was no fulness of abdomen, 
 and he did not acknowledge abdominal tenderness. Two grains of ipecacuanha 
 three of extract of gentian, Dover's powder, and blue pill, each one grain, were given 
 eveiy third hour. The hip-bath and fomentations were used, and the diet consisted 
 chiefly of sago. The improvement was rapid : the stools became less frequent, more 
 copious, feculent ; passed with less straining and no prolapsus. The Dover's powder 
 was omitted and the medicine was continued at longer intervals. He was discharged 
 well on the 15th. 
 
 Opium in the form of Dover's powder, or the compound chalk 
 powder with opium, is also beneficial in the treatment of dysentery 
 in children, and the principles laid down for its use in the adult 
 should be observed, with, however, this additional caution. The 
 astringent effect of opium in the adult is more likely to be adverse 
 in sthenic states of the system when excretion is most active. This 
 principle also applies to the child during the season of growth. 
 The continuous use of opiates is a more common practice in the 
 treatment of dysentery in the child than in the adult; whereas, if 
 the law just stated be correct, it ought to be less so, and to be 
 conducted with more caution. 
 
 When the disease becomes chronic in children, we must trust 
 chiefly to vegetable astringents and the preparations of iron, with 
 judicious adjustment of food and of climate, and attention to the 
 state of the skin. 
 
316 GASTRO-ENTERITIS. 
 
 Section VII. — On Gastro-Enteritis. 
 
 This disease — inflammation of the mucous coat of the stomach, 
 of the small intestine, and of the colon — is not uncommon in its 
 chronic form in cachectic individuals, both European and native. 
 It is characterised by some degree of irritability of stomach, chiefly 
 after taking food, accompanied with more or less diarrhoea. The 
 skin is dry, the body is emaciated, the abdomen retracted, and the 
 tongue florid, glazed, and sometimes aphthous at the tip and edges. 
 In fatal cases the mucous membrane of the stomach presents 
 patches of dark, marbled redness, and is often softer than natural. 
 The lower part of the ileum and the colon are the parts of the in- 
 testinal canal usually affected. The morbid appearances are 
 vascular patches, sometimes with softening, at others with granular 
 exudation. The solitary glands are often enlarged and prominent, 
 and circular ulcers are occasionally found scattered here and 
 there. 
 
 In consequence of the general relation of chronic gastro-enteritis 
 to depraved states of constitution the treatment is perplexing and 
 unsatisfactory. It resolves itself into carefully-regulated diet, 
 attention to the functions of the skin by suitable clothing, the use 
 of opium in small doses, with alkalies, or (according to the dia- 
 rrhoea) vegetable astringents. Dilute hydrocyanic acid with bi-car- 
 bonate of soda, is often very useful in allaying the irritability both 
 of the stomach and of the bowels. An occasional small blister to 
 the epigastrium or right iliac region is also attended with benefit. 
 In selecting a suitable climate, the extremes of heat and cold and 
 much moisture should be avoided. 
 
 The practical lesson inculcated by these brief remarks is the 
 great importance of 'preventing the cachectic states on which the 
 occurrence and intractable nature of gastro-enteritis mainly depend. 
 
 Section VIII. — On Diarrhoea. 
 
 The term diarrhoea occupies a prominent place in the hospital 
 returns of tropical climates, because it is often used in its etymolo- 
 gical, not its pathological sense. It is only correctly applied to in- 
 creased alvine discharges, dependent on active or passive congestion 
 of some part of the mucous lining of the intestinal canal. The 
 increased evacuations consequent on inflammation of the same 
 tissue, either in its early stages or after it has led to structural 
 
DIARIUKEA. 317 
 
 change, are inaccurately designated diarrhoea. Yet this name is 
 often given to chronic dysentery, muco-enteritis, and gastro-enteritis; 
 and the returns of disease are in consequence rendered incorrect 
 and untrustworthy. The diagnosis is not difficult; it rests on a 
 careful consideration of the history of the case and of all the 
 attendant symptoms. 
 
 Let us now consider the varieties of true diarrhoea. 
 
 1. Transient increased feculent discharges, consequent on excess 
 or errors of diet, or exposure to cold, occur in India in the pre- 
 viously healthy, as in all countries, but not so frequently. This form 
 of diarrhoea requires, however, to be watched with care, because, as 
 already explained, both dysentery and cholera often commence with 
 very similar discharges (pp. 221, 281). 
 
 2. In Europeans recently arrived, increased discharges, tinged 
 with acrid bile, — bilious diarrhoea, — occasionally occur ; but this 
 is a rare form of disease in the seasoned European and in the 
 natives of India. 
 
 3. In asthenic or cachectic persons, Europeans or natives, diarrhoea 
 is apt to come on consequent on errors of diet, but much more 
 frequently from cold and wet. The discharges are watery, generally 
 pale, often chalky and yeasty in appearance. We have illustrations 
 of this form of disease in the cold and rainy seasons at hill stations 
 in India, or in the change to colder latitudes at unseasonable periods, 
 or imprudently conducted. In fatal cases, the mucous membrane 
 of the intestine is found pale and attenuated. It is an error to 
 suppose, as many do, that this diarrhoea is symptomatic of hepatic 
 derangement. No doubt the secretion of bile is deficient ; but 
 can it be otherwise when the system is ansemic, and an active 
 derivation of the fluids to the intestinal surface is going on. 
 
 The indications of cure are a regulated diet, derivation to the skin 
 by a suitable climate and appropriate clothing, the use of astrin- 
 gents, and the kind of tonics best adapted to the particular constitu- 
 tional state. If there be a series of amendments and relapses, the 
 disease may continue as a diarrhoea for a considerable period, but its 
 tendency always is, under lengthened continuous persistence, to pass 
 into chronic dysentery, muco-enteritis, or gastro-enteritis: hence 
 the reason why in fatal cases the structural lesions of inflamma- 
 tion are often present. 
 
318 
 
 DYSENTERY AND DIARRIICEA. 
 
 Section IX. — Statistics of Dysentery in the European Hospital, 
 and of Dysentery and Diarrhoea in the Jamsetjee Jejeebhoy 
 Hospital and Byculla Schools at Bombay* 
 
 Table XXIV. — Admissions and Deaths, with Per-centage, from Dysentery, 
 in the European General Hospital at Bombay, for the Five Years from 
 July 1838 to June 1853. 
 
 
 
 
 July 1838 to June 1843. 
 
 Monthly Average. 
 
 
 
 
 Deaths on 
 
 Admissions 
 on total 
 
 Deaths 
 on total 
 
 
 
 
 
 Admissions. 
 
 Deaths. 
 
 January 
 
 78 
 
 17 
 
 21 
 
 8 
 
 14 
 
 2 
 
 39-5 
 
 February 
 
 
 
 29 
 
 12 
 
 41 
 
 8 
 
 7 
 
 
 
 37-5 
 
 March . 
 
 
 
 34 
 
 5 
 
 11 
 
 6 
 
 8 
 
 3 
 
 151 
 
 April . 
 
 
 
 37 
 
 8 
 
 21 
 
 6 
 
 6 
 
 3 
 
 19-5 
 
 May . 
 
 
 
 34 
 
 9 
 
 26 
 
 4 
 
 4 
 
 
 
 11-2 
 
 June 
 
 
 
 49 
 
 9 
 
 18 
 
 3 
 
 6 
 
 2 
 
 17-6 
 
 July . 
 
 
 
 57 
 
 8 
 
 14 
 
 
 7 
 
 9 
 
 21-6 
 
 August . 
 
 
 
 43 
 
 7 
 
 16 
 
 2 
 
 7 
 
 
 
 20-0 
 
 September 
 
 
 
 33 
 
 11 
 
 33 
 
 3 
 
 6 
 
 
 
 21-1 
 
 October 
 
 
 
 47 
 
 3 
 
 6 
 
 2 
 
 6 
 
 
 
 11-1 
 
 November 
 
 
 
 73 
 
 6 
 
 8 
 
 2 
 
 10 
 
 6 
 
 12-7 
 
 December 
 
 
 
 93 
 
 18 
 
 19-3 
 
 15-1 
 
 27-2 
 
 Total 
 
 
 
 616 
 
 113 
 
 18-3 
 
 8-1 
 
 20-7 
 
 Table XXV. — Admissions and Deaths, with Per-centage, from Dysen- 
 tery, in the European General Hospital at Bombay, for the Five Years, 
 from 1844 to 1848. 
 
 
 
 
 1844 to 1848. 
 
 Monthly Average. 
 
 
 
 
 
 
 Deaths 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 on total 
 
 Admissions. 
 
 on total 
 Deaths. 
 
 January 
 
 51 
 
 12 
 
 23-5 
 
 8-2 
 
 26-1 
 
 February 
 
 
 
 29 
 
 9 
 
 31-03 
 
 2-6 
 
 256 
 
 March . 
 
 
 
 32 
 
 4 
 
 125 
 
 6-6 
 
 13-3 
 
 April . 
 
 
 
 21 
 
 6 
 
 28-6 
 
 4-1 
 
 19-3 
 
 May . 
 
 
 
 26 
 
 1 
 
 3-8 
 
 4-5 
 
 3-3 
 
 June 
 
 
 
 34 
 
 3 
 
 8-8 
 
 4-7 
 
 9-09 
 
 July . 
 
 
 
 58 
 
 6 
 
 10-3 
 
 8-5 
 
 16-7 
 
 August . 
 
 
 
 33 
 
 2 
 
 6-06 
 
 6-0 
 
 13-3 
 
 September 
 
 
 
 30 
 
 4 
 
 13-3 
 
 65 
 
 18-2 
 
 October 
 
 
 
 18 
 
 5 
 
 277 
 
 2-9 
 
 13-2 
 
 November 
 
 
 
 38 
 
 5 
 
 13-2 
 
 6-8 
 
 16-1 
 
 December 
 
 
 
 60 
 
 14 
 
 23-3 
 
 11-5 
 
 35-0 
 
 Total 
 
 
 
 430 
 
 71 
 
 16-5 
 
 6-3 
 
 18-4 
 
 * For farther information on the statistics of dysentery and diarrhoea, the reader is 
 referred to Sections I, and 111. of this Chapter. 
 
STATISTICS. 
 
 319 
 
 Table XXVI. — Admissions and Deaths, with Per-centage, from Dysen- 
 t< ry, in the European General Hospital at Bombay, for the Five Years 
 from 1849 to 1853. 
 
 
 
 
 1849 to 1853. 
 
 Monthly Average. 
 
 
 
 
 Death 
 
 Admissions 
 
 Deaths 
 
 
 Admissions. 
 
 Deaths. 
 
 Admissions. 
 
 on total 
 Admissions. 
 
 on total 
 Deaths. 
 
 January 
 
 56 
 
 17 
 
 30-4 
 
 12-4 
 
 43-7 
 
 February 
 
 
 
 23 
 
 4 
 
 17-4 
 
 62 
 
 222 
 
 March . 
 
 
 
 27 
 
 11 
 
 40-9 
 
 6-1 
 
 32-4 
 
 April . 
 
 
 
 37 
 
 6 
 
 16-3 
 
 7-2 
 
 24-0 
 
 May . 
 
 
 
 30 
 
 
 
 167 
 
 5-8 
 
 20-8 
 
 June 
 
 
 
 37 
 
 6 
 
 16-3 
 
 6-4 
 
 20-7 
 
 July . 
 
 
 
 46 
 
 9 
 
 19-6 
 
 8-7 
 
 27-3 
 
 August . 
 
 
 
 41 
 
 8 
 
 19-5 
 
 8-3 
 
 216 
 
 September 
 
 
 
 22 
 
 
 
 22-9 
 
 62 
 
 20-0 
 
 October 
 
 
 
 27 
 
 8 
 
 297 
 
 6-8 
 
 34-8 
 
 November 
 
 
 
 47 
 
 9 
 
 192 
 
 8-9 
 
 30-0 
 
 December 
 
 
 
 61 
 
 17 
 
 27-8 
 
 10-03 
 
 42 5 
 
 Total 
 
 
 
 454 
 
 105 
 
 23-1 
 
 7-8 
 
 29-4 
 
 Table XXVII. — Admissions and Deaths, with Per-centage, from Dysen- 
 tery, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six Tears 
 from 1848 to 1853. 
 
 
 
 
 184S to 1853. 
 
 M 
 
 onthly Averag 
 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths 
 
 on 
 
 total Deaths. 
 
 January 
 
 120 
 
 49 
 
 40-8 
 
 5-7 
 
 10-9 
 
 February 
 
 
 
 93 
 
 26 
 
 27-9 
 
 4-9 
 
 8-1 
 
 March . 
 
 
 
 65 
 
 34 
 
 52-3 
 
 3-02 
 
 8-8 
 
 April . 
 
 
 
 73 
 
 35 
 
 47-9 
 
 3-4 
 
 10-2 
 
 May . 
 
 
 
 91 
 
 20 
 
 21-9 
 
 41 
 
 6-9 
 
 June 
 
 
 
 82 
 
 43 
 
 52-4 
 
 3-8 
 
 14007 
 
 July . 
 
 
 
 129 
 
 55 
 
 426 
 
 0-3 
 
 14-7 
 
 August . 
 
 
 
 118 
 
 46 
 
 38-9 
 
 5-9 
 
 14-03 
 
 September 
 
 
 
 99 
 
 44 
 
 44-4 
 
 4-8 
 
 14-1 
 
 October 
 
 
 
 75 
 
 36 
 
 48-0 
 
 3-5 
 
 10-6 
 
 Ni 'Y ember 
 
 
 
 102 
 
 37 
 
 36-2 
 
 4-7 
 
 112 
 
 December 
 
 
 
 154 
 
 49 
 
 31-8 
 
 66 
 
 123 
 
 Total 
 
 
 
 1,201 
 
 474 
 
 39-4 
 
 4-7 
 
 11-5 
 
320 
 
 DYSENTERY AND DIAERIKEA. 
 
 Table XXVIII. — Admissions and Deaths, with Per-centage,from Diarrhoea, 
 in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six Years from 
 1848 to 1853. 
 
 
 
 
 1848 to 1853. 
 
 Monthly Averag 
 
 e. 
 
 
 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 
 
 Admissions. 
 102 
 
 Deaths. 
 
 on total 
 
 Admissions. 
 
 on total 
 
 Deaths. 
 
 January 
 
 41 
 
 40-2 
 
 4-9 
 
 9-1 
 
 February 
 
 
 
 65 
 
 30 
 
 46-2 
 
 3-4 
 
 9-4 
 
 March . 
 
 
 
 57 
 
 39 
 
 68-4 
 
 2-6 
 
 10-1 
 
 April . 
 
 
 
 73 
 
 22 
 
 30-1 
 
 3-4 
 
 64 
 
 May . 
 
 
 
 83 
 
 24 
 
 28-9 
 
 3-8 
 
 8-4 
 
 June 
 
 
 
 93 
 
 25 
 
 26-8 
 
 4-5 
 
 81 
 
 July . 
 
 
 
 122 
 
 44 
 
 36-4 
 
 6-04 
 
 111 
 
 August . 
 
 
 
 110 
 
 61 
 
 55 - 5 
 
 5-5 
 
 18-6 
 
 September 
 
 
 
 91 
 
 33 
 
 36-2 
 
 4-4 
 
 10-6 
 
 October 
 
 
 
 111 
 
 40 
 
 36-04 
 
 52 
 
 10-03 
 
 November 
 
 
 
 93 
 
 30 
 
 32-1 
 
 4-3 
 
 9-07 
 
 December 
 
 
 
 104 
 
 36 
 
 34-6 
 
 4-5 
 
 9-08 
 
 Total . 
 
 
 
 1,104 
 
 425 
 
 38-5 
 
 4-3 
 
 10-3 
 
 Table XXIX. — Admissions and Deaths, with Per-centage, from Diarrhoea 
 and Dysentery, in the Byculla Schools, for the Seventeen Tears from 
 1837 to 1853. 
 
 
 
 
 1837 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 9 
 
 Deaths on 
 Admissions. 
 
 
 
 January 
 
 95 
 
 1 
 
 1-05 
 
 
 
 February 
 
 
 
 117 
 
 3 
 
 2-56 
 
 
 
 March . 
 
 
 
 142 
 
 4 
 
 2-8 
 
 
 
 April . 
 
 
 
 131 
 
 6 
 
 4-58 
 
 
 
 May . 
 
 
 
 151 
 
 2 
 
 1-32 
 
 
 
 June 
 
 
 
 213 
 
 3 
 
 1-4 
 
 
 
 July . 
 
 
 
 285 
 
 7 
 
 2-43 
 
 
 
 August . 
 
 
 
 195 
 
 9 
 
 4-63 
 
 
 
 September 
 
 
 
 97 
 
 3 
 
 3-09 
 
 
 
 October 
 
 
 
 83 
 
 1 
 
 1-2 
 
 
 
 November 
 
 
 
 95 
 
 2 
 
 21 
 
 
 
 December 
 
 
 
 82 
 
 1 
 
 1-23 
 
 
 
 Total 
 
 
 
 1,686 
 
 42 
 
 2- 19 
 
 
 
321 
 
 CHAP. XV 
 
 ON HEPATITIS. 
 
 Section I. — Comparative Prevalence of Hepatitis. 
 
 The following table shows the ratio of hepatitis to strength in 
 European and Native troops in the three Presidencies : — 
 
 * Presidency, 
 
 EUROPEANS. 
 
 NATIVES. 
 
 - £ - 
 
 « -a 
 
 o 
 
 u '_ -5 
 S~- to 
 C g B 
 
 » ° uo 
 
 5 2 I 
 
 Sol 
 
 cS 
 u - — 
 5 = S 
 B'Se 
 
 IP 
 
 Ed w — 
 
 u to 3 
 
 (S o 
 
 2 5 o 
 
 Bengal . 
 Bombay . 
 Madras . 
 
 5-6.5 
 7-78 
 7-0 
 
 0-40 
 0-41 
 0-29 
 
 7-16 
 
 5-27 
 4-1 
 
 o-io 
 
 0-18 
 0-12 
 
 •007 
 •019 
 ■013 
 
 7-54 
 10-28 
 10-07 
 
 A judgment may be formed of the comparative prevalence of the 
 disease in India, by observing the ratio in other countries ; thus 
 the per-centage of admissions to strength is in — f 
 
 Canada 
 
 Nova Seotia 
 
 England . 
 
 Malta 
 
 Cape of Good Hope 
 
 •7-5 per cent. 
 •82 
 84 
 2-09 
 
 2-18 
 
 Though hepatitis is a more common disease in India than in 
 temperate climates, still it is rare compared with fevers and affec- 
 tions of the bowels, as is proved by the following tabular state- 
 ment : — 
 
 * "Ewart's Vital Statistics," pp. 127, 137. 
 
 f lb. p. 125, where there are also further similar facts in respect to other countries. 
 
322 
 
 HEPATITIS. 
 
 EUROPEAN TROOPS. 
 
 Pbesidexcy. 
 
 Fevers. 
 
 Dysentery and 
 Diarrhoea. 
 
 Hepatitis. 
 
 • £ - 
 
 tL Z — 
 
 lis 
 
 Per-centage 
 
 of Deaths to 
 strength. 
 
 Per-rentage 
 
 of Admissions 
 
 to strength. 
 
 a eg g 
 
 ■ e £ 
 
 Percentage 
 
 of Deaths to 
 strength. 
 
 Bengal . 
 Bombay . 
 Madras . 
 
 72-64 
 61-93 
 31-62 
 
 1-99 • 30-41 
 1-37 27-13 
 0-37 23-43 
 
 2-02 
 171 
 
 1-24 
 
 5-65 
 
 7-78 
 7-0 
 
 0-40 
 0-41 
 0-29 
 
 NATIVE TROOPS. 
 
 Presidency. 
 
 Fevers. 
 
 Dysentery and 
 Diarrhoea. 
 
 Hepatitis. 
 
 « c J 
 £'£ at 
 111 
 
 fa; 
 
 c 
 
 Per-centnge 
 
 of Deaths 
 to strength. 
 
 rt "» cm 
 
 OS c 
 C5 60 
 
 So* 
 
 c- 5 - 
 
 Sf c £ 
 c — c 
 
 i- . 
 
 O B c 
 
 Bengal . 
 Bombay . 
 Madras . 
 
 48-50 
 41-20 
 25-04 
 
 •528 
 
 •57 
 
 •30 
 
 6-18 
 6-57 
 3-08 
 
 •173 
 
 •196 
 
 •190 
 
 0-10 
 018 
 0-12 
 
 •007 
 •019 
 
 •013 
 
 A similar result also appears on examining the returns of the 
 European General Hospital and the Jamsetjee Jejeebhoy Hos- 
 pital, thus : — 
 
 
 „ Dvsenterv and 
 Fevers - "Diarrhoea. 
 
 Hepatitis. 
 
 Per-centage 
 
 of Admissions 
 
 on total 
 
 Admissions. 
 
 Per-ccntage 
 oi Deaths on 
 total Deaths. 
 
 Per-centage 
 
 of Admissions 
 
 on total 
 
 Admissions 
 
 Per-centage 
 
 nf Deaths on 
 total Deaths. 
 
 Per centage 
 of Admissions 
 
 on total 
 Admissions. 
 
 Per-centage 
 of Deaths on 
 
 total Deaths. 
 
 European General 
 Hospital. • 
 
 Jamsetjee Jejeebhoy 
 Hospital . 
 
 19-7 
 9-8 
 
 10-3 
 75 
 
 12-9 * 
 9-0 
 
 28-9* 
 21-8 
 
 3-7 
 lo 
 
 7-8 
 3-0 
 
 From these statements we learn that hepatitis, though a com- 
 mon disease in Europeans in India compared with temperate cli- 
 mates, does not nearly equal fever and affections of the bowels in 
 frequency or in the mortality which it occasions. Moreover I 
 believe that hospital returns in India very generally exaggerate 
 
 * As my own notes do not supply me with the return of diarrhoea in the European 
 General Hospital, I have incorporated the ratios of dysentery of my own tables with 
 those of diarrhoea of Dr. Stovell's Report, for the ten years from 1846 to 1856. 
 
PRELIMINARY REMARKS. 323 
 
 the proportion of hepatitis. A sense of fulness and weight in the 
 region of the liver from congestion and enlargement consequent on 
 recurring fever, are not unfrequently classed as hepatitis, partly 
 from inaccurate diagnosis, but chiefly because the nosological 
 classification in use has not kept pace with the progress of patho- 
 logy and does not provide for these distinctions. 
 
 Notwithstanding my belief that the frequency of hepatitis in 
 Europeans is over-estimated, I am certain that the statement made 
 by Twining, and generally concurred in by writers on tropical 
 disease, that " acute liver disease terminating in abscess is exceed- 
 ingly rare among Asiatics," * is erroneous. In six years the deaths, 
 from hepatitis in the Jamsetjee Jejeebhoy Hospital amounted 
 to 125, and the fifty-five cases of hepatic abscess in natives now 
 before me, and partly detailed in the sequel of this chapter, form 
 but a part of those which at different times have come under my 
 observation. The origin of this common error is easily explained. 
 The imperfect statistics of disease in the Indian army have been 
 applied to the general population of the country, which is equivalent 
 to judging of the forms of disease prevalent in England from the 
 hospital returns of the troops serving in that country. 
 
 Section II. — Preliminary Remarks on the nature of the Symp- 
 toms of Hepatic Disease. — Arrangement of the Subject. 
 
 In distinguishing the diseases of the liver, we are often un- 
 assisted by derangement of its function — that is, by altered condi- 
 tions of the biliary secretion. In many affections of this organ 
 there is no evidence that the secretion is modified ; and though it 
 has been customary to attribute various of the morbid appearances 
 presented by the alvine discharges to a changed state of the bile, 
 and to infer the existence of hepatic disease, yet the proof is 
 frequently insufficient, and the fact that the altered character of 
 the secretions may have been caused by the remedies used is often 
 lost sight of. 
 
 It is, therefore, very necessary that the clinical student should 
 avail himself of all other useful sources of information. Above all, 
 it is essential that he should bring to the inquiry a precise know- 
 ledge of the anatomical position and relations of the organ, and 
 that this should be constantly present to his mind while he inves- 
 tigates its morbid states. 
 
 * Twining, " Diseases of Bengal," vol. i. p. 388. 
 y 2 
 
324 HEPATITIS. 
 
 It is since the practice of percussion has been added to our 
 methods of diagnosis, that great accuracy in respect to the 
 position of the liver has acquired its full value; for by this 
 means we can ascertain during life the normal limits of the 
 organ, and also their increase or decrease. In the normal state 
 there is dulness on percussion from the sixth right rib, downwards 
 to the costal margin. The degree of dulness between the sixth 
 and seventh rib varies according as observation is made under 
 expiration or insjuration. Percussion about the fifth, sixth, and 
 seventh ribs should always be gentle, because as the convex 
 part of the liver rises as high as the level of the fifth rib, strong 
 percussion will indicate dulness higher than the sixth rib, and will 
 prevent us from determining whether the liver is normally, or 
 otherwise, overlapped by the thin part of the lung.* 
 
 There are leading features of the intimate structure of the liver 
 which should also be held in remembrance. The arrangement of the 
 portal capillaries, the position of the portal vein, and its branches 
 in the portal canals. The origin of the radicles of the hepatic 
 vein in the lobules, and their relation there to the portal capillaries. 
 The distribution of the hepatic artery. The situation of the origin 
 of the hepatic ducts. The supposed function of the hepatic cells, 
 and their relation to the terminal parts of the ducts. Nor may we 
 forget that by far the larger proportion of the blood flows through 
 the portal vein to serve the purpose of secretion ; and that a much 
 smaller portion circulates in the hepatic artery to serve for the 
 nutrition of the solid tissues of the organ, and then to mix with 
 the portal blood, and thereby, also, assist in secretion. The liver is 
 moreover abundantly supplied with lymphatics, and with nerves, 
 chiefly derived from the sympathetic system. 
 
 In describing the inflammatory affections of the liver I shall 
 use the terms Hepatitis and Cirrhosis. Hepatitis signifies 
 inflammation of the peritoneal covering of the organ, of its sub- 
 stance, or of both combined. When occurring in the investing 
 membrane, it may be recovered from with, or without, exuda- 
 tion of lymph and consequent adhesion. When occurring in 
 the parenchyma it may be recovered from, and the organ be left 
 
 * Though the great importance of careful systematic percussion in the diagnosis of 
 hepatic disease, is undoubted, still I have reason to believe that it is often very imper- 
 fectly attended to. It has happened to me on not a few occasions to become cognisant 
 of rases, iii which enlargemenl of the liver was undiscovered, though the exercise of 
 moderate skill in percussion could not have failed to detect it. And on the other 
 hand, I have known instances in which congestion or enlargement was erroneously 
 supposed to exist, simply because this means of diagnosis had been neglected. 
 
TATHOLOGY GENERAL REMARKS. 325 
 
 sound ; or exudation of lymph may take place, and abscess may 
 result. 
 
 The symptoms will be distinct or obscure, and the morbid 
 processes will follow a quick or a slow course, and will tend to 
 recovery or structural lesion according to the part and extent of 
 the organ implicated, and the diathesis of the individual affected. 
 
 The term Cirrhosis is applied to that slow inflammatory action 
 which, invading the fibrous and areolar tissues of the portal canals, 
 and generally caused by spirit-drinking, injures the structure of the 
 liver. 
 
 I prefer these terms to " suppurative inflammation," and " adhe- 
 sive inflammation," because the former, as a substitute for " hepa- 
 titis," does not include the cases of peripheral inflammation, and 
 seems to imply that every inflammation of the substance of the 
 liver, not of the character of cirrhosis, necessarily ends in suppura- 
 tion — a conclusion to which the observer of disease in India is 
 unable to assent. My objection to the term cs adhesive inflamma- 
 tion," as restricted to cirrhosis, is, that it would be more correctly 
 applied to those numerous inflammations, primary or secondary, of 
 the peritoneal covering of the liver which lead to exudation of 
 lymph and adhesion of surfaces. 
 
 In arranging my remarks on Hepatitis, I shall consider — 1st, the 
 pathology ; 2nd, the causes ; 3rd, the symptoms ; 4th, the treat- 
 ment. 
 
 Section III. — Pathology. — Preliminary Remarks on the General 
 Pathology of Hepatitis. — Morbid Anatomy of Stage of Vascu- 
 lar Turgescence, of Exudation of Lymph, and Formation of 
 Abscess explained. — The several Courses and Situations of 
 Rupture of Hepatic Abscess. — Abscess Absorption. — Secon- 
 dary Peritonitis and Formation of circumscribed Purulent 
 Sacs. — Secondary Pleuritis, circumscribed and general 
 Empyema. — Secondary Pericarditis. — General Secondary 
 Peritonitis. — Colour of Pus in Hepatic Abscess. 
 
 Before proceeding to describe the morbid anatomy of hepatitis, 
 I would notice a preliminary pathological question of some interest 
 and importance, but which, so far as I know, has not engaged the 
 attention of previous writers. Which are the capillary vessels of 
 the liver concerned in inflammation ? If the pathology of inflam- 
 mation be correct, viz., that it is an altered state of the nutritive 
 processes of the affected part, depending upon something faulty in 
 
 Y 3 
 
326 HEPATITIS. 
 
 one or other of the conditions of normal nutrition, — then the 
 capillaries concerned in inflammation must necessarily be those 
 which circulate, in their normal state, arterial blood for purposes 
 of nutrition. The capillaries of the hepatic artery are the nutrient 
 vessels of the solid structures of the liver, and consequently the 
 only ones which can be directly engaged in the inflammatory pro- 
 cesses of those structures.* On the other hand, the portal capil- 
 laries circulate venous blood for purposes of secretion, and are 
 not supposed to take any part in the nutrition of the liver; 
 they are therefore not directly engaged in inflammation. This 
 is not merely an unimportant speculation because — Firstly, if 
 we regard the small capacity of the capillaries of the hepatic artery 
 in comparison with those of the portal vein, we have, under the 
 view that the former are those concerned in inflammation, an expla- 
 nation of the fact that the bulk of the organ is little increased in 
 inflammation compared with congestion — a deranged state in 
 which the capacious portal capillaries are directly implicated. 
 Secondly, this view helps to explain how it happens that the secre- 
 tory function of the liver is often not deranged in hepatitis. Thirdly, 
 it tends to remove that difficulty which practical writers on hepati- 
 tis have experienced in reconciling the results of clinical observa- 
 tion with therapeutic theory. It has been urged that to give mercury 
 with a view to its cholagogue action in hepatitis is opposed to the 
 doctrine that the special stimulants of secreting organs are contra- 
 indicated in the active inflammations of these organs. But this 
 principle — doubtless true when the secreting capillaries and the 
 inflamed capillaries are the same, and both carrying arterial blood, 
 — cannot correctly apply to the liver, if the secreting capillaries 
 and the inflamed capillaries are distinct from each other. Further, 
 if we hold that the capillaries of the hepatic artery finally pass into 
 the portal veins, then to quicken the portal capillary circulation by 
 increasing secretion seems, in theory, a rational method of lessening 
 stagnation in the capillaries of the hepatic artery. These observa- 
 tions are not now made with any view of advocating the mercurial 
 treatment of hepatitis, for this question will be discussed elsewhere ; 
 but simply with the object of showing that the question — which 
 are the capillary vessels engaged in the inflammation, is not an idle 
 
 * I am aware that it may bo urged that the hepatic rolls must lie classed with the 
 solid structures of the liver, and thai (viewing the close analogy between secretion and 
 nutrition) in one sense it may be said that they are nourished by the pacta] capillaries. 
 But this is apart from the argument, and the usual meaning of nutrition, which, 
 speaking generally, is a process requiring as ono of its conditions arterial blood and 
 arterial capillaries. 
 
PATHOLOGY — STAGE OF TUMESCENCE. 327 
 
 one, but is intimately related to the therapeutics, as well as to the 
 physical signs, and the symptoms of hepatitis. 
 
 In considering the morbid anatomy of hepatitis, it is import- 
 ant to remember the great size of the liver, and the consequent 
 fact that inflammation will vary according as it involves a greater 
 or less extent, and one or several parts of the substance or surface. 
 
 That inflammation of the capsule of the liver, with but little 
 implication of the parenchyma, may really occur is not to be 
 questioned. We may believe that in some instances recovery 
 takes place and leaves behind no trace of disorder. In other in- 
 stances, however, adhesions between the opposing peritoneal surfaces, 
 or an opaque and thickened state of the membrane, without appre- 
 ciable change of the parenchyma, result. Appearances occasionally 
 found after death prove this ; but from their rarity we are justified 
 in concluding that inflammation, limited to the periphery of the 
 liver, is not a common form of disease in India. This is the com- 
 mon opinion, and a review of my own cases serves to confirm it. 
 Still the subject is one to which further attention should be 
 directed, for in recorded cases (my own as well as others) 
 positive information is often defective. It is hardly necessary 
 to observe that my present remarks do not apply to the almost 
 universal co-existence, at one period or other, of inflammation of 
 the peritoneal covering with that of the parenchyma : its absence 
 is exceptional, just as in the pleura and lung. 
 
 When the substance of the liver is the seat of inflammation, then 
 a period of vascular turgescence, analogous to the first stage of 
 pneumonia, is the first pathological condition. This may be resolved 
 by treatment, or may lead to interstitial exudation of lymph and 
 its ulterior changes. These morbid processes may affect portions 
 of the organ ranging from the size of a pea to that of an orange 
 and upwards ; and in number from one to many. It is seldom, if 
 ever, that inflammation of the entire substance of the liver occurs. 
 
 Opportunities of studying the post-mortem appearances of the 
 first stage of parenchymatous hepatitis are necessarily limited, for 
 death seldom occurs at this early period of the disease. Still occa- 
 sional instances of death from some other cause, the first stage of 
 hepatitis being present (Case 6), and the inspection of the parts of 
 the liver immediately surrounding exudations of lymph enable us 
 to ascertain the general appearance of vascular turgescence of the 
 liver. The structure is redder and softer than natural, and blood 
 oozes from it when cut. Kokitansky adds, that it is largely 
 granular. 
 
 Y 4 
 
32S HEPATITIS. 
 
 The large dark-red liver, easily lacerable into a bloody pulp, de- 
 scribed by the older writers on tropical disease, and by them re- 
 garded as evidence of inflammation, is not the state just described. 
 These were not appearances resulting from inflammation, but were 
 conditions of the organ found in fatal cases of congestive malarious 
 fever in full-blooded Europeans, and caused by accumulation of 
 deteriorated blood in the capacious hepatic venous systems. 
 
 Under the continuance of inflammation, however, the morbid 
 process will not long remain in the state of mere vascular turgescence. 
 Interstitial exudation of coagulable lymph, of varying extent will 
 soon follow. Still, so long as the lymph maintains the liquid form 
 in which it is first exuded, there is hope of complete recovery by 
 re-absorption and resolution. When, however, the lymph has 
 coagulated in the interstices of the parenchyma, then one of the 
 three following courses will result:- — 
 
 1. The liquid parts of the exudation may be absorbed, and the 
 solid lymph become organised into fibrous tissue. This termination 
 presupposes a good diathesis, exudation of limited extent, and the 
 return of the surrounding parenchyma to its normal state of capil- 
 lary circulation. We have evidence, I believe, of this occurrence 
 in the fibrous nodules or patches that are sometimes found in the 
 liver after death. (Cases 83, 84.) 
 
 2. The exuded lymph, instead of becoming organised, may re- 
 liquefy, be absorbed, and disappear. This termination is likely to 
 occur only in a good diathesis, when the exudation has been of. 
 limited extent, is recent, surrounded by tolerably norma,! structure, 
 has not been circumscribed by an organised layer, and has not been 
 so copious as materially to interfere with the vitality of the tissues 
 amid which it is placed. 
 
 3. The lymph changes into pus, the tissues amongst which it has 
 been deposited become softened, liquefy and disappear, and the 
 whole is more or less circumscribed by membrane of low organisation. 
 Hepatic abscess has formed. This termination is favoured by the 
 extent of the structure involved, the severity of the inflammatory 
 action, the copiousness of the exudation, and above all, by the 
 diathesis of the individual affected, and sometimes by the nature of 
 the cause. 
 
 This progress from vascular turgescence to the formation of 
 abscess may sometimes be distinctly traced, as I have been 
 enabled to verify in several instances. The following are the 
 appearances which have come under my notice : — 
 
 (a) A part of the substance of the liver is redder and softer 
 
PATHOLOGY — FORMATION OF ABSCESS. 32 'J 
 
 than the surrounding structure. (/>) Another portion exhibits 
 a similar appearance, but with the addition of a circumscribed 
 part of fawn yellow colour of moderate texture, caused by lymph 
 deposited in the centre of the inflamed tissues, (c) In another 
 part, a similar fawn-coloured circumscribed portion, but softer and 
 friable in the centre, indicating that the lymph has begun to 
 change into pus. (cZ) In a more advanced stage, the centre of 
 the deposit becomes broken down, and converted into pus ; the 
 parts immediately adjacent to the pus being shreddy and fiocculent, 
 those beyond fawn-coloured and firm, bounded by reddened paren- 
 chyma gradually passing into healthy structure, (e) In a still 
 more advanced stage, the outer layer of lymph becomes organised, 
 in varying degrees, into a membranous investment, and the central 
 jDarts — lymph and tissue — change more or less completely into pus, 
 varying in character according to the diathesis of the individual. 
 But even in this stage the inner surface of the investing membrane 
 is not unfrequently roughened and fiocculent from portions of the 
 vascular or other tissues, which, remaining in a condition more or 
 less organised, form nuclei round which flakes of shreddy lymph 
 become attached. 
 
 But the history of the formation of the abscess is not yet com- 
 pleted. More lymph exudes from the inner surface of the investing 
 membrane, and changes into pus. The sac becomes distended, the 
 bulk of the liver increased, and tumefaction takes place in different 
 directions, according to the situation of the abscess. Adhesion of 
 opposing serous surfaces follows; then the circumscribing wall be- 
 comes thin on one side by interstitial absorption, and pointing and 
 rupture succeed. Sometimes the tendency to point and to rupture 
 is counteracted by the sac becoming thickened and strengthened in 
 the following manner. The surrounding parenchyma becomes 
 compressed by the increasing sac, and, in consequence, the lobular 
 structure, for two or three lines around, is atrophied and disappears, 
 but the connecting tissue remains. (Case 99.) 
 
 The completion of these processes, that is, the formation of an 
 outer organised membrane, the change of the central lymph and 
 tissues into pus, the adhesions, interstitial absorption, and rupture 
 — must depend on the constitution of the individual, the size and 
 number of the abscesses, and the judgment displayed in the medical 
 treatment. In the greater number of hepatic abscesses death takes 
 place while these processes are yet in progress. 
 
 In this description of the formation of hepatic abscess, sketched 
 from actual observation, we find nothing different from what occurs 
 
330 HEPATITIS. 
 
 in the course of an ordinary phlegmonous abscess in a good con- 
 stitution : the parts of the lymph most remote from the living 
 tissues — the central — change into pus ; those adjacent to the living 
 tissues— the peripheral — become organised into membrane. 
 
 Without pretending to assert that this is the only way in which 
 abscesses of the liver are formed, I am very certain that it is the 
 most common. It readily explains why these abscesses are gene- 
 rally not single, and why, when several, they are often in various 
 stages of progress. Though it is no doubt true that large abscesses 
 are sometimes formed by the coalition of several adjoining small 
 ones, still I do not concur with Rokitansky in considering that this 
 is the only mode ; for I think there can be no question that a large 
 hepatic abscess has sometimes its origin in a single extensive lymph 
 exudation. 
 
 In these remarks reference has not been made to diffuse sup- 
 puration of the liver. In truth I have no knowledge of it. The 
 absence of circumscribing tissue may be observed in that stage 
 when, as yet the lymph has not all broken down ; but when the 
 change into pus has been nearly completed, there is, according to 
 my observation, always a limitary tissue of some kind. 
 
 The cases which follow (94 to 102) will be found to illustrate, 
 in some degree, the remarks which have now been made; also 125, 
 137, 140, 141, 172. 
 
 94. Abscess in the brain not suspected during life. — Abscess in the liver, with pneu- 
 monia of the lowest lobe of the right lung, revealed by symptoms. — Vascular turgescencc 
 of liver. — Thomas Saunders, boiler-maker, aged thirty-six, of stout habit, was admitted 
 into the European General Hospital on the 9th August, 1838. He had arrived lately 
 in India, and had suffered whilst in England from pain of his right side. He had been 
 ill for five days before admission with pain of head, side, and limbs. These symptoms 
 had lessened, but the pain of the right side had increased much the night before 
 admission ; it was at the margin of the ribs, was accompanied with cough and im- 
 peded full inspiration. After free leeching, the warm bath and purgatives, the side 
 became easy ; but the pain continued to recur from time to time, attended with head- 
 ache and frequent pulse, and hot skin towards evening. He was dull of hearing on 
 admission ; his manner was slow and undecided, and his hands tremulous ; his spirits 
 were depressed, and the pulse easily excited. The bowels were kept free by mercurial 
 and other medicines ; leeches and blisters were applied, and quinine was at different 
 times given. On the 1st. September it was thus reported : Is still nervous, but makes 
 no complaint of pain ; the pidse is easily excited ; there is abnormal fulness of the right 
 hypochondrium. About two inches below the right nipple, laterally and posteriorly 
 below the inferior angle of the seapida, there is dulness on percussion; the respiratory 
 murmur is obscure, with occasional sibilus and crepitation ; the latter, smaller behind 
 and rather suberepitous laterally. On the left side of the chest there is occasionally 
 sibilus, and mucous rhonchus ; there is no cough. Subsequently the cough became 
 troublesome, and the pulse frequent, and on the 16th he became drowsy for the first 
 time, then insensible, and died at 7 p.m. 
 
 Inspection twelve hours after death. — Head. — In the anterior and middle lobe of the 
 
PATHOLOGY — FORMATION OF ABSCESS. 331 
 
 right hemisphere there was an abscess of considerable size, the inner surface having 
 in parts a red fungous appearance ; and the surrounding substance of the brain was 
 softened. Abdomen. — The substance of the liver was red and softened, and adhered 
 to the ribs and the diaphragm ; on separating the latter adhesion a small abscess was 
 discovered, and opposed to it the lung adhered to the diaphragm. The lowest lobe of 
 the right lung was hepatised, and the left lung was congested with blood. 
 
 95. Hepatitis. — Several abscesses in the right lobe. — Nodules in the left lobe. — 
 The mucous coat of the colon ulcerated. — Serous effusion in the head without 
 symptoms. — John Robinson, aged twenty-six, a seaman, tall and fair, was admitted 
 with symptoms of acute hepatitis on the 7th February, 1840. He stated that 
 he had been ill since the day before admission. He was freely bled at the arm, 
 and very freely leeched, mercury was used internally and externally without inducing 
 ptyalism. On the 12th there began to be evening febrile accessions, which continued. 
 On the loth there was fulness at the margin of the right ribs with hepatic sound an 
 inch below them and to two inches from the nipple. The fulness of the side increased, 
 he became sallow and emaciated. The dejections were generally light yellow and 
 thin. The breathing became oppressive, and he died on the 22nd. 
 
 Inspection. — Head. — There was a thin veil of serum on the convex surface of tho 
 brain, and an ounce at the base of the skull. Chest. — The lungs were emphysematous, 
 and the liver encroached on the chest to the level of the fourth rib. Abdomen. — There 
 were no adhesions between the concavity of the diaphragm and the surface of the liver. 
 In the right lobe of the liver there were several abscesses, each the size of an orange. 
 There was one to the right of the mesial line and superficial ; two were at the concave 
 surface of the lobe, and their walls were in close adhesion with the hepatic flexure of 
 the colon. The inner surface of the walls of the abscesses was very flocculent when 
 floated in water. The left lobe filled the left hypochondrium, was of pale colour, and 
 presented whiter defined proportions the size of a pea, like tubercles in appearance, but 
 not so hard in texture. The colon was studded with closely set circular ulcers, some 
 of them sloughy ; where the adhesions to the liver were, there the ulcerations had 
 advanced furthest. At the end of the ileum there was granular yellow lymph effused. 
 
 96. Dysentery' complicated with delirium tremens. ■ — Milkiness of the arachnoid. — ■ 
 Matting of the omentum over thecolon. — Numerous sloughy ideerations of the mucous coat 
 of the cweum. — Many abscesses in liver. — Cornelius Moriarty, aged forty-six, a Serjeant 
 in the Grand Arsenal, of dissipated habits, and in hospital at different times with 
 delirium tremens. He was admitted on the 7th November, 1840, with symptoms of 
 hepatitis, complicated with delirium tremens. He died comatose on the 11th. 
 
 Inspection five hours after death. — The liver enlarged and mottled yellow, was 
 brittle and hard in texture, and seven or eight small abscesses were detected ; the 
 largest was the size of a walnut, the others the size of horse-beans. The smaller ones 
 were occupied with thick adhesive pus, the large one had the appearance of paren- 
 chyma infiltrated with purulent matter, but not yet broken down, and the sur- 
 rounding texture was mottled red and friable. The description of the other morbid 
 appearances is omitted. 
 
 97. Blii strates formation of abscess from breaking down of lymph deposit. — Pus 
 tinged with bile. — The corpuscles granidar and broken down. — Surrounding tumes- 
 cence. — The liver of a dysenteric patient with abscess was sent to me from the 
 European General Hospital. In the right side of the right lobe there was a part, the 
 size of a large orange, the centre pulpy and broken down ; around it, for quarter of an 
 inch, there was a thick layer of buff-coloured structure ; around that, for some dis- 
 tance, an engorged part. In one other place there was a yellow-buff portion the size 
 of a bean, without central pulpy state. The rest of the organ was healthy. Hepatic 
 cells were distinct under the microscope. In the central pulpy part the puriform fluid 
 was tinged yellow (bile) ; examined under the microscope, the biliary tinge was very 
 
332 hepatitis. 
 
 marked, and the corpuscles in greater measure had separated into their constituent 
 granules. 
 
 98. — Hepatitis. — Abscesses : in one, breaking clown of the 'parenchyma ; in the other, 
 the deposit in the interstitial tissue had not yet broken down into pus. — Mucous coat of 
 the colon dark red, and covered with firm granidar exudation. — Richard Cox, aged 
 forty-six, a seaman of the ship Tweed, was admitted on February 4th, 1841. He 
 stated that he had ailed for a week with dry cough, increased during the two days 
 previous to admission, and attended with pain at the lower part of the chest 
 extending to the epigastrium, and attended with pain on pressure. Pidse frequent ; 
 skin dry. He was bled once and leeched frequently ; took calomel in ten-grain doses. 
 The pain never ceased, though it was relieved. The mouth did not become affected. 
 There was not much purging, but the skin became washy, pulse feeble, countenance 
 collapsed; and he died on the morning of the 12th. 
 
 Inspection six hours after death. — Chest. — There were old adhesions of the pulmo- 
 nary to the costal pleura on both sides. Abdomen. — On the lateral part of the right 
 lobe of the liver there was a superficial abscess, containing dark reddish serous fluid ; 
 the inner surface of the sac was yellow and floceulent. About the middle of the 
 anterior part of the right lobe there was a somewhat prominent part, which, when 
 incised, showed a yellow substance the size of a walnut, softened in the centre, firmer 
 beyond. The parenchyma of the liver was generally mottled buff. The mucoxis coat 
 of the colon presented a dark red surface throughout the greater part, covered with a 
 yellow granular firm exudation with frequent traces of ulceration. There was com- 
 mencement of yellow deposit in one of the kidneys. 
 
 99. Hepatitis. — An abscess lined by firm membrane in the right lobe. — Several 
 nodules in different places of the liver ; in some suppuration commencing at the centre. 
 — Traces of ideeration in the colon. — Granular exudation on the mucous coat of the 
 rectum, — John Richard Paxiper, aged twenty-six, an Indo-Briton, was admitted on 
 the 29th January, 1841. He stated that for three weeks he had suffered from pain of 
 the right hypochondrium, increased much during the two days previous to admission. 
 The pain prevented full inspiration and decubitus on the right side. The pulse was 
 badly developed and frequent. He was leeched and blistered, and an attempt was 
 made to affect the system by the moderate exhibition of calomel and opium and 
 mercurial inunction. The pain was much relieved ; never, however, completely 
 removed. No fulness at the margin of the ribs occurred. The gums became swollen, but 
 he was never fully under the influence of mercury. On the 1st February dysenteric 
 symptoms appeared for the first time, following a seven-grain dose of calomel, and 
 attended with a good deal of tenesnuis till about the 5th. After this, the bowels were 
 moved generally seven or eight times in the twenty-four hours, the dejections being 
 brown and watery. He lost flesh. From the 8th the treatment was chiefly palliative, 
 anodynes with quinine and light nourishment. He died on the 17th. Rigors are not 
 noted as having occurred in any of the reports. 
 
 Inspection eighteen hours after death. — Body emaciated. Head. — There was a thin 
 veil of serum on the convex surface of the brain. Chest. — The right lung was emphy- 
 sematous, and adhered by tender bands to the diaphragm. The left lung was closely 1 
 United to the costal pleura. There were no tubercles in the lungs. The heart was 
 healthy. Abdomen. — The liver did not extend beyond the ribs. The surface was of 
 buff colour, externally and internally. The lateral part of the right lobe adhered to 
 the concavity of the ribs; and underneath the adhesions there was an abscess the size 
 of an ostrich egg, containing about twenty ounces of thick pus, and lined by a firm 
 cartilaginous membrane: beyond it, for three or four lines, the substance of the liver 
 was cartilaginous and condensed. From the inner surface of the sac loose fiocculi 
 depended. Elsewhere, here and there, in both lobes, there were round buff-yellow 
 defined portions from the size of a tare to a horse-bean, some consistent throughout, 
 others with a drop of pus in the centre. The mucous coat of the colon was pale, with 
 
PATHOLOGY — FORMATION OF ABSCESS. 333 
 
 traces of ulcers in process of cicatrisation. In the rectum there was granular lymph. 
 The mucous coat of the pyloric end of the stomach was mammillated ; at the cardiac 
 end there were dark brown vascular ramifications, but the texture of the coat was 
 sound. The kidneys were healthy. 
 
 100. Hepatitis. — Two large abscesses from degeneration of lymph and tissue. — TJie 
 liver mottled buff. — The raucous coat of the colon dark grey with red patches, and 
 several ulcers. — The kidneys malformed. — James M 'Martin, aged thirty-eight, of the 
 ship Ingleborough, was admitted into hospital on the 2nd February, 1841. He stated 
 that for a fortnight previously he had suffered from dysentery, and had passed blood 
 for several days. There was much tenderness across the abdomen, Pidse 100, irri- 
 table. He was bled to sixteen ounces, and freely leeched. The blood was cupped and 
 sizy. During his stay in hospital, the pain was chiefly about the margin of the right 
 ribs, shooting downwards to the iliac region, or backwards, or towards the epigas- 
 trium. Latterly there was distinct fulness and tenseness at the margin of the ribs. 
 On the 4th there was a distinct febrile paroxysm with rigors. The dysenteric symp- 
 toms were little urgent till the 12th, when a considerable quantity of brick-red puri- 
 form matter was dejected, and continued till his death, on the 14th. At first the case 
 was treated as one of dysentery, and ipecacuanha pills were given ; but they were 
 rejected and in consequence omitted. Subsequently an attempt was made to induce 
 mercurial action, but irritation residted, and it was not persisted in. Latterly wine 
 with quinine and opium were given. 
 
 Inspection tvjenty hours after death. — Chest. — The lungs were emphysematous, but 
 otherwise healthy; no costal or diaphragmatic adhesions. Abdomen. — There were 
 two large absdesses in the liver : one, to the right of the gall-bladder, had thin ante- 
 rior and lateral walls opposed to the abdominal parietes and the concavity of the false 
 ribs, and its lower wall adhered firmly to the hepatic flexure of the colon ; but there 
 was no communication with the gut. The other abscess, the size of a large orange, 
 was in the centre of the right lobe. There were no adhesions to the diaphragm. The 
 contents of both abscesses were dark brown, and quite serous. The inner surface of 
 the sacs was flocculent. The rest of the liver had a bright buff mottled appearance. 
 The walls of the colon were not thickened. The mucous coat was dark grey with 
 dark red patches and numerous extensive superficial ideers. There was a malformation 
 of the kidneys. The two kidneys were connected, and in a horse-shoe form, the con- 
 vexity downwards, extended across the abdomen, before the vessels and behind the 
 mesentery, — the whole length about ten inches, — the transverse part about one inch 
 and a half broad. Throughout the whole extent the cortical and tubular parts might 
 be traced, but the texture was soft and yellow, and probably altered by disease. 
 There were two ureters following their usual course. 
 
 101. Abscess in the liver. — Sac smooth without floccidi. — Large intestine, with 
 sloughy ulceration of the mucous coat. — Complicated with intermittent fever, which at 
 the commencement was the prominent feature. — Several lymph nodules.— -David Hop- 
 kirk, Indian Navy, aged twenty-six, was admitted on the loth December, 1840, under 
 the head of intermittent fever, and died on the 9th February. He had been ill for 
 three weeks before admission with regular febrile paroxysms. There was also pain, 
 increased on pressure, at the upper part of the abdomen. The chief symptoms during 
 his residence in hospital were the frequent recurrence of this abdominal pain with 
 occasional febrile paroxysms, with rigors at first — tendency to dysenteric symptoms — 
 marked during the last ten clays by considerable purging and tenesmus, with gradual 
 loss of flesh. He was never brought fully under the influence of mercury, though 
 calomel was given freely with this intention. He was bled freely, leeched and blis- 
 tered. There was clavus hystericus at one time, the result probabl}- of the depletory 
 measures. 
 
 Inspection eight hours after death. — Body emaciated. Bead. — Brain pale, with 
 
334 HEPATITIS. 
 
 about four drachms of serum at the base of the skull. Chest. — The lungs were emphy- 
 sematous, and there were old adhesions of the right lung to the costal pleura. The 
 heart was healthy. Abdomen. — The omentum spread over the intestines adhered to 
 the brim of the pelvis and to the ccecum. In many places the intestine, chiefly the 
 ccecum and sigmoid flexure, was black and friable. The inner surface of the gut 
 throughout presented a ragged sloughy appearance, with hardly a trace of the mucous 
 coat. The lateral part of the right lobe of the liver adhered to the parietes, and at 
 the point of adhesion there was a superficial abscess, the size of an ostrich egg ; the 
 sac lined with a firm, smooth membrane. In the parenchyma, and around the abscess, 
 there were several yellow points, the size of a pin's head ; and in the centre of the 
 right lobe there was one the size of a horse-bean. The liver was red and firmer than 
 natural. The mesenteric glands were generally enlarged, many of them being larger 
 than an almond. In the kidneys yellow degeneration had advanced considerably ; in 
 one it was uniform, in the other it was striated. 
 
 102. Large hepatic abscess, with shreddy f accident walls and surrounding vascular 
 turgescence. — No intestinal ulceration. — Shaik Abdoo, forty-three years of age, a Mus- 
 sulman, servant in a grog-shop, using spirits freely, of somewhat emaciated frame, 
 after ten or twelve days' illness, with pain of right side, cough, and daily double 
 febrile accessions, was admitted into the clinical ward on the 29th November, 1848. 
 There was dry cough, hiccup, tenderness below the right ribs, a yellow coated tongue 
 with florid edges, high-eoloiu'ed urine, relaxed bowels, and febrile disturbance. There 
 was a sense of induration with dulness in the epigastric region, and below the margin 
 of the right ribs to within about an inch of the umbilicus. These symptoms con- 
 tinued with aggravation of the diarrhoea, and he died on the 8th December. He was 
 treated with leeches over the tender part, followed by a blister, and calomel three 
 grains, ipecacuanha one grain, opium half a grain every fourth hour. Slight fulness 
 and tenderness of the gums on the 4th. 
 
 Inspection eleven hours and a half after death. — Chest. — Both lungs collapsed, and 
 were crepitating. Bight lung. — There were old adhesions between the upper lobe and 
 the costal pleura. The base of the lung adhered to the upper surface of the diaphragm, 
 by recently effused lymph, and the lateral surface of the third lobe to the opposite 
 costal pleura. A portion of this lobe was cedematous. No adhesions of the left lung. The 
 heart and pericardium were healthy. Abdomen. — The liver was so much enlarged as 
 to reach on the right and left sides to the level of the tenth and eleventh ribs, and to 
 a point about two inches above the umbilicus. There were tender adhesions between 
 the right lobe and the diaphragm, also between the gall-bladder and the adjacent 
 border of the right lobe of the liver and the colon, as well as between the lower sur- 
 face of the liver and the duodenum. An abscess occupied the lower and posterior part 
 of the right lobe, and was A r ery superficial at the lateral part, so that the walls, which 
 had contracted adhesions with the opposite parietal peritoneum, gave way and 
 remained adherent to the latter, and seemed to consist only of the visceral peritoneum 
 thickened. The abscess was large, about the size of a cocoa-nut, and contained pus 
 with abundant shreddy-looking flocculi. The portion of the substance of the liver 
 surrounding llie abscess was red, and the rest was mottled white and red, and was 
 very firm under the knife. The ascending colon passed obliquely upwards and inwards 
 to tin' notch in the anterior border of the liver and to the gall-bladder, and thence 
 (lie transverse part stretched downwards towards the left iliac fossa, close to the 
 anterior superior spinous process of the os ileum, and thence it passed upwards, then 
 downwards, as the descending colon. No disease of the large intestine, except that 
 its mucous membrane was thinner than natural, and softer in parts: it was not ulce- 
 rated. The stomach was quite concealed by the liver, and pushed more towards the 
 left side than natural ; it was also very contracted, so much so that it appeared no 
 larger than the intestine. Kidneys healthy in structure. Cranium not opened. 
 
PATHOLOGY — ABSCESS OPENING INTO LUNG. 335 
 
 Courses followed by Hepatic Abscess. — Having traced the 
 manner in which abscess in the liver is formed, I shall 
 now describe the different directions in which it may point and 
 rupture. 
 
 1. Hepatic abscess may open into the lung or sac of the pleura. 
 
 2. Into the stomach, or some part of the intestinal canal. 
 
 3. Into the pericardium. 
 
 4. Into the biliary ducts. 
 
 5. Into the cavity of the peritoneum. 
 
 6. Externally on the surface. 
 
 I shall here notice the first five directions, and leave the sixth to 
 be considered in connection with the question of puncturing hepatic 
 abscess as a part of treatment. 
 
 1. Into the Lung or Sac of the Pleura. — As the right lobe of 
 the liver is the most common seat, and as abscess is frequently 
 formed not far distant from the convex surface of the organ, a ten- 
 dency to point towards the diaphragm, and open through it, is not 
 an uncommon occurrence. This, according to my observation, is 
 the direction in which hepatic abscess most frequently opens ; more 
 so, even, than on the external surface, unless puncture is had re- 
 course to. Taking 140 cases of hepatic abscess, the notes of which 
 are before me, and which constitute only a part of my experience 
 in this form of disease, I find that 14 or ten per cent, opened into 
 the lung, or sac of the pleura. Dr. Stovell reports that of the 
 cases of hepatitis in the European General Hospital during ten 
 years, abscess opened into the lungs or pleura in 3*837 per cent.* 
 When the abscess has been small, single, not deep, and the consti- 
 tution tolerably preserved, then there is a fair chance of recovery 
 after communication with the lung. On the other hand, when 
 the abscess is large or not single, and the constitution is either 
 originally bad, or much reduced by disease or injudicious treat- 
 ment, then a fatal issue, with exhausting hectic fever, is the 
 usual termination. 
 
 The most satisfactory results of hepatic abscess communicating 
 with the lung are those reported by Dr. Stovell f , viz., sixteen cases, 
 with nine recoveries. The symptoms presented by the successful 
 cases justify the inference, that the abscess in each had been small 
 
 * The reader will not fail to notice that Dr. Stovell' s data differ from mine. He 
 gives the ratio to the total admissions of hepatitis. I give the ratio of a certain 
 number of cases of hepatic abscess. 
 
 t " Transactions, Medical and Physical Society," No. 1, Second Series ; and again 
 No. 3, Second Series, p. 43. 
 
336 HEPATITIS. 
 
 and single. My own notes do not suppty an equal success ; for, of 
 the four following cases, the history of three, in which recovery 
 promised, is incomplete. 
 
 103. Abscess in the liver discharged by the lung, followed by convalescence. — Proceeded 
 to England, and died shortly after arrival. — No account of the post mortem appear- 
 ances. — Robert , aged fifty-one, lieutenant, of the pension list, thirty-two years' 
 
 service in India, resident in Bombay, a free liver, and the subject of occasional hepatic 
 ailments, was admitted into the General Hospital on the 23rd June, 1842. He com- 
 plained of occasional uneasiness of the right side, want of appetite, and irregular 
 bowels. On the night of the 4th July he was seized with a fit of coughing, and 
 ejected about six ounces of frotlry puriform-looking fluid. He continued till the 17th 
 Ausust expectorating puriform matter, at times of brick-red colour, and occasionally 
 to the extent of several ounces in the course of the day. After the 17th the puriforni 
 expectoration ceased, but occasional scanty mucous sputa were ejected. He improved 
 in general health, left the hospital on the 6th September, and proceeded to England 
 by sea; but died shortly after his arrival in that country on the 8th February, 1843 ; 
 under what circumstances is not known. 
 
 104. Hepatic abscess attributed to blows. — Opening into the lung. — Improvement. — 
 Becord as to the issue incomplete. — Syud Merim, a Mussulman labourer of forty years 
 of age, about two months before his admission into the clinical ward, on the 28th 
 June, 18-50, received several blows on the right side of the chest, in a quarrel. He 
 experienced no inconvenience till a month afterwards, when acute pain came on sud- 
 denly in the right hypoehondrium. with difficulty of breathing. On admission, he 
 was a good deal reduced ; the respiration was short and hurried. The ensiform car- 
 tilage, the margins of the ribs, and a Line drawn from the left tenth rib across the 
 abdomen above the umbilicus, formed the boundaries of a full, resistant, and dull 
 space. The dulness extended upwards to the fourth right rib, and there was bulging 
 below the fifth rib. The decubitus was dorsal, the pulse feeble, the bowels regular, 
 and he suffered from evening febrile accessions. On the 23rd June he expectorated 
 eight ounces of pink-coloured sero-puriform fhud, with some relief to the dyspnoea. 
 There was now more or less expectoration daily, with less febrile disturbance. On 
 the 2nd July the bulging of the right false ribs had nearly disappeared. He con- 
 tinued to improve slowly, but, becoming discontented, he left the hospital on the 8th 
 July ; after which date there is no record of his case. He was treated with anodynes 
 and tonics. 
 
 105. H'patic abscess opening through the lung. — Besult of the case not recorded. — 
 Luxuman Ragoo, a Hindoo blacksmith, of thirty-five years of age, using about three 
 ounces of spirits daily, was admitted into the clinical ward on the 22nd February, 
 1853. There was some degree of fulness of the lower part of the right side of chest, 
 with sense of induration and dulness for three inches below the right false ribs. The 
 dulness reached upwards to the fifth rib. There was pain, on pressure, below the 
 right false ribs, and in the epigastrium. Decubitus easy on all sides. Had occasional 
 short dry cough. Suffered two months before from occasional febrile accessions. These 
 ceased; but about ten days before admission, while engaged in his ordinary avoca^ 
 tions, he suddenly felt uneasiness of the right hypoehondrium. For six days the 
 
 Is had been relaxed. On the 26th he began to expectorate pinkish muco-puriform 
 sputa. This continued sometimes copiously, and on the 1st March all fulness below 
 the margin of the right ribs had ceased, and dulness did not reach above half an inch 
 below them. Subsequently (lie cough was still troublesome, but the sputa chiefly 
 consisted of frothy mucus. Throughout this time there was little constitutional dis- 
 turbance, and the diarrhoea had ceased. The diary of the case closes abruptly on the 
 Ctli of March, through carelessness of the clinical clerk, without record of the issue. 
 
TATHOLOGY — ABSCESS CTENING INTO LUNG. 337 
 
 106. Hepatic abscess communicating with the lung. (?) — Result not known. — Isaac 
 Ibrahim, a Mussulman cart-driver, of forty years of age, was admitted into the clinical 
 ward on the 5th November, 1852. He was emaciated. The respiration was short and 
 hurried, and the right side did not move freely. There was complete dulnoss of the 
 right dorsal and lateral regions, with defective resonance of the scapular, interscapular 
 and mammary, with absence of vocal thrill and respiratory murmur in the two first. 
 There was no induration or dulness below the right ribs, but pain on pressure there. 
 On measurement, the right side of chest exceeded the left by half an inch. He was 
 troubled with cough and expectoration of muco-puriform red-tinged sputa. Bowels 
 relaxed. He said that he had suffered from intermittent fever five months before, 
 which ceased in fifteen days, and was followed by pain below the margin of the right 
 ribs, and of the right shoulder. The cough came on about six weeks before admission, 
 was mild for the first fifteen days, but then became troublesome, and the sputa tinged 
 red. The dysenteric symptoms had existed for a month. Admitted that he had used 
 spirituous liquors pretty freely. He remained in hospital till the 12th November, 
 when he was removed by his Mends. During his stay he experienced evening febrile 
 accessions. 
 
 Remarks. — The physical signs and symptoms were hardly adequate to determine the 
 diagnosis of hepatic abscess, communicating with the lung ; but, coupled with the 
 history, they were probably sufficient. 
 
 The common expression, hepatic abscess has opened into the 
 bronchi, is not correct if it be meant to imply that direct com- 
 munication has taken place between the abscess and a large 
 bronchial tube. In fatal cases it will be generally found that 
 adhesions have formed between the diaphragm and the con- 
 cave base of the right lung on the one side, and the convex surface 
 of the liver on the other ; and that a ragged excavation exists 
 in the lower part of the lung communicating with the abscess in 
 the liver. Occasionally an opening into the sac of the pleura is 
 observed, as well as into the lung ; and sometimes it is only into 
 the pleura, causing empyema. 
 
 Of ten cases before me, the six following are narrated in illustra- 
 tion of these remarks : — 
 
 107. Dysentery. — Secrmdary hepatic abscess forming obscurely. — Opening into the 
 lung. — No -ulceration of the intestine. — Eustom Khan, a worker in tin, a Mussulman, 
 of thirty-five years of age, reduced in flesh, not using spirits, was, after twelve days' 
 illness, admitted into the clinical ward on the 21st December, 1851. He suffered from 
 dysenteric symptoms, without abdominal fulness or induration, or febrile excitement. 
 After the 29th there were occasional accessions of fever, commencing with chills and 
 terminating with sweating. The dysenteric symptoms continued, but in less degree ; and 
 on the 29th January there was pain of the right shoulder for the first time, and on 
 the 30th, below the margin of the right ribs, on full inspiration, but without dulness. 
 There was apparent fulness of the right side of the chest, from the nipple to the margin 
 of the ribs, but dulness did not reach above the fifth rib. The right side of abdomen 
 was more resistant than the left, respiration was short and hurried, the pain of 
 shoulder and side continued, and on the 5th February there was dulness and indura- 
 tion for half an inch below the ribs. On the 8th there was troublesome cough, and 
 extension of the dulness an inch below the ribs. The febrile accessions had become 
 less, and the dysenteric symptoms were almost gone. On the 18th the right side, at 
 
 Z 
 
338 HEPATITIS. 
 
 the nipple, measured an inch more than the left. On the 23rd five ounces of pinkish 
 puriforni sputa were expectorated ; this continued more or less -with occasional recm - - 
 reuce of dysentery till the 19th April, when he died. The urine was frequently tested, 
 but showed no trace of albumen. 
 
 Inspection twenty hours after death. — Abdomen. — The cavity of the abdomen con- 
 tained a pint of limpid serous fluid. On removing the enlarged liver, with the right 
 lung which adhered firmly to the diaphragm, a large abscess, the size of an ostrich egg, 
 containing about a pint and a half of healthy pus, was foimd in the substance of the 
 right lobe. The walls lined by thin fibrous membrane were formed inferiorly, and on 
 the left side, by the parenchyma of the liver ; on the right, superiorly, by the dia- 
 phragm, but at the right edge of the superior wall, for the space of about two and a 
 half inches in circumference, the diaphragm was absorbed and destroyed, and the pus 
 lay in contact with the substance of the inferior lobe of the right lung, which was also 
 absorbed forming a slight excavation, having a surface, red, soft, and irregular, but 
 not lined by adventitious membrane, nor communicating with a large bronchial tube. 
 The left lobe of the liver was healthy. Both kidneys were pale, but healthy. The 
 mucous lining of the large intestine presented here and there patches of redness ; 
 otherwise it. and the other coats were healthy. Peyer's glands, solitary and agminated, 
 were slightly enlarged, but not ulcerated. The coats of the small intestine were thin 
 and pale. The other viscera were healthy. Chest. — Both cavities of the chest con- 
 tained about a pint of clear serous fluid. The left lung was healthy. The two upper 
 lobes of the right lung were soft and crepitating ; but the inferior lobe which adhered 
 firmly posteriorly to the pericardium and to the diaphragm, though in its upper half 
 healthy, was towards its base red, dense, and very cedematous. 
 
 108. Large hepatic abscess with brick-red pits. — Smaller one opening into lung. — 
 Brick-nd sputa, — No diarrhoea tit! just before death. — Intestines not examined. — A 
 spirit drinker. — Kalloo. a 3Iussulinan sailor, a native of Calcutta, twenty-six years of 
 age, in bad condition, was admitted, after twenty days' illness attributed to excessive 
 spirit-drinking, into the clinical ward on 18th April, 1849. The respiration was 
 thoracic, and chiefly with the left side. There was dulness of the right side of the 
 chest, from the foiu'th rib to the margin. The abdomen was generally soft, with ex- 
 ception of induration without prominence, for two and a half inches below the right ribs, 
 with pain on pressure, augmented by cough and full inspiration. There was febrile 
 heat, and frequent small pulse; but the tongue was moist and nearly clean. He 
 stated that his illness commenced with fever, ushered in with chills, and that after 
 seven days there was pain of the right hypochondriac region, with a marked evening 
 exacerbation of fever, sometimes terminating in sweating. Cough, pain of right side, 
 and hectic fever persisted, and on the 23rd there was crepitus anteriorly above the 
 third right rib, and below it didness and absence of breath sounds. After the 27th 
 the mucous sputa became tinged of a brick-red colour, and were sometimes copious. 
 The urine, generally free, ranged from 1001 to 1016 in density, and showed no trace 
 of albumen. There was no diarrhoea till three days before death, on the 7th May. 
 He was treated with anodynes, quinine, and mineral acids, and a small blister was 
 applied above the right nipple when the crepitus was detected, sponging the side with 
 nitro-muriatic lotion having been previously used. 
 
 \ — Abdomen. — A large abscess containing upwards 
 of two pints of reddish-coloured thick pus, occupied the outer side of the right lobe 
 of the liver. It projected from the concave surface towards the colon. The liver 
 adhered final; to the lateral abdominal parietes and to the diaphragm, and these parts 
 formed the external lateral wall of the abscess. Another small abscess the size of a 
 hen's i '1 the upper convex surface of the right lobe, separated from the upper 
 
 wall of the large abscess by a layer of compressed parenchyma, about an inch in 
 thickness; Thi> small the diaphragm, by a free orifice with 
 
PATHOLOGY — ABSCESS OPENING INTO LUNG. 339 
 
 rounded edges, into a sac, the size of an orange, in the base of the third lobe of the right 
 lung. At the anterior and lateral part of this sac, about the level of the fifth and 
 sixth ribs, there was a gangrenous opening into the cavity of the pleura, which was 
 filled with grey serous, fetid pus ; and the pleura, in contact with the effusion, had a 
 o-reyish gangrenous look, and was covered with flakes of friable lymph. The upper 
 ami middle lobes of the right lung were compressed against the mediastinum by the 
 pleuritic effusion. Both kidneys, when divested of their capstdes, presented a red 
 and yellow mottled appearance. 
 
 109. Hepatic abscess opening through the lung. — ■ Causing pleuritis and effusion. — 
 
 Also presenting externa////, /ait not opened. — Goohee , a Mussulman sailor of stout 
 
 frame, a native of Calcutta, thirty-eight years of age, and for twenty years engaged 
 in voyages to all parts of the world, and habitually using spirits freely, was after a 
 month's illness admitted into the clinical ward on the 6th August, 1850. The res- 
 piration was short and hurried, and the lower part of the right side of chest moved 
 imperfectly. Occasional crepitus was audible in the lower part of right mammary 
 region, but there was no abnormal duhiess. The abdomen was full, resistant below 
 the margin of the right ribs, with dulness, but no distinct induration, for three inches 
 below the ribs. He had dull pain of the right hypochondrium, increased by full inspira- 
 tion and pressure below the ribs, occasional cough, with frothy mucous sputa. The 
 bowels were rather slow. Morning and evening chills but no febrile heat were com- 
 plained of. and the tongue was moist and almost clean. While at sea he had been attacked 
 with fever, followed in three days with acute pain of right side, and attributed to wet. 
 The fever, he said, left him, but the pain persisted. After admission, evening febrile 
 aecessions,with night sweats, were noticed, and the bowels began to be relaxed. On the 
 29th August there was indistinct fluctuation between the seventh and eighth right ribs, 
 an inch and a half external to a vertical line dropped from the nipple. The fluctuating 
 point became more distinct and prominent, and there was general bulging of the lower 
 right chest. The cough had persisted with mucous sputa, but on the 26th September the 
 sputa became more copious, pinkish, and mueo-puriform ; on the 27th eighteen ounces 
 were expectorated. The fulness, tenseness,and fluctuation disappeared, and the hectic 
 fever lessened. From this to 10th October there was relation between the quantity of 
 the sputa and the uneasiness and tenseness of the side, and the absence or presence 
 of fluet nation. On the 10th October severe pain of the right side of chest was com- 
 plained of, and on the 14th that side ceased to move in respiration. The diarrhoea, 
 more or less present during his residence in hospital, increased. Exhaustion and 
 dyspnoea became aggravated, and he died on 20th October. 
 
 The treatment previous to the 29th August consisted in the application of small 
 blisters to the right side, the use of quinine, combined with ipecacuanha and opium, 
 and occasionally blue pill. Afterwards anodynes, tonics, and stimulants, with suitable 
 nourishment, were the means used. 
 
 Inspection twelve hours after death. — Chest. — On removing the sternum, a fluctuating 
 sac was seen to the right of the mediastinum formed of partially organised lymph. It- 
 was somewhat pyriform in shape, in contact, anteriorly, with the ribs and their carti- 
 lages, posteriorly, with the anterior surface of the third lobe of the right lung, and 
 rested, interiorly, upon the diaphragm which was here normal in structure. On laying 
 open the sac a large quantity of limpid serous fluid was found mixed with flakes of 
 fibrine ; and it was further divided into two or three saeculi by bands of friable 
 lymph. When traced upwards, this sac was found to be separated by a layer of 
 lymph from another large one from which, on being opened, a few bubbles of gas 
 escaped. This second sac contained a large collection of fluid (about a pint) sero- 
 purulent in character ; it involved almost the whole of the right pleura, compressed 
 the two upper lobes of the lung against the mediastinum, and passed behind the third 
 lobe, as far as the diaphragm, — being, however, separated from the lateral, anterior. 
 
340 HEPATITIS. 
 
 and inferior surfaces of this lobe by the firm connections which these parts of the lobe 
 had formed with the costal pleura and diaphragm. On cutting into the third lobe, 
 a ragged and irregular cavity was seen, which, laterally, approached very nearly to 
 the surface, and was torn open on the lung being separated from its adhesions to 
 the costal pleura, and here it had probably communicated with the sac of the 
 pleura, and led to empyema. Inferiorly, this cavity communicated through the 
 diaphragm with a circumscribed excavation, about the size of a large orange, situated 
 in the upper and lateral part of the right lobe of the liver, lined by a membrane with 
 irregular surface, and extending from the sixth to the tenth rib. The abscess in the 
 liver communicated externally, at the most prominent part of the swelling noticed in 
 the side during the lifetime of the patient, through the intercostal space between the 
 seventh and eighth ribs, The intercostal muscles were in this situation in a gangren- 
 ous state, and the contents of the abscess were infiltrated into the surrounding areola 
 tissue for the distance of an inch around. The abscess contained a few ounces of sero- 
 sanguineous pus, similar in character to the matter expectorated. In other respects, 
 the liver was normal, both in size and structure ; it projected about two inches below 
 the right false ribs. The left lung was healthy and free from adhesions. The intes- 
 tines were discoloured externally, but were not examined internally. The kidneys 
 were healthy. The heart was not examined. 
 
 110. Hepatitis, ending in abscess discharged through the lung. — An abscess in the 
 third lobe of the right lung, communicating freely through the diaphragm with the 
 abscess in the liver. — Mucous coat of the large intestine ulcerated. — Many of the ideers 
 cicatrised. — John Shea, aged twenty-eight, was admitted into hospital on the 22nd 
 November, 1840, in a moribund state, and died eight hours after admission. He had 
 been sent from the sloop Clive, off Aden, and had been first taken ill with hepatitis 
 on the 6th August ; had improved, but the disease recurred severely on the 23rd of 
 the same month. There had been severe pain increased by decubitus on the left side, 
 and pressure upwards. On the 6th October, he was suddenly seized with expectora- 
 tion of pus, which continued with diarrhoea till the period of his death. 
 
 Inspection twelve hours after death. — Head. — Nothing worthy of note. Chest. — 
 Neither lung collapsed. The posterior part of the left one was very oedematous, the 
 anterior emphysematous with a few tubercles disseminated. The right lung adhered to 
 the costal pleura, and to the diaphragm by tender lymph ; there were a few tubercles in 
 the upper lobe. The rest of the lung was very oedematous, but chiefly the third lobe, 
 which was also in parts hepatised. At the anterior part of the base of the third lobe, 
 there was a cavity the size of an orange, with a ragged and flocculent inner surface, 
 which communicated tlrrough the diaphragm with an abscess in the upper part of the 
 right lobe of the liver, about the size of a small orange, superficial, and lined with a firm 
 membrane with irregular flocculent surface. The rest of the liver was healthy, and not 
 mottled. On the surface of the heart there were many white pearly spots ; but the 
 organ was sound. Abdomen, — There were a few ounces of serum in the cavity. The 
 stomach, much distended, occupied the whole space lietween the umbilicus and ribs; 
 its mucous coat was pale and sound in texture. The colon, covered by the stomach, 
 was contracted, and had formed no unnatural adhesions. The mucous coat was red- 
 dened in parts, and there were a few small circular ulcers, with the cicatrices of many 
 others, chiefly distinguished by their dark grey colour, their depression below the rest 
 of the surface, and closer connection to the subjacent tunics. The edges of some of 
 the ulcers were puckered, but those of the greater number were rounded, and not 
 thickened. The kidneys and spleen were healthy. 
 
 111. Two II' /"it ic abscesses. — One opening into the lung, with expectoration of di p 
 bile-tinged pwriform sputa,- -An Indo-Portuguese, of twenty-six years of age, was ad- 
 mitted into tin' Jamsetjee Jejeebhoy Hospital, on the 8th January, 1848, ill with 
 toms of hepatitis for sis weeks. He stated, thai three days before admission, 
 
PATHOLOGY — ABSCESS OPENING INTO LUNG. 341 
 
 he began to expectorate sputa of bloody appearance and intensely bitter taste. After 
 admission, the sputa consisted of ordinary pus ; but on the 9th they became of deep 
 yellow colour, thick and glairy, easily expectorated, and in great quantity, and the 
 swelling of the right side, much less than on admission, extended downwards to a line 
 drawn transversely from the umbilicus. The abdomen was swollen, and pain was 
 felt to the right of the epigastrium under the cartilages of the false ribs. He said 
 that it had before extended over great part of the right side of the chest. Dejections 
 whitish. Died rather suddenly on the night of the 17th. 
 
 Inspection. — -Abdomen. — Opaque pinkish or chocolate-coloured fluid, svith flocculi 
 of lymph, was found in great abundance in the abdomen. The peritoneum of paries 
 and viscera was of red colour. A large abscess in the left lobe of the liver pressed on the 
 stomach, having at its upper part the substance of the Hver extended over it, but this 
 gradually thinned away, and at the lower part, the wall was formed of the thickened 
 peritoneal covering. Another large abscess occupied the lower part of the right lobe 
 of the liver. Both these abscesses contained pus, very slightly tinted of a greenish 
 yellow, and that in the abscess of the left lobe was more abundant and thinner ; both 
 had ragged walls. There were adhesions to the stomach and duodenum. The capsule 
 of Glisson was thickened. The gall-bladder contained only a Httle viscid mucus of a 
 greenish colour. At the upper part of the right lobe there was adhesion to the dia- 
 phragm, and corresponding thereto the right lung was also adherent. On separating 
 the adhesion of the lung, a cavity was opened which extended into a small abscess in 
 the Hver with thick firm bning of adventitious membrane. The neighbouring portion 
 of the liver was much gorged with blood, and the cavity extended upwards into the 
 lower part of the lung ; its walls there being very ragged and uneven, and the sur- 
 rounding portion of the lung was hepatised and gorged with blood. The portion of this 
 common abscess which was in the liver contained only thick whitish pus ; while that 
 which was in the lung contained pus of deep yellow or greenish yellow, and its ragged 
 walls were deeply stained of the same colour, and on pressing the abscess before open- 
 ing it, deep yellow fluid was made to flow upwards through the divided bronchial 
 tubes. 
 
 Bemarks. — Dr. Leith was present with me at the inspection cf this case. To him 
 I am indebted for the note of the appearances observed, and for the information that 
 he had not long before witnessed a somewhat similar case of bile-tinged sputa in the 
 hospital of the Bombay police corps. 
 
 112. Abscess in the liver opening through the diaphragm into the sac of the pleura 
 and causing purulent effusion there. — James Oakhum, aged thirty-two, a feeble man 
 of reduced and emaciated habit, was admitted into the European General Hospital on 
 the 27th September, 1843. He stated that he had been under treatment for eight 
 days, suffering from pain of the right side, first under the clavicle, subsequently at the 
 margin of the right ribs, and that he had been leeched and blistered. On admission, 
 the skin was hot and dry, and the tongue florid at the tip. On the 28th he com- 
 plained of pain at the margin of the right ribs, impeding full inspiration ; and late- 
 rally and posteriorly there was perfect dulness and inaudible respiratory murmur. 
 Evening febrile exacerbation, and occasional diarrhcea, but seldom any complaint of 
 pain of the side were present till the 3rd October, when in addition he began to be 
 troubled with cough, accompanied on the 4th with expectoration of thin puriform 
 fluid. The cough, the puriform sputa, the dulness of the right side, the febrile symp- 
 toms, the occasional diarrhoea continued, accompanied with progressive emaciation 
 and collapse, and latterly short and oppressed breathing, till the morning of the 12th 
 October, when he died. 
 
 Inspection eleven hours after death. — The body was much emaciated. Chest. — On 
 the right side, from the fourth rib downwards, anteriorly, the lung adhered to the 
 costal pleura, and to the diaphragm ; but there was no adhesion of the posterior part 
 
 Z 3 
 
342 nErATixis. 
 
 of the lung. At the posterior part of the right side of the chest, and also the anterior 
 above the level of the fourth rib, there were about two pints of faint reddish-coloured 
 puriform fluid. This effusion communicated through the diaphragm behind the lung, 
 with an abscess in the upper and posterior part of the right lobe of the liver, larger 
 than an orange. The lung was compressed, but healthy in texture. The left lung 
 was healthy. The abdominal viscera were not particularly examined, but the intes- 
 tines were healthy externally. 
 
 I have met with cases in which the symptoms of hepatic 
 abscess had been well marked, and the occurrence of puriform 
 expectoration suggested that communication had taken place be- 
 tween the abscess and the lung, and yet examination after death 
 failed to verify it. Three cases of this nature are before me. 
 In the two first an opening was carefully looked for, but not found ; 
 and the condition of the lung was not such as to account for the 
 character of the sputa. In the third the sufficiency of the examina- 
 tion is doubtful, and the base of the right lung was hepatised. 
 From such cases it may be surmised that when interstitial absorp- 
 tion is in progress in the wall of an abscess, between the liver and 
 the lung, and the tissues are becoming soft and succulent, the thinner 
 contents of the sac may perhaps pass through by imbibition before 
 the occurrence of actual rupture. At all events, this question may 
 be proposed for future inquiry to solve. 
 
 2. Hepatic Abscess opening into the Stomach or Intestine. — 
 Five cases, 3*57 per cent, of this termination have come under 
 my notice. Dr. Stovell's ratio to the admissions from hepatitis is 
 0-451. Of my five cases three recovered. In two the abscess was 
 supposed to have opened into the colon, in one into the stomach 
 and colon. In one of the fatal cases the situation and marked de- 
 crease of the swelling favoured the belief that an abscess had 
 opened into the stomach; but neither vomiting nor purulent 
 dejections occurred ; yet, after death, the diagnosis was proved to 
 be correct, for communication existed between the abscess and 
 the stomach. In this case the pus must have oozed slowly into 
 the stomach, and thence passed in small quantity at a time through 
 the intestinal canal, probably in an altered form. In the other an 
 opening into the colon was found after death, but the account of 
 the symptoms during life had been incomplete. 
 
 It is a common belief that the discharge of hepatic abscess into 
 the alimentary canal is not rare ; and that it is always clearly 
 indicated by the sensations of the patient and by free vomiting or 
 dejection of pus. My experience, however, does not confirm this 
 opinion. In two of my cases (113, 115) the pus must have drained 
 so slowly into the canal as not to affect the appearance of the dis- 
 
TAUTOLOGY — ABSCESS OPENING INTO STOMACH. 343 
 
 charges, though its presence had been carefully looked for. In 
 other two (116, 117) pus was present ; and in my remaining case 
 (114) there was no record of the symptoms. I am satisfied 
 that there has been much loose observation and inaccurate 
 record on this subject ; and that too much weight has been 
 generally accorded to the statement of the patient. At all 
 events, in two or three instances in which this supposed occur- 
 rence has been reported to me, the evidence has failed to 
 convince me. 
 
 The following are the five cases to which I have adverted : — 
 
 113. Abscess in the left lobe of the liver opening into the stomach. — No vomiting. — 
 No detection of pus in the intestinal discharges. — No intestinal ulceration. — Ibrahim 
 
 Mahomed, a Mussulman water-carrier, of thirty years of age, using spirits, and at one 
 time opium, habitually, was admitted into the clinical ward on the 30th June, 1853. 
 He was emaciated, countenance anxious, pulse small. In the epigastric region there 
 was a painful swelling, the size of a cocoa-nut, prominent, soft, indistinctly fluctuating, 
 not pointing, but somewhat tense. Decubitus on the bach, or either side. Three 
 months before, a small swelling appeared in the situation of the present large one, 
 and gradually increased; it was not very painful, and not attended with fever. 
 He had suffered from fever before the swelling was noticed ; but then there was no 
 pain in the region of the liver. His bowels had been regular, and there had not been 
 any vomiting. On the 3rd July the size and prominence of the swelling were less, 
 the bowels had been four times opened, and the discharges were reported to be dark 
 coloured. From the 4th to the loth there was no recurrence of diarrhoea, the evacu- 
 ations were feculent, and still the swelling lessened. Its prominence was gone on the 
 12th. On the 16th again diarrhoea, with discharges described as thin, feculent, and 
 of buff yellow. The swelling was now gone, and dulness did not extend more than 
 two niches below the ensiform cartilage. There had been no vomiting. From this 
 time there were occasional dysenteric symptoms, occasional slight febrile accessions, 
 and a failing pulse; then, on the 2nd August, copious intestinal discharges; and 
 death on the 4th. Treated with anodynes and tonics. The urine gave no traces of 
 albumen. 
 
 Inspection twelve hours after death. — Chest. — The anterior siu'face of the lungs was 
 pale, spongy, and somewhat emphysematous at the edges. No adhesions. Heart. — 
 The walls of the left ventricle were thickened, and the cavity small. Abdomen. — The 
 external surface of the liver was of dark red colour. The liver extended to about 
 two inches below the ensiform cartilage, and about two and a half inches below the 
 margins of the right false ribs. There were not any adhesions between it and the 
 diaphragm, but the concave surface of the left lobe adhered firmly to the smaller cur- 
 vature of the stomach, and to the pancreas. On separating the adhesions to the pan- 
 creas, an opening about the size of a rupee, with dark grey edges, was apparent in the 
 liver. The opening conducted into an empty sac, about the size of a large orange, 
 situated in the inferior siu'face of the left lobe. This sac was lined by a firm mem- 
 branous layer, with irregular surface ; it also communicated, by au opening suffi- 
 ciently large to admit an ordinary blow-pipe, with the stomach close to its pyloric end. 
 The substance of the liver, for about half an inch beyond the upper wall of the sac, 
 was of dark grey colour, indurated and condensed. The inferior wall of the sac was 
 about a quarter of an inch thick, partly fibrous and partly condensed substance of the 
 liver. The substance of the right lobe of the liver was healthy. Stomach. — Much 
 distended, and containing about a pint and a half of light-coloured yellow turbid fluid 
 with white floating flakes, which, examined under the microscope, showed no pus glo- 
 
 7. 4 
 
344 HEPATITIS. 
 
 tmles. Intestines. — In general pale, except at the end of the ileum and rectum ; in 
 both these situations a blush of redness was seen, and the membrane was softer than 
 natural. Kidneys. — Eight one healthy. Left one somewhat lobulated, of pale buff 
 colour, externally and internally ; cortical substance encroached considerably on the 
 tubular portion, which in places was very indistinct. 
 
 114. An abscess of the liver communicating with the colon. — Others in -process of 
 repair by absorption, — An old man was admitted into the Jamsetjee Jejeebhoy 
 Hospital with fulness below the margin of the right ribs, indicating the existence of 
 hepatic abscess. Before death the fulness had lessened considerably, but how caused 
 was not understood. 
 
 Inspection after death. — Towards the thin edge of the right lobe of the liver there 
 was an abscess the size of an orange, having the concave surface adherent to the right 
 kidney for its lower wall. It communicated by an opening the size of a goose-quill 
 with the hepatic flexure of the colon. The mucous membrane around the opening was 
 free of disease. The walls of the abscess were almost cartilaginous in density. The 
 substance of the liver was very firm, and here and there were yellow dense circum- 
 scribed deposits the size of a horse-bean and upwards in size. They were tubercular- 
 looking in appearance ; and in one, the size of a walnut, the contents were soft and 
 putty-like. The contents of both were examined under the microscope. The dense 
 tubercular-Hke matter consisted of small granules. In the less consistent there were 
 also granules ; but some of them had, in many places, aggregated into distinct cor- 
 puscles : it seemed as if the breaking down of the pus corpuscles, and the escajie of 
 their contained granules, had not proceeded to the same extent. These, then, had 
 been abscesses, and were in process of repair by absorption. There was Bright's dis- 
 ease of the kidney in this case.* 
 
 115. Hepatic abscess, recovered from, by probable opening into the colon. — Mahomed 
 Jaffer, a Mussulman, forty-five years of age, a painter, using spirits occasionally, and 
 the subject, a year before the date of the present case, of hepatic symptoms, was ad- 
 mitted into the clinical ward on the 5th December, 1853. He was reduced, the coun- 
 tenance was anxious, skin hot, pulse frequent, small and sinking. The respiration 
 was somewhat hurried. Below the margin of the right ribs and the ensiform cartilage, 
 there was resistance, tenderness, and dulness, bounded below by a line drawn from 
 the eighth left rib, curving to about half an inch above the umbilicus, and extending 
 to the eighth rib on the right side. Decubitus easiest on the back and right side. 
 The tenderness on pressure was considerable ; fever and pain of abdomen had come 
 on siuniltaneously twenty days before admission. The fever was remittent, with mid- 
 day exacerbation and evening remission. On the 13th December there was epigastric 
 fulness with indistinct fluctuation. Now there was abatement of fever; but he had 
 troublesome cough with frothy mucous sputa. On the 24th, while turning in bed, 
 lie experienced a peculiar sensation in the swelling, as if something had given away, 
 and on examination it was found to be considerably diminished. No diarrhcea, no 
 trace of pus in the evacuations. There was now gradual slow decrease of the swelling, 
 with occasional febrile recurrences ; and he was discharged on the loth February, 
 1854, with a small induration perceptible an inch and a half above the umbilicus, not 
 painful, but with dulness, continuous upwards with that of the liver. He was treated 
 chiefly with quinine and anodynes, then dilute nitric acid, and occasional laxatives, 
 and warm water application to the epigastrium. 
 
 * About the same time, somewhat similar appearances were brought to my notice 
 in a preparation sent to me from the European General Hospital. In this the mem- 
 branous sac was distinct, the contents being partly pulpy, partly tough, and presenting 
 an appearance of layers. It was in the cirrhosed liver of an emaciated sailor, who 
 died of ascites. In this case there was also granular degeneration of the kidney. 
 
PATHOLOGY — ABSCESS OPENING INTO PERICARDIUM, ETC. 345 
 
 116. Hepatic abscess. — Opening into the colon (?) — Recovery. — Camajee Yellojee, aged 
 forty-eight, a Jew of intemperate habits, was admitted into hospital on the 6th March, 
 1837. There was tenderness below the margin of the right ribs, which he said had 
 existed for a month. On the 7th, purging during the night reported ; evacuations not 
 seen : but a pale-coloured stool passed on the 7th consisted chiefly of pus, as proved 
 by the microscope. After this there was no further appearance of pus. 
 
 117. Hepatic abscess. — Opening into the colon and stomach (?) — Recovery. — Pestonjee 
 Dadabhoy, aged twenty, an intemperate Parsee buggy driver, was admitted into 
 hospital on the 18th January, 1857, with symptoms of acute hepatitis. Fulness at 
 the epigastrium indicated the formation of abscess. On the 27th there was vomiting. 
 The ejected matters were not kept, but the epigastric fulness became very sensibly 
 diminished ; and on the 28th, about two ounces of unmixed pus were passed by stool. 
 Afterwards there was no more vomiting, and no further traces of pus in the dejections. 
 He left the hospital on the 22nd March, improved in flesh, and with no signs of 
 hepatic enlargement. 
 
 3. Hepatic Abscess opening into the Pericardium — is very 
 rare. Rokitansky and Graves each report a case. There is one 
 recorded by Mr. Fowler.* Mr. Leahy, a very intelligent apothecary 
 of the Bombay establishment, gave me the notes of a case observed 
 by him at Peshawnr in the Bombay Fusileer Regiment ; in it there 
 were two abscesses, one communicating with the right lung, the 
 other with the pericardium. I have never witnessed this termina- 
 tion of hepatic abscess. 
 
 4. Hepatic Abscess opening into the Biliary Duct. — It is stated 
 in systematic works that this is the most favourable course for 
 hepatic abscess to follow ; but surely this assertion rests on theo- 
 retic grounds. The only case, with which I am acquainted, proving 
 that hepatic abscess sometimes communicates with the ducts, and 
 may be discharged by this channel, is recorded by Dr. Leith in the 
 following words : — " The case of a foot-artilleryman, sent from 
 Bombay with abscess of the liver, who died in the hospital, is 
 worthy of notice, although he does not come properly within the 
 subject of this report. The tumefaction in the side gradually dis- 
 appeared ; and after his death the abscess was found nearly empty, 
 and two hepatic ducts communicating with it were found carrying 
 pus to the duodenum." t 
 
 5. Hepatic Abscess opening into the Cavity of the Peritoneum. 
 — My cases do afford distinct evidence of rupture of hepatic abscess 
 into the sac of the peritoneum : in two it was probable, but was 
 not positively established. 
 
 Contents of Abscess removed by Absorption. — The different 
 
 * " Transactions of the Medical and Physical Society of Bombay," Second Series, 
 No. 2, p. 305. 
 f " Transactions of the Medical and Physical Society of Bombay," No. 4, p. 57. 
 
34 G HEPATITIS. 
 
 directions in which hepatic abscess may discharge its contents have 
 been described, and we have found that, in a small proportion of the 
 cases, recovery results. But it is not only by this course that hepatic 
 abscess may be recovered from. Cases sometimes occur in which 
 the existence of abscess has been undoubted, and the fluctuating 
 swelling has gradually lessened and finally disappeared without any 
 appreciable discharge.* The inference that in such cases the re- 
 moval of the pus has been effected by absorption, is confirmed 
 by appearances occasionally found after death. The process is 
 probably of this nature : first, normal capillary circulation in the 
 tissues around, then absorption of the liquor puris, with conse- 
 quent shriveling and breaking up of the corpuscles into their con- 
 stituent granules — an encysted putty-like or cretaceous residuum 
 being left. Three cases (118 — 120) which I shall presently narrate, 
 and case 114, will serve to illustrate this process of absorption, 
 which is fully recognised by Rokitansky. Case 121 was probably 
 recovered from by absorption. 
 
 118. Two hepatic abscesses in process of absorption. — Death from cholera. — - 
 Painful decubitus on right side explained by situation of one of the abscesses. — Ul- 
 ceration of colon. — Annajee, a Hindoo labourer, of thirty-two years of age, acciistoined 
 to the moderate use of spirits, and of six grains of opiuni daily, after eight days' 
 illness was admitted into the clinical ward on the 10th of December, 1850, not reduced 
 by sickness. The respiration was somewhat hurried and oppressed, but occasional 
 bronehitic rales were the only signs of pidmonic disease. The abdomen was full and 
 somewhat resistant. On the right side, dulness on percussion reached from the sixth 
 rib to a line drawn obliqiiely from the left eighth costal cartilage to the point of the 
 last right rib. Between this line and the margin of the ribs, there was distinct in- 
 duration, and pain increased by pressiu'e. Decubitus dorsal, and on the left side, but 
 causing pain and distress of breathing on the right. There was febrile disturbance, a 
 tremulous tongue, and regular bowels. The local symptoms had been present eight 
 days, and the febrile five. On the 23rd he complained of pain of the right shoulder. 
 Under the use of cautious leeching, small blisters and quinine, combined with 
 ipecacuanha and blue pill, the induration and dulness below the margin of the right 
 rib had almost disappeared by the 29th. But the pain of right shoulder continued, 
 and the cough was more troublesome, with increase of bronehitic rales. The urine 
 was frequently examined : it was generally free, somewhat turbid, and without albumen. 
 On the 7th January the induration was gone, and the dulness extended about an 
 inch below the ribs ; the pain of shoulder had ceased, and the cough was less trouble- 
 some. Had recurrence of febrile disturbance on the 13th. Symptoms of cholera came 
 on on the 15th, and he died on the morning of the 16th. There were slight dysenteric 
 symptoms on the 18th and 19th Decemher. 
 
 Inspection six hours after death. — Abdomen. — On opening the cavity, the thin edge 
 of tin' right lobe of the liver was seen projecting to the extent of about an iuch 
 beneath the ensiform cartilage and the cartilage of the eighth and ninth ribs of the 
 
 * I have not thoughl il necessary to consider the question of the elimination of 
 the contents of hepatic abscess by the kidney. I think with those who believe that 
 the transfer of entire pus corpuscles from the liver to the urine, through the blood 
 and secreting processes, is physiologically impossible. 
 
PATHOLOGY — ABSCESS REMOVED BY ABSORPTION. 347 
 
 rio-ht side. There were firm adhesions of the most prominent part of the convex 
 .surface of the right lobe to the under surface of the diaphragm, and a good deal of 
 difficulty -was experienced in removing the organ from the abdominal cavity. On 
 incisino- the right lobe of the liver at the site of the adhesions, corresponding in 
 situation to the bodies of the seventh and eight right ribs, there was a small abscess 
 the size of a pigeon's egg, with firm membranous walls, and containing healthy pus. 
 Between the cavity of the abscess and the diaphragm only a thin layer of the paren- 
 chyma intervened. A little above and to the left of this there was another abscess 
 the size of an olive, also bounded by a membranous cyst and containing yellow 
 putty-like substance, which was amorphic and granular, with here and there a 
 corpuscle. The rest of the liver was healthy. The small intestine was dis- 
 tended with gas, and the large one was contracted. At the end of the ileum 
 the mucous membrane presented enlarged glands, and small superficial ulcers 
 were observed in the sigmoid flexure and the upper part of the rectum. Other- 
 wise the coats of both the small and large intestines were healthy. Spleen of 
 smaller size than natural The kidneys were healthy. Chest. — There were firm 
 adhesions of both lungs to the costal pleurae, and of the base of the right lung to the 
 convex surface of the diaphragm. The pulmonary tissue was in part crepitating, and 
 in part woolly to the feel, and when incised presented a pale appearance, intermixed 
 with numerous black specks. The heart was healthy. 
 
 119. Four hepatic abscesses. — General peritonitis, but no evidence of abscess rupture. 
 — Two of the abscesses in p?-ocess of cure by absorption. — Dajee Gungajee, a Hindoo 
 buggy driver, of thirty-three years of age, using spirits habitually, was admitted into 
 the clinical ward on the 4th of December, 1851. The countenance was anxious, 
 the respiration short, and thoracic ; the abdomen was tense, tender, and somewhat 
 tympanitic ; the decubitus was dorsal, and the thighs flexed ; the skin was coldish, 
 and the pidse thready. The tongue was coated white on the sides, but florid at the 
 tip and centre. His illness commenced seven days before with fever, followed by 
 uneasiness below the right false ribs, which gradually extended over the abdomen, and 
 three days ago attained its present severity. Under the application of a blister to 
 the abdomen, the use of quinine and opium, wine and ammonia, he lingered till the 
 9th December. He had received a blow on the right side of his chest two months 
 before the present attack. 
 
 Inspection nineteen hours after death. — Chest. — There were some old adhesions 
 between the base of the right lung and the diaphragm. The substance of both the 
 lungs was healthy. The heart of natural size and normal. Slight firm deposit on 
 the lining membrane of the ascending aorta. Abdomen. — There was about a pint of 
 red-tinged serum in the cavity of the abdomen. The intestines were distended, and 
 presented streaks of redness on the peritoneal surface, and flakes of lymph existed 
 between the convolutions as well as between the lateral parietes and the ascending 
 colon. The liver, much enlarged, extended three inches below the margin of the right 
 false costal cartilages, and across to those of the opposite side. Extensive lymph 
 effusion existed between the left lobe of the liver and the anterior parietes. The 
 concave surface of the liver was firmly adherent to the transverse colon, to the 
 stomach at its pyloric extremity and to the duodenum, by a thick layer of lymph. 
 There were also firm adhesions between the convex surface of the liver and the 
 diaphragm, and the posterior wall of the abdomen. On separating the adhesions 
 between the concave surface of the liver, stomach, and duodenum, the walls of an abscess 
 in the liver gave way about an inch to the left of the gall-bladder which was firmly 
 adherent to the colon. The abscess was about the size of a large orange, and yellow 
 flaky matter was attached to the inner surface of the membranous cyst which enclosed 
 it. In the centre of the right lobe of the Liver was another abscess the size of a 
 cocoa-nut, not communicating with the one on the concave surface, but just above it ; 
 
348 HEPATITIS. 
 
 it contained thick flocculent pns, enclosed by a thin membranous layer. At the pos- 
 terior edge of the right lobe there was another abscess distinct from the two above 
 described. It was about the size of a hen's egg, and contained thick putty-like pus ; 
 the walls were of thickened membrane more organised. In the left lobe towards its 
 concave surface there was included, in a still thicker membranous sac, a fourth col- 
 lection of still more consistent and putty-like contents ; it was the size of a walnut. 
 The concave surface of the liver immediately over the cyst had a somewhat depressed 
 and puckered appearance. The substance of the right lobe of the liver presented 
 generally a dark red colour, and was not softened ; the left lobe was of pale colour, 
 and more lacerable. The putty-like contents of the third and fom'th abscesses, sub- 
 mitted to the microscope, presented no trace of pus corpuscles, but consisted of small 
 granular matter, with an oil globule here and there. The spleen was much smaller 
 than natural The right kidney congested and lobulated ; the left somewhat pale. 
 The mucous membrane of the stomach presented variegated patches of redness, best 
 marked at the lesser curvature. 
 
 120. Hepatic abscess in process of cure by absorption. — Hybattee Sinday, aged 
 forty -nine, a water-carrier, was admitted into hospital under Dr. BaUingalTs care, 
 on the 16th April, 1857. He was emaciated, affected with phthisis and diarrhoea. 
 He died on the 28th. 
 
 Inspection. — -There were tubercles in both lungs, with cavities in the upper lobes. 
 About the middle of the liver, posteriorly, there was a single abseess-sac about the size of 
 a small apple, filled with putty-like matter. The walls were thick and firmly organised. 
 The gall-bladder was full of dark-coloured concretions. The solitary glands of the 
 large intestine were distinct, and there were sloughy ulcers here and there. 
 
 121. Hepatic abscess. — Absorption. — Recovery. — Narayen Nuthoo, aged twenty-four, 
 admitted 25th November, 1857. A prominent fluctuating circumscribed swelling in 
 the epigastric region, reached to the umbilicus. It was suspected to be hydatid. 
 But after a fortnight it gradually lessened and finally consisted merely of slight in- 
 duration three inches below the ensiform cartilage — without prominence or fluctuation. 
 The bowels were relaxed for three or four days, but the evacuations were not seen 
 and they were not coincident with the decrease of the swelling. 
 
 Secondary partial peritonitis. — Circumscribed Puriform Sacs. 
 — It has been already stated (pp. 327 and 329) that secondary 
 inflammation of the peritoneal covering of the liver, in the course 
 of hepatic abscess, with consequent adhesion, is the rule. In oc- 
 casional cases, there is absence of peritonize inflammation. But 
 in other cases there is another kind of deviation : in this the 
 secondary peritonitis has not led to adhesion at all points, but a 
 portion of the lymph changing into pus has formed a circum- 
 scribed sac between the liver and the opposed surface. The most 
 common situation is between the liver and the diaphragm ; but it 
 may also occur in relation with the concave surface of the organ. 
 Sometimes the sac communicates with the hepatic abscess : more 
 frequently, however, it is merely superimposed. 
 
 A collection of pus, however, may form in close proximity to 
 the liver, independent of hepatic abscess, as is shown in the two 
 following cases (122, 123). The first was communicated to me by 
 Mr. Plumptre, the medical officer in charge of the Sanitarium at 
 
TATIIOLOGY SECONDATIY TAKTIAL PERITONITIS. 349 
 
 Poorundhur. On the 29th December, 1858, I saw the case on 
 the occasion of my visit to the station — and never doubting that it 
 was abscess of the left lobe, recommended that it should be punc- 
 tured in a few days. 
 
 122. Purulent sac, between the liver and the diaphragm, communicating with the 
 hft lung. — No hepatic abscess. — A private in the 3rd Dragoon Guards, aged thirty- 
 two, of 12 years' service, and ten months in India, after dysentery, reputed colic, 
 and dyspepsia, was sent from Kirkee to Poorundhur on 22nd September, 1858. He 
 had pain of epigastrium extending to the left hypochondrium. No enlargement. 
 The symptoms were considered to be dyspeptic, and he was discharged free of pain on 
 the 8th November. He was re-admitted on the 26th November, with return of 
 pain and suspected enlargement of the left lobe of the liver. Discharged on 11th 
 December. Ee-admitted on the 20th. There was now distinct swelling at the left 
 side of the epigastrium with dulness for three inches around. On the 29th it was 
 prominent, obscurely fluctuating and tending to point. It was opened with a bistoury 
 on the 4th January. Bed-tinged pus discharged freely, and was always increased 
 after eating. There was hectic fever and increasing emaciation. On the 7th February 
 he expectorated with little effort a considerable quantity of greenish yellow pus. 
 Up to the 23rd February the puncture looked healthy, but now the edges became 
 gangrenous. On the 25th the abdomen was tense, distended, and tender, the features 
 anxious, the pulse 110, and somewhat sharp. He died on the 1st March. 
 
 Inspection fourteen hours after death. — Body emaciated. There were six pints of 
 sero-pus in the abdomen. The intestines were distended, and their surface smeared 
 with flakes of friable lymph. A large purulent sac existed between the liver and the 
 diaphragm. It communicated with the punctured wound, also with the left lung, which 
 which was consolidated at its base and firmly adherent to the diaphragm. No direct 
 communication with the cavity of the peritoneum was discovered, The substance 
 of the left lobe was not implicated. The liver was enlarged and of nutmeg ap- 
 pearance. The diaphragm was adherent to the surface of the left lobe at the circum- 
 ference of the sac. 
 
 123. Amputation of the right hand, followed by general bad health, and chronic 
 hepatitis. — A purulent sac between the liver and the ribs filled with foetid pus. — Hepa- 
 tization of the lower part of the right lung. — Gresham Stewart, aged thirty-one, 
 gunner's mate Honourable Company's steamer Cleopatra. On the 29th of July, 
 1842, the right arm was amputated above the wrist in consequence of a severe injury 
 received while incautiously extracting the charge of a gun. The operation was per- 
 formed immediately after the accident. On the 8th August he was admitted into the 
 European General Hospital. Union had not taken place and the stump presented a 
 sloughy appearance. He, by degrees, however, improved, and was discharged well on 
 the 5th October. He was re-admitted on the 5th November, sallow and reduced, with 
 feeble pulse, complaining of occasional shooting pain of the right hypochondrium, and 
 at times suffering from diarrhoea. He continued labouring under these symptoms, 
 more or less till towards the end of January, when the pain of the right hypochon- 
 drium increased and became more constant, with coated tongue and sharpish pulse. 
 On the 10th February, it was reported that there was distinct hard swelling of several 
 inches in circumference over the lateral part of the right false ribs, commencing about 
 the sixth rib and extending to the tenth. There was no preceptible fluctuation. 
 During the night of the 11th, there was haemoptysis to a considerable extent, succeeded 
 the following day by cough with rusty-coloured sputa, at times inconsiderable quantity. 
 Under these symptoms, much harassed by cough, he lingered, and died on the 27th 
 February, very much emaciated. 
 
 Inspection twelve hours after death. — The body much emaciated. Abdomen. — Be- 
 
350 HEPATITIS. 
 
 tween the liver and the ribs there was a sac containing fceticl dark-coloured pus ; the 
 walls of the sac being sloughy and ragged. [This purulent sac was opposed to the site 
 of the tumefaction during life, but there was no purulent effusion between the ribs 
 and the integuments, nor had the pus made a way through the intercostal muscles.] 
 The peritoneal surface of the liver was in one or two places abraded, but the substance 
 of the organ was not implicated. There was no communication between the abscess 
 and the sac of the pleura, or the lungs. Chest. — The right lung adhered to the costal 
 pleura and to the diaphragm, a ad was in the first stage of hepatisation, giving out 
 frothy blood-coloured serum when pressed. There was a considerable quantity of 
 serum in the pericardium. The other viscera, though attenuated, were healthy. 
 
 That purulent collections may occur consequent upon ordinary 
 secondary peritonitis, and independent of hepatic abscess, is proved 
 by the cases just narrated. The occurrence may be held to indicate 
 a depraved diathesis. There is moreover a practical lesson in 
 these circumscribed sacs. They teach us to be cautious in attri- 
 buting a pointiDg fluctuating swelling in the right intercostal spaces 
 below the seventh, and in the epigastrium, to the presence of hepatic 
 abscess : it may be caused by a collection of pus between the liver 
 and the diaphragm. 
 
 Cases 124 to 127 are of secondary partial puriform peritonitis 
 in connection with hepatic abscess; also 160, 161, 168, 172. 
 
 12-4. Abscess in the liver. — Also one external and circumscribed communicating with 
 former. — Bark red colour of mucous surface of large intestine, which contained much 
 
 clotted blood. — Serjeant 0. M , of Her Majesty's 40th Regiment, aged thirty-two, 
 
 was admitted into hospital at Belgaum, on the 21st June, 1830. This man was a hard 
 drinker, and was said to have been ill with dysentery fourteen days before admission. 
 There was much purging with severe tenesmus and griping. The dejections were 
 scanty, mucous and bloody, then became red, watery, and foetid, and for the last two 
 days before his death consisted entirely of grumous, dark-coloured blood. Tenderness 
 of abdomen moderate. He sunk gradually, and died July 2nd. 
 
 Inspection. — On opening the abdomen a superficial abscess presented itself: situated 
 on the superior surface of the thin edge of the right lobe of the liver, having for its 
 walls, posteriorly, the liver, anteriorly, the abdominal parietes. inferiorly, the colon ex- 
 tremely distended and adhering to the margin of the liver. The abscess dipped down 
 between the ascending colon and the concave surface of the liver, and then communi- 
 cated with another abscess, which occupied the whole interior of the right lol.e of the 
 liver; and below it terminated in a large collection of pus. situated behind the caput 
 ccecum. The coecum and ascending colon were internally of dark red colour, and filled 
 with clotted blood; and in parts of the colon the peritoneal was the only tunic left. 
 The liver was light coloured, and adhered to the right side and to the diaphragm. 
 Adhesions existed between the right lung and diaphragm, oj>po=ite to those of the 
 liver. 
 
 125. Hepatic abscess bounded by a firm sac. — A circumscribed sac in the peritoneal 
 cavity over flu- edge of the liver. Substance of the liver mottled red and white. — 
 1 ' forty, of slighl habit, a seaman, admitted on the 24th March, 
 
 1811. He stated that he had suffered from acute pain of the right hypochondrinm at 
 the margin of the ribs, for four days, attended with frequent purging. The pain was 
 acute, preventing full inspiration, and extending downwards in the direction of the 
 right iliac region. Pulse 100, sharpish, bul easily compressed. Skin moist. Tongue 
 
TATIIOLOGY — SECONDARY PARTIAL PERITONITIS. 351 
 
 coaled in the centre, and florid at the tip. He was Lied to sixteen ounces and freely- 
 leeched : he bore the depletion badly. The pain continued unabated, and frequent 
 vomiting was superadded. On the 28th, there was fulness and tenseness extending 
 from the right iliac fossa to the margin of the ribs and reaching as far as the umbili- 
 cus. The left side was supple. He died at midnight of the 30th. At the beginning, 
 two full doses of calomel with opium were given ; it was then omitted and camphor 
 mixture with spiritus ammonise aromaticus and wine substituted. 
 
 Inspection seven hours after death. — Head. — The brain was firm, and there was a 
 thin veil of serum beneath the arachnoid membrane at the interspaces of the convolu- 
 tions. Chest. — The lungs did not collapse, in consequence of their emphysematous 
 state. Abdomen. — The omentum adhered in places to the intestines and also to the 
 edge (partly overlapping it) of the right lobe of the liver. There was a portion of the 
 substance of the liver, the size of a large orange at the thin part of the right lobe, of 
 white colour, in parts tolerably firm, in others pulpy, in others breaking down into 
 pus, — bounded by a firm sac, from which the white part could be scraped ; and over 
 that portion of the liver there was a circumscribed abscess bounded by the abdominal 
 parietes, the omentum, and liver. The substance of the liver generally was mottled 
 red and white. The colon was contracted, with ulcers, here and there, on its mucous 
 coat. 
 
 126. Abscess in the liver communicating with purulent deposit in the right iliac 
 region. — Habitual constipation. — The sigmoid flexure of the colon much contracted. — A 
 gentleman, aged about forty-six, of full habit, and subject to occasional attacks of 
 gout and rheumatic swelling of the joints, after a residence of twenty-seven years in 
 India, at the end of 1832 (previous to which time, thoxigh subject to constipation, he 
 had never suffered from acute visceral disease), was attacked with inflammation of the 
 bowels attended with constipation, and requiring much general and local depletion for 
 its removal. After convalescence he went to the Cape of Good Hope, resided there 
 one year, and returned to Bombay at the commencement of 1835. About two months 
 before I saw him, consequent on exposure to cold, and irregularities of diet, diarrhoea 
 supervened, alternating with occasional constipation, and scybalous discharges. When 
 he came under my care on the 17th April, 1835, he was much reduced from his usual 
 fulness. The expression of countenance was languid and anxious. The tongue was 
 florid. The bowels were relaxed, the dejections being of dark-green colour, watery, 
 and offensive. There was tenderness on pressure of the right iliac region. On the 
 27th April, occasional drowsiness was for the first time observed, and there was in- 
 creasing weakness. Death took place at noon of the 2nd May, having been preceded 
 by vomiting of inky coloured fluid. 
 
 Inspection four hours after death. — Abdomen. — The parietes of the cavity and the 
 omentum were loaded with fat. The stomach was filled with dark inky coloured fluid, 
 but, with the exception of softening of some points of the mucous coat, was healthy. 
 There was a collection of pus in the right iliac region, circumscribed by part of the 
 concave surface of the liver, the fundus of the gall-bladder, a matted portion of the 
 omentum, the ascending colon, and the right kidney. It communicated with an ex- 
 tensive, but very superficial abscess, on the inferior surface of the liver, to the right of 
 the lobulus Spigelii. The descending colon was contracted, and the sigmoid flexure 
 was of about the diameter of a swan's quill. The mucous lining of the ccecum and 
 ascending colon was thickened, and presented black mottled patches with the traces of 
 cicatrices. All the coats of the descending colon and of the sigmoid flexure were 
 thickened, but there was no puckered irregularity of the inner surface. The small 
 intestine was filled with dark green viscous contents. 
 
 127. A circumscribed sac between the liver and the ribs. — An abscess in the substance 
 of the right lobe. — The mucous coat of the colon studded with circular ideers. — George 
 Bignel, of moderate habit, aged twenty-eight years, and nine months resident in India 
 
352 HEPATITIS. 
 
 for three clays before admission into hospital on the 2nd January, 1840, had suffered 
 from pain of the right side, shooting to the shoulder, and impeding full inspiration. 
 He was twice freely bled and very freely leeched and blistered ; and on the 8th, 9th, 
 and 10th, he was mildly under the influence of mercury. He did not convalesce in a 
 satisfactory manner, and on the 29th there was recurrence of the pain of the side, and 
 the liver was distinctly felt two inches below the ribs. The fulness below the ribs 
 became subsequently more distinct, and there was hepatic sound almost to the nipple. 
 He suffered frequently from pain of the side, became emaciated, subject to hectic and 
 diarrhoea, with a tongue florid at the tip. He died on the 26th February. 
 
 Inspection. — Head. — There was an ounce of serum at the base of the skull and a 
 veil of serum between the arachnoid and pia mater on the convex surface of the brain. 
 Chest. — There were old adhesions of the right lung to the diaphragm and posterior 
 parietes, and firm adhesions of the liver to the concavity of the ribs. There was a 
 circumscribed purulent sac between the surface of the liver and the ribs. The liver 
 extended three inches below the margin of the ribs, and in the upper part of the right 
 lobe there was an abscess, the size of a hen's egg, with flocculent walls. The mucous 
 coat of the stomach was of red-brown colour, but sound in texture. The mucous coat 
 of the large intestine presented a surface of closely set circular ulcers, in places running 
 into each other, and giving a honey-combed appearance to the membrane ; in places 
 the margins of the ulcers were of bright red colour, and were generally softened in 
 texture. 
 
 Secondary Pleuritis, leading to General or Circumscribed 
 Empyema. — It has just been shown that secondary inflammation 
 of the hepatic peritoneum may lead to the formation of a purulent 
 sac instead of adhesions. A reference to the cases quoted in 
 different parts of this chapter will show that secondary diaphrag 
 matic peritonitis, is very frequently associated with secondary dia- 
 phragmatic pleuritis, leading to adhesion between the base of the 
 right lung and the diaphragm. But just as in the peritoneum, we 
 may have in the pleura a similar deviation from this rule. Instead 
 of adhesions taking place, or sometimes in association with them, 
 the lymph changes into pus, and general or circumscribed empyema 
 is the consequence. It is important to know that there may be 
 empyema co-existing with hepatic abscess, not caused by communi- 
 cation, but merely by extension of inflammatory action through 
 the diaphragm, — in individuals prone to the suppurative process. 
 It appears, then, that empyema, from communication, or indepen- 
 dent of it, is not an unfrequent complication, and it sometimes 
 renders the diagnosis of hepatic abscess obscure : the signs of the 
 empyema may be attributed to the encroachment of the liver on 
 the chest ; or, if rightly interpreted, they may throw a doubt over 
 the previous diagnosis of hepatic disease. 
 
 It is not, however, only in the pleura that we have evidence of 
 the extension of inflammation from one diaphragmatic surface to 
 the other. It may also occur, but much more rarely, in the 
 jit'i'icavdium. Of this I have met with two instances (131, 132j. 
 
TATIIOLOGY — SECONDARY TLEURITIS. 353 
 
 In one the relation of the pericarditis to hepatic ahscess was well 
 shown. These two cases, and three (128 to 130) illustrative of 
 my remarks on empyema, are here submitted. The latter may be 
 considered in connection with cases 170, 171, which exemplify the 
 same morbid state. 
 
 128. Abscess in the liver. — Empyema of the right pleura. — Symptoms not well 
 marked. — Dejection of a pint of clotted blood before death. — Mucous coat of the colon 
 dark red with ulceration. — Richard Dunstan, aged thirty-nine, two years in India, 
 was admitted on the 16th January, 1841. He was reduced in flesh, having been ill 
 for several days, and having taken no food. He complained chiefly of uneasiness at 
 the epigastrium not amounting to pain, nor increased by pressure, full inspiration or 
 decubitus on either side. Skin moist, Pulse 112, feeble, and easily compressed. He 
 continued languid, depressed, with collapsed and anxious countenance, feeble and quick 
 pulse, tongue sometimes dry in the centre, sometimes brownish, bowels generally 
 scantily moved, but on the 23rd there was passed by stool more than a pint of clotted 
 blood. He died early the following morning. 
 
 Inspection eight hours after death, — Chest, — The heart and left lung were healthy. 
 Adhesions connected the third lobe of the right lung to the diaphragm, and there were 
 about thirty ounces of sero-purulent fluid in the right sac of the pleura. Flakes of 
 lymph lined the costal pleura and parts of the pulmonary pleura. Abdomen. — The 
 liver filled both hypochondria, the right lobe adhered to the diaphragm, and in that 
 lobe there were two abscesses of considerable size. The left lobe was healthy in 
 texture. There were patches of vascularity here and there in the stomach. The 
 colon contained dark claret -red slimy contents ; the mucous coat had, throughout, a 
 reddish tint, and presented several patches of ulceration. 
 
 129. Abscess in the liver. — Effusion of four pints of serum, with lymph, in the right 
 pleura. — Ulcerated colon. — No coma, — Scrum between the pia mater and arachnoid, and 
 two or three ounces at the base of the skull. — James Roberts, aged twenty-nine, a 
 gunner, of feeble habit, was under treatment for acute hepatitis, from the 30th April 
 t<> the 16th May, 1839. He was bled and leeched freely, took calomel and opium, 
 but not to ptyalism, and he was discharged well. Was re-admitted into hospital on 
 the 5th June, affected with diarrhoea, which, under much variety of treatment, con- 
 tinued more or less troublesome. On the 3rd July, distinct hardness and tumefaction 
 between the margin of the right ribs and the crest of the os ilium, was first noted. 
 Blisters were frequently applied without benefit. He continued to lose ground. 
 Became more emaciated and sallow, and on the 3rd August, it is noted tor the first 
 and only time, that he had been much troubled with cough during the previous night. 
 The sinking increased, and he died at 3 p.m. of the 24th. 
 
 Inspection fifteen hours after death. — No evident tumefaction of either side of the 
 abdomen or chest. Head. — The membranes were exsanguine. The convex surface of the 
 brain was veiled with a thin layer of serum, and there were between two and three ounces 
 at the base of the skull. Chest. — The right sac of the pleura contained about three or 
 four pints of clear fluid serum at the upper part, thickened with flocculi of lymph at the 
 posterior and lower parts. The costal and pulmonary pleurae were coated with adherent 
 flocculi of lymph. The lung was condensed against the mediastinum. There was about 
 half a pint of serum in the left pleura, and about three ounces in the cavity of the peri- 
 cardium. The left lung and the heart were healthy. Abdomen. — The right lobe of the 
 liver extended for three inches below the margin of the right ribs ; and the edge of the 
 lobe, to the right of the gall-bladder, was occupied 1 >y an abscess, the size of a large orange 
 with dense fibrous walls. The hepatic flexure of the colon and part of the omentum 
 were matted to the walls of this abscess. Close to the diaphragm there was another 
 abscess in the right lobe, and there were adhesions of the convex surface of that lobe 
 
 A A 
 
354 HEPATITIS. 
 
 to the diaphragm. The rest of the surface of the liver was mottled white. The 
 mucous coat of the ccecum was studded with small follicular ulcerations, some of them 
 cicatrising. The rest of the mucous coat of the colon was nearly healthy. Stomach 
 healthy. The kidneys were both rather enlarged. The left of buff colour, with the 
 tubular and cortical parts not well defined. The right one was nearly natural in 
 texture, with buff streaks of the cortical part. There was about a pint of serum in 
 the cavity of the abdomen. 
 
 Remark. — The record shows a want of attention to the physical signs, as the exist- 
 ence of the pleuritic effusion does not seem to have been detected. 
 
 130. A small purulent sac circumscribed in part by the base of the right lung anil by 
 the diaphragm, and extending to the fissure between the second and third lobes of the 
 right lung, mistaken for hepatic abscess. — Serjeant James Deans, aged twenty-nine, of 
 feeble habit, From November 1842 to April 1843, was almost continuously under 
 treatment in the Artillery Hospital, suffering from dysentery, attended at times with 
 much abdominal tenderness. From the 5th to the 21st December, he was again under 
 treatment for a similar complaint. On the 29th January, 1844, he was re-admitted 
 with febrile symptoms attended with cough, pain of chest and frothy expectoration-. 
 These symptoms continued with more or less alleviation, and the sputa at times as- 
 sumed a globular appearance with rusty tinge, till the 7th February, when he was 
 transferred from the Artillery to the Exu*opean General Hospital. The cough continued 
 troublesome, there was occasional hectic fever ; the expectoration became more copious 
 and puriform in character with a reddish tinge, more or less deep. A mucous rale 
 was heard over the chest. He continued under these symptoms, gradually losing 
 strength, and latterly suffering from a complication of dysenteric symptoms, and died 
 on the 31st March. 
 
 Inspection six hours after death. — The body much emaciated. Chest. — The left lung 
 was healthy and collapsed completely. The right one adhered in parts to the costal 
 pleura and very generally to the diaphragm. The upper lobe was collapsed. Between 
 the base of the lung and the diaphragm, and also in the fissure between the second and 
 third lobe, there was a circumscribed sac containing about six ounces of thick pus, and 
 the portions of the lung adjacent to it were indurated and hepatised. There Was no 
 communication through the diaphragm. Abdomen. — Old adhesions connected the omen- 
 tum in several places to the abdominal parietes. The liver was much enlarged, grey, 
 and indurated, and extended to the crest of the os ilium, but was without any abscess. 
 
 131. Hepatitis. — Abscess in the liver. — Five pints of pus in the sac of the right pleura. 
 — A layer of lymph on the surface of the heart and inner surf ace of the pericardi 
 General peritonitis, with effusion of lymph and sero-purulent fluid. — Stephen Cain, a 
 pensioner, aged fifty, of broken habit, after eight days' illness was admitted into 
 hospital on the 24th January, 1840. He complained of pain of the right side, shooting 
 from the margin of the ribs to the shoulder. On the 4th February there was tenseness, 
 fulness, and hardness, at the margin of the right ribs, and the pulse was feeble. The 
 feebleness of the pulse continued. On the 7th the breathing was somewhat oppressed, 
 and there was general painful distention of the abdomen. He died on the 14th February. 
 
 Inspection. — There was an oxmce of serum at the base of the skull. Chest. — There 
 were five pints of pus in the sac of the right pleura. The inner surface of the pericar- 
 dium and outer of the heart, were red and roughened by a thin layer of firm granular 
 lymph. There was commencing disease of the aorta above the valves, but no hyper- 
 trophy of the heart. Abdomen. — The liver projected two or three inches beyond the 
 margin of the ribs, and there was an abscess about the size of an orange, and circum- 
 scribed, chiefly between the diaphragm and the upper surface of the liver. The 
 peritoneal surface of the intestines was dark red. The convolutions were united by 
 flakes of lymph, and sero-purulenl fluid was effused among them. The mucous coat 
 of the stomach was of dark Leaden grey colour. 
 
TATHOLOGY— SECONDARY GENERAL PERITONITIS. 355 
 
 132. Pericarditis. — The inner surface of the pericardium and the outer side of the 
 heart com red with a thick layer of irregvlar lymph. — Also effusion of serum and displace- 
 ment of the liver, partly caused by the distended pericardium. — Abscess of the liver. — 
 John Devair, aged twenty-five, seaman, was admitted on the 12th November, 1840. 
 He stated that he had been ill for two months and a half; that his complaint began 
 with pain of the abdomen, shooting from the hypogastrium and the left side, thence 
 through the chest. These symptoms were not attended with diarrhoea, constipation or 
 difficulty of micturition ; but his statement was confused. He passed a restless night, 
 and on the 13th, the epigastrium was tense, resisting, and painful on pressm-e ; and 
 on percussion, the sound was dull almost to the umbilicus, also midway between the 
 crest of the os ilium of the right side and false ribs, and extended into the hypochon- 
 drium. The breathing was a good deal oppressed ; the skin above natural tempera- 
 ture ; pulse 120, feeble and compressible; tongue pretty clean. Anteriorly, on the 
 right side of the chest and below the nipple, the sound was clear on percussion. On 
 the left there was much dulness about the cardiac region, extending to the arch of the 
 left false ribs and to the sternum ; no bulging. On the 20th the uneasiness of the 
 chest and dyspnoea were increased, and he had suffered from rigors ; the pulse was 
 100, very irregular, unequal, with occasional intermission ; the abdomen full and tense. 
 Between the left nipple and the sternum the action of the heart was perceptibly 
 increased ; and there was a very distinct fremissement, more distinct at that situation 
 than at the apex of the heart. There was now almost constant orthopncea ; pulse 
 very feeble. On the 23rd the fremissement had ceased. He died on the night of the 
 24th. 
 
 Inspection ten hours after death. — Body not much emaciated. Chest. — The pericar- 
 dium completely occupied the anterior part of the chest and extended into the right 
 side for some distance ; its transverse diameter was fully ten inches, and it reached 
 from the top of the sternum to the diaphragm, to which muscle it adhered firmly, as 
 also to the inner aspect of both lungs. There were about twenty-two ounces of clear 
 serum in the cavity of the pericardium. The inner surface of the pericardium was 
 lined throughout with a layer of lymph, a line in thickness, with a rough reticulated 
 inner surface of dark red colour ; this layer could be peeled from the pericardium 
 with tolerable facility. The outer surface of the heart was coated with a similar layer 
 of lymph, more firmly adherent, however, and presenting a more irregular and reticu- 
 lated external surface ; where the greatest irregularity existed (chiefly at the posterior' 
 part) thick bands of firm but friable lymph, about an inch or more in length, extended 
 1 "'t ween the pericardium and the heart. The heart itself and the vessels were healthy. 
 The lungs, with the exception of some old adhesions and some slight oedema, were 
 also healthy, and there was trifling serous effusion in the right cavity of the pleura. 
 Abdomen. — The transverse colon, much distended with air, occupied the umbilical 
 region. The liver, displaced by the distended pericardium, extended four inches below 
 the sternum, and about three below the last right false rib. There was an abscess in 
 the left lobe of the liver, lined with a firm membrane with flocculent surface ; it was the 
 size of an orange, and was adherent to the diaphragm where opposed to the adhesions 
 of the pericardium. The stomach was healthy. The cortical part of both kidneys 
 was streaked white and red, and these organs were considerably enlarged. 
 
 Secondary General Peritonitis. — Secondary general peritonitis 
 is not unfrequent in the advanced stages of hepatic abscess. It 
 occurred in 10 per cent, of the cases at present under review. Its 
 access is generally marked by symptoms sufficiently distinct ; and 
 flaky lymph or sero-pundent effusion is found after death. It has 
 been already stated that the opening of an abscess into the cavity 
 of the peritoneum is rare ; and there can be no doubt that in the 
 
 A A 2 
 
356 HEPATITIS. 
 
 majority of instances general peritonitis is not due to a direct cause 
 of this kind, but is merely additional evidence of the tendency of 
 secondary inflammations to arise in the course of hepatic abscess, 
 and, by the form which they assume, to indicate the degree of 
 cachexia present. 
 
 The four cases which follow are of this nature. On this point of 
 pathology reference may be further made to cases 140, 172, 185. 
 
 133. General peritonitis. — Abscess of the liver following head symptoms. — Serous 
 effusion in the head with thickening of the arachnoid me?nbrane, — The kidneys had 
 Undt rgone yellow degeneration. — Garrott Dunn, aged thirty-eight, of spare habit, was 
 admitted into the European General Hospital, on the 6th August, 1838. He was deaf, 
 and could not give a distinct account of himself. He articulated indistinctly. Com- 
 plained of vertigo with a constant singing noise in his ears. He was bled from the 
 arm, and cupped on the back of the neck, his head was shared, and his bowels were 
 freely acted upon by purgative medicine. He continued with more or less of these 
 symptoms till the 17th October. Throughout this period, the deafness was constant, 
 the vertigo and noise occasional. He was cupped, leeched, and blistered several 
 times. Aperient medicine was from time to time exhibited. The action of mercury 
 was induced mildly on the system. The decoction of sarsaparilla was also given, first 
 with the hydriodate of potass, and then with corrosive sublimate. The head symp- 
 toms at one time presented a periodic tendency, and quinine was exhibited. No 
 benefit resulted from these different courses of treatment, and on the 17th October, in 
 addition to the former symptoms, tenderness of the abdomen was complained of 
 attended with diarrhoea. Leeches were applied, and anodynes and absorbents given. 
 On the 25th there was distinct fulness to the right of the epigastrium, accompanied 
 with tenderness. Under these symptoms he gradually sunk, and died on the 8th 
 November. 
 
 Inspection twelve hours after death. — Eody emaciated. Head. — There was increased 
 turgescence of the vessels of the pia mater on the upper surface of the brain and over 
 the posterior lobes. There was also opaque thickening of the arachnoid membrane in 
 .many places, chiefly at the dipping down between the hemispheres of the brain. 
 .There was about an ounce and a half of serum in the ventricles, and a considerable 
 quantity at the base of the skull. The substance of the brain was quite firm and 
 natural in all parts. Chest. — The lungs were healthy. A thin layer of old lymph 
 for the extent of an inch in diameter was attached to the serous covering of the 
 heart. Abdomen. — There was a small quantity of sero-puruleiit fluid in the cavity 
 of the abdomen. The intestines were distended with gas, and adhered in places by 
 flakes of lymph to the abdominal parietes. The whole of the peritoneal covering of 
 the right lobe of the liver was covered with flakes of lymph, and there were flakes 
 between the stomach and liver, and a close matting of the edge of the left lobe to the 
 colon ; that intestine was also closely embraced by the omentum. In the left lobe of 
 the liver, at the point of adhesion to the colon (the site where there had been fulness 
 and pain before death), there was an abscess the size of an orange. The substance of 
 the right lobe was healthy. In places of the mucous lining of the colon, there was 
 dark grey discoloration. In others a thinning of the coats, chiefly to all appearances 
 induced by the removal of the free surface of the mucous tunic. In the descending 
 colon and sigmoid ilexure, there were a few round ulcers, and some dark grey 
 cicatrices. The mucous lining of the stomach was covered with adhesive mucus, was 
 dark grey al the cardiac end, marbled dark red a1 the pyloric, but was neither Boftened 
 nor thickened. The cortical substance of b >th kidneys had undergone yellow degenera- 
 tion to a considerable extent. 
 
TATIIOLOGY — SECONDARY GENERAL TERITONITIS. 357 
 
 134. General peritonitis. — Matting of the omentum over the coecum. — Round ulcers 
 ■in the colon, and an abscess in the liver. — Antone Lopes, aged forty-two, a Portuguese 
 seaman, who had arrived from Goa about two months before his admission into the 
 European General Hospital, on the 22nd January, 1839. On admission into hospital, 
 his countenance was sallow and anxious. The abdomen was somewhat distended 
 and tense, with tenderness over the coecum. The tongue was expanded and little 
 furred. The pulse was feeble. He stated that he had been affected with dysenteric 
 symptoms for about twenty days, that the purging, at first considerable, had decreased, 
 and that the pain had increased, during the two or three days before admission. On 
 the 23rd there was a distinct defined hardness felt over the ccecum. He gradually and 
 slowly lost ground, and died on the 7th February. The tumour at the site of the 
 coecum continued distinct, till the 2nd of February, when the fulness and tenderness 
 of the abdomen became more general. At first, leeches were applied to the abdomen 
 and at three different times a blister was applied. For the first two or three days, 
 blue pill or calomel were given with ipecacuanha and opium, and afterwards sulphate 
 of quinine with a small quantity of hydrargyrum cum creta with opium and ipecacu- 
 anha. Then the ipecacuanha and mercury were left off, and the quinine was given 
 with opium and aromatic confection. 
 
 Inspection five hours after death. — Body emaciated. Abdomen moderately distended. 
 Head. — About an ounce and a half of serum in the cavity. Abdomen. — The omentum 
 crossed from the ninth or tenth left false rib, adhered to the anterior parietes, passed 
 obliquely to the hollow of the right os ilium, and thus divided the cavity into two parts. 
 The upper contained about a pint of pus in a circumscribed sac lined with false mem- 
 brane, and covering the projecting edge of the liver, the stomach, and part of the 
 omentum. The lower division contained about two pints of clear serum with flakes of 
 lymph. There was vascularity of the peritoneal covering of the small intestine and much 
 matting of the convolutions in the pelvis, and to the bladder. The coecum was matted 
 firmly to the omentum and to the hollow of the os ilium, and tore readily on attempting 
 to separate it. The descending colon w r as covered with flakes of lymph. There were 
 round isolated ulcerations, the size of a sixpence here and there, in the colon. Tho 
 liver was much enlarged and contained a large abscess in the right lobe lined with 
 firm membrane ; the parenchyma was of dark red colour, and mottled white. The 
 mucous lining of the stomach was thickened. The left kidney had partly undergone 
 yellow granular degeneration ; the right one was not examined. Chest. — The 
 thoracic viscera were healthy. 
 
 135. General peritonitis, with sero-purulent effusion and abscess in the liver. — James 
 Harrison, aged thirty-three, of slight habit, a sub-conductor in the Ordnance Depart- 
 ment, was admitted into the European General Hospital on February 2-5th, 1839. 
 He had served thirteen years in India, had suffered from dysentery whilst at Deesa in 
 1829, and was under treatment in the General Hospital for fever about ten months 
 before the present date. On admission he stated that some days previously be had 
 experienced un easiness at the epigastrium, for which he was leeched and took medi- 
 cines. Since the day before admission, there had been pain and much tenderness of 
 the right iliac region, with sense of induration and dulness, extending from two 
 inches above the crest of the os ilium, to the margin of the right false ribs, and to 
 within two inches of the umbilicus. Pulse 88, small, sharpish. The tongue was pretty 
 clean. Features sharp and anxkms. He vomited the day before admission, but not 
 since. One hundred leeches were applied to the abdomen, a warm bath ordered, and 
 calomel with ipecacuanha and opium given. On the following day (26th), the pain 
 continued; pulse 84, weak. A large Mister was applied to the abdomen. At the 
 evening visit there was no febrile exacerbation, the bowels had been four times moved 
 by the castor oil, and the evacuations were yellow and watery. The pulse small and 
 feeble. Calomel three grains, quinine two, and opium one, in the form of pill, were 
 
 A A 3 
 
358 HEPATITIS. 
 
 ordered at bed-time. From this time, the pain of the abdomen was more or less com- 
 plained of, and on the fourth, the distention had considerably increased. The pulse was 
 generally from 80 to 88, feeble and often thready ; the skin was cold and damp ; the 
 tongue was moist and without fur, and two or three watery yellow evacuations were in 
 general passed daily. The treatment consisted of quinine in combination with 
 hydrargyrum cum creta and half a grain of opium thrice daily. He died on the night 
 of the 5th March. 
 
 hispection eight hours after death. — Body not much emaciated. Abdomen. — "Was 
 moderately distended and tense. The omentum, vascular and thickened was matted 
 over the transverse colon, the edge of the liver, and the ccecum. It also adhered firmly 
 to the hollow of the os ilium. There was general redness over the peritoneal coat of 
 the bowels, with flakes of lymph. There were about three pints of sero-pnrnlent 
 fluid in the cavity of the peritoneum, chiefly between the right lobe of the Liver and 
 the ribs, and in the iliac and pelvic regions. The liver was of natural size, mottled 
 and of pale fawn colour, except in the neighboiu'hood of two or three small abscesses 
 in the right lobe, where the mottling was dark red. The coats of the ececuni and 
 colon were not thickened ; their mucous coat was of dark grey colour, but not ulcerated. 
 The stomach was healthy. In the left kidney the distinction of cortical and tubular 
 portion was not well defined ; the right kidney was healthy. The thoracic viscera 
 were healthy. Head. — At the base of the skidl there was an ounce of serum. 
 
 136. Probably small superficial abscess of under surface oflobzdus Spigelii, leading to 
 apuriform.sac in gastro-hepatic omentum, and this by rupture to gencred peritonitis. — 
 Jaundice. — Ingan Khan, a Mussulman butler, using spirits in moderate quantity, of 
 forty years of age, and in reduced condition, was admitted into the clinical ward on 
 the 19th October, 1850. The respiration was somewhat hurried, partly abdominal 
 and partly thoracic. There was some degree of general fidness of the abdomen, and a 
 line drawn from the point of the right ninth rib to within two inches of the umbilicus, 
 and then obliquely upwards to the eighth left rib, formed the lower limit of a distinctly 
 full and almost circumscribed induration, of which the thoracic margin was the upper 
 boundary ; this space was dull on percussion, painful on pressure, deep inspiration, and 
 coughing. There was some yellowness of the conjunctivae, febrile disturbance, a 
 coated tongue, constipated bowels, and high-coloured urine. The illness was of twenty 
 days' duration, and commenced with febrile symptoms. These recurred every evening 
 with chills, and terminated with sweating. Suffering much as on admission, he con- 
 tinued under treatment till the 29th October, when, in consequence of alleviation of 
 the epigastric uneasiness, he was urgent for his discharge. He was re-admitted on 
 the 1st November with anxious countenance, hurried and short respiration, and small 
 frequenl pulse, and skin about the natural temperature. There was epigastric tender- 
 ness, and some degree of general abdominal fulness; but the epigastric induration was 
 scarcely perceptible, and the dulness was limited below by a line curving from the 
 cartilage of the eighth right rib to that of the seventh left rib. On the 2nd the symptoms 
 of general peritonitis were fully marked. He died on the morning of the 3rd. The 
 urine was frequently examined, hut gave no si^ns of albumen. Sewas treated chiefly 
 with modei-ate leeching, small blisters, laxatives, quinine, diaphoretics, and anodynes. 
 
 Inspection light lour.* after death.— Abdomen. — About two pints of straw-coloured 
 serum were contained in the cavity of the peritoneum. The intestines wife generally 
 distended with tlatus; their peritoneal surface presented a dusky hue chiefly where 
 I Im convolutions were in contact, with flakes of lymph here and there. The Ivmphy 
 effusion was abundanl on the convex surface of the liver, which seemed somewhal 
 compressed, and adhered to the diaphragm by friable hands. The thin edge of a part 
 
 of the concave surface of the left lobe of the liver was firmly adherent to the stomach, 
 
 the transverse colon, and the hepatic flexure. Easily separable adhesions also existed 
 between the righl lobe of the liver, the fundus of the gall-bladder, and the lateral 
 
TAUTOLOGY — CONTEXTS OF ABSCESS. 3o9 
 
 part of the diaphragm. The omentum was matted over the ascending colon, and 
 reached as far as the right abdominal ring. On separating the adhesions between the 
 concave surface of the liver and the stomach, a thick layer of friable lymph was seen 
 on the surface of the latter and on the duodenum, with a few ounces of sero-pus, 
 which seemed to proceed from a sac, chiefly formed in the gastro-hepatic omentum. 
 One part of its wall was in relation with the inferior surface of the lobulus Spigelii. 
 This lobe was compressed, its tissue of a dark-red colour, mottled, and presenting 
 near the surface, and in relation with the wall of the sac, two or three purulent 
 deposits, each the size of a small bean. The transverse or portal fissure, with the 
 large blood-vessels and duct, were not involved. No other traces of abscess were 
 detected in any other part of the liver, which was of normal size, and extended from 
 the level of the fifth to the ninth rib. "When incised in various directions, its surface 
 presented an olive-green colour, and was somewhat indurated, seemingly from a state 
 of commencing cirrhosis. The upper surface of the right lobe was much puckered. 
 The mucous membrane of the stomach was covered with a large quantity of pidtaceous 
 mucus, but its texture was in every respect healthy. The mucous membrane of the 
 duodenum presented a dark-red eoloiu', but it also was normal in structure. Chest. — 
 The lungs collapsed freely. Old adhesions connected in places the costal to the pul- 
 monary pleura on both sides. 
 
 These details show that circumscribed collections of pus in rela- 
 tion with the peritoneum and pleura, also puriform general peri- 
 tonitis, are not uncommon events in the course of hepatic abscess. 
 This result is probably dependent on the cachectic condition of the 
 individuals affected. But here the question ma}^ be proposed, 
 whether these complications are due to particular forms of cachexia ? 
 If so, and if we have diagnostic symptoms of these cachexia?, it is 
 evident that we shall be in possession of knowledge likely to bear on 
 prognosis and treatment. Is this tendency to suppurative inflam- 
 mation related to the cachexia of malaria, scorbutus, struma, mer- 
 cury, intemperate spirit drinking, syphilis, prolonged elevation of 
 temperature, habitual residence in a vitiated atmosphere, or to that 
 which co-exists, as cause or effect, with Bright's disease of the 
 kidney ? My own observations are insufficient to elucidate these 
 important practical questions ; but it is very probable that further in- 
 vestigation will establish a relation between these forms of secondary 
 inflammation and the cachexia of Bright's disease. On referring 
 to my cases, with a view of testing the likelihood of this suggestion, 
 I am disappointed by finding them so frequently defective. Many 
 of them were recorded at a time when attention had not as yet 
 been generally directed to this important part of pathology. Yet 
 imperfect as they are, granular degeneration of the kidney is noted 
 in six of the eighteen cases, and in the remaining twelve the state of 
 the kidney is not described. 
 
 Clm ruder of the contents of Hepatic Abscesses. — In the cases 
 detailed in these pages the appearance presented by the pus in 
 hepatic abscesses is so generally stated, that I should have thought 
 
360 hepatitis. 
 
 it unnecessary to allude to the subject more particularly. But 
 there are statements made on this point by Kokitansky and Budd, 
 differing so materially from the results of my own experience, that 
 it would be an omission on my part not to advert to them. 
 
 Rokitansk}^ says : " A large abscess of long standing, invariably 
 contains pus mixed with a considerable amount of bile, which arises 
 from the communication established between the cavity and larger 
 gall ducts."* 
 
 We are not told of the number of cases on which this general 
 statement is grounded ; nor whether the presence of bile was deter- 
 mined from the general colour of the pus, or by the microscope or 
 by chemical tests. Assuming from the expression, " considerable 
 amount of bile," that the inference has been drawn from the colour 
 as appearing to the naked eye, I find myself unable to assent to 
 the assertion of this eminent pathologist. 
 
 There are before me 98 cases in which the morbid appearances 
 of hepatic abscess are described, and ten others in which the 
 contents were artificially discharged. They were all observed and 
 noted by myself, but of only four (97, 111, 137, 141) is a bile- 
 tinged state of the pus recorded ; and I can hardly think that so 
 notable a character, if existing, would in 104 cases have failed to 
 attract my attention. I place the more confidence in my own 
 observations, because since becoming aware of the opinion of 
 Tvokitansky, and feeling how opposed it was to my previous belief, 
 I have spoken with several of my professional friends, whose 
 experience in this form of disease has been considerable, and have 
 hitherto found that their conclusions coincide with my own. The 
 statement of the able German pathologist cannot therefore be 
 considered applicable to hepatic abscess in India, as hitherto 
 observed. 
 
 In Dr. Budd's work on Diseases of the Liver are the following 
 
 remarks : — 
 
 % " Many of the old writers describe the pus of abscess of the liver as being generally 
 red or claret-coloured, but this statement is incorrect. In all the abscesses of the liver 
 that I have examined, the pus was white or yellowish, just like that of a phlegmon. 
 The error of those who have described it as being reddish, resulted, perhaps, from 
 their having met with a case in which flic abscess opened into the lung, and in which 
 the pus, in its passage through the lung, became mixed with blood and broken-down 
 pulmonary tissue. They describe the matter expectorated, and not the matter con- 
 tained in the abscess. It is not very uncommon for an abscess of the liver to open 
 into the Lung. Several instances of this kind have fallen under my own notice, and 
 in all of them the matter expectorated was a dirty red or brownish pus. The reddish 
 
 * "Pathological Anatomy," Sydenham Society, vol. ii. p. 132. 
 
CAUSES — TREDISPOSIXG AND EXCITING. 361 
 
 colour of the pus was acquired on its passage through the lung. The matter in the 
 abscess was yellowish or white." * 
 
 Cases 108, 149, 161, 165, confirm the statement of the old 
 writers, that the pus in hepatic abscess is sometimes of a red 
 colour, and do not accord with the opinion above expressed by Dr. 
 Budd. 
 
 Haspell having observed a pink colour of the contents in two of 
 his three successful cases of puncture of hepatic abscess, has 
 inferred that this colour is a condition of the early stage of the 
 abscess, and that when present in punctured abscess it justifies a 
 favourable prognosis. These inferences, deduced from very limited 
 data, are not supported by my cases 161, 165. 
 
 Inflammation of the Ported or Hepatic Vein --is a pathological 
 state of interest and importance; but it is one with which I 
 have little practical acquaintance. Of portal phlebitis I have not 
 met with a case, and have only seen the morbid appearances in 
 one of hepatic phlebitis. In this case there was abscess, and the 
 branches of the hepatic vein in its neighbourhood were dilated, 
 contained pus, and their coats were somewhat thickened. 
 
 Section IV. — Etiology of Hepatitis. — Exciting Causes.- — Ex- 
 ternal Cold, elevated Temperature, Intemperance, Mechanical 
 Causes. —Importance of Predisposing Causes stated. — The 
 Complication of Hepatic Abscess and Dysentery considered in 
 reference to the Pyoemic Theory of the Causation of Hepatic 
 Abscess. 
 
 In the etiology of dysentery, much importance was attached to 
 those conditions of the atmosphere which reduce the temperature 
 of the surface of the body, as an exciting cause. The same view 
 may be taken of the etiology of hepatitis. Dysentery was found to 
 prevail most in the cold months, November, December, January ; 
 next in June, July, and August ; and then in February and 
 March. 
 
 On comparing the proportional admissions from hepatitis per 
 cent, of the total hospital admissions with those from dysentery f , 
 the following differences may be noted: — 1. The admissions from 
 dysentery are fully twice as numerous as those from hepatitis ; 2. 
 The months of February and March are those of greatest prevalence 
 
 * " On Diseases of the Liver," Second Edition, p. 98. 
 t Pages 274 and 362. 
 
362 HEPATITIS. 
 
 of hepatitis, then follow November, December, January. The hot 
 months, April and May, as well as September and October, take 
 precedence of the monsoon months, June, July, August, which 
 latter, in the instance of dysentery, stood next to the cold 
 months. 
 
 Why the admissions from hepatitis in February and March have 
 in both hospitals exceeded those of the three preceding colder 
 months, I am unable to explain, but probably more extended data 
 will show that it is accidental. The fact, however, does not affect 
 the conclusion, that external cold is a common exciting cause of the 
 disease. It is not improbable, when we bear in mind the advanced 
 stages of disease at which admissions take place into general hos- 
 pitals, more especially at seaports, that a scrutiny of the admissions 
 of February and March would prove that a proportion of them had 
 commenced in the months which preceded. 
 
 The admissions of dysentery were fewest in the hot months 
 April and May * ; but we find that the admissions of hepatitis in 
 these months came next to the cold months, and took precedence 
 of the rainy months. Without attaching undue importance to 
 limited and partial statistics, it may be remarked that these results 
 tend to confirm the generally admitted impression, that elevated 
 temperature has more influence in the causation of hepatitis than 
 of dysentery. To this subject I shall presently more particularly 
 advert. 
 
 Proportional Admissions from Hepatitis in different Seasons. 
 
 
 European 
 General 
 Hospital. 
 
 Jamsetjee 
 Jejeebhoy 
 Hospital. 
 
 February, and March, — transition from cold months. 
 November, December, January, — cold months . 
 April and May, — hot months ..... 
 September, October, — transition from rains 
 June, July, August, — rainy months .... 
 
 4-8 
 3-8 
 34 
 3-2 
 29 
 
 2-0 
 17 
 1-6 
 1-0 
 1-4 
 
 Annual proportion .... 
 
 37 
 
 1-5 
 
 When explaining the causes of dysentery I dwelt at considerable 
 length on the importance of a right appreciation of predisposing 
 conditions as favouring the action of the exciting cause. The 
 principles then inculcated are equally applicable to hepatitis. 
 
 * This remark is only strictly applicable to the European General Hospital ; for in 
 the Jamsetjee Jejeebhoj Eospital the admissions from dysentery in April and May 
 
 took precedence of those of February and March. 
 
CAUSES — PREDISPOSING AND EXCITING. 363 
 
 Whether, of the various kinds of cachexia alluded to as predis- 
 posing to dysentery, there are some rather than others which pre- 
 dispose to hepatitis, is a question for future inquiry to determine ; 
 but allusion may be made to one or two points relating to it. 
 Tbere is nothing before me to show that there is any particular 
 connection between hepatic abscess and the tubercular diathesis. 
 Tubercles in the lungs were found only in one of the cases of hepatic 
 abscess. Tubercles in the liver were noticed in only three cases — 
 one (48) of melanosis of the colon, the other two of tubercular 
 phthisis. 
 
 The evidence that intemperance in drinking exercises a peculiar 
 influence in causing hepatitis is by no means conclusive. That a 
 considerable proportion of both European and native hospital 
 admissions from hepatitis are of intemperate individuals is 
 undoubted ; but this fact is equally true of other forms of dis- 
 ease. That the cachexia engendered by spirit drinking and the 
 exposure to cold and wet consequent on the direct effect of intoxi- 
 cation, are often operative in inducing disease, is also not to be 
 questioned : but there is nothing in my notes or my impressions 
 to convince me that these are more frequent causes of hepatitis 
 than of dysentery. Spirit drinking as a special cause of cirrhosis 
 is not called in question, but this is a form of disease common to 
 the spirit drinker in all countries, and almost exclusively confined 
 to his class. That hepatitis, on the other hand, in its severest 
 forms, is not an unusual event in persons of temperate habits, — is 
 a statement which experience in India will generally confirm. 
 
 Is hepatitis, with a liability to suppuration, peculiarly related to 
 cachexia engendered by the prolonged influence of elevated tem- 
 perature ? I believe that it is so. It is very probable that future 
 research will show that the exhausted and enfeebled by continued 
 heat, and its associated debilitating conditions, are very prone to 
 hepatitis, and that in such individuals the inflammation is very 
 frequently excited by exposure to external cold — I mean to such 
 depression of temperature as suffices to influence bodies whose 
 power of generating heat is low. 
 
 But there is another question to propose in regard to heat. Is 
 it ever the exciting cause of hepatitis, as it assuredly sometimes is 
 of cerebral disease? The occurrence in the hot months of the 
 year of hepatitis in plethoric Europeans, lately arrived in India, 
 with excreting functions deranged by free living, is probably 
 sometimes best explained on the supposition that tropical heat is 
 occasionally an exciting cause of hepatitis. 
 
364 HEPATITIS. 
 
 Cases 166, 171, and two others not detailed, show that mechani- 
 cal causes are not to be overlooked in the etiology of hepatitis. 
 
 In my remarks on jaundice as a complication of remittent fever, 
 a case (38) is detailed, in which a lumbricus was found in the 
 hepatic duct. In the case which follows, a lumbricus * was found 
 in the centre of an hepatic abscess. These circumstances are suf- 
 ficient to justify the idea that hepatitis may be sometimes caused 
 by entozoa. The fact that dracunculi have also been detected in 
 the liver may countenance the probability that the lumbricus is 
 not the only entozoon which may act in this manner. 
 
 137. Large abscess in right lobe, flocculcnt walls, communicating with a branch of 
 the hepatic vein. — Lumbricus in the abscess. — Pus orange coloured. — No ulceration of 
 large intestine. — Jaundice. — Hurree Gomajee, a Hindoo eart-driver, of thirty-five 
 years of age, and using spirits to the extent of three ounces daily, was admitted 
 into the cliuical ward on the 9th January, 1853. He was much reduced. The 
 conjunctiva? were tinged yellow, and there was slight cedema of Loth feet. The 
 respiration was short and hurried, the pulse small and compressible, and the tongue 
 florid at the tip and edges. An indistinctly fluctuating swelling occupied the epigas- 
 trium, bounded inferiorly by a curved line from the tenth left rib to the eleventh 
 right rib, crossing the umbilicus. It was painful. He stated that fifteen days before 
 he was injured on the back by a log of wood ; that two daj-s afterwards, pain of the 
 right hypochondrium, with febrile symptoms, set in ; and that the swelling appeared 
 six days before admission. The pulse became feebler, the dyspncea increased, and ho 
 died on the 12th with very slight diarrhoea. The urine gave no signs of albumen. 
 
 Inspection four hours after death. — All the white tissues were tinged yellow. — ■ 
 Chest. — There were old adhesions between the costal and pulmonary pleura of the 
 right side. The lungs were crepitating and spongy. Opaque patches were found on 
 the external surface of the heart ; the cavity of the left ventricle was somewhat 
 smaller than natural. A'alves healthy. Abdomen. — No traces of peritonitis were 
 observed except some adhesions which existed between the concave surface of the 
 liver and transverse colon, and also with the kidney of the right side. Adhesions 
 were also found between the convex surface of the liver and the diaphragm. The 
 liver extended as low as the tenth rib on the left side, and the last rib on the right 
 side, and occupied the whole of the abdomen above these points ; it was of dark mot • 
 tied red colour externally. On making an incision, an abscess was found occupying 
 almost the entire right lobe. It contained about two pints of orange-coloured sero- 
 pus, and a large quantity of pulpy flocculent matter was loosely adherent to the walls 
 of the abscess. A lumbricus was found in the abscess. The small portion of the 
 right lobe left around the abscess was of red colour. On incising the left lobe, thin 
 pus was seen to flow freely from a large branch of the hepatic vein, which could be 
 traced to the abscess, with which it communicated. The substance of the left lobe, 
 free of abscess, was mottled red and white. The stomach was contracted. The mu- 
 cous surface was rugous, and dotted red here and there. There was some degree of 
 increased vascularity of the mucous lining of the rectum, with commencing granular 
 deposit on the mucous surface. No trace of ulceration anywhere. The kidneys were 
 healthy. 
 
 * There is an excellent specimen oflumbriei in the biliary ducts in the Museum at 
 Fort Pitt, Chatham. I have also seen another in the Museum of Comparative 
 Anatomy at the Jardiu des Plantes at Paris; and no doubt many others might 
 readily be found. 
 
PY(EMIC THEORY OF ABSCESS 
 
 365 
 
 The co-existence of hepatic abscess and ulceration of the mucous 
 membrane of the large intestine, is treated by me, in connection 
 with the etiology of hepatitis in consequence of the explanation of 
 this event, lately proposed by Dr. Budd. His opinion is that a 
 very frequent, if not the exclusive, cause of inflammation of the 
 liver— not cirrhosis — is the transmission to the organ of pus or 
 vitiated secretions from an ulcerated intestinal surface. This 
 doctrine necessarily implies the termination in abscess of every 
 inflammation thus arising. In other words, it rejects the termi- 
 nation of hepatitis by resolution. 
 
 On these views I shall simply observe that, if we acknowledge 
 pyaemia as a pathological condition, we must allow that the 
 occasional occurrence of hepatic abscess, in the manner supposed, 
 is sufficiently probable. As a general proposition, however, it is at 
 variance with the results of clinical research in India, as the 
 following remarks will, I believe, sufficiently prove : — 
 
 1. Fatal dysentery with ulceration but without hepatic abscess 
 is a common occurrence in India. Fifty cases are now before me 
 and many of them have been cited in this work. Intestinal ulce- 
 ration without hepatic abscess is almost invariable in European 
 countries. Eecovery from dysentery, in which ulceration had pro- 
 bably been present, is not unfrequent in India. These facts, which 
 show a very large amount of intestinal ulceration without hepatic 
 abscess, are not consistent with the idea that abscess of the liver, 
 when existing, is always, or most commonly, the sequence of the 
 direct transmission to the organ, of the morbid matter of intestinal 
 ulcers. If this doctrine were true, ulceration of the intestines and 
 abscess of the liver would be much more frequently co-existent. 
 
 2. Primary uncomplicated hepatitis is not an unusual disease 
 in India. Restricting my inquiry to the five years of my service 
 in the European General Hospital, I find that, of the total admis- 
 sions of hepatitis, 318, or 86 per cent, recovered; and this is a 
 result incompatible with the pyoemic origin of hepatitis. This state- 
 ment may be met by the objection that the numbers are probably 
 incorrect, from mistakes in diagnosis and the inclusion of cases of 
 cirrhosis. But making every allowance for this, it cannot be sup- 
 posed that the error was committed in all the successful cases, but 
 avoided in the 14 per cent, of fatal ones. 
 
 3. There are now before me, twenty-one fatal cases of hepatic 
 abscess without ulceration of the intestine. Setting aside all other 
 arguments, these positive facts are conclusive against the theory that 
 pycemia from intestinal ulcers is the exclusive cause of hepatic 
 
366 HErATITIS. 
 
 abscess. Six of these cases (138 to 143) will presently be narrated; 
 and seven others (107, 113, 135, 137, 162, 166, 168) are elsewhere 
 detailed. 
 
 4. There is good reason for believing that the records of patho- 
 logy misrepresent the natural proportion of intestinal ulceration 
 and hepatic abscess. I have long entertained the opinion that 
 mercurial and other purgatives, too frequently repeated in hepa- 
 titis, materially favour the access of muco-enteritis and subsequent 
 ulceration. This suspicion is confirmed by the fact, that of my 
 twenty-one cases of abscess without ulceration, sixteen occurred in 
 Datives admitted into hospital in advanced stages and not pre- 
 viously treated with mercurial and other purgatives. 
 
 138. A large abscess in the liver. — No dysenteric symptoms. — No ulceration. — No 
 projection of liver below the ribs. — John "Williams, a seaman, aged twenty-eight, was 
 admitted into hospital on the 20th May, 1838, with acute pain at the scrobiculus 
 cordis, increased by pressure, attended with febrile excitement, and on the 22nd, 
 extending to the right hypochondrium, and affected by deep inspiration and decubitus 
 on the left side. On the 30th he had rigors, followed by febrile excitement, and 
 subsequent hectic. There was no enlargement below the edge of the right false ribs, 
 but there was a perceptible though not great bulging of the ribs, and a want of 
 depression of the intercostal spaces, with dulness to the axilla. Latterly there was 
 much irritability of stomach, but nothing ejected except ingesta and the mucous 
 secretions. Throughout the whole period of illness there were no symptoms of 
 dysentery or diarrhoea. On the contrary, laxatives were often required; and gene- 
 rally, and more especially latterly, the evacuations were formed, and perfectly natural. 
 He died September 5th. 
 
 Inspection fifteen hours after death. — Bod} r much emaciated ; perceptible bulging of 
 the right hypochondrium and filling up of the intercostal spaces. Chest. — The lungs 
 were collapsed and crepitating. There was no effusion into the chest, Tender adhe- 
 sions existed between the upper surface of the diaphragm and base of the right lung. 
 The liver had pushed the diaphragm to the level of the second rib, at the most convex 
 part of its arc ; and its curve touched the ribs at the level of the xipper part of the 
 fourth. The left side of the chest was natural. Abdomen. — The liver adhered to the 
 abdominal parietes at the margin of the false ribs, but did not project beyond it. The 
 entire right lobe adhered to the diaphragm, and was completely occupied by a large 
 abscess, containing serous fluid at its upper surface and pus below, in all about four 
 pounds. The sac was lined by a firm cartilaginous membrane, to which yellow flocculi 
 adhered. The thin layer of parenchyma interposed between the peritoneal covering 
 and the lining membrane of the sac was dense and fibrous, and nowhere above half an 
 inch in thickness. The left lobe was mottled. The gall-bladder contained some bile. 
 The stomach and intestines were almost natural. There was a good deal of congestion 
 of the mucous coat of the depending parts of the small intestine, and also of the 
 coecum; but the texture was quite sound. The colon was partially occupied with 
 formed and perfectly natural feculence. The kidneys were healthy. 
 
 139. Hepatitis. —Abscess in lh<: right lobe.-—Mncous c<>"f of ///<■ large intestine dark 
 red without ulceration. -Thomas Hall, aged thirty-two, private in Her Majesty's 
 15th Hussars, was admitted into hospital on the 9th January, 1840. He stated that 
 he had suffered more or Less t'i pain of the right side for three weeks before admis- 
 sion. <>n the i:sth there was dulness two inches below the margin of the right ribs, 
 but not extending into the epigastrium; it subsequently reached as high as the nipple. 
 lie died on the 1.5th March. 
 
PYCEMIC THEORY OF ABSCESS. 3G7 
 
 Inspection. Head. — There was a thin veil of serum on the convex surface of the 
 
 lira in, ami an ounce at the base of the skull. Chest. — The lungs were collapsed. 
 
 Abdomen. The liver reached to the level of the third rib, and there were tender 
 
 adhesions between the right lung and the diaphragm. It also extended two inches 
 below the niar°in of the ribs, and there were adhesions to the diaphragm and con- 
 cavity of the ribs. An abscess containing three pints of thick pus occupied the right 
 lobe, and the upper wall consisted merely of the diaphragm and the peritoneal coating 
 of the liver. The rest of the liver was mottled. The cardiac end of the stomach was 
 mottled red. The mucous coat of the large intestine was dark red and dark grey in 
 parts, but not ulcerated. 
 
 140. Chronic pneumonia of upper part of left lung. — Secondary hepatitis and 
 abscess, with flocculent vails, and peritonitic inflammation. — No intestinal ulceration. — 
 Huree Mydhur, forty years of age, a Hindoo sailor, was admitted, after a month's 
 illness, into the clinical ward on the 27th June, 1848. He had cough, with muco- 
 puriform expectoration, and he pointed to the left subclavian and mammary regions 
 as the seat of pain, and there defective respiratory movement was evident. There 
 was also dulness on percussion, siibcrepitus and bronchial sounds. He continued 
 under observation till the 17th July, when he died. There was more or less hectic 
 fever, and frequent cough with sputa, sometimes brick-red and purifonn. On the 9th 
 there was delirium. On the 10th, fulness of the epigastric region, and dulness to 
 within an inch of the umbilicus, and uneasiness on pressure there. He gradually lost 
 strength, but there was no diarrhoea. From admission up to the 13th, a cautious 
 endeavour to affect the system with mercury was made, but without success. It was 
 during this mercurial course that the hepatic symptoms appeared. 
 
 Inspection. — The lung of the right side was crepitating and healthy. The left lung 
 adhered firmly to the lateral part of the parietes of the chest, and was separated with 
 difficulty. In the lateral part of the upper lobe, separated by a thin wall from the 
 pleura, there was an excavation of two or three inches in length, the evident result of 
 gangrene of that part of the lung. The inner surface of the excavation was irregular, 
 of dark grey and black colour ; and the boundary was dense and membranous. The 
 rest of the upper lobe was in a state of grey induration, and the upper part of the 
 second lobe was red and indurated, but in some parts still permeable to air. The 
 mucous membrane of the bronchial tubes was dark red. There were three or four 
 ounces of serum in the pericardium. The heart healthy. Abdomen. — General friable 
 adhesions of lymph over the entire peritoneal siu'face, with purulent effusion amongst 
 them. The liver mottled white in its texture. Two large abscesses existed in the 
 right lobe, with flocculent shreds adherent to their inner surfaces. The concave sur- 
 face of the liver adhered by thick layers of lymph to the stomach and colon, and, 
 on separating these, the lower wall of the largest abscess readily gave way ; it was 
 supported by these other viscera. The mucous coat of the large intestine was healthy. 
 
 141. Three abscesses in different steigcs of progress. — Pus bile-tinged. — General 
 peritonitis without rupture. — No ulceration of the intestines. — Sagoo Beekia, a Hindoo 
 cultivator, thirty-five years of age, and of temperate habits, was admitted into the 
 clinical ward on the loth January, 1854. He was in good condition. The respiration 
 was short and hurried, and chiefly thoracic. There was cough and mucous expec- 
 toration, and crepitus was audible in the right dorsal region. A swelling dull to 
 percussion occupied the space between the margin of the ribs, and a line drawn from 
 the tenth left rib across the umbilicus to the last right rib. The dulness reached 
 upwards to the right fifth rib. The tongue was florid at the tip and edges. The pulse 
 was small. Decubitus was easiest on the right side. The bowels were reported regular. 
 He stated that, a month before, he became affected with fever, ushered in with chills, 
 which left him about six days before admission, when the swelling and pain of the 
 epigastrium began to appear. On the 18th and 19th the bowels were relaxed, and 
 
3G8 HEPATITIS. 
 
 febrile accessions were noted. He died on the 20th of January. The occurrence of 
 general peritonitis was not distinctly marked. 
 
 Inspection three hours after death. — There was about a pint and a half of serum in 
 the cavity of the abdomen. The serum was tinged yellow, and mixed with abundant 
 flakes of lymph. There were also yellow flakes effused on the surface of the peritoneum, 
 chiefly that covering the liver. The liver extended across the abdomen from the 
 eighth left rib to the crest of the right ilium. The convexity of the right lobe ex- 
 tended as high as the fourth rib. There were firm adhesions and exudation of lymph 
 between the convex surface of the liver and the diaphragm. On incising the liver, 
 an abscess about the size of a cocoa-nut was found at the upper part of the right 
 lobe. It was separated from the diaphragm by a thin layer of the sulistance 
 of the liver. The abscess contained pus, in part thick and pulpy, and the walls were 
 lined by a thin membrane, which presented a flocculent appearance when floated in 
 water. In the lower part of the right lobe there was another abscess the size of 
 a mango, separated from the upper one by a layer of the sulistance of the liver, 
 about a quarter of an inch thick. The walls of this abscess were similar to those of 
 the other. The rest of the substance of the right lobe was of a dark red colour. At 
 the upper part of the left lobe there was a third abscess, about the size of a mango, 
 containing yellow-coloured pus (tinged with bile). The walls were lined by a thicker 
 and firmer membrane than those of the other abscesses, and less flocculent when floated 
 in water. The remainder of the substance of the left lobe was not so dark-coloured 
 as that of the right. Emphysematous bulke the size of a pigeon's egg occupied the 
 thin edge of the left lung. There were adhesions between the left lung and peri- 
 cardium ; also between it and the walls of the chest. Slight adhesions existed 
 between the base of the right lung and the diaphragm. There was emphysema of 
 the middle and third lobes. There were white opaque patches on the surface of the 
 heart, but the structure and valves were healthy. The ececum was of dark red 
 colour. There was no thickening or ulceration of the mucous membrane of the 
 large intestine, nor of any part of the small intestine. Kidneys healthy. Spleen 
 healthy. 
 
 142. Hepatic abscess. — No ulceration of the intestine. — Shaik Ibrahim, aged twenty- 
 five, after two months' illness, was admitted on the 3rd May, 1857. He was emaci- 
 ated, and complained only of purging. There was no fulness of the right side noticed 
 during life. He died on the 9th. 
 
 Inspection. — An abscess the size of a cocoa-nut existed in the right lobe of the liver. 
 There were firm adhesions to the diaphragm. There was caries of the ninth and tenth 
 ribs, and a sloughy state of the tissues external to them. No trace of ulceration in 
 any part of the intestinal canal. 
 
 143. Hepatic abscess. — No intestinal ulceration. — Deen Mahomed, aged forty, was 
 admitted into the clinical ward on the 22nd October, 1857, with well marked hepatic 
 abscess. Bowels confined. Secondary peritonitis came on, and he died on the 9th 
 November. 
 
 Inspection. — One large encysted abscess occupied the right lobe of the liver. There 
 was no trace of ulceration of the mucous membrane of large or small intestines, but 
 redness with slight granular exudation in places. 
 
 The co-existence of hepatic abscess and intestinal ulceration may- 
 be classed in the following manner: — 
 
 1. Cases in which hepatitis lias been primary, with secon- 
 dary ulceration, generally not coming on till suppuration has well 
 advanced. 
 
 2. Cases in which dysentery has been primary, with hepatic 
 
TYCEMIC THEORY OF ABSCESS. 3GU 
 
 secondary abscess, occurring generally in advanced stages of the 
 dysentery. 
 
 3. Cases in which dysentery and hepatitis have been coincident, 
 but, in general, not well marked, and with the symptoms of the 
 dysentery, not unfrequently for a time, giving place to those of the 
 hepatitis. This form, however, is rare compared with the other 
 two, and will be more particularly noticed in connection with the 
 symptomatology of hepatitis. 
 
 Primary hepatitis ending in abscess and attended by secondary 
 dj^sentery is not difficult to understand, when we bear in mind the 
 frequency, nay almost the universality, with which the hectic 
 stage of phthisis pulmonalis, and of other forms of extensive 
 suppurative disease, are associated with intestinal ulceration : this 
 event occurring in the hectic stage of suppuration of the liver is 
 merely an illustration of this general law, and nothing more.* In 
 my notes of fatal cases of hepatic abscess with ulcerated intestine, 
 there are seven in which this sequence is evident. 
 
 Primary dysentery followed by secondary hepatic abscess, is the 
 only form of this complication which affords support to the 
 pyoemic theory. But that pyoemia is the ordinary cause even 
 of this is not for the following reasons a logical deduction from 
 the facts : — ■ («) Dysenteric ulceration, without hepatic abscess, 
 is common, (b) Intestinal ulceration is almost universal in the 
 advanced stage of phthisis pulmonalis, and is always unassociated 
 with hepatic abscess, (c) There is no reason for believing that 
 particular climates favour pyoemia. (cZ) There is much that is com- 
 mon in the predisposing and exciting causes of dysentery and 
 hepatitis, (e) It ma}^ be frequently observed that individuals, in 
 whom hepatitis occurs secondary on dysentery, have previously suf- 
 fered from hepatic disease. (/) It is a well-known pathological law 
 that, in the progress of primary inflammations, there is a predis- 
 position to secondary inflammations, and that these generally 
 prefer an organ weakened by previous disease, or by the in- 
 fluence of other predisposing causes. (</) The liver and large 
 intestine are associated in function. It might therefore be reason- 
 ably anticipated that they would also be occasionally associated 
 in their pathological conditions. 
 
 * This statement is not to be met by the argument that the ulceration of the intes- 
 tines in phthisis is tubercular, and consequently merely a further development of the 
 diathesis. That such is the character of the ulceration in a proportion of cases may 
 doI be questioned, but the result of my observation of phthisis in India leads me to 
 believe that in the majority of cases in that country the ulceration of the large intes- 
 tine does not differ in character from that frequently observed in dysentery. 
 
 B 15 
 
370 HEPATITIS. 
 
 A consideration of these facts leads me to the conclusion that 
 hepatic abscess, occurring in the course of dysentery, is, for the 
 most part, simply an instance of a secondary inflammation arising 
 in an organ predisposed by previous disease or other influences, 
 and is not caused by pycemia. The abscess was, apparently, 
 the result of secondary hepatitis, in nine of my cases. 
 
 In respect to those cases in which dysentery and hepatitis appear 
 to be coincident, I would merely observe that when we recollect 
 how much there is common in the causes of these two affections, 
 the wonder is that this original co-existence is not very frequent 
 instead of being rare. 
 
 Section V. — Symptoms of Hepatitis. — Early Stages. — Pavn, 
 Respiratory Movements. — Physical Signs. — Altered Secretion, 
 Jaundice. — Constitutional Disturbance. — Suppuration.- — 
 Course of Hepatic Abscess. 
 
 The size, situation, and relations of the liver, the constitution of 
 the patient, and the duration of the attack, should always be borne 
 in mind in investigating the symptoms of hepatitis. It should also 
 be remembered that the inflammation may affect varying extents 
 of the organ, as well as one part, or several, of its surface or sub- 
 stance, — separate or combined. 
 
 In the early stages of acute hepatitis pain will vary in degree, 
 according as the inflammation affects the peritoneal covering or is 
 confined to the parenchyma. In the former case it will be distinct 
 and often acute. In the latter dull — a sense of weight and un- 
 easiness rather than pain — and apt to be obscure, when only 
 limited portions of the organ are engaged, and when the constitu- 
 tion is asthenic. The pain will be increased, occasionally indeed 
 only appreciable, by pressure, full inspiration, and turning to the 
 left side. Sometimes in obscure cases uneasiness, not otherwise 
 detected, may be elicited by meeting the liver, as it descends under 
 full inspiration, by gentle pressure, upwards, with the hand placed 
 on the anterior surface of the abdomen below the margin of the 
 right ribs. 
 
 Pain will vary in situation according to the part of the liver 
 affected. It may exist at the posterior, lateral, or anterior parts of 
 the arch of the right ribs below the sixth; at the margin of the 
 right ribs from the seventh to the last, or at the epigastrium just 
 below the ensiform cartilage. But pain from the sixth to the 
 eighth or ninth rib, may be caused by pleuritis or pneumonia: in 
 
SYMPTOMS — TAIN, RESPIRATION. 371 
 
 this diagnosis, auscultation will materially assist us. It is not often 
 that primary pleuritis or pneumonia is so limited in extent ; but 
 should partial friction murmur, or crepitus, indicate that these 
 affections exist, then it may be inferred that the liver is not im- 
 plicated, because the co-existence of hepatitis and pleuritis or 
 pneumonia, common enough in the advanced stages of the first- 
 named disease, is rare at its commencement. 
 
 Care must be further taken not to confound costal pain, related 
 to muscular or fibrous tissue and rheumatic diathesis, with the pain 
 of internal inflammation. The history of the patient, and a 
 consideration of the other symptoms, should protect us from an 
 error of this kind. 
 
 Pain below the margin of the right ribs may proceed from the 
 colon, the duodenum, the biliary ducts or gall-bladder, and here 
 again a judicious review of the associated symptoms must guide 
 the diagnosis. 
 
 If the clinical student remembers what has been said (p. 327), 
 on the infrequency in India, of inflammation of the periphery, 
 compared with that of the substance of the liver, he must already 
 have arrived at the conclusion, that pain is often not a prominent 
 symptom of hepatitis. 
 
 "What is the value of pain of the rigid shoulder as a symptom 
 of hepatitis? It is present in a small proportion of cases, but 
 absent in the majority. W hen present it gives additional emphasis 
 to the other symptoms, but its absence in no respect detracts from 
 their import. 
 
 We are often materially assisted in detecting inflammation of 
 the liver, by carefully attending to the movements of the lower 
 part of the right side of the chest and of the same side of the 
 abdomen, under inspiration. Defective movement of the lower 
 right chest, and of the abdominal wall below the right costal mar- 
 gin, in the absence of thoracic disease, suggests the existence of 
 hepatitis, as might be anticipated, when we recollect the great ex- 
 tent of the hepatic surface, in relation with the diaphragm, and the 
 movements impressed upon it by the contractions of this muscle. 
 But while importance is thus attached to these partial imperfect 
 inspiratory movements, it must not be forgotten that the inflam- 
 mation may be so limited and so deep as to be removed from the 
 influence of the pressure of the diaphragm. Therefore normal 
 respiration does not necessarily imply the absence of hepatitis. 
 
 Nor may we overlook the relations of the concave surface of the 
 liver to the stomach, and the explanation which this affords of the 
 
 B B 2 
 
372 HEPATITIS. 
 
 occasional occurrence of vomiting. But this symptom is more 
 frequently observed in the advanced than in the early stages of 
 hepatitis. 
 
 Do physical signs assist us in the diagnosis of the early stage 
 of hepatitis? 
 
 At the commencement of inflammatory action there is always an 
 increased quantity of Mood in the affected capillaries, and when 
 this derangement is of an organ well supplied with blood, aug- 
 mented bulk must be a necessary consequence. 
 
 If there be general inflammation of the substance of the liver, 
 the size of the organ will be increased, and a sense of weight and 
 tension in the hepatic region, usually aggravated by turning to 
 the left side, will be complained of. 
 
 Enlargement of the liver may be ascertained by careful manual 
 examination, below the margin of the right ribs. There, the edge 
 of the organ may be felt, and this result will be favoured by 
 causing the patient to incline towards the left side, while we gently 
 raise the liver, with the left hand placed on the inferior dorsal 
 region, towards the right hand applied below the margin of the 
 ribs. But if hepatitis exists pain may materially interfere with ac- 
 curate palpation. This, however, is of little consequence, for the 
 lower as well as the upper limit of the organ may be more accu- 
 rately determined by gentle percussion. Clinical physicians doubt- 
 less differ in their estimate of these two methods of investigation. 
 My own preference is for percussion made gently and from below 
 iijnvards as respects the lower limit, and from above downwards 
 as respects the upper limit. It is hardly necessary to add, that 
 both in palpation and percussion regard must be had to the condi- 
 tion of the contents of the adjacent hollow viscera. 
 
 Enlargement is, however, not so common a sign of the early stage 
 of hepatitis as casual reflection might suggest. The capacity of the 
 capillaries of the hepatic artery — those concerned in inflammation 
 — is small compared with that of the portal capillaries ; therefore 
 cnhirgernent of the liver from capillary turgescence is a more pro- 
 bable sequence of fulness of the portal vein than of the hepatic 
 artery. Portal capillary turgescence is not hepatic inflammation, 
 but hepatic congestion; therefore augmented size of the liver, quickly 
 appearing, is more likely to arise from the latter than from the 
 former; moreover, general inflammation is rare, but the conditions 
 which favour general congestion are of common occurrence: they 
 are disease of the heart and of the lungs, also the deteriorated 
 blood, and deranged balance of circulation in malarious fevers. 
 
STlinOMS ENLARGEMENT, JAUNDICE. 373 
 
 A liver, tense and enlarged by congestion, is often also tender 
 on pressure ; therefore, on the detection of enlargement, we must 
 carefully inquire for the other symptoms of inflammation, and for 
 the conditions which favour congestion ; also whether the patient 
 has previously been the subject of hepatic enlargement from re- 
 curring fever, or from malarious or other cachexia. The result of 
 this inquiry will decide the diagnosis. 
 
 This question of diagnosis from enlargement rests on the hj 7 po- 
 thesis of general hepatitis, but as the inflammation is commonly 
 limited in extent, it follows, that hepatitis, in its early stages, is 
 frequently unattended by enlargement. 
 
 Mr. Twining believed that deep-seated hepatic inflamma- 
 tion was generally indicated by a peculiar tense state of the upper 
 part of the right rectus muscle. Subsequent observers have not 
 confirmed this opinion. That the muscular fibres of the anterior 
 abdominal walls often spasmodically contract to keep off the pres- 
 sure of the hand from a tender organ beneath, is true ; and the 
 tension or resistance thereby occasioned, — whether occurring at 
 the margin of the right ribs, or elsewhere, — is often a valuable 
 sign of subjacent inflammation. But that this sign has any special 
 relation to deep-seated hepatic inflammation is not in accordance 
 with my experience. 
 
 Do altered states of the biliary secretion, as evidenced by the 
 condition of the alvine discharges, assist us in the diagnosis of 
 hepatitis ? Most certainly not. Clinical research is on this point 
 in keeping with physiology and pathology. If the bile be secreted 
 from the portal capillaries, if hepatitis be a derangement of the 
 capillaries of the hepatic artery, and generally only of a small 
 portion of them — then the reasonable inference is, that hepatitis 
 is not unlikely to be attended with a normal state of the biliary 
 secretion. Observation of the disease proves the accuracy of this 
 conclusion. In hepatitis the secretion may be normal ; or it may 
 be excessive or defective. 
 
 The bile is secreted by the portal capillaries. Pathology teaches 
 us that the circulation in these is often deranged, and suggests that 
 altered secretion is more likely to be related to deranged circulation 
 of the portal vein than of the hepatic artery ; and that when it 
 occurs in hepatitis it is not a symptom of it, but of co-existing 
 portal derangement. Both observation and theory justify the 
 statement that the state of the biliary secretion is of little value as 
 a sjinptom of hepatitis. 
 
 Jaundice is mentioned as a symptom of hepatitis in systematic 
 
 B D 3 
 
374 HEPATITIS. 
 
 works on disease ; and considerable prominence has been given to 
 it, even in a recent able special treatise on the diseases of the liver. 
 But, as regards India, the statement is erroneous. In that 
 country jaundice is very seldom present in hepatitis ; and its 
 absence or presence is of no account in determining the diagnosis. 
 In evidence of the accuracy of this statement, I need only refer to 
 the numerous cases of hepatic abscess now before me. There are 
 only five in which jaundice has been noted, and in them the ex- 
 planation is sometimes supplied by such events as the presence of 
 a lumbricus in the abscess (137), or the pressure of pus in the 
 neighbourhood of the common and hepatic ducts* (136). 
 
 Pain, enlargement, deranged secretion of the liver, and modified 
 function of adjacent organs, in their relation to the symptomatology 
 of commencing hepatitis, have been considered ; but we have yet 
 to inquire whether general or constitutional symptoms are of 
 importance. 
 
 The local symptoms which have been described may be preceded 
 by a sense of chilliness, to be followed by heat of skin and fre- 
 quency of pulse; and some degree of this febrile disturbance 
 generally continues throughout the course of the disease. 
 The pulse is more or less full, the tongue more or less coated, 
 and the bowels are generally confined. The degree of these 
 symptoms has reference to the state of the constitution, being 
 more marked in the sthenic than in the asthenic. 
 
 It was stated that not unfrequently dysentery may exist without 
 much febrile disturbance. The same fact is true of hepatitis, more 
 especially when the central parts of the organ are the seat of the 
 inflammation ; and it is very probable when the morbid action is 
 of limited extent and the diathesis asthenic. 
 
 It has been already explained (p. 278), that when inflammation 
 attacks individuals, ■ — European or native, — who have been ex- 
 posed, for some time, to the influence of malarious climates, the 
 symptomatic fever frequently assumes a remittent form. This 
 remark applies to hepatitis as well as to other inflammations ; but 
 the fact has been more frequently noted by me in natives than in 
 Europeans. 
 
 Such, then, are the symptoms on which we may rely for the 
 
 * I do not, in connection with hepatitis, make prominent allusion to a dark, dingy 
 appearance of the skin not unfrequently observed in Europeans suffering from acute 
 di in Imlia, and which may be held to indicate an inadequate elimination of bile; 
 
 because, though occasionally present in hepatitis, it is not confined to that disease, 
 and ran hardly he considered a symptom of it. When observed, however, it neces- 
 sarily direets our attention to the condition of the liver and its functions. 
 
SYMPTOMS. HEPATIC ABSCESS. 375 
 
 diagnosis of acute hepatitis in its eaxly stages. They are some- 
 times, it appears, sufficiently distinct and expressive ; but at other 
 times, unfortunately, vague and unsatisfactory. This obscurity, 
 moreover, is most apt to attend inflammation of that part of the 
 oro-an, and in that kind of constitution, in which suppuration is 
 likely to occur. 
 
 Though, then, the diagnosis of hepatitis may be occasionally 
 doubtful, still I entertain the belief that too much prominence has 
 been given to this feature by practical writers. My conviction is, 
 that with a careful inquiry into symptoms, local and general, the 
 observation of the diathesis, and a just attention to the previous 
 history as respects former disease and exposure to predisposing and 
 exciting causes, hepatic abscess, unsuspected or undetected dming 
 life, ought to be a much rarer event than is generally supposed. 
 The contrary opinion has a manifest tendency to encourage 
 careless investigation. 
 
 When hepatitis occurs in individuals of good diathesis, is seen 
 early, and is met by judicious treatment, the symptoms, local and 
 general, will, for the most part, gradually disappear, and the 
 individual be restored to health. 
 
 In many cases, however, in consequence of bad diathesis, or 
 advanced stages, or other causes, recovery does not take place, 
 in some suppuration occurs, and hepatic abscess is formed. It is 
 of importance to be able early to detect this result and to note its 
 progress, because principles of treatment different from those suit- 
 able to the antecedent stages are indicated. There can be no doubt 
 that tardiness in detecting suppuration and in modifying the treat- 
 ment accordingly has led to undue mortality from hepatic abscess. 
 
 I proceed now to describe the symptoms which indicate that 
 hepatic inflammation has terminated in suppuration. When 
 the pain or other symptoms of hepatitis have continued with little 
 or no abatement, there may appear after some time — eight or 
 twelve days — increased fulness of the lower right false ribs, or 
 fulness or tenseness below their margin or in the epigastrium, 
 attended with increased dulness on percussion. Or the signs may 
 point to enlargement upwards. There may be short dry cough, 
 the respiration may be short and thoracic, and dulness on percus- 
 sion may extend above the normal limit. Or in some cases the 
 signs of increase both upwards and downwards may be combined. 
 When such phenomena occur in succession to well-marked symp- 
 toms of acute hepatitis, there can be no doubt that abscess has 
 formed. 
 
 c n 4 
 
376 hepatitis. 
 
 But this distinct transition of the inflammation into abscess is 
 not the usual course. Some degree of alleviation, consequent, 
 perhaps, on the treatment employed, is more common : the pain 
 may cease, or be very much lessened, and the febrile excitement may 
 pass away ; but emaciation increases, and a constant sense of lan- 
 guor is experienced. This state may continue for some days. 
 Then occasional chills * may be complained of, or some degree of 
 febrile excitement may be apparent towards evening, slight at first, 
 perhaps overlooked, but soon increasing in degree, and assuming 
 the character of hectic, with a tongue florid at the tip and edges, 
 or tending to be apthous. With all this constitutional disturbance, 
 there ma} r , as yet, be no return of local symptoms — no signs of 
 enlarging liver ; but, notwithstanding this, slowly-developed hectic 
 fever, consecutive on previous symptoms of hepatitis, affords 
 almost conclusive evidence that suppuration is in progress, and will 
 shortly be proved by the positive signs of hepatic abscess. Some 
 degree of uneasiness and sense of weight will, however, be usually 
 experienced in the region of the liver ; or a feeling of oppression at 
 the lower part of the chest, attended with dry cough. Sometimes, 
 at this stage, acute pain of the right side comes on suddenly, 
 caused either by tension from the increasing contents of the ab- 
 scess, or by sudden recrudescence of the inflammation ; and now, if 
 the previous symptoms have not been carefully noted, and the right 
 diagnosis formed, a serious error may be committed. This sudden 
 access of acute pain may be interpreted as indicating the onset of 
 primary acute hepatitis ; and injudiciously active treatment may, 
 in consequence, be adopted. 
 
 The disease still advancing, the physical signs of consider- 
 able enlargement, gradually appear. If in the direction down- 
 wards, it will be indicated by fulness and hardness and dulness at 
 the margin of the right ribs, and for some distance below them ; if 
 the left lobe is the seat, the fulness and dulness will be in the 
 epigastrium. If, on the other hand, the enlargement be towards 
 the chest, there will be cough, impaired movement of the lower 
 part of the right chest, and increasing dulness above the sixth rib. 
 
 With these physical signs of enlarging liver, and symptoms of 
 deranged function of adjacent organs, there will be increasing 
 emaciation, continuance of hectic fever, and at times acute pain of 
 
 * In respect to the occurrence of rigors, in the course of hepatitis, I would remark 
 thai when distinct they afford strong suspicion, but not certain evidence, of suppu- 
 ration ; for I have known them present in cases in which abscess did uot result. On 
 the whole, the symptom is not of much value, and the observer will be in continual 
 error if be allows their absence to influence his diagnosis. 
 
SYMPTOMS — HEPATIC ABSCESS. 377 
 
 the side. Then, at this stage, dysenteric symptoms, chronic in 
 character, generally appear; or, to express it otherwise, secondary 
 inflammation of the mucous membrane of the large intestine, 
 usually passing on to ulceration, is apt to arise. 
 
 The hepatic abscess has been traced to a stage in which its ex- 
 istence is no longer doubtful, and its still further progress has to 
 be described. But before doing so, I am desirous of also following 
 to the stage at which we have now arrived — 1, abscess not preceded 
 by well-marked symptoms of hepatitis, — the obscure cases to which 
 reference has been made on several occasions ; 2, abscess secondary 
 on dysentery ; 3, those cases in which dysentery and hepatitis have 
 been coincident, but the symptoms of both have been badly deve- 
 loped, and the issue has been in hepatic abscess. 
 
 1. We have just learnt that hepatic abscess is sometimes deve- 
 loped in this manner, viz., the symptoms of hepatitis are more or 
 less, it may be entirely, removed, and are succeeded by certain 
 phenomena, which, viewed in connection with the fact of previous 
 symptoms of hepatitis, justify the conviction that suppuration has 
 taken place. But hepatic abscess may occur, unpreceded by dis- 
 tinct symptoms of hepatitis, and the question now is, by what 
 means, under these circumstances, may we detect or infer its pre- 
 sence. We fix our attention on the symptoms which are so expres- 
 sive in succession to those of marked hepatitis, viz., loss of flesh, 
 sense of languor and debility, florid tongue, occasional chills, even- 
 ing flushings of heat gradually passing into hectic fever. Should 
 these occur in an individual of sallow complexion, cachectic from 
 elevated temperature, mercurial courses, mental anxieties; or the 
 subject, at former times, of attacks of hepatitis, or of deranged 
 bowels with pale discharges, and not addicted to the intemperate 
 use of spirits, or certainly tainted with malaria, then we may 
 entertain a strong suspicion that we have to deal with an ob- 
 scure hepatitis passing into suppuration. In the instance of the 
 spirit drinker, we must keep in view the probability of cirrhosis. 
 In the instance of the tainted with malaria, we must consider the 
 probability of this influence, being a sufficient explanation of the 
 symptoms. 
 
 The chief difficulty, however, will be experienced in those 
 occasional cases in which the abscess forms slowly *, is small, 
 
 * An interesting case of long existing abscess is given by Dr. Budd, at p. 1G9 of 
 his work, second edition. 
 
 Dr. Maclean, of the Madras army, in a very valuable paper on the "Abuse of Mer- 
 cury in Hepatic Disease," in the third number of the " Indian Annals of Medicine," 
 also quotes a case of obscure and old hepatic abscess. Careful perusal of the cases 
 
378 HEPATITIS. 
 
 deep, becomes encysted, and quiescent, or has partially undergone 
 absorption. For such may endure for months, it may be years, and 
 give, only occasionally, and at long intervals, obscure indication of 
 its presence. Still, even in these rare instances, the feeble general 
 health and the character of the occasional derangements, viewed in 
 connection with the previous history, may generally serve to excite 
 our apprehension in respect to the condition of the liver. 
 
 I find in my notes the following case illustrative of the general 
 tenor of these remarks on the symptoms of obscurely forming 
 hepatic abscess. Several years ago I attended a delicate European 
 female, with acute hepatitis. She recovered under the cautious 
 use of leeching, and gentle mercurial influence. Subsequently she 
 became pregnant, and was delivered at the full period. She 
 nursed for several months, but was obliged to discontinue. Then, 
 as I learnt, she suffered from occasional febrile accessions, and re- 
 laxed bowels, and became emaciated, but made no complaint of 
 pain in the region of the liver. This state continued, with occa- 
 sional abatement, but no suspicion of serious organic disease was 
 entertained. The symptoms were thought to depend on debility 
 from lactation. I now incidentally saw her, as a friend rather than 
 professionally, between six and seven o'clock in the evening, and 
 was much struck with the great emaciation, the hot dry skin, the 
 feeble frequent pulse, and very florid tongue. I made no examina 
 tion of the side. Three or four days afterwards she died suddenly ; 
 hepatic abscess had burst into the sac of the peritoneum. 
 
 2. Let us next notice the cases of hepatic abscess which are 
 distinctly secondary on dysentery. The disease, we may suppose, 
 has been correctly viewed as dysentery, it has attained to such 
 degree of progress, that ulceration has jDrobably resulted ; or, not 
 unfrequently, the symptoms indicate that improvement has com- 
 menced, but it is not steady, the emaciation and languor being 
 greater in degree than the amount of the dysenteric symptoms can 
 satisfactorily explain. If, under these circumstances of dysentery, 
 an evening febrile accession, with increasing floridity of tongue, is 
 detected, then there are good grounds for suspecting that abscess 
 has either formed, or is forming in the liver, to become evident, in 
 due course, by the usual physical signs. A large proportion of such 
 cases will be found to be of individuals predisposed to hepatitis by 
 former disease, or by those influences which have been already 
 several times mentioned, and the recognition of which, under the 
 
 narrated in this chapter will discover several in which the course of the abscess was 
 very slow. 
 
SYMPTOMS — HEPATIC ABSCESS. 379 
 
 circumstances now adverted to, will tend to confirm the diagnosis of 
 hepatic abscess. 
 
 3. But it is not to the advanced stages of dysentery that a co- 
 existing hepatitis with tendency to terminate in abscess is con- 
 fined. It sometimes happens that the dysenteric symptoms have 
 been present for a few days only, have not been severe, perhaps 
 neglected; then the symptoms of hepatitis creep on slowly and 
 obscurely, and as they become confirmed, the dysenteric symptoms 
 may disappear, or continue in a subdued form. Here we have an 
 illustration either of the two diseases originating at the same time 
 under the influence of the same causes, or of a primary disease, 
 slight in degree, giving place to the greater development of a 
 secondary one. This relation of hepatic abscess to dysentery is 
 very rare compared with that in which the hepatitis is a feature of 
 the advanced stages of dysentery. But it is very important— its 
 gravity is apt to be overlooked. It is not confined to the cachectic 
 and old resident, but has been witnessed by me only in Europeans. 
 I have the impression that it will probably be found to be related 
 to the predisposing influence of depressed vital actions consequent 
 on malaria, mental anxiety, or other similar causes. This form of 
 disease is well illustrated by the following case : — 
 
 144. Slight dysenteric symptoms of some clays' duration, followed by febrile symp- 
 toms. — Those of hepatic inflammation coming on obscurely, and ending in abscess.— 
 
 Mr. H , a gentleman, about thirty-five years of age, who had been resident some 
 
 years in Bombay, at the beginning of July 1847, suffered from occasional dysenteric 
 symptoms. He passed small quantities of blood-tinged mucus. This, however, had 
 abated much, without treatment, I saw him first on the 16th July. There was not 
 any febrile disturbance, no uneasiness on pressure of the abdomen, and the scanty 
 discharges did not take place more frequently than twice or thrice in the twenty-four 
 hours, but he passed sleepless nights. On the 17th slight uneasiness of the right side 
 of the abdomen was first complained of, and on the 18th there was a febrile accession, 
 which recurred with greater severity on the evening of the 19th, with uneasy epigas- 
 trium, occasional retching, a coated tongue, and a dingy yellowish tinge of the skin. The 
 dysenteric symptoms had ceased. There was now fever, with morning remission and 
 evening exacerbation ; and on the 22nd there was considerable pain below the right 
 ribs, on turning to the left side, and on full inspiration ; and on the 23rd there was 
 general fulness of the lower right ribs, but the liver was not detected below them. 
 On the 24th, after pain suddenly and severely felt below the right ribs and over the 
 abdomen generally, relieved by sinapisms and anodynes, a distinct defined hardness 
 midway between the ribs and iliac fossa became perceptible. There was now abate- 
 ment of the febrile disturbance, cessation of the dysenteric symptoms, and quiescence 
 of the hepatic ; and he was sent early in August to the Cape of Good Hope, in a com- 
 fortable ship. He died shortly after arrival there of hepatic abscess. He was treated 
 with free leeching, calomel, ipecacuanha and opiates, with quinine during the febrile 
 remissions. 
 
 Having described the different circumstances under which sup- 
 puration in the liver may become developed, I return to the history 
 
380 HEPATITIS. 
 
 at that stage when, however originating, the existence of abscess has 
 become certain ; and proceed to follow it to its several issues. 
 
 In a large proportion of cases, death takes place in consequence 
 of the exhausting effects of hectic fever, and co-existing diarrhoea, 
 without rupture* of the abscess. This is the course when there are 
 many abscesses scattered about the substance of the liver, or when 
 one or two large abscesses exist deep in the parenelryma of the 
 right lobe. The fatal termination is, no doubt, in instances, 
 hastened by the too long-continued use of antiphlogistic remedies, 
 intestinal irritants, or injudicious operative proceedings. In these 
 circumstances of hepatic abscess, the prognosis is necessarily most 
 unfavourable, but it forms no part of the art of medicine to add to 
 the danger by unseasonable interference. 
 
 The abscess may advance to the external surface, fluctuate dis- 
 tinctly, and point at the margin of the right ribs, the epigastrium, 
 or an intercostal space. If life be prolonged, rupture will take 
 place, and the likelihood of a successful result will depend on the 
 state of the constitution, on the abscess being single or not, being 
 seated in the thin parts of the organ or extending to its deeper 
 structures, and on its being associated, or not, with dysentery. But 
 the natural course in cases of this kind has been frequently modified 
 by surgical interference, and our data are therefore rendered im- 
 perfect. The question of the puncture of hepatic abscess will be 
 considered as part of the treatment. 
 
 Hepatic abscess may extend in the proximity of the diaphragm, 
 and pleuritis and pneumonia of the base of the right lung may be 
 excited. This may be indicated by, in addition to cough and de- 
 fective respiratory movement, friction murmur, or crepitus. This 
 event is most likely to occur when the abscess is large. 
 
 A "hepatic compression rhonchus" has been described by Dr. 
 Walshe, as present in enlargement of the liver, and is attributed by 
 him to expansion of the lower portion of the lung previously com- 
 pressed. It has been inferred, that this sign may serve to assist in 
 the diagnosis of abscess when pressing upwards, and causing 
 compression of the lung. I am unacquainted with this sign, and 
 though I may not question the accuracy of Dr. Walshe's observation, 
 or the justness of his explanation*, yet I may doubt its applicability 
 without great caution to hepatic abscess ; for here there is a great 
 
 * I may observe, that my knowledge of Dr. Walshe's opinion is derived from an 
 interesting inquiry into the " £ ad Pathology of Al scess in the Liver," lately 
 
 published by Mr. E. J. Waring, Residency Surgeon a1 Travancore, and the able author 
 of a "Manual of Practical Therapeutics." 
 
SYMPTOMS — HErATIC ABSCESS. 381 
 
 probability that, by less practised ears, the rhonchus may be con- 
 founded with friction murmur, and thus the existence of pleuritis be 
 overlooked. I am the more confident in this opinion, because my 
 late much valued friend, Dr. Malcolmson, committed this error, in the 
 year 1838. In a paper published in the 21st volume of the Trans- 
 actions of the Medico-Chirurgical Society, he describes a sound 
 between " a crepitous rattle and a bleating," and he attributed it 
 to comj)ression of the thin edge of the lung ; but it is evident from 
 the description of the appearances after death, that the sound heard 
 had been a friction murmur. " At the spot where the sound was 
 heard, there was a slight adhesion of the thin margin of the lung 
 to the sixth and seventh ribs." 
 
 When the pleuritic inflammation has terminated, as occasionally 
 happens, in circumscribed or general effusion, then there may be 
 doubt whether the dulness, absence of vocal thrill, and other signs 
 of displacement and compression of the lung, are due to empyema, 
 or simply to enlargement of the liver. Perhaps this difficulty ought 
 only to be experienced in cases which come under notice at this 
 advanced stage, and in which there has not been the opportunity of 
 observing the early symptoms, and thus ascertaining the previous 
 existence of hepatitis. If the following case had occurred in a 
 hospital in Europe, there would have been little hesitation in at 
 once determining it to be one of right pleuritic effusion ; but 
 admitted into a hospital in India, in which hepatic abscess en- 
 croaching on the chest, sometimes associated with empyema, is not 
 an unfrequent event, there was room for the doubt which was 
 experienced, and which is expressed in the heading of the statement. 
 
 145. Diagnosis doubtful : uJtcthcr right 'pleuritic effusion, or large hepatic abscess, 
 or both conjoined. — Shaik Chanel, twenty-one years of age, a Mussulman butler, of 
 emaciated frame, and with anxious countenance, addicted to the moderate use of 
 spirits, was admitted into the clinical ward on the 13th November, 1852. The res- 
 piration was short, hurried, and chiefly thoracic, and the movement of the right side 
 of the chest was defective. The right dorsal, lateral, and mammary regions were 
 completely, the scapidar and interscapular slightly, dull on percussion. In these dull 
 situations, bronchial respiration was audible, and vocal thrill altogether absent. In the 
 subclavian resonant region the respiration was puerile. The precordial dulness com- 
 mencing at the second left rib, was bounded internally by the left sternal border, and 
 below was continuous with the hepatic dulness. The heart's apex beat between the 
 fourth and fifth left ribs, half an inch below and external to the nipple. The right 
 side across the nipple exceeded the left by one inch. Below the margin of the right 
 ribs, there was sense of induration, with dulness, continuous with the thoracic dulness. 
 A curved line from the point of the right twelfth rib, to that of the tenth left rib, and 
 passing about an inch above the umbibcus, formed the lower limit of this indurated 
 and .lull space. Decubitus easiest on the back, most difficult on the left side. Com- 
 plained of pain of the right side, and occasional cough. Stated that five months 
 before he had suffered from intermittent fever, and been cured. It recurred, how- 
 
382 HEPATITIS. 
 
 ever, six weeks before admission, followed by cough. The induration below the ribs 
 had been first noticed fifteen days ago. He continued under observation, suffering 
 from febrile accessions, dyspnoea, some increase in the size of the right side of chest, 
 till the 23rd, when he was removed by his friends. The urine had given no trace of 
 albumen. 
 
 I add another instructive case, in -which the error in diagnosis 
 was committed, probably in consequence of adhesions preventing 
 the descent of the liver, and the great extension upwards of the 
 abscess preventing marked lateral bulging. 
 
 146. Hepatic abscess mistaken for pleuritic effusion. — Pascoal Kyttan, aged forty, 
 was admitted into hospital on the 28th February, 1S57, after ten days' illness. There 
 was hurried respiration, febrile heat, feeble pulse, tenderness below the right ribs, with 
 didness for an inch, defective movement of the right side of chest, dulness of lateral, 
 infra-scapular and lower scapular regions with defective breath sounds, occasional 
 crepitus and feeble vocal thrill ; also slight general fulness of the right infra-mammary 
 and infra-axillary regions. He continued suffering from evening febrile exacerbations, 
 more or less dyspnoea, sometimes pain of right side of chest. Crepitus was heard, 
 from time to time, and friction murmur was on one occasion suspected in the infra- 
 scapular regions. He died on the 2nd March. 
 
 Inspection. — The right lobe of the liver was throughout its entire surface firmly 
 adherent to the diaphragm. It did not project above an inch below the ribs. It was 
 converted into a large abscess sac, the upper wall of which for a considerable extent 
 consisted chiefly of the diaphragm, which ascended to the third rib. The gall-bladder, 
 full of bile, was part of the lower wall. There was pretty firm adhesion of the 
 diaphragm to the base of the lung ; but no engorgement or solidification of the lung 
 there or elsewhere ; it crepitated throughout. The left lung was also healthy. The 
 left lobe of the liver was healthy, and was pushed over to the curve of the left ribs. 
 There was streaked vascularity of the mucous membrane of the colon, with two or 
 three superficial ulcers with gramdar exudation in the ccecum and rectum. 
 
 Hepatic abscess may point at the diaphragm, rupture, and 
 communicate ■with the lung. («) If the abscess has been large and 
 has opened into a bronchial tube of some size, a considerable 
 quantity of pus may be quickly expectorated, and if the constitution 
 has been good, recovery may take place; but communication with 
 the lung in this manner is of rare occurrence, (h) The abscess may 
 be small, and, on opening into the substance of the lung, may 
 excite, in some degree, inflammation in the tissues adjacent, then 
 muco-puriform sputa, generally tinged red, will be expectorated in 
 moderate quantity, for varying periods, and if the constitution 
 has been good and the abscess single, there will be a fair chance of 
 restoration to health. The majority of recovered cases of abscess 
 communicating with the lung are of this nature, (c) The al 
 may be large and open into the substance of the lung, excite 
 inflammation, softening, liquefaction of tissue, and lead to the 
 formation of a ragged cavity, of varying size, in the base of the 
 lung, and continuous with the sac in the liver. The sjjuta then 
 
SYMPTOMS — HEPATIC AESCESS. 383 
 
 will be rnuco-puriform or sero-puriform, often in considerable 
 quantit}-, generally of red or brown tint, very rarely bile-tinged, 
 and expectorated with harassing cough. A fatal result will take 
 place in periods longer or shorter, according to the diathesis. In 
 such cases careful auscultation should detect the presence of 
 cavernous sounds in the base of the lung. 
 
 In " Xotes on Hepatitis," as observed by me in the European 
 General Hospital, presented to the Bombay Medical and Physical 
 Society in May 1815, and published in No. VI. of their "Trans- 
 actions," I find the following remark relative to the opening of 
 hepatic abscess into the lung : — 
 
 " This expectoration of brick-red puriform fluid I am disposed to consider as patho- 
 gnomonic of abscess in the liver opening into the lungs, because there is not any disease 
 of the lungs in -which we can conceive, as a result, the co-existence of pus intimately 
 intermixed with blood ; the one, pus, being the result of an advanced stage of inflam- 
 matory action ; the other, blood, the result of an early stage of the same action. But 
 when we suppose that the pus comes from the liver, and the blood from the lung 
 irritated by the foreign body, the co-existence is sufficiently intelligible." 
 
 Dr. Budd, in his " Treatise on Diseases of the Liver," * published 
 
 in June 1845, writing of the opening of hepatic abscess into the 
 
 lung, thus expresses himself: — 
 
 '• "When this happens, it is marked by very characteristic symptoms, by a new train 
 of stethoscopic phenomena, which it is perhaps unnecessary to detail, and by the sud- 
 den expectoration of a dirty red or brownish puriform matter. The peculiar colour 
 of this matter, which has been already noticed, arises from the pus, in its passage 
 through the lung, becoming mixed with blood and broken down pulmonary tissue. 
 There is no matter bike it expectorated in any disease of the lung itself ; and I believe 
 that its appearing is pathognomonic of abscess of the liver, or at least of abscess perfora- 
 ting the lung. I observed it in several instances in the Dreadnought, and more than once 
 was led by it to detect an abscess in the liver, of which I had previously no suspicion." 
 
 Here, then, are two observers, remote from each other, unac- 
 quainted with each other's researches, making at the same time, 
 and very nearly in the same words, the same observation relative 
 to a symptom of disease ; yet both were certainly in error in re- 
 gard to the exclusive light in which they viewed the symptom. 
 
 The kind of sputa, which I have described in my remarks on 
 pneumonia, under the designation of red-tinged muco-puriform 
 sputa, observed in states of asthenic pneumonia, is not to be distin- 
 guished from that which I formerly considered to be pathognomonic 
 of hepatic abscess having opened into the lung. Confiding in my 
 former investigations, I, in more instances than one, committed an 
 error in diagnosis, after my transference from the European to the 
 Jamsetjee Jejeebhoy Hospital brought me for the first time into 
 practical acquaintance with asthenic forms of pneumonia. 
 * First edition, page 88. 
 
3S4 HEPATITIS. 
 
 The diagnosis between asthenic pneumonia and communicating 
 hepatic abscess, when undue importance is not attached to this 
 character of the sputum, may, no doubt, in the majority of cases, 
 be satisfactorily made out ; but yet not in all. as the following cases 
 will serve to illustrate : — 
 
 147. Asthenic 'pneumonia mistaken for communicating hepatic abscess. — Dhoondee 
 Pelajee, a Hindoo mason, fifty years of age, was after twenty days' illness, admitted 
 into hospital, on the 24th January, 1S46, affected with fever, anxiety, dyspnoea, and 
 pain across the lower and anterior part of the chest. There were bronchitic rales, with 
 crepitus and bronchial respiration in the posterior part of the right side of the chest. 
 The disease was considered to be pneumonia. But on the 26th the pain extended 
 from the right nipple to two inches beyond the margin of the right ribs ; and there 
 was dulness on percussion throughout this extent. The sputa were of brick-red 
 colour, and in detached masses. The opinion was then entertained that there was 
 abscess of the liver, which had opened into the lung, and that the pneumonia was 
 secondary. He died on the 30th January. The liver extended an inch beyond the 
 margin of the ribs ; it had formed slight adhesions with the diaphragm, was congested 
 with blood, but without abscess or other disease of structure. The right lung adhered 
 to the diaphragm and the ribs by tender adhesions ; the lower lobe was in a state of 
 red induration. 
 
 148. Whether asthenic pneumonia or communicating hepatic abscess — doubtful. — 
 Allawoodeen, a Mussulman weaver, thirty-seven years of age, was admitted into the 
 clinical ward on the 27th December, 1850. He had been ill four months. He was 
 emaciated ; his respiration was short and hurried ; there was dulness, with some slight 
 bidging of the lower part of right side of the chest. There was defectiveness there of 
 vocal thrill, and absence of sound under the stethoscope. There was tenderness 
 below the margin of the right ribs. He had constant troublesome short cough, expec- 
 torated red-tinged opaque mucus, and suffered from hectic. The illness had com- 
 menced with pain of the right side of chest and margin of the ribs four months 
 before admission ; the cough and expectoration had existed for six weeks. The sputa 
 became mueo-puriforni, and tinged red. About a month after admission there were 
 signs of a cavity at the lower angle of the right scapula, and dysenteric symptoms 
 came on. He was removed from the hospital in a moribund state. This case was 
 entered Pneumonia in the hospital returns, but I am very doubtful of the accuracy of 
 the diagnosis that was then formed. I believe now that hepatic abscess had opened 
 into the lung. 
 
 Abscess may open into the stomach or intestinal canal, the 
 peritoneum or pericardium, but I have not under this head any 
 remarks to make in addition to those already offered on the patho- 
 logy of these events (pp. 342, 345). 
 
 Section VI. — Treatment of Early Stages. — Blood-lettvng, general 
 and local. — Mercurial and other Purgatives. — Mercurial 
 1 1 ijl uen ce. — Bl iste rs. — Treatme n t when A bscess is fori ruin g 
 and is perfected. — Question of Puncture considered. — Change 
 of Climate. 
 
 I shall first describe the treatment of the early stages of acute 
 hepatitis, and then that which is applicable after suppuration has 
 
TREATMENT BLOOD-LETTING. 385 
 
 taken place. Several of the remedies which have been noticed in 
 the chapters on fever and dysentery will again come under review ; 
 but I shall not deem it necessary to reiterate principles which 
 have been already fully explained. 
 
 Success in the treatment of hepatitis, as iu all inflammatory 
 diseases, depends on the recency of the attack, and the diathesis 
 of the patient — whether favourable to resolution or to disorga- 
 nisation. 
 
 General Blood-letting. — When the period of the attack renders 
 it probable that the inflammation has not passed the stage of 
 vascular turgescence or commencing exudation — when the general 
 aspect of the patient, the rate, fulness, and firmness of the pulse, 
 and increased temperature of the skin, indicate febrile disturbance 
 with sufficiency of blood and excessive action of a heart of adequate 
 power — then general blood-letting should be had recourse to. 
 
 Vascular turgescence will always be increased when the blood 
 not deficient in quantity is impelled by a heart of adequate power 
 and excited action ; and this evil may be best controlled by general 
 blood-letting. 
 
 But it is only in the early stage of hepatitis in Europeans not 
 long resident in India, and uninjured by the depressing influences 
 of malaria, elevated temperature and intemperance — or in the 
 sthenic natives of the more temperate regions of India — that 
 we may expect the conditions which are visually benefited by 
 general blood-letting. Moreover, we must be careful that even in 
 suitable cases this remedy is not used in an injurious degree. 
 
 It is the most prompt and therefore the best means of reducing 
 excessive action of the heart, co-existing with sufficiency of blood. 
 But when the action has been reduced, and the blood diminished 
 in quantity, the utility of general blood-letting ends ; and from 
 this time, if persisted in, it becomes injurious, by favouring 
 the change of exuded lymph into pus, and lessening the 
 chance of subsequent repair. The useful application of general 
 blood-letting is chiefly limited to the stage of vascular tur- 
 gescence. If it be used in the stage of exudation (exception 
 being made in favour of those occasional cases in which the 
 conditions indicating its expediency are still present), it will 
 generally prove ultimately injurious. It is impossible to be 
 more precise, or to lay clown rules as to whether the quantity 
 of blood abstracted should be sixteen, twenty, or thirty ounces, or 
 whether it should be repeated or not; but there can be no 
 question, that the excessive blood-letting advocated by some 
 
 c c 
 
386 HEPATITIS 
 
 (especially Mr. Twining) is altogether at variance with the prin- 
 ciples which I have been endeavouring to inculcate. 
 
 When these remarks are regarded in connection with those 
 on the pathology, etiology, and symptoms of hepatitis, the con- 
 clusion must be evident, that general blood-letting is a remedy 
 not frequently required in the treatment of this disease as it pre- 
 sents itself to the practitioner in India.* 
 
 Local blood-letting, chiefly by leeches, is of more general appli- 
 cation. It is valuable in succession to general blood-letting, and 
 also in those cases for which general blood-letting is unsuitable. 
 The number used and the frequency of repetition must depend on 
 the size of the leech, the stage of the disease, the severity of the 
 symptoms, and the character of the diathesis. Though local blood- 
 letting is also most beneficial in the early stages of vascular tur- 
 gescence ; still it is of value after exudations have taken place — 
 even after their degeneration has commenced — for it acts favourably 
 on the surrounding turgescent parts. It must always be remem- 
 bered that exuded lymph will not become absorbed — will not go 
 through the other processes that may be most favourable to resto- 
 ration — unless the capillary circulation immediately surrounding 
 it be in a tolerably normal state. In using leeches, however, 
 in these more advanced stages of inflammation, especial regard 
 must be had to the state of the constitution ; for if there be doubt 
 of its ability to bear further loss of blood without injury, we must 
 desist, and call to our aid other means of derivation. 
 
 As remedies subsidiary to blood-letting and useful in the same 
 stage as well as subsequently, fomentations frequently applied, or 
 the warm water compress with bandage and appliances to prevent 
 evaporation, may be mentioned. 
 
 Mercurial and other Purgatives. — The principle on which the 
 action of calomel and of other purgatives is useful, in certain con- 
 ditions of the early stages of dysentery, has been explained at 
 some length. They favour, by increasing secretion, the free 
 movement of the blood in the portal capillaries and the mucous 
 lining of the small intestine ; and thus tend to relieve stagnation 
 of blood in the capillaries of the large intestine. These remedies 
 form also an important part of treatment in the early stages of 
 
 * It can hardly be necessary to say, that this observation is to be understood as 
 applying to medical practice in India in the aggregate. The proportion of cases 
 calling for genera] blood-letting in the practice, of different individuals, will vary ac- 
 cording to the field in which it is followed. I really fear that I may be charged with 
 tediousness in tho reiteration of this principle ; but I have seen so much neglect of its 
 observance in the course of my service, that excess of caution may well be pardoned. 
 
TREATMENT — MERCURIAL AND OTHER PURGATIVES. 387 
 
 certain conditions of hepatitis ; and their efficacy is explainable on 
 the same principle. The blood of the arterial capillaries of the 
 liver, equally with that of the mucous membrane of the large 
 intestine, is passed into the portal capillaries ; and, consequently, 
 free circulation in the latter must equally tend to lessen stagnation 
 in the capillaries of the hepatic artery. Therefore the frequently- 
 quoted remark of Abercrombie — " If the liver be supposed to be 
 in a state of torpor, mercury is given to excite it ; if in a state of 
 acute inflammation, mercury is given to moderate the inflamma- 
 tion and reduce the action," conveys to my mind no expression of 
 inconsistency. 
 
 Consecutive on general blood-letting, or the early application of 
 leeches, it is generally useful to give ten grains of calomel and 
 one of opium, with so much ipecacuanha as the stomach is tolerant 
 of, and in four or five hours afterwards, a moderate dose of castor 
 oil, or compound jalap powder. The necessity of repeating these 
 means will bear relation to the sthenic state of the system, the 
 recency of the attack, the presence of congestion of the portal 
 capillaries, and a deranged state of the biliary secretion. The 
 symptoms of portal congestion are : — (a) A yellow-coated tongue, 
 without irritation of the mucous lining of the mouth to account for 
 it. (6) Scanty alvine discharges, dark or pale, (c) General fulness 
 of the upper part of the abdomen, with, it may be, the physical 
 signs of hepatic enlargement, (d) A dingy state of the skin and 
 scanty high-coloured urine. 
 
 Calomel and other purgatives are used, not to exercise any 
 direct effect on the inflamed capillaries, but to remove a co-existing 
 congestion of the portal capillaries, which must tend to prevent a 
 return to normal circulation in the capillaries of the hepatic artery. 
 This combined derangement is likely to be present, in such degree 
 as to require these remedies, only in the early stages of hepatitis 
 and in systems well supplied with blood. In advanced stages, in 
 previously healthy individuals, and in cachectic constitutions in all 
 stages, these means are contra-indicated, because a tendency to 
 dysentery is a characteristic feature of cachexia as well as of an 
 advanced stage of hepatitis ; and there is no more certain exciting 
 cause of it, in these states, than calomel and purgatives. When 
 under these latter circumstances there is suspicion of portal stag- 
 nation, or other indication for the use of eliminants, then small 
 doses of blue pill in combination with ipecacuanha, or the extract 
 of taraxacum with an alkali, and the external application of nitro- 
 muriatic acid should be resorted to. 
 
388 hepatitis. 
 
 Ipecacuanha is very beneficial in hepatitis, given to the degree 
 that may be practicable ; but there is not that tolerance which is a 
 characteristic feature of dysentery. So true is this that when a 
 dysenteric patient is intolerant of ipecacuanha, we should make it 
 a rule to investigate closely the condition of the liver. 
 
 In combining opium with calomel, the quantity must be regulated 
 by the tendency, or not, to gastric or enteric irritation. 
 
 Quiescence in the recumbent posture, and a very restricted diet, 
 are essential adjuvants in the management of the early stages of 
 acute hepatitis. 
 
 By steadily observing this system of treatment we may hope, in 
 persons of good diathesis, to cure the disease by resolution in a 
 considerable proportion of cases in which it has not advanced 
 beyond vascular turgescence or commencing exudation. But to 
 ensure this result an important caution is necessary. We must be 
 careful not to commit the error of thinking that the removal of 
 the inflammation and the cessation of the symptoms are always, or 
 even generally, coincident events. The deranged capillaries return 
 slowly to their normal state, and, probably, do not commonly 
 attain it till some time after the symptoms have disappeared. The 
 latter event is in all likelihood rather coincident with the period 
 when the onward progress of diseased action has been checked, 
 and return to a healthy state has fairly commenced. Belapse is 
 apt to occur, and is often traceable to the error just adverted to. 
 When the disease has clearly existed recovery must still be regarded 
 as incomplete till several days have elapsed since the removal of pain 
 and febrile disturbance ; and during this period the patient should be 
 confined to bed, the diet should still be most carefully regulated, 
 and any derangement of the secretions be corrected by gentle means. 
 
 But the attack may be only moderated, not removed, by the 
 means of treatment recommended ; and the conclusion, that exuda- 
 tion and coagulation of lymph are taking place is forced upon us. 
 Or the case may have come under treatment at that stage which 
 renders it probable that this event had already occurred. What 
 are the resources of our art under these circumstances ? Let us 
 recollect what pathology has taught us, — (a) That plastic lymph 
 exuded and coagulated may become organised into fibrous tissue, 
 and thus cause more or less permanent organic injury. This 
 is an occasional but rare result of hepatitis, (b) Plastic lymph 
 exuded and coagulated, instead of becoming organised, may 
 speedily re-liquefy, and be absorbed, and thus complete recovery 
 may result. But this event necessarily implies a nearly normal 
 
TREATMENT — ME&CUBY. 389 
 
 state of the capillary circulation, and of the quantity and quality of 
 the blood, in the surrounding tissues. To effect this termination is 
 the object of treatment in this stage of hepatitis, and we have good 
 reason for believing that it is not unfrequently attended with suc- 
 cess, (c) Plastic lymph may be exuded in such quantity, and so 
 remote from normal structure, that its organisation into tissue, or 
 its removal by absorption, is impracticable ; it necessarily, in part, 
 becomes converted into pus, and abscess is formed. Or, aplastic 
 lymph may be exuded. It is inorganisable, and has no tendency to 
 be absorbed, partly from its excessive quantity and bad quality, 
 partly because the capillaries around are unfit to absorb. It 
 changes into pus, and in this manner also abscess is formed. 
 Both these results are common in hepatitis. 
 
 It would seem, then, that it is only under the second contin- 
 gency (b) that there is still the opportunity of complete restoration. 
 The question may be thus put. Lymph not in excessive quantity 
 having exuded and coagulated, and efficient means for controlling 
 the surrounding deranged capillary circulation having been used — ■ 
 do we possess remedies calculated to favour the fusion and absorp- 
 tion necessary to recovery ? The answer is, the mild constitutional 
 influence of mercury is believed, and probably with truth, to 
 possess this power. 
 
 But, does this admission not suggest that mercury may also be 
 beneficial when, from abnormal condition of surrounding parts, 
 excessive quantity or bad quality of lymph, pus is formed, but is not 
 absorbed ? Certainly not, for when exuded lymph tends to change 
 into pus, the action of mercury will favour this tendency, that is, 
 promote suppuration and the formation of abscess. 
 
 If these pathological and therapeutic doctrines approximate to 
 the truth, then we are provided with a principle of treatment of 
 hepatitis by induction of mercurial influence, viz. : — When the 
 disease, in a good diathesis, is at that stage in which the exu- 
 dation of lymph is likely to be going on, mercurial influence is 
 indicated. If, on the other hand, the diathesis is bad, or there is 
 reason to believe that suppuration has already taken place, mer- 
 curial influence is contra-indicated. 
 
 It is evident then that mercury can only be used with advantage 
 in hepatitis when, by careful observation and inquiry, the stage of 
 the disease and the diathesis of the patient have been ascertained 
 with tolerable accuracy. The opinion at one time generally enter- 
 tained, that mercury exercises some special power in hepatic 
 inflammation, is unsupported by clinical experience. This erro- 
 
 c c 3 
 
390 HEPATITIS. 
 
 neous doctrine is perhaps, in part, to be traced to inattention to the 
 distinction between the cholagogue and the constitutional action of 
 this agent : the nature and application of the former have already 
 been explained, and my present remarks are to be understood as 
 having exclusive reference to the latter. 
 
 Instead of thinking that the constitutional influence of mercury 
 has a special value in hepatitis, I believe, for the following 
 reasons, that more caution and discrimination are required in 
 its application in this disease than in the other membranous or 
 parenchymatous inflammations, in the treatment of which it is 
 generally used. 
 
 1. There is no organ so prone in India as the liver to become 
 the seat of suppuration, and the constitutional states which favour 
 this result of inflammation and frequently cause it, are certainly 
 aggravated by mercury. 
 
 2. The opinion that gentle ptyalism may prevent hepatic abscess, 
 can only be true in those cases for which mercury is indicated in 
 accordance with the principles just explained. That suppuration, 
 after mercurial influence, has not been an unusual occurrence in 
 the treatment of hepatitis, has been amply proved by the clinical 
 experience of myself and others. The statement made long since, 
 and repeated by Annesley and others, that, hepatic abscess, when 
 present, prevents the constitutional action of mercury, probably 
 rests on very insufficient evidence, for it is difficult to believe that 
 the experiments necessary to determine the question have been 
 frequently made. I have mj^self no practical acquaintance with 
 the use of mercury in the treatment of hepatic abscess. 
 
 3. The cases before me, more particularly those of sick officers, 
 show a marked predisposition in those who have been the frequent 
 subjects of mercurial influence to suffer from uneasiness in the 
 region of the liver, and to be affected with pale alvine discharges, 
 languor, &c. Under these circumstances, the liver is undoubtedly 
 liable to become the seat of sub-acute inflammation from ordinary 
 exciting causes, as cold. This statement accords with the observa- 
 tion made by Graves *, that enlargement of the liver is sometimes 
 a feature of mercurial cachexia. 
 
 I now return to details of practice. If the symptoms of acute 
 hepatitis treated from the outset in a good constitution are not 
 speedily and decidedly removed by blood-letting, mercurial and 
 other purgatives, rest and appropriate diet, then mercurial influ- 
 ence with the continuance of other suitable measures, is indicated, 
 * " Clinical Loctures," vol. i. p. 448. 
 
TREATMENT — COUNTER- IRRITATION. 391 
 
 and it may be best induced by from two to four grains of calomel, 
 with a quarter or half a grain of opium, and a grain of ipecacuanha, 
 when tolerated, every third, fourth, sixth, or eighth hour; so 
 regulating the dose as not to interfere with sleep, or to produce 
 more effect than distinct swelling of the gums with slight 
 ptyalism. 
 
 When, however, the case has first came under notice after two or 
 three days' illness, mercury may be expedient from the very com- 
 mencement of the treatment. 
 
 Should, on the other hand, the disease be first submitted to our 
 care at such stages, and with such symptoms, as render the exist- 
 ence of suppuration probable, then, whatever may be the character 
 of the diathesis, mercury is contra-indicated. And this is equally 
 the case, if, whatever the stage of the disease, the appearance of 
 the patient, or the history, denote a previous cachexia. When the 
 contra-indication depends on cachexia, then we may inquire whether 
 other alterative deobstruents, as liquor potassas or the iodide of 
 potassium, are likely to be advantageous. On this point I am un- 
 able to speak with confidence : liquor potassse has seemed to me 
 of use in some cases. 
 
 To find an agent which improves the plasticity of the lymph and 
 the general nutritive processes, and to abstain from mercury — 
 which has an opposite action — are the points to which attention 
 should be chiefly directed in the treatment of hepatitis in cachectic 
 constitutions. 
 
 Blisters. — Sooner or later in all cases of persisting hepatitis there 
 comes a stage when we are no longer justified in attempting to 
 lessen vascular turgescence by the derivative action of leeches ; and 
 then we must avail ourselves of those other means which act 
 similarly without causing much evacuation from the blood, as dry 
 cupping, rubefacients, epispastics. 
 
 If a normal capillary circulation in the parts adjacent to exuded 
 lymph be a necessary condition of absorption — or of the organisation 
 of the limitary layer — when absorption is impracticable — the 
 reduction of vascular turgescence by derivation is an indication not 
 confined to the early stages of hepatitis, but extends also to the more 
 advanced periods, and is then to be effected by the class of remedies 
 now under notice. Of these, the cantharides blister is the most 
 generally used. But a very large one is inexpedient.* One from 
 
 * There is a caution relative to large blisters to which it may be useful to allude. 
 There is a risk that cutaneous and subcutaneous fulness, from serous infiltration con- 
 sequent on the irritation of a blister, when at and below the margin of the ribs, may 
 
 c c 4 
 
392 HEPATITIS. 
 
 three to four inches square, placed over the affected part of the 
 liver, is preferable. The use of blisters may be commenced when 
 the stage for leeches has passed. Blisters cease to be beneficial 
 and begin to be injurious when abscess has fully formed, and is 
 advancing to the nearest surface. The reason is plain. At this 
 stage some degree of inflammation favours the interstitial absorp- 
 tion and the adhesions necessary to the safety of the remaining 
 chance of recovery. Nothing can be more irrational than the 
 application of a large blister over the right hypochondrium, tumid 
 from hepatic abscess, yet I have witnessed this. 
 
 My remarks have been confined to blisters, but dry cupping, 
 sinapisms, turpentine oil, iodine paint, and tartar emetic ointment, 
 all act on the same principle, though less efficaciously. 
 
 Let us now suppose that the treatment has been unsuccessful, 
 and that abscess has formed. Eecovery may still take place by 
 one or other of the courses described in my notice of the pathology 
 and symptoms ; and we must now consider what are the means 
 which best conduce to this end, and what are those which tend 
 to prevent it. 
 
 Mercurial and all other depressing remedies must be at once 
 abandoned. There may be a transition stage when antiphlogistics 
 are contra-indicated, but in which, from the character of the febrile 
 disturbance, tonic remedies and regimen may be doubtful : in this, 
 opiates or other anodynes, with mild diaphoretics or other gentle 
 eliminants, may be temporarily employed. Then we may gradually 
 pass to the use of tonics — as quinine with dilute sulphuric acid, or 
 nitric acid, with a bitter infusion, — while the opiate is continued at 
 bed-time. The diet should also be improved, by addition of light 
 puddings, milk, animal broths, jellies, and eggs, adjusted to the 
 condition of the digestive organs and the assimilating powers. 
 Wine or beer, when they do not excite the pulse or irritate the 
 gastro-enteric linings, are also necessary. 
 
 I have already expressed my belief that the injudicious con- 
 tinuance of mercurial and other purgatives in the advanced stages 
 of hepatitis is, in part, the cause of the frequent co-existence of 
 intestinal ulceration. These remedies must be altogether omitted; 
 and should eliminants be indicated, we must trust to taraxacum, 
 alkalies*, nitric acid, and the external use of nitro-muriatic acid. 
 
 be mistaken for the sign of enlargement of the liver, and lead to an erroneous im- 
 pression of the progress of the disease. 
 
 * Of hydrochlorati' of ammonia, used with this view by German physicians, I have 
 no experience, but the Indian practitioner will do well to try it. 
 
TREATMENT — PUNCTURE OF ABSCESS. 393 
 
 When the abscess has opened into the lung, anodynes, tonics, 
 and support, regulated to meet the requirements of particular 
 cases, are the means of treatment. When the abscess has opened 
 into the alimentary canal, similar remedies must be given, 
 and intestinal irritants be carefully abstained from. When the 
 abscess has opened into the sac of the peritoneum, the pleura, or 
 pericardium, and inflammation of these serous tissues has been 
 excited, or when general peritonitis has arisen, in the more com- 
 mon manner, independent of rupture, then, though the issue is in 
 general too surely fatal, we may prolong life and palliate suffering 
 by giving opium, in doses of from one to two grains every third or 
 fourth hour, in the manner recommended by Dr. Stokes of Dublin. 
 
 \\ nen the abscess tends towards the external surface, then, in 
 addition to the means advised in the other courses, we may 
 endeavour to lessen discomfort by warm water applications, or 
 cataplasms. When fluctuation has become apparent, the question 
 of piii i during the abscess falls to be considered. I shall best 
 explain myself on this point of practice, by stating the amount, 
 results, and deductions of my own experience. 
 
 Puncture of Hepatic Abscess, — The notes of twenty-four cases 
 in which I have witnessed the puncture of hepatic abscess are before 
 me. Of these, eight may be classed as successful, and sixteen as 
 unsuccessful. 
 
 Of the eight favourable cases, there was complete recovery in 
 five ; the history was incomplete, but restoration probable, in two : 
 there was recovery from the punctured abscess, but death a year 
 afterwards from a second abscess, in one. In all these cases the 
 abscess pointed at the epigastrium, or at the margin of the right 
 ribs, above the level of the ninth. They were all of moderate size, 
 and, from their position, it may be inferred that the}- had formed 
 in the thin part of the left lobe, or in the thin edge of the right 
 lobe. We may further, from the fact of recovery, conclude that in 
 each instance the abscess had been single. 
 
 These eight cases, 149 to 156, are here detailed. 
 
 149. Hepatic abscess pointing at the epigastrium and successfully punctured. — Trocar 
 used. — Cassim Mabomed, a Mussulman butcher, aged fifty, was admitted into the 
 Jamsetjee Jejeebhoy Hospital, on the 23rd August, 1848. There was a prominent 
 swelling in the epigastric region, chiefly in the mesial line and towards the right side ; 
 it was soft with obscure fluctuation without discoloration of the skin, or tension, and 
 the right side of the chest was resonant on percussion as low as the sixth rib. He 
 stated that about a year before admission he had received a blow on the epigastrium, 
 that the swelling made its appearance some time afterwards, and had gradually in- 
 creased to its present size. He continued under observation till the 1st of September, 
 not suffering from febrile accessions, when the swelling, which was much in the same 
 
394 HEPATITIS. 
 
 state as on admission, was punctured by a trocar, and about four ounces of red-coloured 
 pus were discharged. On the 2nd, one ounce, and on the 3rd, three ounces more 
 of reddish pus escaped from the puncture. He continued without fever, the discharge 
 gradually lessening, and left the hospital on the 13th September, when the discharge 
 had ceased, the wound had healed, and there was only a sense of thickening per- 
 ceptible in the situation of the swelling. 
 
 150. Hepatic abscess pointing at the epigastrium, punctured successfully. — Gungajee 
 Saccaram, a Hindoo, aged twenty-five, after a month's illness was admitted into the 
 Jamsetjee Jejeebhoy Hospital on the 18th April, 1846. There was a prominent 
 tumour in the centre of the epigastrium, tense, and apparently superficial. There was 
 no tenseness at the margin of the right rib, and no dulness on percussion ; there was 
 slight heat of skin. The abscess was punctured, and some dark grey-coloured pus 
 discharged. On the 19th the swelling had become considerably reduced, but there 
 was still a good deal of discharge of thick pus tinged with blood. On the 22nd there 
 was very little discharge, no tension, but considerable hardness around the puncture, 
 and the tongue continued coated, but there were no febrile accessions. On the 27th 
 the fulness and hardness had decreased much, but there was still slight discharge. 
 On the 12th 3Iay he left the hospital, the fulness and hardness and puriforni dis- 
 charge having disappeared. 
 
 151. Hepatic abscess pointing between the eighth right rib and umbilicus, successfully 
 punctured. — Through the kindness of Dr. Arbuckle I had the opportunity of seeing, 
 about the year 1850, an English medical gentleman affected with hepatic abscess. It 
 pointed about three inches below the margin of the right ribs, in about a line drawn 
 vertically from the cartilage of the eighth rib. The abscess was opened, and recovery 
 took place. This gentleman died about two years afterwards, but with what symptoms 
 there is no record in my notes. 
 
 152. Hepatic abscess punctured. — Recovery. — Krushnah Poonjajee, a Hindoo cart- 
 driver, of thirty years of age, a spirit drinker, was admitted into the clinical ward, 
 on the 11th January, 1853. He was much reduced, and his countenance was anxious. 
 A prominent swelling reached from the margin of the right false ribs and the ensiform 
 cartilage to half an inch below the umbilicus. It was dull, and the didness passed 
 upwards to the level of the fifth rib. The swelling was painful, distinctly fluctuating, 
 and at its lower part there was a small circidar opening from which purulent discharge 
 issued. Two months and a half before he had suffered from febrile accessions, and 
 pain below the margin of the right false ribs. In fifteen days afterwards a small 
 swelling below the margin of the ribs was noticed. It had gradually increased, and 
 the opening with discharge of three ounces of pus took place the night before ad- 
 mission. He had suffered from frequent accessions of fever, commencing with chills, 
 but not from bowel affection. The opening was enlarged with a bistoury, and two 
 pints of brick-red pus discharged. The discharge continued profuse till the 20th, then 
 gradually lessened, and the wound finally closed, and he was discharged well on the 
 4th March. Kecovery was somewhat retarded by dysentery at the end of January 
 and early part of February. 
 
 Remark. — This case occurred in my absence, when Dr. Forbes "Watson had charge 
 of the clinical ward. 
 
 153. Hepatic abscess, punctured at the point of the right ninth rib. — Recovery. — 
 Nursingah, a Hindoo labourer, of thirty-fire years of age, suffered three months and a 
 halt', before admission into the clinical ward, from daily accessions of fever, followed 
 in fifteen days by pain of right hypochondrium, which had continued till the time of 
 his admission, on the loth September, 1851. He was in the habit of occasionally 
 using spirits. On admission he was reduced in flesh. The respiration was somewhat 
 hurried. There was some degree of fulness of the right hypochondrium, and dulness 
 from the fifth rib to two inches below the margin of the right false ribs, where an 
 
TREATMENT — PUNCTURE OF ABSCESS. 395 
 
 induration was perceptible, somewhat conical, and obscurely fluctuating at the point 
 of the ninth rib. The pain was increased by decubitus on either side, and deep inspi- 
 ration. There was not any cough. There was slight heat of skin, and the bowels 
 were regular. The fluctuation having become more distinct, on the 20th September a 
 puncture was made at the point of the ninth rib, with a straight bistoury ; twenty 
 ounces of healthy-looking pus were discharged, and a similar quantity on the evening 
 of the same day; and again ten ounces on the 26th. From that time till the 19th 
 February, 1852, there was daily slight reddish-tinged discharge. Then it ceased, the 
 wound closed, and he was discharged well on the 15th March, when abnormal dulness 
 below the ribs no longer existed. Treated with tonics, wine and support.* 
 
 151. Hepatic abscess pointing between the right ninth rib anil umbilicus, punctured. — 
 Case not followed to the close, but in all probability successful. — Fakeer Mahomed, a Mus- 
 sulman Lascar, aged forty, addicted to the use of spirituous liquors, was admitted into 
 the Jamsetjee Jejeebhoy Hospital on the 17th April. Below the margin of the right 
 false ribs there was a distinctly circumscribed swelling, reaching from the cartilage of 
 the seventh rib to within two inches of the umbilicus, and in a transverse direction 
 from the ninth rib to the linea alba, painful on pressure and on full inspiration. He 
 stated that the swelling had first appeared about two months before admission, and 
 had gradually increased, during which time he had also been affected with irregular 
 febrile accessions. The swelling became slowly more prominent; and on the 26th 
 May, when fluctuation was distinct, an opening was made with a bistoury, and about 
 six ounces of pus evacuated, and slight discharge continued for several successive days. 
 On the 4th July another distinct fluctuating point, close to the former orifice was 
 opened, and an ounce of pus discharged. Discharge from these orifices continued in 
 quantity daily from a drachm or two to an ounce. About the 25th July the swelling 
 again began to increase and to be painful; and on the 29th, while coughing, the 
 orifice of the abscess, which had closed, again opened, and about seven ounces of pus 
 were discharged. The tumour again subsided, and a slight daily discharge took place. 
 During his residence in hospital he had frequently febrile accessions, and on two or 
 three occasions dysenteric symptoms were present for several successive days. He 
 had not lost in strength since his admission, and there was a fair prospect of recovery 
 when this note was taken. There is no further record of the case. 
 
 155. Hepatic abscess pointing at the epigastrium, punctured. — Ecsidt not known; pro- 
 bably successful. — Shaik Mahomed, a Mussulman butler, about thirty years of age, of 
 intemperate habits, was admitted into the Native General Hospital on the 4th March, 
 1845. There was a prominent pointed swelling towards the left side of the epigas- 
 trium, with considerable surrounding indurated swelling, said to have appeared twenty 
 days before admission, but preceded for two months by fever. On the 24th the tumour 
 was opened, and about eight or ten ounces of pus were discharged. He continued in 
 hospital till the 6th May, with more or less discharge from the abscess, and frequent 
 recurrences of fever. When he left the hospital the discharge had ceased, and the 
 swelling was very much lessened, not painful, and the febrile accessions no longer 
 recurred. He was readmitted into the hospital on the 2nd June with return of swell- 
 ing of side and discharge from the opening. He remained in the hospital for five 
 days, and then left it ; and since then he has not been heard of. This case did not 
 come under my observation till about the middle of April, about twenty days after the 
 abscess had been opened. 
 
 * This patient was again in hospital in April 1857, with slight fever. He stated 
 that after he left the hospital, in 1852, he returned to his native place in the Decean, 
 remained there well for three years, then came back to Bombay, and in good health 
 followed his occupation of labourer till eight days before his second admission, when 
 he became affected with slight fever and jaundice, but no hepatic pain or dulness. 
 The cicatrix from the puncture was distinct at the point of the ninth rib. 
 
396 HEPATITIS. 
 
 156. Chronic hepatic abscesses: one was punctured and healed, but there was no 
 adhesion to the abdominal wall at site of puncture found after death. — Ulceration of 
 colon, but dysentery clearly secondary. — Second abscess, cenel death. — Essoo Govinda, a 
 Hindoo labourer of sixty years of age, of emaciated frame, and using spirits freely, 
 was admitted into the clinical ward on the 9th December, 18-48. An indurated painful 
 swelling occupied the epigastric and umbilical regions. It was indistinctly circum- 
 scribed, but its lower part was plainly felt about three inches below the margin of the 
 right false ribs. There was no fever. He was treated with bitter infusions, mineral 
 acids, taraxacum, iodine, and iron. The swelling was sponged with nitro-muriatic 
 acid lotion, a small blister was applied, and latterly iodine ointment. He was dis- 
 charged on the 24th January, 1849, with the swelling lessened, free of pain, but still 
 quite distinct. He returned to his Tillage and to his usual occtvpations. A year 
 afterwards the swelling being, as he reported, in the same state as on his discharge 
 from hospital, was opened with a lancet by a native hakeen, and a pint of pus dis- 
 charged. It healed quickly. He was readmitted into the clinical ward on the 25th 
 December, 1850. There was general fulness of abdomen, and a curved line from the 
 ninth left to the tenth right rib marked the lower boundary of an indurated enlargement 
 dull on percussion. There was a small puckered cicatrix caused by the puncture, 
 about an inch below the point of the eighth right rib. He had been affected with 
 dysentery for about six weeks. Under these he sank, and died on the 28th December, 
 three days after admission. 
 
 Inspection seven hours after death. — Body emaciated. Abdomen somewhat full, 
 but not tympanitic. Abdomen. — There were about five ounces of serous fluid in the 
 sac of the peritoneum. Both the small and large intestines were contracted. The 
 liver projected about three inches below the ensiform cartilage, and for some distance 
 below the eighth and ninth costal cartilages of the left side, and the eighth, ninth 
 and tenth ones of the right. Below the point of the tenth costal cartilage of the right 
 side, on the convex surface of the liver near its free margin, corresponding iu situation 
 to the fundus of the gall-bladder, there was seen a small puckered cicatrix. There 
 was no adhesion of this or of any other part of the convex surface of the projecting 
 portion of the liver to the abdominal parietes, and the small puckered cicatrix ob- 
 served on the surface of the latter did not correspond to that on the liver, but was an 
 inch and a half above and internal to it. There were firm adhesions between the 
 posterior part of the convex surface of the right lobe of the liver and the under surface 
 of the diaphragm, also between the concave one and the upper extremity of the right 
 kidney and the hepatic flexure of the colon. On incising the liver in the situation of 
 the cicatrix, a white and fibrous appearance four lines in extent was seen. At the 
 place of adhesion of the right kidney, with the under surface of the right lobe, and in 
 the substance of the latter, there was an abscess of the size of a large orange, extending 
 half way up the lobe, and containing healthy pus. It was bounded by a membranous 
 sac, the inner surface of which was free from floating flocculi. The whole of the right 
 lobe, and especially that part of it surrounding the abscess, was red and mottled. The 
 left lobe was pale, and of natural size. No communication was found between the 
 hepatic flexure of the colon and the cavity of the abscess, or between the latter and 
 the right kidney. The mucous membrane of the ascending transverse, and a part of 
 the descending colon, was of a dark grey colour generally, with small circular ideers 
 here and there. The walls of the small intestine were thin and pale, and the mucous 
 membrane extensively corrugated, but nowhere was any ulceration seen. The right 
 kidney, when incised, presented a healthy appearance, and there was no purulent 
 cavity or infiltration at its upper end. Chest. — There were firm adhesions of both 
 lungs to the costal pleuraj, and of the base of the right one to the convex surface of 
 tin! diaphragm. The structure of both was spongy and crepitating, of white colour 
 and intermixed with numerous dark specks. About two ounces of serous fluid in the 
 
TREATMENT — PUNCTUKE OF ABSCESS. 397 
 
 pericardium. Heart of natural size, but with a somewhat greater quantity of fat than 
 usual over its surface. Head not examined.* 
 
 Of the sixteen fatal cases, there was, in thirteen, gangrene of the 
 structures around the puncture, more extensive generally in the 
 tissues subjacent, than in the skin itself, thus showing that the 
 progress of the gangrene had been from within outwards. Of these 
 thirteen cases fatal with gangrene, the opening had been made in 
 an intercostal space in five, and below the last rib in one. In these 
 six cases the abscess had been either in the thick part of the right 
 lobe, or there had been a sac between the liver and diaphragmf , or 
 both combined. In the remaining seven cases the opening had 
 been made at or near the epigastric region ; and on comparing 
 these with the successful ones punctured at the same situation, it 
 appears that in those fatal with gangrene the abscess was large, or 
 not single, or pointed rather at the concave than the convex surface 
 of the liver, so that some thickness of parenchyma had to be cut 
 through before the sac could be reached : or the constitution was 
 very cachectic. 
 
 The thirteen following cases are those in which gangrene took 
 place : — 
 
 157. Abscess in the liver pointing between the right seventh and eighth ribs. — Opening 
 into the lung and also externally. — Gangrene of the integuments around the orifice, also 
 of the intercostal muscles, and caries of a rib. — William Harris, aged twenty-three, was 
 in hospital in September 1841, with hepatitis. Discharged on the 17th, re-admitted on 
 the 10th October, with return. The disease ran into abscess, and about the 28th there 
 was expectoration of brick-red sputa, which continued. There was tumefaction 
 between the right seventh and eighth ribs with fluctuation, and an opening was made 
 there on the loth December. Brick-red puriform discharge and air passed from the 
 wound. He gradually lost ground and died on the 1st February. 
 
 Inspection six hours after death. — The orifice between the seventh and eighth ribs 
 not far from their junction with the cartilage was enlarged from sphacelus. The 
 parts underneath the integument were in a state of gangrene, and for about the 
 extent of two inches between the seventh and eighth ribs the intercostal muscles 
 had been destroyed. The seventh rib, for about two inches in length, was carious, 
 and in consequence was fractured near its junction to the cartilage. The abscess in 
 the liver was very superficial, bounded by the convex part of the right lobe, the dia- 
 plmigm and the ribs. The base of the third lobe of the right lung adhered to the 
 diaphragm; part of it was condensed and at its anterior point there was communica- 
 tion with the abscess in the liver, and an excavation in the substance of the lung the 
 size of a walnut. There were old adhesions of the surface of the liver ; also of the 
 
 * We may not doubt the fact of abscess having been opened in this case and cured. 
 The question arises, Was there absence of adhesion when the abscess was opened, or 
 may we suppose that, consequent on the cure of the abscess, adhesions previously 
 existing, but now no longer required, were gradually removed by atrophy ? The latter 
 is, I think, the probable view, and it is countenanced by the want of correspondence 
 found after death between the external and the internal cicatrices. 
 
 f Case 122 may be added to these. 
 
398 HEPATITIS. 
 
 omentum to the abdominal parietee. Chest. — ~No effusion into the sac of the pleura 
 and the greater part of both lungs were collapsed and crepitating. 
 
 158. Hepatic abscess punctured over the last right false rib. — Getngrene and sloughing 
 
 around the wound. — Death. — No inspection. — Mr. , apothecary on the Bombay 
 
 establishment, aged about thirty-four ; after an attack of fever, suffered from acute 
 hepatitis early in June 1843. He was freely depleted, and the constitutional effect 
 of mercury was induced. There was a recurrence of the attack, and he was again 
 similarly treated; but fulness of the right side, with pain, continued, and he had 
 become much reduced. In this state he was sent from Surat to Bombay, and came 
 under my care in the European General Hospital, on the 22nd August. He complained 
 of constant pain of the right side, and there was circumscribed tumefaction over the last 
 false rib. On the 30th August there was an opening made in the swelling and a con- 
 siderable quantity of pus, at times tinged with blood, was discharged. On the 14th 
 September commencing sphacelation of the soft parts around the orifice of the abscess 
 was first remarked, and on the 16th the sphacelated portion was in diameter about an 
 inch and a half, the orifice being in the centre. He died on the 19th September. 
 There was not any examination of the body made after death. 
 
 159. Large hepatic abscess punctured. — Death from exhaustion, with sloughing of the 
 wound. — No examination after death. — Shaik Mahomed, a Mussulman, of twenty-one 
 years of age, not addicted to the use of spirits, a native of Bengal, and following for 
 a period of six years the occupation of stoker in a steam-boat, about a year before his 
 admission on the 13th March, 1850, into the clinical ward, had suffered from quartan 
 fever, when he relinquished his usual employment. Twenty-five days before admis- 
 sion he had been attacked with sudden sharp pain of the right side of the abdomen, 
 followed by fever. On admission the respiration was short, hurried, and chiefly 
 thoracic and the decubitus was dorsal. There was occasional troublesome dry cough, 
 and much pain of the right hypochondrium, aggravated by pressure, coughing, and 
 any movement of the body. There was general fulness and prominence of the right 
 hypochondrium, with tenseness and sense of induration below the margin of the right 
 false ribs. Dulness reached from the right nipple to midway between the last false 
 rib and the crest of the ilium, and extended obliquely across the abdomen to the 
 point of the left ninth rib. Fluctuation was perceptible opposite the point of the last 
 right rib. The impulse of the heart was increased and its apex beat in the intercostal 
 space between the fourth and fifth rib directly below the left nipple. There was heat of 
 skin, and a pulse frequent and compressible. The bowels were reported to be regular 
 and the urine scanty and high coloured. The fluctuation was more distinct on the 
 2nd October, and an opening was made with a straight bistoury between the eleventh 
 and twelfth rib. He died exhausted on the 24th. The edges of the wound showed 
 a sloughy appearance after the 16th. After the operation, the tenseness and pain 
 were lessened, the respiration became freer, and the cough less ; but there were even- 
 ing febrile accessions, with night sweats, more or less relaxation of the bowels, 
 increasing emaciation and failing pulse. The discharge of seventy-two ounces of pus, 
 sometimes tinged red, is recorded, but subsequent to the last quantity noted, there was 
 a constant draining from the wound. The treatment consisted of anodynes, mineral 
 acids, astringents, and support with milk, chicken-broth, eggs, and wine. Examination 
 of the body after death was not permitted. 
 
 160. Superficial abscess of right extremity of the liver leading to circumscribed sac be- 
 ta; , „ the organ and lettered abdominal walls. — Puncturt d b( twet n the f< nth and eh v< nth 
 rib. — Sloughy state of wound, necrosis of rib, and death from hectic fever. — Mahano- O o, 
 thirty years of age, a Hindoo washerman, using spirits, was, after two months' illness, 
 admitted in a reduced state into the clinical ward, on the 24th June, 1850. The 
 respiration was slightly hurried. In the right hypochondrium there was a hard circum- 
 scribed painful swelling, covered by the six lower ribs, which bulged outwards over it. 
 
TREATMENT — rUNCTURE OF ABSCESS. 399 
 
 The abdomen was generally soft and retracted ; but an indurated edge was felt for 
 about an inch below the ninth, tenth, and eleventh right ribs. He was anaemic and 
 without febrile disturbance, or enteric irritation. Stated that the pain of side, first 
 felt two months before when engaged in his occupation, had gradually increased, and 
 that the swelling first attracted his attention seven days before admission. There had 
 been no fever. Febrile accessions, however, were noted while he was under observa- 
 tion. On the 29th the upper part of the swelling was distinctly fluctuating, and it 
 was opened with a bistoury on the 3rd July. Exhausted with hectic, and continued 
 red-tinged discharge, but without diarrhoea, he died on the 11th August. The wound 
 was puffy on the 23rd July, and sloughy on the 4th August. The urine gave no 
 signs of albumen. The treatment consisted of anodynes, quinine, and sidphuric acid, 
 and support. 
 
 Inspection ten hours after death. — Immediately below the end of the tenth rib 
 was an opening of about the size of a dollar. The surrounding parts were dark, 
 sloughy, and bounded by a dark blue line, about four inches in circiimference ; and, on 
 looking into the opening, the eleventh rib was observed hanging bare at the bottom of 
 it. Chest. — The left lung was collapsed, and its structure soft and crepitating. 
 Numerous firm adhesions existed between the right lung and the costal parietes, partially 
 also to the diaphragm : its substance was healthy. There was about an ounce and a 
 half of clear watery fluid in the sac of the pericardium. On the posterior surface of 
 the right ventricle of the heart there was a white patch the size of half a rupee. 
 Abdomen. — There was an oval cavity of about the size of a large orange, apparently 
 bounded internally by the omentum, externally, by the diaphragm, corresponding to 
 the last four lower ribs, and the lateral abdominal parietes for about three inches 
 below the margin of the right false ribs. Superiorly, the cavity was found to com- 
 municate freely and to be continuous with a large excavation about one inch and a 
 half in depth, and eight in circumference, situated at the right extremity of the liver. 
 This excavation was defined by a dark bluish line. The liver extended from 
 the eleventh rib on the right side to the middle of the seventh, left. On cutting 
 deeper into the substance of the liver, near to the abscess, two or three spots of 
 yellowish-white colour, apparently from effusion of lymph, were observed. The other 
 portions of the liver were healthy. That part of the wall of the abscess in which the 
 substance of the liver was not involved, was much thickened, and on cutting into it, soft 
 pulpy matter was found to ooze out on pressure. There were adhesions between the 
 convex surface of the liver and the diaphragm, as well as between the concave surface 
 and the pylorus. The stomach was contracted, and its coats were somewhat thickened. 
 The transverse colon was much distended. The kidneys healthy. 
 
 161. Abscess in the liver puncher ed. — Carious ribs projecting into the abscess. — At 
 first superficial and leading to circumscribed sac between liver and diaphragm. — Also 
 empyema of right pleural sac without communication. — Cumblin Eowjee, aged twenty, 
 a Maratha labourer, emaciated; after two months' illness, was admitted 5th May, 
 1852. Pulse small, breathing short and hurried. A distinct prominent, uncircum- 
 scribed, fluctuating swelling, neither tense, red, nor hot, existed on the right side of 
 the chest from the sixth rib downwards. In the epigastric region there was abnormal 
 dulness, and an indurated edge was felt to within an inch of the umbilicus, and ex- 
 tending from the tenth or eleventh right to the ninth left false rib. There was slight 
 cough, not communicating impulse to the swelling. The feet and legs became (Edema- 
 tous. Dyspncea increased. The swelling became more prominent and pointing. It was 
 punehvred on the 13th May between the eighth and ninth rib, and four pints of brick- 
 coloured pus were discharged. On the 16th commencing gangrene around the opening 
 was observed. A slough larger than a rupee formed. He died on the 22nd. 
 
 Inspection twenty hours after death. — Chest. — There were fifty ounces of sero- 
 purulent fluid in the right pleural sac ; flakes of lymph coated the costal pleura, and 
 
402 HEPATITIS. 
 
 abscess had been situated, was much reduced in size ; its structure was a good deal 
 indurated, and when incised it was found to be of a reddish-colour around the abscess. 
 The liver was smaller than natural, rather hard in texture, firmly adherent by its 
 rio-ht lobe to the diaphragm and abdominal wall ; and the adjacent portion of the colon 
 was firmly united to its concave or under surface. There was only one abscess. The 
 gall-bladder was contracted. The kidneys were healthy. The intestines were not 
 examined. Chest. — There were old adhesions, chiefly of the right lung to the costal 
 pleura and diaphragm. The posterior part of both lungs, and the second and third 
 lobes of the right, were redder than natural, somewhat indurated, and gave out 
 frothy serum when incised. The heart was healthy. 
 
 165. A single abscess at the thin edge of the left lobe of liver existing for five months, 
 punctured. — Gangrene of the orifice. — Dysenteric symptoms latterly. — Ulceration of 
 mucous membrane of the colon. — Antonio Francis, a native Christian, a sailor, of thirty- 
 four years of age, was under treatment in hospital for a swelling in the epigastric region 
 from the 17th May to the 15th June, 18-19, when he was discharged relieved of pain, 
 but with persistence of the swelling. He was readmitted on the 5th October, in 
 reduced condition. The respiration was chiefly thoracic, but there were not any signs 
 of pulmonary disease. The abdomen for the most part was soft, but immediately above 
 the umbilicus, and ascending to midway between it and the ensiform cartilage, there 
 was a circumscribed prominent swelHng tender to the touch without fluctuation, slightly 
 pulsating, but without murmur under the stethoscope on any part of its surface, and 
 with clear sound on percussion between it and the margin of the right ribs. The 
 bowels were regular. He suffered from evening febrile accessions. The swelling 
 became more prominent, and fluctuation was distinct on the 16th, when the abscess 
 was opened, and seven ounces of pinkish-coloured pus were discharged. The febrile 
 accessions recurred, dysenteric symptoms set in on the 26th, and he died on the 18th 
 November. 
 
 Inspection three hours after death. — Abdomen.— The opening made into the abscess 
 was on a level with the ninth rib, and a probe passed readily through it into the sac. 
 On removing the skin over it, there was found a sloughy state of the parts around the 
 opening for about an inch and a half in diameter. The peritoneum was chiefly adhe- 
 rent to the abdominal wall over the abscess sac, which was about the size of a small 
 orange, and occupied the very edge of the left lobe of the liver. It was empty. The 
 serous covering of the left lobe of the liver had in general an opaque appearance. The 
 liver was not enlarged. The small intestines were much distended with gaseous eon- 
 tents, and a portion of them was displaced upwards. They presented externally, in 
 part a dark red, and in part a dark leaden grey colour; but no patches of lymph were 
 observed. The transverse colon contained dark grey adhesive matter, and adhered 
 closely to the sac ; but there was no communication between them. Its mucous sur- 
 face was of dark red colour— presented a rugous appearance, with several variously 
 sized circular ulcers, some apparently cicatrised, and others in an active state of ulcer- 
 ation. No further examination was permitted. 
 
 166. Two hepatic abscesses: one punctured, with increase of febrile sym] 
 attributed to fist blows,— Habits temperate.— Diarrhcea, with redness of mucous mem- 
 bram of colon. No ulceration.— Conmencing gangrene at the openiny in the abscess.— 
 Dooluh Dewsell, a Hindoo carpenter, twenty-seven years of age, in good condition, 
 and reporting himself to be of temperate habits, was admitted, after twelve days' 
 illness, into the clinical ward of the Jamsetjee Jejecbhoy Hospital on the 13th July, 
 1849. The respiration was short, hurried, chiefly thoracic, and bronchitic rales were 
 audible in different parts of the efo Bt. The abdomen was full, somewhat tense, and 
 i, nder on pressure— chiefly so, however, at the upper part, where an indurated fulness 
 was perceptible, extending below the right false ribs, occupying the epigastrium and 
 part of the left hypochondrium, and reaching almost to the umbilicus. It was some- 
 
TREATMENT — PUNCTURE OF ABSCESS. 403 
 
 what prominent in the epigastric region. The decubitus was chiefly dorsal. During 
 the first six days of his illness the symptoms had not attracted his attention much, 
 but then they increased in severity, and were attended with febrile disturbance. They 
 were attributed to fist blows, received in endeavouring to separate two individuals 
 who were fighting. He was under observation thirteen days. The hepatic symptoms 
 persisted ; the fever had marked evening exacerbations. There was occasional vomiting 
 and relaxed bowels. The prominence at the epigastrium increased, and fluctuation 
 was indistinct on the 18th. He died on the 25th. After leeching and a ten-grain 
 dose of calomel, with opium, four-grain doses of quinine were given, with blue pill, at 
 intervals during the remissions, and with the effect of lessening the exacerbation. On 
 the 23rd the abscess was opened with a bistoury. There was a good deal of bleeding 
 from the wound at the time, and free discharge on that day, and on the 25th ; but 
 there was increase of fever and diarrhoea, a failing pulse, and collapse of features. 
 The result was clearly hastened by the operation. 
 
 Inspection fourteen hours after death. — The costal cartilages and cellular tissue were 
 slightly tinged yellow. Chest. — Lungs collapsed and crepitating. The third lobe of 
 the right lung was compressed almost flat against the posterior wall of chest. Heart 
 natural. Abdomen. — Between the skin and subjacent structures around the opening 
 in the abscess, there was a boggy state of the tissue, caused by infiltration of dark red 
 serum. Stomach and intestines distended with gas. The liver extended considerably 
 beyond the margin of ribs, and for a space about four or five inches in diameter, 
 adhered firmly to the parietes. The omentum was also matted there. The thin edge 
 and a portion of the inferior surface of the left lobe of the liver had adhered firmly to 
 the anterior surface of the stomach. The abscess, the size of a cocoa-nut, occupied a 
 great portion of the left side of the right lobe, and to a considerable extent the sub- 
 stance of the left. It contained about half a pint of thick fiocculent pus, and some 
 white firm bands were seen crossing it. Its walls presented a rough and irregular 
 appearance. The anterior part, the thinnest, was separated from the abdominal 
 parietes by a portion of liver about a quarter of an inch thick. A thin small portion 
 of its upper wall intervened between the abscess and the diaphragm, but was free from 
 adhesions to that muscle. On separating the liver from the stomach, the surface of 
 the latter was found adherent to the wall of another abscess, the size of a large orange. 
 Its walls were entire, with the internal surface irregular: it was filled with sero- 
 puriform matter. The two abscesses were separated from one another by a thin 
 portion of the substance of the liver. The large intestine was laid open, the mucous 
 surface was discoloured red, but no ulceration was detected anywhere. Kidneys 
 healthy. 
 
 167. Hepatic abscess pointing at the epigastrium, punctured. — Sloughing around 
 the wound. — Death. — Early in the year 1854, I saw, in company with Dr. Miller, of 
 Bombay, a case of hepatitis in a European artificer. The symptoms were well 
 marked; abscess formed. The tumefaction was chiefly in the epigastrium. Fluctua- 
 tion became distinct, and after tendency to pointing had become apparent, the abscess 
 was opened with a bistoury, and considerable discharge of pus followed and continued 
 for the two or three succeeding days. Then a sloughy state of the edges of the punc- 
 ture took place and extended, and the patient died. These notes I write from recol- 
 lection, as I have no written memoranda of the case. I do not know whether the 
 body was examined after death. 
 
 168. Cirrhosis of Liver.— Abscess in thin edge of liver, punctured. — 'Purulent sac 
 between liver and diaphragm. — Ulceration of large intestine. — Death. — Lingoo, a 
 Hindoo labourer, of thirty-six years of age, addicted to the habitual use of spirits, was 
 admitted on the 2nd July, 1852, into the clinical ward. He was a good deal emaci- 
 ated, and the respiration was somewhat thoracic. Close to the ensiform cartilage, 
 and extending about half an inch to the right of the mesial line, there was a swelling, 
 
404 HEPATITIS. 
 
 the size of a large orange, somewhat conical, with its apex slightly reddened and 
 fluctuating. It varied somewhat in position, according as decubitus was on the right 
 or left side, and "became somewhat depending and more prominent in the sitting and 
 standing positions. It was free of pulsation. There was no dulness on percussion 
 around it, except at its upper and right side, where the didness was continuous with 
 that of the liver. It was tender on presstire. No cough or vomiting. Decubitus 
 easiest on the right side. Bowels relaxed. He had first observed the swelling three 
 months before, when it was the size of an egg. Suffered from dysenteric symptoms 
 about six weeks before admission, and from irregular febrile accessions for fifteen days. 
 Pidse feeble, tongue coated in the centre, and florid at the tip and edges. The abscess 
 was opened on the 27th, and eight ounces of thick pus were discharged. With con- 
 tinuing discharge, relaxed bowels, nightly hectic fever, and sloughy ulcerated state of 
 the punctured wound, he gradually lost ground, and died on the 7th August. He was 
 treated with quinine, opium, nourishment, and wine. 
 
 Inspection twenty-one hours after death. — Body much emaciated. Chest. — The lungs 
 were collapsed, and in appearance perfectly healthy. The lower part of the base of 
 the right lung was found attached to the corresponding portion of the diaphragm by 
 firm adhesions. There was, however, no condensation of the lung. The heart was 
 healthy. Abdomen. — The intestines presented, externally, a healthy appearance. The 
 mucous membrane of the descending colon, sigmoid flexure, and a part of the rectum, 
 was somewhat thickened, and numerous small circular ulcers existed here and there. 
 The liver did not extend below the margins of the ribs. It was much smaller than 
 natural, dense and contracted. Its surface was corrugated, and studded with small 
 yellow projections, each about the size of a pin's head. It was firmly adherent to the 
 abdominal parietes, a little below and internal to the margin of the cartilage of the 
 left tenth rib, corresponding to the external opening in the skin. The exposed par! 
 of the right lobe was likewise adherent to the adjoining parietes ; and at the lower 
 margin, a little above the gall-bladder, the surrounding adhesions formed a small sac, 
 containing a small quantity of serum. The diaphragm was firmly attached to the upper 
 surface ; and to the right, about opposite the middle of the seventh rib, it was sepa- 
 rated from the liver by a sac, the size of an orange, containing a quantity of glairy, 
 tenacious pus. At the parts corresponding to the puncture, two small abscesses, each 
 about the size of a small filbert, separated from each other by a thin septum, were 
 found ; their walls were dense and fibrous. A section of the liver presented a surface 
 studded with minute granules. The lower part of the liver, the pancreas, and duode- 
 num, were adherent together by dense fibroxis tissue. The gall-bladder was filled 
 with light-coloured greenish fluid. The kidneys were healthy. The spleen was a 
 little smaller than natural. 
 
 1G9. — Hepatic abscess in epigastric region, punctured ; very little discharge. — Dysen- 
 tery. — Death. — No examination. — Baga Saiboo, a Hindoo bricklayer of twenty-five 
 years of age, using spirits occasionally, was admitted in an emaciated state into the 
 clinical ward on the 1st October, 1852. At the epigastric region, in the middle line 
 between the ensiform cartilage and the umbilicus, there was a prominent fluctuating 
 swelling about the size of a large orange, painful on pressure, dull on percussion, and 
 immovable. Respiration hurried and chiefly thoracic, pulse small, bowels relaxed. 
 Six weeks before, while at work, was seized with shivering, followed by fever and pain 
 at the site of the swelling, which when first noticed was small ; it gradually increased. 
 The actual cautery was applied ten days before admission, and had left an eschar 
 about I lie size of half a rupee. The dysenteric symptoms were of fifteen days' duration. 
 The swelling was opened with a bistoury to the left of the eschar, but only blood w;\s 
 discharged, and on the 1th about an ounce of unhealthy pus. The swelling did not 
 lessen much, the discharge was slight, the eschar separated, and was followed by 
 sloughy ulceration, which extended to the puncture. The diarrhoea continued. He 
 
TREATMENT — PUNCTURE OF AESCESS. 405 
 
 was removed on the 13th October in a moribund state by his friends. He was treated 
 with quinine, opium, and wine. 
 
 In the three cases, fatal without gangrene, the abscess had been 
 large and punctured at the margin of the right ribs. In two there 
 was complication of pleuritic effusion, and in one several abscesses, 
 with general peritonitis. These cases are now submitted. (170 
 to 172.) 
 
 170. Abscess partly of right and of left lobe, punctured. — Death from secondary 
 dysentery. — Ulccreition of large intestine. — Effusion in both pleural sacs. — Luximan 
 Luckman, age I thirty-five, a Hindoo labourer, using spirits habitually, but in moderate 
 quantity, was admitted into the clinical ward on the 19th December, 1853. He was 
 emaciated, and the respiration was somewhat short and hurried, and chiefly thoracic. 
 The pulse was small and frequent, the bowels regular. Between a curved line drawn 
 from the eighth left rib, — passing quarter of an inch above the umbilicus to the ninth 
 right rib, — and the margin of the right ribs, there was induration with constant pain, 
 increased by pressure and cough. The space noted was also dull on percussion, and 
 the dulness extended upwards to the fifth rib. Decubitus was easiest on the left side. 
 The tongue was moist, and somewhat coated in the centre. Fifteen days before ad- 
 mission he had felt pain of the right hypochondrium, followed by febrile symptoms, 
 characterised by evening accessions, commencing with chills, and terminating with 
 slight sweating. SHght swelling first appeared seven days after the commencement of 
 the attack. On the 28th the swelling became more prominent and indistinctly fluctu- 
 ating ; and on the 30th, the fluctuation being distinct, a puncture was made with a 
 bistoury, and seven ounces of red-tinged serous fluid with floating lymph-flakes were - 
 evacuated. He was at this time also troubled with hiccup. From this date the discharge 
 continued, gradually, however, lessening with subsidence of the swelling, and no ap- 
 pearance of sloughing of the puncture. On the 12th January dysenteric symptoms 
 began, and continued more or less till his death on the 20th February. The urine 
 gave no traces of albumen. He was treated with tonics, opiates, gallic acid, suitable 
 nourishment, and wine. 
 
 Inspection eight hours after death. — External appearances : — Body very much 
 emaciated and free from rigor mortis. A little to the right side of the median Line, 
 and about an inch below the ensiform cartilage, there was a small opening, through 
 which thin yellowish discharge oozed. Chest. — -Neither lung was collapsed. There 
 were about ten ounces of turbid serum in the right pleural sac, and about six ounces 
 in the left. There were firm adhesions at the upper and back parts of the right lung ; 
 also some tender ones at the lower part anteriorly. There were no adhesions between 
 the base of this lung and the diaphragm ; nor any between the left lung and the 
 parietes of the chest. The external surface of the whole of the right lung, and the 
 anterior surface of the left lung were pale, dry-looking, and woolly to the feel. The 
 anterior parts of both lungs were emphysematous, but the posterior parts were healthy 
 and crepitating. On incising both hmgs in different parts, frothy serum oozed out 
 from some portions, but nothing further abnormal was detected. There were about 
 three ounces of clear serum in the sac of the pericardium. The heart was smaller than 
 natural, but healthy. Abdomen. — No traces of general peritonitis present. The liver 
 was somewhat larger than natural ; it reached an inch below the margin of the right 
 false ribs, and above as high as the fifth rib. The thin margin of the liver, with a 
 portion of the anterior surface, formed firm adhesions with the anterior parietes of the 
 abdomen to the extent of about three inches in diameter. These adhesions were 
 around the puncture. The convex surface of the right lobe of the liver was adherent 
 to the diaphragm in parts, and the concave surface was firmly adherent to the trans- 
 verse colon, part of the duodenufii, and the pyloric end of the stomach. On enlarging 
 
 D D 3 
 
406 HEPATITIS. 
 
 the artificial opening, the abscess was found to occupy part of the left, and part of the 
 right lobe of the liver, and Mas the size of a common orange. Its contents consisted 
 of thin, puriform, orange-coloured matter. On removing the contents, the walls of the 
 abscess were found to be hard and somewhat cartilaginous. At the lower part of the 
 abscess the substance of the liver was of darkish red colour ; but the remaining por- 
 tions of the organ were healthy. The intestines were grey-coloured externally. The 
 transverse colon and the duodenum adhered to the concave surface of the liver ; but 
 there was no communication between the abscess and either of these hollow viscera. 
 There was some degree of vascidarity of the mucous membrane of the rectum, and of 
 the transverse and descending colon, and there were about ten or fifteen circular ulcers 
 in the rectum, each the size of a large pin's head. The mucous membrane of the ileum 
 and jejunum was also slightly vascular here and there; but no ulcer was anywhere 
 detected. The left kidney was somewhat larger than the right, and its cortical por- 
 tion encroached slightly on the tubular portion. The right kidney seemed to be 
 healthy. — The spleen was of natural size and healthy. 
 
 171. Pleuritic effusion. — Abscess in the liver punctured. — Attributed to a blow. — 
 Death the day after the abscess was opened. No examination. — Wittoo Bappoo, a 
 Hindoo cart-driver of thirty-two years of age, was under treatment from the 21st 
 December, 1851, to the 14th January, 1852, when he was transferred to the clinical ward. 
 The symptoms had indicated the presence of pneumonia and hepatitis, for which he 
 had been cupped, taken antimony, and been brought under the influence of mercury 
 with temporary advantage. From the 4th January, however, there had been more 
 complaint of cough and pain of different parts of the right side of the chest, followed 
 by complete dulness on percussion of that side, and absence of vocal thrill ; and such 
 continued to be the state of the chest on admission into the clinical ward, when, also, 
 the circumference of the right side was found to be half an inch greater than that of 
 the left. There were fulness, sense of induration and dulness below the margin of the 
 right false ribs, bounded by a line curving from the point of the right tenth rib to that 
 of the left eighth. There was occasional cough, and decubitus was easiest on the 
 right side. There was some degree of febrile heat, and the gums were still tender 
 from the merciny. The swelling below the right ribs became gradually more prominent ; 
 and on the 27th January there was another oval swelling detected above the umbilicus. 
 On the 6th February there was fluctuation of both swellings. On the 7th the one 
 below the right ribs was opened at the point of the eighth rib, and twelve ounces of 
 pus discharged, with diminution of both swellings. He died on the 8th. The urine 
 had been frequently examined, but gave no traces of albumen. He attributed his 
 illness to a blow on the right hypoehondrium from the cross-beam of a bullock-cart. 
 Examination of the body not permitted. 
 
 172. Large abscess of right lobe of liver opened with trocar. — Several abscesses 
 in left lobe in different stages. — Also nodules of lymph. — Emam Bukus, aged about 
 forty, was admitted into the Native General Hospital on the 13th January, 1845. 
 He suffered from febrile symptoms, and pain of the right hypoehondrium of six days' 
 duration. By means of leeches, a blister, and mercurials, not, however, carried to the 
 extent of affecting the system, the pain of the side was much relieved, but an evening 
 febrile accession persisted. On the 27th his breathing became short, the countenance 
 anxious, and there was slight fulness of the right hypoehondrium apparent. On the 
 1st February the fulness of the side was distinct and somewhat prominent, and sense 
 of fluctuation was perceptible. The abscess was opened by a trocar below the edge of 
 the false ribs, and twelve ounces of thick pus were discharged; and on the 3rd and 
 4th there was a further discharge of several ounces of pus following re-introduction of 
 the cannla, which had been removed. After the operation there was increased anxiety 
 of countenance ; the breathing became shorter and more oppressed; the febrile acces- 
 sions continued to recur, and he died on the evening of the 5th. There were not at 
 any time symptoms of dysentery or diarrhoea. 
 
TREATMENT — rUNCTURE OF ABSCESS. 407 
 
 Inspection eight hours after death. — Abdomen. — In the cavity of the abdomen, amongst 
 the convolutions of the intestines, there was about a pint of sero-puriform fluid. The 
 peritoneal surface of the small intestine and of the colon presented a deep blush of 
 redness ; and thin flakes of friable lymph were efiused generally on the surface, and 
 caused adhesions of the convolutions. The liver adhered firmly to the abdominal 
 parietes for some distance around the orifice made by the trocar, which had penetrated 
 a large abscess occupying the lower and anterior lateral part of the right lobe. The 
 inner surface of the sac was lined by thick sloughy-looking shreds. Between the 
 diaphragm and the convex surface of the right lobe there was a circumscribed sac 
 containing about half a pint of sero-puriform fluid, similar in appearance to that con- 
 tained in the abdominal cavity. The abscess in the liver seemed to communicate 
 with this sac ; but no communication could be traced between it and the cavity of the 
 abdomen. In the left lobe there were two or three small abscesses, ranging in size 
 from a walnut to a goose's egg. One or two yellow circumscribed portions were also 
 observed, caused by interstitial effusion of lymph — the condition which so generally 
 precedes the formation of abscess. 
 
 My opinions on this question of practice have been formed 
 chiefly on the facts now detailed, because observers who have 
 hitherto written with authority on this subject have done so on 
 still more limited experience. Annesley had witnessed only five 
 cases of puncture of hepatic abscess ; of these two recovered. Mal- 
 colmson five, all fatal. Stovell* five, with four deaths. Haspel 
 seven, with four deaths. Again, in many of the scattered records 
 of hepatic abscess, including cases in which puncture had been 
 practised, the situation of the swelling and of the opening is not 
 mentioned. Such cases are of no value in determining this prac- 
 tical question. 
 
 My cases show that when the abscess is not very large, is singlef , 
 situated in the thin part of the left lobe, or thin edge of the 
 right, and is allowed to point at the epigastrium, or margin of the 
 right ribs above the ninth, then puncture with a bistoury or lancet 
 will very generally be attended Avith success. This result will be 
 materially favoured by previous careful treatment and by the ab- 
 sence of dysentery or other complication. 
 
 The two successful cases quoted by Annesley were of this simple 
 nature ; and no doubt it was on them that this author grounded his 
 just opinion, that hepatic abscess ought not to be punctured till 
 distinct pointing and inflammatory blush on the skin have taken 
 place. A successful case alluded to by Twining, two narrated by 
 
 * Dr. Stovell, in his subsequent decennial report, gives seven cases with six 
 deaths. 
 
 f We may form a judgment as to the size of the abscess, and its being single 
 or not, by careful percussion in all directions; and it is of much importance that 
 this means of acquiring precise knowledge of the size of the liver be not neglected 
 in such cases. By inattention to this rule prognosis becomes needlessly vague and 
 uncertain. 
 
 D D 4 
 
408 hepatitis. 
 
 Haspel, one by Stovell, and one by Arnott*, are also confirmatory 
 of the inference drawn from my own successful cases. But I would 
 go still further, and say there is nothing decisive on record to prove 
 that success has as yet attended the puncture of hepatic abscess 
 under any other circumstances than those which have just been 
 stated. 
 
 This degree of success, however, does not assert much in favour 
 of surgical interference ; for it is most probable that in such cases 
 a favourable termination would equally have resulted from non- 
 interference and spontaneous rupture. Dr. Budd has advocated the 
 latter course in such cases. The common surgical rule of punc- 
 turing when there is distinct pointing and inflammatory blush, 
 seems to me the preferable course ; but at best it is a difference of 
 little moment in practice. 
 
 Gangrene of the tissues around the wound took place in 13 of my 
 16 fatal cases. 
 
 This event was first noticed by Mr. Caesar Hawkins f, but he 
 considered his cases to be malignant disease not hepatic abscess. 
 Dr. Malcolmson, of the Madras Medical Service f, corrected Mr. 
 Hawkins's erroneous inference, and quoted two cases of hepatic 
 abscess opened and followed by gangrene. This result of puncture 
 of hepatic abscess, so familiar to myself and to others, and so im- 
 portant in reference to practice, is not even alluded to by any other 
 writer with whose works I am acquainted. 
 
 Malcolmson attributed the gangrene to the lowered vitality 
 of the thinned and diseased tissues, and recommended the early 
 opening of the abscess as the best means of preventing it; but 
 this explanation, and the practical inference from it, are only par- 
 tially correct. 
 
 I have elsewhere (p. 328) fully described the usual process by 
 which abscess is formed in the liver; and I have called attention to 
 the fact, that when the abscess is large, some time must elapse before 
 the shreddy flocculent debris of the structure of the organ, adherent 
 to the inner surface of the sac, can liquefy and disappear. If an 
 abscess in this state be opened and air admitted, then putrefac- 
 tion of these devitalised tissues must be the consequence, and the 
 weakened structures around becoming contaminated will readily 
 pass into gangrene. It is in this manner that, in many instances, 
 the liability to gangrene after puncture may be best explained. In 
 
 * " Transactions, Medical and Physical Society of Bombay," No. 1, New Series. 
 
 f "Transactions, Medico-Cbirurgical Society," toL xviii. 
 
 ! Ibid., vol. xxi., and " Edinburgh Medical and Surgical Journal," vol. li. 
 
TREATMENT — PUNCTURE OF ABSCESS. 409 
 
 such cases the error has not been delay. On the contrary, the 
 abscess has been prematurely opened in violation of a sound surgical 
 principle which directs that the operation should be postponed till 
 concoction is completed. 
 
 Yet, under some circumstances, there is truth in Malcolmson's 
 opinion that the gangrene may be due to lowered vitality from 
 thinning of the tissues, and defect of nutrition ; and that in these 
 the error of delaying the opening the abscess has generally been 
 committed. 
 
 The cases which have been detailed seem to me to point to a 
 practical rule in this apparent difficulty. 
 
 In the five cases in which the puncture was made in an inter- 
 costal space, the gangrene of the soft parts and the carious or 
 necrosed state of the ribs, was caused by the combined influence of 
 inflammatory action, and the increasing pressure of the pus over 
 an extensive surface. If surgical interference under these circum- 
 stances is to be of any avail, then it must be had recourse to, early 
 — so soon as bulging of the side and obscure fluctuation indicate 
 the presence of fluid. And we may act in this manner with less 
 apprehension of bad effects from putrefying tissues, because a 
 reference to the cases will show that the pus is collected chiefly 
 between the liver and the parietes, and that when it communicates, 
 the abscess is generally superficial and not likely to have much 
 flocculent debris adherent to its walls. 
 
 In seven of the cases fatal with gangrene, the opening had been 
 made at the epigastrium or near the margin of the right ribs. 
 From a consideration of these in connection with those fatal with- 
 out puncture, it may be inferred that when the liver occupies the 
 epigastrium, reaches to within an inch of the umbilicus, extends 
 two inches and more below the margin of the right ribs, becomes 
 gradually prominent in these situations, and in time gives a sense 
 of diffuse fluctuation, we have to do with large abscess in the 
 thick substance of the organ. This is the condition of hepatic 
 abscess in which there is much likelihood of parenchymatous debris 
 requiring concoction, and in which there is danger of gangrene and 
 irritative fever consequent on putrefaction from premature punc- 
 ture. In these cases we should delay, and this course may be fol- 
 lowed with the less hesitation, for there is, in these circumstances, 
 little risk of gangrene from mere thinning of the tissues. 
 
 But, I have expressed my belief that success has, hitherto, only 
 attended the puncture of small, distinctly pointing abscesses, 
 situated in the thin parts of the liver; and the question natu- 
 
410 HEPATITIS. 
 
 rally suggests itself, whether the operation ought to be confined 
 to these conditions, and altogether abandoned in the kind of cases 
 which are at present under review. My past experience would 
 prompt an affirmative reply; but we must not hastily conclude 
 that the resources of our art are thus limited. 
 
 From the cases narrated it is evident, that when a free opening 
 is made with a bistoury, or large trocar, the large abscess emptied, 
 and air admitted, death is not thereby prevented, but, on the con- 
 trary, is frequently hastened. Therefore if good is to be effected 
 by surgery in such cases, it must be by a different kind of opera- 
 tive proceeding. The modification in the operation of puncturing 
 the chest in pleuritic effusions, advocated by Dr. H. M. Hughes 
 and Mr. Edward Cock*, might be extended to the opening of large 
 hepatic abscesses. The slow and gradual evacuation of the pus by 
 repeated puncture at suitable intervals with a small trocar, com- 
 bined with the careful exclusion of the atmospheric air, is worthy 
 of trial. The objection that the thick part of the contents of 
 the sac will not be evacuated by this method is not of much 
 w T eight, for we may believe that it may remain as a residuum, 
 and be subjected to those changes which take place in the cure by 
 absorption. 
 
 The following, then, are my conclusions on the question of punc- 
 turing hepatic abscess. 
 
 1. When the swelling is not larger than an orange, and points 
 conically at the epigastrium, or below the margin of the right ribs, 
 we should wait till an inflammatory blush appears on the skin, and 
 then open the abscess with a bistoury, sufficient^ freely to admit 
 of the ready discharge of the contents without pressure. The case 
 should afterwards be treated in accordance with ordinary surgical 
 principles. If the abscess has been single, and the constitution 
 not very much impaired, success will frequently attend this pro- 
 ceeding. 
 
 2. When there is general bulging of the right ribs below the 
 seventh, with distinct fluctuation and pointing at an intercostal 
 space, it is immaterial whether a puncture be made or spon- 
 taneous rupture take place. In both circumstances there will be 
 gangrene, from thinning, of the soft tissues, and probably caries 
 or necrosis of one or more ribs. 
 
 3. When the liver occupies the epigastrium, reaches to within 
 an inch of the umbilicus, extends two inches and more below the 
 
 * " Guy's Hospital Reports," Second Scries, vol. ii. p. 48. Mr. Cock uses a trocar 
 of one-twelfth of an inch in diameter. 
 
TREATMENT — PUNCTUBB OF ABSCESS. 411 
 
 margin of the right ribs, becomes gradually prominent in these 
 situations, and after a time obscurely fluctuating, then prema- 
 ture puncture either freely with a bistoury or a large trocar, will 
 lead to irritative fever and gangrene of the soft tissues around 
 the opening from within outwards, due to the putrefaction, from 
 admission of air, of the devitalised tissues adherent to the inner 
 wall of the sac. 
 
 4. If there be general bulging of the right ribs below the 
 seventh, fulness of the intercostal spaces, and obscure fluctuation, 
 then puncture may be made with a small trocar, in the manner 
 advocated by Mr. Cock in respect to pleuritic effusion. As delay 
 .in these circumstances is inexpedient, an exploring needle may be 
 used in doubtful cases. 
 
 5. When prominent extensive swelling at the epigastrium, or 
 below the right ribs, with diffuse sense of fluctuation, indicates the 
 existence of large abscess in the thick part of the liver, we should 
 allow sufficient time for maturation; and then, when fluctuation 
 has become distinct, we may puncture with a small trocar, observ- 
 ing the same principles in respect to gradual evacuation, repetition 
 of the operation, and careful exclusion of air. While, however, we 
 lay down the rule of waiting a suitable time for the maturation of 
 the abscess, we must take care nut to delay so long as to give time 
 for the formation of very dense unyielding walls, — an obstacle to 
 success which has been justly pointed out by Dr. Budd. 
 
 The three first conclusions are based on clinical observation, 
 but the fourth and fifth are suggestions grounded on sufficient 
 experience of the failure of other procedures. 
 
 Further, it must always be remembered, that the probability of 
 success, under all circumstances, will depend on the state of the 
 constitution, and the conservative care with which the medical 
 treatment has been conducted throughout, and the absence of 
 dysentery or other serious complication. 
 
 We must, moreover, be careful that the object of surgical inter- 
 ference be justly appreciated, for there is a tendency in many 
 minds, to over-estimate its value, and therefore to apply it un- 
 suitably. In the small distinctly pointing abscess, it is of little 
 consequence whether we puncture or trust to spontaneous rupture. 
 In the large and deep abscess, we know that restoration cannot 
 take place unless the contents of the abscess are discharged, and 
 that spontaneous rupture is unlikely, till such destruction of parts 
 and exhaustion by hectic fever have ensued as to render recovery 
 impossible; therefore, when the local conditions are appropriate, 
 
410 HEPATITIS. 
 
 rally suggests itself, whether the operation ought to be confined 
 to these conditions, and altogether abandoned in the kind of cases 
 which are at present under review. My past experience would 
 prompt an affirmative reply; but we must not hastily conclude 
 that the resources of our art are thus limited. 
 
 From the cases narrated it is evident, that when a free opening 
 is made with a bistoury, or large trocar, the large abscess emptied, 
 and air admitted, death is not thereby prevented, but, on the con- 
 trary, is frequently hastened. Therefore if good is to be effected 
 by surgery in such cases, it must be by a different kind of opera- 
 tive proceeding. The modification in the operation of puncturing 
 the chest in pleuritic effusions, advocated by Dr. H. M. Hughes 
 and Mr. Edward Cock *, might be extended to the opening of large 
 hepatic abscesses. The slow and gradual evacuation of the pus by 
 repeated puncture at suitable intervals with a small trocar, com- 
 bined with the careful exclusion of the atmospheric air, is worthy 
 of trial. The objection that the thick part of the contents of 
 the sac will not be evacuated by this method is not of much 
 weight, for we may believe that it may remain as a residuum, 
 and be subjected to those changes which take place in the cure by 
 absorption. 
 
 The following, then, are my conclusions on the question of punc- 
 turing hepatic abscess. 
 
 1. When the swelling is not larger than an orange, and points 
 conically at the epigastrium, or below the margin of the right ribs, 
 we should wait till an inflammatory blush appears on the skin, and 
 then open the abscess with a bistoury, sufficiently freely to admit 
 of the ready discharge of the contents without pressure. The case 
 should afterwards be treated in accordance with ordinary surgical 
 principles. If the abscess has been single, and the constitution 
 not very much impaired, success will frequently attend this pro- 
 ceeding. 
 
 2. When there is general bulging of the right ribs below the 
 seventh, with distinct fluctuation and pointing at an intercostal 
 space, it is immaterial whether a puncture be made or spon- 
 taneous rupture take place. In both circumstances there will be 
 gangrene, from thinning, of the soft tissues, and probably caries 
 or necrosis of one or more ribs. 
 
 3. When the liver occupies the epigastrium, reaches to within 
 an inch of the umbilicus, extends two inches and more below the 
 
 * " Guy's Hospital Reports," Second Scries, vol, ii. p. 48. Mr. Cock uses a trocar 
 of onc-twclflh of an inch in diameter. 
 
TREATMENT PUNCTURE OF ABSCESS. 411 
 
 margin of the right ribs, becomes gradually prominent in these 
 situations, and after a time obscurely fluctuating, then prema- 
 ture puncture either freely with a bistoury or a large trocar, will 
 lead to irritative fever and gangrene of the soft tissues around 
 the opening from within outwards, due to the putrefaction, from 
 admission of air, of the devitalised tissues adherent to the inner 
 wall of the sac. 
 
 4. If there be general bulging of the right ribs below the 
 seventh, fulness of the intercostal spaces, and obscure fluctuation, 
 then puncture may be made with a small trocar, in the manner 
 advocated by Mr. Cock in respect to pleuritic effusion. As delay 
 in these circumstances is inexpedient, an exploring needle may be 
 used in doubtful cases. 
 
 5. When prominent extensive swelling at the epigastrium, or 
 below the right ribs, with diffuse sense of fluctuation, indicates the 
 existence of large abscess in the thick part of the liver, we should 
 allow sufficient time for maturation; and then, when fluctuation 
 has become distinct, we may puncture with a small trocar, observ- 
 ing the same principles in respect to gradual evacuation, repetition 
 of the operation, and careful exclusion of air. While, however, we 
 lay down the rule of waiting a suitable time for the maturation of 
 the abscess, we must take care nut to delay so long as to give time 
 for the formation of very dense unyielding walls, — an obstacle to 
 success which has been justly pointed out by Dr. Budd. 
 
 The three first conclusions are based on clinical observation, 
 but the fourth and fifth are suggestions grounded on sufficient 
 experience of the failure of other procedures. 
 
 Further, it must always be remembered, that the probability of 
 success, under all circumstances, will depend on the state of the 
 constitution, and the conservative care with which the medical 
 treatment has been conducted throughout, and the absence of 
 dysentery or other serious complication. 
 
 We must, moreover, be careful that the object of surgical inter- 
 ference be justly appreciated, for there is a tendency in many 
 minds, to over-estimate its value, and therefore to apply it un- 
 suitably. In the small distinctly pointing abscess, it is of little 
 consequence whether we puncture or trust to spontaneous rupture. 
 In the large and deep abscess, we know that restoration cannot 
 take place unless the contents of the abscess are discharged, and 
 that spontaneous rupture is unlikely, till such destruction of parts 
 and exhaustion by hectic fever have ensued as to render recovery 
 impossible ; therefore, when the local conditions are appropriate, 
 
412 IIEPATITIS. 
 
 and the general strength still sufficient, the operation is proposed 
 as a reasonable measure. When, however, before local conditions 
 are suitable, great prostration of strength has come on, puncture is 
 an injudicious proceeding: it cannot possibly be of service, but 
 will probably increase the prostration, hasten the fatal issue, and 
 discredit the healing art. 
 
 There are still some points to notice in reference to this ques- 
 tion of practice. When the abscess is not single, then the chances 
 of recovery after puncture are very materially lessened, and the 
 frequent co-existence of several abscesses in the liver has been 
 urged as an argument against the operation. In 76 of my fatal 
 cases examined after death, the abscess was single in 27 ; and if to 
 these are added my 8 cases of successful puncture, it will give 35 
 single in a total of 84. In other words, 41*6 per cent. Mr. 
 Waring's* deductions from more extensive data are still more 
 favourable, viz. of single abscess 62-105 per cent. 
 
 From these facts, it may be concluded, that the other conditions 
 being favourable, we may act in the hope that the abscess may be 
 single, and not be swayed by doubts to the contrary. 
 
 Incertitude of the existence of adhesions, between the surface 
 of the liver at the seat of abscess and the abdominal walls, has 
 also been a difficulty with many, in this operation. My own ob- 
 servation would lead me to say, that too much has been made of 
 this objection, for it certainly has not been confirmatory of the 
 remark made by Mr. Twining, viz. : — "It is surprising how often 
 suppuration of the liver occurs without any adhesion of its peri- 
 toneal coat to adjacent parts, although the abscess be near the 
 surface." 
 
 I find in my notes only three cases of this nature : of these 
 173 and 180 are the most striking. The absence of adhesion in 
 hepatic abscess has with me been very exceptional, and in none 
 of the cases could the question of puncture have practical \y 
 arisen; and I further incline to the opinion that the cases of 
 non-adhesion quoted by other writers may all be included in the 
 same category. 
 
 jMoreover, if in practice we use the bistoury only when there is 
 distinct pointing and inflammatory blush, and the small trocar 
 Under the other circumstances when puncture is determined on, 
 we incur no risk. In the first case we are sure that adhe- 
 sions exist. In the possible exceptional instances of the second, 
 
 * " An Inquiry into the Statistics and l'aihology of Abscess in (lie Liver," p. 18. 
 
TREATMENT — PUNCTURE OF ABSCESS. 413 
 
 the use of a trocar and the partial evacuation of the abscess remove 
 the danger of effusion into the peritoneal sac. I therefore attach 
 no value to the suggestion made by Graves and others, of prelimi- 
 nary proceedings undertaken with the view of ensuring adhesion. 
 
 173. Large abscess in the right lobe. — The liver free of abnormal adhesions.— The 
 cicatrices of former ulcers in the colon. — Jaundice. — Enlarged glands in the course of 
 the ducts. — To the kindness of Dr. Bird, at a time prior to my appointment to the 
 European General Hospital, I was indebted for the opportunity of witnessing the 
 following case : — 
 
 A sailor from the Rattlesnake, who had been upwards of twenty years at sea and 
 much in hot latitudes, and lately affected with dysentery, succeeded by symptoms of 
 hepatic disease, was admitted into the European General Hospital in January 1836. 
 He was jaundiced, and there was much pain and fulness of the right hypochondrium. 
 As the disease progressed the edge of the liver was distinctly felt some distance 
 below the ribs. He died. 
 
 On examination a large abscess occupied almost entirely the right lobe of the liver, 
 and forced its thin edge much below its natural situation. The internal surface of 
 the abscess was lined with irregular, thick lymph, and the surrounding parenchyma 
 of the organ was dark red and friable. There were not any peritoneal adhesions to 
 the diaphragm or elsewhere, and none of the base of the right lung to the diaphragm. 
 The gall-bladder was much distended with bile and tense, and the site of the ducts 
 was occupied by numerous enlarged glands, some the size of an olive. The mucous 
 lining of the stomach at the pyloric end was of dark slate grey colour, but without 
 softening. There had been considerable vomiting during life. The colon was normal 
 externally, and without peritoneal adhesions. The coats were thin, and in many 
 places there were the distinct cicatrices of former ulcers, and the whole surface had a 
 metallic lustre, caused by tenacious light grey not abundant contents. There was not 
 any further disease detected. 
 
 The risk of wounding a distended gall-bladder has also been 
 urged as a difficulty in the practice of puncturing hepatic abscess. 
 The error would seem on more than one occasion to have been 
 committed, therefore extreme caution may very properly be en- 
 joined. Still I do not think that apprehension of this dan- 
 ger will often be experienced in practice in India. Considerable 
 distention of the gall-bladder is not of frequent occurrence, 
 at least, I have only met with five instances of it (42, 43, 173, 
 186, 187), and in only the two last was it evident during life. 
 The signs of hepatic abscess, when advanced to the stage justi- 
 fying puncture, are moreover so well marked as to afford little 
 room for error. 
 
 There is still another observation to make on this subject. Dr. 
 Budd remarks : " In India it seems now to be a common practice 
 to thrust a long exploring needle into the liver where the presence 
 of abscess is suspected ; and, now and then, perhaps the disease 
 may be cured in this way." Then follow some very just reflections 
 condemnatory of this practice. I desire to put the medical service 
 of India right with the profession on this point. 
 
414 HEPATITIS 
 
 About twenty years ago, Dr. Murray, Inspector-General of Her 
 Majesty's Hospitals, recommended the proceeding in question on 
 theoretic grounds, for his previous practical knowledge of hepatic 
 abscess had been very limited. The practice was for a time 
 followed by some of those who came within the sphere of his 
 official influence, and its vague and unsatisfactory records are to 
 be found in the Madras Medical Journal. It was never intro- 
 duced into the Bombay Presidency, and from personal inquiry, I 
 feel myself justified in saying, that it has now no existence in the 
 sister presidencies, and has almost ceased to be remembered. 
 Under these circumstances it is unnecessary to examine critically 
 Dr. Murray's peculiar doctrines. I will only add, in the words 
 with which Dr. Stovell concludes his very able comments on 
 hepatic abscess*: "For my own part, I must confess, I cannot 
 conceive the existence of any case which could require, or even 
 justify, the adoption of such a measure." 
 
 Cure by Absorption. — Eecovery from hepatic abscess by dis- 
 charge of the contents spontaneously, or by artificial opening, and 
 subsequent granulation and cicatrisation has been considered in 
 detail ; but we must not overlook the probability of cure, by 
 absorption of the liquid parts of the pus, and the formation of a 
 small cyst of putty-like or cretaceous residuum. Five cases in 
 which this process was distinct, have come under my observation 
 (p. 345); but I entertain the belief, that it is more common, 
 especially in small abscesses, than is at present supposed, and that 
 it would be a still more frequent result if, on the suspicion of sup- 
 puration, every attention were given to the conservation of the 
 constitution and of a normal capillary circulation in the unaffected 
 parts of the organ. 
 
 On Change of Climate. — The principles respecting change of 
 climate in dysentery are equally applicable to hepatitis, and need 
 not be repeated (p. 312). 
 
 In persons whose constitutions are deteriorated by long residence 
 in India, and who are subject to hepatic inflammation, there should 
 be no hesitation in recommending, at a suitable time as respects 
 the disease, and at the appropriate season, change to a more tem- 
 perate climate. 
 
 If the presence of hepatic abscess be suspected, and the strength 
 be still such as to encourage hopes of recovery by processes of 
 repair, this result will undoubtedly lie favoured by change to a 
 
 * "Transactions, Medical and Physical Society of Bombay," No. 1, New Series, 
 p. 188. 
 
IN FEMALES AND CHILDREN. 415 
 
 more temperate and tonic climate. But the measure must be so 
 conducted as to avoid the risk of recurrence of acute inflammation 
 from the excitement of travelling or sudden reductions of tempera- 
 ture ; while at the same time the advantages of appropriate regimen 
 and medical treatment are secured. If this principle be just, then, 
 a lengthened sea-voyage in a comfortable ship to more temperate 
 latitudes, is the only kind of change that affords the prospect of 
 benefit. A journey to an elevated hill-station, or the discomforts 
 and excitements of the overland route, destroy the remaining 
 chances of recovery and ought to be invariably discouraged. 
 
 When the existence of hepatic abscess is undoubted, and pros- 
 tration considerable, then change of any kind is injurious. The 
 fatigue of movement, the disappointed hope, and the absence of 
 that careful nursing which solaces the close of exhausting disease, 
 will increase the suffering, add to the prostration, and hasten 
 death. This, indeed, may seem a proposition so self-evident as 
 hardly to merit notice ; yet, I say it advisedly and from personal 
 knowledge, there is much popular delusion on this point, and not 
 unfrequently great professional weakness in ministering to it. 
 
 Section VII. — Hepatitis in Females and in Children. 
 
 Females. — The statistics* of the Bengal and Madras Presidencies 
 show that hepatitis is much rarer in European women than men. 
 The per-centage to strength in the former is 1*95, and in the 
 latter, 4 - 3. There is no record of the proportion in Bombay. 
 
 Though the symptoms in women correspond with the description 
 which has already been given, yet an error in diagnosis, against 
 which the practitioner should be on his guard, is not unfrequently 
 committed. 
 
 That acute pain, related to the hysteric diathesis and simulating 
 acute inflammatory disease, may be present in the female is a 
 familiar fact. When we bear in mind the inroads that are made 
 on female health in India by child-bearing, and lactation, in ad- 
 dition to climatic influences ; and that this lowered condition of 
 health favours the development of hj^steric phenomena, we can 
 have no difficulty in believing that acute pain in the hepatic region 
 in anaemic females in India has often been injudiciously treated as 
 hepatitis. But such mistakes ought not to occur ; for the history, 
 the diathesis, the presence of other hysteric phenomena, the 
 absence of febrile symptoms, the very acuteness of the pain, and 
 * Ewart's " Vital Statistics," \\ 129. 
 
41 G HEPATITIS. 
 
 its relation to attention being fixed on it or removed from it, are 
 sufficient to prevent them. 
 
 Children. — The ratio of hepatitis in children is in Bengal 0*05, 
 and in Madras, 0*3 per cent, of strength ; and the returns of the 
 Byculla Schools prove the rarity of the disease in Bombay at the 
 same period of life : the admissions in 1 7 years were 9, and 1 death, 
 in a strength of from 250 to 300 children. I have no practical 
 knowledge of hepatitis in childhood. The case of hepatic abscess 
 in a Parsee child of ten years of age, reported * by Dr. Miller, 
 is the youngest with which I am acquainted. 
 
 Section VIII. — Occasional Difficulties and Errors of Diagnosis. 
 
 I conclude my observations on hepatitis by quoting two cases, — 
 one reported by Mr. Impeyf, the other by Dr. E. H. Hunter. 
 The)'- illustrate well the difficulties that may occasionally beset the 
 diagnosis of hepatitis. 
 
 * 174. Aneurism of the abdominal aorta. — Acute pain of right hypochondrium and 
 shoulder. — The edge of the liver distinct. — Treated four times for disease of the liver. — ■ 
 I abridge Mr. Impey's case : — 
 
 John Hudson was admitted into hospital on the 30th of October, complaining of 
 acute tenderness of the right hypochondrium. The pain affected the right shoulder, and 
 was most felt by decubitus on the right side. The edge of the liver was distinctly 
 felt. There was Httle febrile disturbance. The pain subsequently extended towards 
 the right groin. He continued to suffer without relief till the 23rd of November, when 
 he was found in a state of pulseless collapse, and died shortly afterwards. He had 
 been a temperate man, but latterly had used opium in considerable quantity. He was 
 id with local blood-letting, counter- irritation, and purgatives. 
 
 Inspection four hours after death. — Abdomen. — The liver and intestines were in a 
 normal state. An aneurism of the abdominal aorta, of oblong shape, and the size of a 
 cricket ball, occupied with concentric layers of fibrine, was found resting on the border 
 and sides of the last dorsal and three superior lumbar vertebrae. The aneurism had 
 burst at its most prominent part below the right renal artery; and blood was exten- 
 sively diffused under the peritoneum. The bodies of the second, third, and fourth 
 lumbar vertebrae were corroded to the depth of half an inch. 
 
 The case reported by Dr. R. H. Hunter J of Her Majesty's Second 
 Regiment is of interest. At one time the patient was supposed to 
 have hepatitis running on to abscess; at another, hepatic abscess 
 conjoined with dysentery; at another, tumour over the aorta ; and 
 at one time aneurism of the aorta. 
 
 * 1 7-j. A tumour, situated between the edge of the liver and tht transverse colo 
 
 " Private Matthew Sellard was first admitted on the nth of June with diarrhoea, ac- 
 companied with pais on pressure in the hypogastric region, for which he was leeched, 
 and took medicines, chiefly absorbents and opiates, with occasional laxatives; and so 
 
 * "Transactions of the Medical and Physical Society of Bombay," No. 10. p. 303. 
 t Ibid. No. 7, p. 177. \ Ibid. No. 3, p. 134. 
 
STATISTICS. 417 
 
 far recovered, as to be able to return to his duty on the 14th of the following month. 
 On the 19th, was again admitted with similar complaints. The pain on pressure was 
 now in the epigastric region, where a firm circumscribed tumour was very perceptible, 
 yielding a sharp, heaving impulse. Soon after, he became subject to occasional vomit- 
 ing, and at last his symptoms assumed a decided hepatic and dysenteric character ; 
 under which he rapidly sunk. Died on the 21st September, at 3 a.m. — Autopsy ; 11 
 a.m. Liver enlarged and of a very pale yellow colour, very soft and lacerable, having 
 from its free edge hanging, and firmly attached to the transverse colon, an encysted 
 tumour the size of a large egg, filled with soft brain-like matter, and its cyst lined 
 with gritty osseous plates and spikes. The colon, particularly, in its transverse arch, 
 was extensively thickened and ulcerated." 
 
 Section IX. — Statistics of Hepatitis i/n the European General 
 Hospital and the Jamsetjee Jeejebhoy Hospital, at Bombay. 
 
 We may conclude that cases of cirrhosis are also included in 
 these Tables. The great mortality under the head Chronic Hepatitis 
 in the Jamsetjee Jejeebhoy Hospital shows that a large proportion 
 of the admissions must have been of hepatic abscess. 
 
 The proportion of admissions to total admissions is 3*7 in the 
 European General Hospital, and in 1*5 in the Jamsetjee Jejeebhoy 
 Hospital. The rate of mortality is 14 - 1 in the former, and 34 per 
 cent, in the latter. The comparative admissions in different sea- 
 sons have been already stated, p. 362. 
 
 In the European troops of the Bombay Presidency * the ratio 
 of attacks of hepatitis to the strength is about 7 "4 per cent. ; the 
 jDroportion of deaths to treated, 5*7, and of deaths to aggregate 
 mortality, 9*5. 
 
 In the European troops of the Madras Presidency f the ratio of 
 hepatitis to strength is 7*178, and of deaths to treated, 4-009. 
 
 In the native troops of the Madras Presidency the ratio of ad- 
 missions to strength is 0-143 and of deaths to treated, 11-917. 
 
 Here, again, as in respect to dysentery, there is a higher rate of 
 mortality from hepatitis in the native than in the European troops 
 of the Madras army. The remark made on this feature of dysen- 
 tery, p. 237, is equally applicable to this disease. 
 
 * Mr. "Webb's Medical Statistics. 
 
 f "Mortality and Chief Diseases of the Troops under the Madras Government," by 
 Lieut.-Col. W. H. Sykes, F.RS. Journal of the Statistical Society of London, May 
 1851. The statistics of hepatitis have been already stated (p. 321) from Dr. Ewart's 
 tables — but still I leave these figures, as in the first edition, drawn from other sources. 
 They very nearly correspond. 
 
 F. E 
 
418 
 
 HEPATITIS. 
 
 Table XXX. — Admissions and Deaths, with Per-centage, from Hepatitis, 
 Acute and Chronic, in the European General Hospital at Bombay, for 
 the Five Years from 1838 to 1843. 
 
 
 
 
 1838 to 1843. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 February 
 
 
 
 45 
 39 
 
 6 
 11 
 
 135 
 28'2 
 
 8-2 
 7-0 
 
 14-0 
 34-3 
 
 March . 
 
 
 
 36 
 
 3 
 
 8-3 
 
 7-1 
 
 9-0 
 
 April . 
 May . 
 
 
 
 41 
 
 25 
 
 5 
 
 2 
 
 121 
 
 8-0 
 
 7-0 
 2-9 
 
 12-2 
 
 2-4 
 
 June 
 
 
 
 31 
 
 3 
 
 9-6 
 
 39 
 
 5-9 
 
 July . 
 August . 
 
 
 
 23 
 24 
 
 2 
 
 8-3 
 
 3-2 
 39 
 
 5-4 
 
 September 
 October 
 
 
 
 23 
 22 
 
 9 
 1 
 
 391 
 4-5 
 
 4-2 
 30 
 
 25-7 
 1-9 
 
 November 
 
 
 
 25 
 
 5 
 
 20-0 
 
 3-6 
 
 18-5 
 
 December 
 
 
 
 36 
 
 5 
 
 139 
 
 5-8 
 
 10-6 
 
 Total 
 
 
 
 370 
 
 52 
 
 14-0 
 
 4-8 
 
 11-6 
 
 Table XXXI. — Admissions and Deaths, with Per-centage, from Hepatitis, 
 Acute and Chronic, in the European General Hospital at Bombay, for 
 the Five Years from 1844 to 1848. 
 
 
 
 
 1844 to 1848. 
 
 Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 
 15 
 
 2 
 
 13-3 
 
 2-4 
 
 4-3 
 
 February 
 
 
 
 15 
 
 3 
 
 20-0 
 
 2-9 
 
 8-6 
 
 March . 
 
 
 
 15 
 
 1 
 
 6-6 
 
 3-1 
 
 33 
 
 April . 
 
 
 
 10 
 
 1 
 
 10-0 
 
 1-9 
 
 32 
 
 May . 
 
 
 
 18 
 
 2 
 
 11-1 
 
 3-1 
 
 66 
 
 June 
 
 
 
 11 
 
 2 
 
 18-2 
 
 1-5 
 
 606 
 
 July . 
 August . 
 September 
 October 
 
 
 
 7 
 17 
 16 
 13 
 
 1 
 
 4 
 4 
 
 14-3 
 
 25-0 
 30-8 
 
 1-03 
 3-1 
 35 
 2-1 
 
 2-8 
 
 18-2 
 10-6 
 
 November 
 
 
 
 13 
 
 2 
 
 15-4 
 
 23 
 
 6-4 
 
 December 
 
 
 
 19 
 
 1 
 
 5-2 
 
 36 
 
 2-5 
 
 Total 
 
 
 
 109 
 
 23 
 
 13-0 
 
 25 
 
 6-9 
 
STATISTICS. 
 
 419 
 
 Table XXXII. — Admissions and Deaths, with Per-centage, front Hepatitis 
 Acute and Chronic, in the European General Hospital at Bombay, for 
 the Five Years from 1849 to 1853. 
 
 
 
 
 1849 to 1853. 
 
 M 
 
 outhly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 on total 
 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 
 17 
 
 4 
 
 23-5 
 
 38 
 
 10-2 
 
 February 
 
 
 
 15 
 
 2 
 
 133 
 
 4-1 
 
 11-1 
 
 March . 
 
 
 
 13 
 
 2 
 
 15-4 
 
 2-9 
 
 59 
 
 April . 
 
 
 
 15 
 
 2 
 
 133 
 
 2-9 
 
 8-0 
 
 May . 
 
 
 
 U 
 
 1 
 
 7-1 
 
 27 
 
 4-2 
 
 June 
 
 
 
 13 
 
 2 
 
 15-4 
 
 2-3 
 
 69 
 
 Julv 
 
 
 
 12 
 
 1 
 
 8-3 
 
 2-2 
 
 3-0 
 
 August 
 
 
 
 20 
 
 2 
 
 10-0 
 
 4-05 
 
 5-3 
 
 September 
 
 
 
 14 
 
 
 
 357 
 
 3-9 
 
 20-0 
 
 October 
 
 
 
 13 
 
 1 
 
 77 
 
 33 
 
 4-3 
 
 Noveml ifir 
 
 
 
 11 
 
 — 
 
 — 
 
 22 
 
 — 
 
 December 
 
 
 
 15 
 
 
 
 533 
 
 2-5 
 
 12-5 
 
 Total 
 
 
 
 172 
 
 27 
 
 15-7 
 
 2-9 
 
 7'5 
 
 Table XXXIII. — Admissions and Deaths, with Per-centage, from Acute 
 Hepatic Affections, in the Jamsetjee Jejeebhoy Hospital at Bombay, for 
 the Six Years from 1848 to 1853. 
 
 
 
 
 1848 to 18c3. 
 
 Monthly Average. 
 
 
 
 
 t,„_»i„ Admissions 
 
 Deaths on 
 
 
 Admissions. 
 
 Deaths. 
 
 Admissions. Admissions . 
 
 total Deaths. 
 
 January 
 
 24 
 
 1 
 
 4-2 
 
 115 
 
 0-2 
 
 February 
 
 
 
 32 
 
 2 
 
 6-3 
 
 1-7 
 
 0-7 
 
 March . 
 
 
 
 20 
 
 1 
 
 5-0 
 
 0-9 
 
 0-3 
 
 April . 
 
 
 
 18 
 
 — 
 
 — 
 
 0-9 
 
 — 
 
 May . 
 
 
 
 12 
 
 ■ — 
 
 — ■ 
 
 0-6 
 
 — 
 
 June 
 
 
 
 11 
 
 1 
 
 9-1 
 
 0o 
 
 0-3 
 
 July . 
 
 
 
 11 
 
 — 
 
 — 
 
 0-6 
 
 — 
 
 August . 
 
 
 
 23 
 
 8 
 
 34-8 
 
 1-2 
 
 2-4 
 
 September 
 
 
 
 7 
 
 2 
 
 286 
 
 0-28 
 
 06 
 
 October 
 
 
 
 5 
 
 — 
 
 — 
 
 0-2 
 
 — 
 
 November 
 
 
 
 19 
 
 4 
 
 21-0 
 
 0-9 
 
 1-2 
 
 December 
 
 
 
 26 
 
 4 
 
 154 
 
 11 
 
 101 
 
 Total 
 
 
 
 208 
 
 23 
 
 1106 
 
 0-8 
 
 0-6 
 
 E E 2 
 
420 
 
 HEPATITIS. 
 
 Table XXXIV. — Admissions and Deaths, with Pef-ceritage, from Chronic 
 Hepatic Affections, in the Jamsetjee Jejeebhoy Hospital at Bombay, of 
 the Six Years from 1848 to 1853. 
 
 
 
 
 1848 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 February 
 March . 
 April . 
 May . 
 June 
 July . 
 August . 
 September 
 October 
 November 
 December 
 
 
 
 27 
 16 
 13 
 18 
 22 
 18 
 7 
 21 
 19 
 11 
 15 
 11 
 
 17 
 
 16 
 9 
 7 
 
 12 
 4 
 3 
 
 13 
 7 
 3 
 5 
 6 
 
 63 
 100 
 
 69 
 38 
 54 
 22 
 42 
 61 
 36 
 27 
 33 
 54 
 
 
 
 2 
 9 
 5 
 2 
 8 
 9 
 8 
 2 
 3 
 5 
 
 1-3 
 
 0-8 
 
 ' 0-6 
 0-9 
 101 
 
 ' 0-9 
 0-3 
 11 
 0-9 
 0-5 
 0-7 
 0-5 
 
 3-8 
 5-0 
 2-3 
 2-4 
 4-2 
 1-3 
 0-9 
 4-0 
 2-2 
 0-9 
 1-5 
 1-5 
 
 Total 
 
 
 
 198 
 
 102 
 
 515 
 
 0-8 
 
 25 
 
421 
 
 CHAP. XVI. 
 
 ON CIRRHOSIS, CONGESTION, LARDACEOUS AND FATTY ENLARGEMENT, 
 
 CANCER AND HYDATID OF THE LITER. AFFECTIONS OF THE BILIARY 
 
 DUCTS AND GALL-BLADDER. — BILIARY CALCULI. — JAUNDICE. 
 
 INCREASED AND DEFECTIYE SECRETION OF BILE. 
 
 The subjects of this chapter will be treated very briefly, for they 
 are now well understood, and described in systematic works. 
 
 Section I. — Cirrhosis. — Pathology. — Symptoms. — Treatment. 
 — Complication with Hepatic Abscess. 
 
 This disease is common in India, as in other countries, in the classes 
 addicted to the habitual free use of spirits. It consists of chronic 
 inflammation of the areolar tissue of the portal canals, even to their 
 smallest ramifications, followed by exudation of lymph which be- 
 comes slowly organised into contractile fibrous tissue. This process 
 leads to a diminution of the calibre of the branches of the portal 
 vein, the hepatic artery and duct, with probably obliteration of 
 some of their smaller divisions. From this, atrophy of the lobular 
 structure of the liver results, and the diminished flow of blood 
 through the portal vein favours congestion of the capillaries of the 
 mucous membrane of the alimentary canal, hence haemorrhages, 
 also of the peritoneal capillaries, hence ascites. 
 
 The exudation in the early stages, before organisation, con- 
 traction, and lobular atrophy have taken place, may cause enlarge- 
 ment of the liver and its extension below the margin of the ribs. 
 With progressing organisation the lymph contracts, the lobules 
 become atrophied, and the size of the organ is often very consider- 
 ably diminished. The liver now becomes hard and tough, and 
 when cut shows a surface variegated with white streaks, and some- 
 times presents the appearance of little globular nodules, the size 
 of a pea, imbedded in a capsule of fibrous tissue. The external 
 surface becomes irregular and tuberculated in appearance — a state 
 
 E E 3 
 
422 CIRRHOSIS. 
 
 caused, it is believed, by the contractile organisation of the lymph 
 exuded in the proximity of the capsule. The colour of the liver in 
 cirrhosis varies according to the quantity and quality of the retained 
 bile. It may be of pale buff colour, or of bright yellow, or of 
 an olive-green tint. These statements will be found to be verified 
 by cases* detailed in this work. 
 
 It is further important to recollect that this condition of the liver 
 exists in a very depraved diathesis, the result of the habits which 
 induce the local disease, and of the imperfect purification of the 
 blood, arising from structural unfitness of an important excretory 
 organ. 
 
 The symptoms are more or less uneasiness or pain of the hepatic 
 region, with some degree of febrile disturbance, in the early stages. 
 In the more advanced periods, the diagnosis chiefly depends on the 
 deranged digestive functions, the sallow complexion, the increasing 
 emaciation, the intemperate habits, and finally the ascites, or the 
 gastric or intestinal haemorrhage. 
 
 Considering the circumstances in which cirrhosis occurs, the 
 treatment is necessarily unsatisfactory. When the early symptoms 
 are present, a modified antiphlogistic treatment by leeches, small 
 blisters, and moderate mercurial and other eliminants, will be of 
 benefit, but there can be no prospect of permanent improvement 
 unless the habit of spirit drinking be abandoned. 
 
 When the cachectic diathesis, always present in some degree in 
 this disease, is regarded, there can be little hesitation in determin- 
 ing that the constitutional action of mercury is contra-indicated 
 This conclusion may perhaps be occasionally questionable at the 
 commencement, but as the disease advances there can be no room 
 for doubt ; and on the whole we shall act wisely by making the 
 rule absolute. In the advanced stages there is little to be done 
 beyond adjusting the regimen to the ability of the impaired organs, 
 aiding the eliminating power of the liver by taraxacum, hydro - 
 chlorate of ammonia, nitric acid, and the external use of nitro- 
 muriatic acid ; checking the haemorrhages by suitable astringents, 
 and favouring the removal of ascites by varying arrangements of 
 diuretics and the external application of iodine lotions. 
 
 The two following cases illustrate several of the features of this 
 disease : — 
 
 17G. Cirrhosis, with enlargement. -Ascites and Jaundice. — Samuel John Adams, a 
 native Christian, of twenty-five years of age, usine; spirits habitually, was admitted in 
 an emaciated Mate into the clinical ward, on the 23rd July, 1849. The respiration 
 
 * Cases Gl, 170 to 181. 
 
PATHOLOGY. 423 
 
 was short and hurried. The abdomen was tense, swollen, bulging laterally, and dis- 
 tinctly fluctuating ; dulness on percussion reached to the right fifth rib, and fourth left 
 rib, anteriorly, and to the angle of the scapulae, posteriorly. The sonnds of the heart 
 were normal, but least heard between the third and fourth ribs, midway between the 
 sternum and left nipple. There was cedema of the lower extremities. The pulse was 
 small. The tongue moist, but coated yellow in the centre, and florid at the tip and 
 edges. There was faint yellowness of the conjunctiva?, and the bowels were relaxed. 
 He stated that the jaundice had been present for three months, that irregular febrile 
 symptoms had come on fifteen days before admission, were succeeded by the ascites, 
 and this by the anasarca. The diarrhcea increased after his admission, and he died 
 on the 27th. The urine gave no traces of albumen, and its quantity had increased 
 under the use of diuretics. 
 
 Inspection ten hours after death.— Mi the tissues were tinged yellow. The abdomen 
 was swollen, and the lower extremities were cedematous. Chest. — The lungs collapsed, 
 were soft and crepitating, and without adhesions. There was neither pleuritic nor 
 pericardial effusion. The base of the heart reached to the second costal cartilage, and 
 its apex was opposite to the fourth intercostal space from pressure upwards by the 
 abdominal fluid. The structure of the heart was normal. Abdomen. — There were 
 about six* pints of yellow turbid serum in the peritoneal sac. The omentum was 
 somewhat thickened. The liver, chiefly its left lobe, was considerably enlarged, its 
 surface was very irregular and lobulated, and was of olive-green colour. It reached 
 transversely to the ribs of the left side, and upwards on both sides to the upper margin 
 of the fifth rib. The gall-bladder was empty, and its structure was indurated. The 
 kidneys were somewhat enlarged, but there was no trace of yellow degeneration. The 
 spleen was much enlarged, somewhat firm in structure. The whole tract of the intes- 
 tinal canal was laid open. The sub-mucous tissue was, in places, cedematous; but 
 with the exception of patches of dark red discolouration of the mucous membrane of 
 the ccecum and some enlargement of the follicles there, there was no other disease. 
 
 177. Ascites. — Liver small and indurated, — Cirrhosis. — Considerable effusion of 
 scrum in the head, — Patrick McDonald, aged forty-eight, a serjeant on the pension 
 list, a tall spare man, was admitted 23rd July, 1838, into the European General 
 Hospital. He had been twenty-eight years in India, and about four years ago suffered 
 from jaundice. On admission the abdomen was distended, fluctuation was distinct, and 
 the legs and feet were cedematous. His illness had commenced in the beginning of 
 June, with anasarca of the legs. The urine was scanty and not coagulable. The 
 treatment in the first instance consisted in the exhibition of diuretics of different kinds 
 and in different modes of combination— calomel with squills, colchicum wine, tincture 
 of squills, tincture of digitalis, nitrous ether, and the different neutral diuretic salts 
 combined latterly with some bitter infusion, or a solution of quinine ; an occasional 
 purgative was also exhibited. Under this treatment, at first the urine increased much 
 in quantity, and the swelling of the abdomen and the anasarca of the limbs decreased ; 
 the alvine evacuations were never pale or deficent in bile. The diuretics now lost 
 their effect, the fluid re-accumulated; he was tapped about the 19th October; again 
 on the 2nd November, and thirty -five pints of of straw-coloured serum were drawn off; 
 again on the 12th November, and twenty-one pints; on the 13th December, twenty- 
 six pints; on the 31st December, twenty-three pints; on the 7th January, twelve 
 pints ; and on the 4th February, twenty-three pints of slightly turbid serum were 
 drawn off. Throughout this period, the medical treatment was merely palliative and 
 tonic, with an occasional endeavour to re-excite the action of the kidneys. He 
 ultimately became occasionally delirious, and died on the 11th February. 
 
 Inspection four hours after death. — Body emaciated. Head. — There were about two 
 
 * The MS. is not distinctly legible in regard to the quautity of the serum, and that 
 stated above is therefore not positively given. 
 
 K E 4 
 
424 CIRRHOSIS. 
 
 ounces of serum between the arachnoid membrane and pia mater, on the convex 
 surface of the brain, and at the base of the skull, and six drachms in the ventricles. 
 Chest. — The lungs collapsed and were healthy ; the heart was healthy ; and there was 
 no fluid in the cavity of the pleura. Abdomen. — Eight pints of whey-coloured serum 
 were contained in the cavity. The stomach was much dilated, and occupied the left 
 hypoehondrium, the epigastrium, and part of the right hypochondrium. The trans- 
 verse colon was also much dilated. The peritoneal surface of the greater part of the 
 small intestine had a close-set pearly covering* in irregular patches, about the thick- 
 ness of silver paper, easily peeled from the peritoneal lining, and extending in a con- 
 tinuous but thinner layer over the mesentery. The peritoneal coat was thinner, not 
 pearly, not easily separable from the tunics, and clearly distinguishable. The liver was 
 about half its natural size, and adhered by long areolar bands to the side ; its texture 
 was much indurated, pale buff, like cow's udder, with many pale yellow granules scattered 
 throughout. There was a small quantity of bile in the gall-bladder. The spleen was 
 dense, its peritoneal coat was thickened and pearly. The mucous lining of the stomach 
 was of natural texture, but marbled red at the cardiac end and thinned at the pyloric. 
 The contents of the small intestine were tinged with bile. The mucous coat of the 
 sigmoid flexure of the colon was vascular. Where the transverse colon was dilated, 
 there were no mgse, but these were numerous and in all directions where the dilata- 
 tion ceased. The tubular and cortical parts of the kidneys were not so distinctly 
 defined as usual, but these organs were otherwise healthy. 
 
 It is generally stated that cirrhosis of the liver and hepatic 
 abscess do not occur together. This is doubtless correct of Euro- 
 pean countries, but it is not so of India, where the co-existence of 
 the affections is not very unusual. I quote four cases illustrative 
 of this remark : — 
 
 178. Abscess in the liver. — Cirrhosis. — Sloughy -perforations of large intestine, but 
 no thickening of its coats noted. — Private M. E , aged twenty-seven, of Her Ma- 
 jesty's 40th Regiment, was admitted into hospital, at Belgaum, on the 19th July, 
 1830. He had been six months in India, and never in hospital before ; but had, for 
 some days before admission, suffered from pain of abdomen and deranged bowels. On 
 admission, there was tenderness of abdomen, hot skin, full pulse, dejections frequent 
 and morbid. On the 6th August he had slight pain of right side, but it was gone on 
 the following day. Died August 11th. 
 
 Inspection. — The liver was of natural size. Its whole surface was rough, granular, 
 and covered with healthy peritoneum. The internal structure was occupied by nume- 
 rous small abscesses, the size of a hen's egg, and containing thin green watery pus. 
 The parenchyma of the liver, when cut, presented a surface of light gamboge, yellow 
 colour ; and was found to consist of mimerous small nodules, each about the size of a 
 pea, and confined to a distinct capsule, from which it could readily be picked out. 
 
 * I must call attention to the thin pearly layer that invested the peritoneum in this 
 case. I am doubtful whether it is to an appearance of this kind or not that Dr. Budd 
 alludes at p. 139 of his treatise, as induced by peritonitis. It seems to me that a 
 more likely explanation of the appearance described in this case may be, suggested. In 
 the normal state of the peritoneum, a very slight epithelial investment suffices for 
 protective purposes ; but when serum has for a long time been in contact with the 
 peritoneal Burface, then further protection is required, and epithelial hypertrophy 
 may ensue. I would look upon this thin layer as a thickened epithelium. This is a 
 point, however, in respect to which there shoidd not be doubt, for the microscope will 
 readily resolve it. 
 
TATHOLOGY. 425 
 
 It was in these capsules that suppuration seemed to have commenced. The liver ad- 
 hered to the concave surface, and the right lung to the convex surface of the diaphragm. 
 The gall-bladder was full of dark bile. The omentum covered the whole surface of the 
 small intestine, and, where not inflamed, was thinner than natural, as if stretched. 
 Fleshy and thickened at the points of adhesion, the omentum adhered to the eoecum 
 and descending colon ; and when pulled away from the latter situation, it was found 
 that the coats of one side of the descending colon had been completely removed, and 
 the loss supplied by the omentum and the abdominal parietes. The sigmoid flexure 
 formed two or three folds in the cavity of the pelvis, and at the angle of each fold the 
 coats of the intestine were destroyed on one side, for the extent of the size of a dollar, 
 the loss being supplied by the opposite side of the folds and by the omentum. The 
 urinary bladder formed the wall of one perforation the size of a dollar. 
 
 179. Abscess in liver with cirrhosis, notwithstanding ptyalism. — Displacement of 
 colon. — Adhesion of it to the leftside of diaphragm. — Sloughy ulceration of large 
 
 intestine, without thickening. — Private W. H , of Her Majesty's 40th Eegiment, 
 
 aged forty-three, after one day's illness, was admitted into hospital, at Belgaum, on 
 the 22nd July, 1830. There was much tenderness across the lower part of the epi- 
 gastric region, and the dejections were frequent. He was freely bled and leeched, and 
 the pain left him ; the dejections became bilious and no longer contained blood. On 
 the 25th, ptyalism. 28th, medicines omitted. The dejections were natural, and he 
 seemed to be convalescent. From the 1st of August to the 10th, the dejections con- 
 tinued feculent and formed, with occasionally, however, some drops of reddish mucus 
 passed with tenesmus. On the 10th the purging returned, the tenesmus increased, the 
 dejections became morbid, and the abdomen tender. From this time all the symptoms 
 became aggravated. Ptyalism could not be again induced, and he died, on the 26th 
 August. 
 
 Inspection. — The omentum was shrivelled up and laid upon the transverse colon. 
 This intestine, throughout its Course, adhered to the abdominal parietes, and to the 
 great curvature of the stomach, following its cardiac extremity, and adhering to the 
 left side of the diaphragm. On the right side the transverse colon adhered to the 
 concave surface of the liver, and firmly to the gall-bladder. The coats of the bowel 
 were thinned, and in some places perforated : the gall-bladder, for example, formed 
 the wall of a perforation. The ascending and descending colon ulcerated internally, 
 were of rather contracted calibre, and adhered firmly to the parietes of the abdomen. 
 When these adhesions were separated in some places, the contents of the bowel 
 escaped. The peritoneal surface of the small intestine was of a dark red colour with 
 here and there patches of effused lymph. The left lobe of the liver was small, hard, 
 and carneous. The right lobe not so hard, was mottled and contained many 
 small abscesses in its structure, none of them, however, larger than a horse-bean. 
 There was not any adhesion of the external siu-face of the liver, but in some places 
 there were depressed and puckered cicatrices. The coats of the different vessels in 
 the substance of the liver seemed thickened, and felt cartilaginous and hard under the 
 scalpel. The gall-bladder contained thin watery bile. The lung on the left side 
 adhered to the diapliragru, opposite to the^adhesions formed between that muscle and 
 the colon. 
 
 180. Abscess in liver, notwithstanding ptyalism. — Cirrhosis. — Ccecum and ascending 
 
 colon thickened and ulcerated. — Private B. A , aged twenty-one, was admitted 
 
 into hospital at Belgaum, on the 1st August, 1830, affected with griping and passing 
 mucous dejections. On the 3rd, when the gums were tender, the dejections became 
 bilious and feculent, and continued so till August 17th, with however irregular action 
 of the bowels and occasional griping, but without tenderness of abdomen, or febrile 
 excitement. On the 17th, blood was observed in the alvine discharges. From this 
 date the symptoms became aggravated. The dejections, however, retained their bilious 
 
426 HEPATIC CONGESTION. 
 
 colour, though there was no intermixture of blood and vitiated mucus. No ptyalism. 
 Died September 8th. 
 
 Inspection. — The liver, without adhesions, was of slate colour externally, somewhat 
 enlarged, and extended beyond the cartilages of the ribs. Near the thin edge of the 
 left lobe there was an abscess, yellow, elevated above the surface, about the size of 
 a hen's egg, and containing thick pus. The liver was hard in structure. The gall- 
 bladder was full of dark bile, and had formed firm adhesions with the colon and 
 the pyloric portion of the duodenum. There was less peritoneal inflammation than is 
 generally met with. The omentum was vascular, but had contracted few adhesions. 
 The caput coecum and ascending colon were distended, hard, and thickened. The 
 former was drawn upwards from its usual situation in the iliac fossa. The mucous 
 membrane of the larger intestine was ulcerated, but nowhere was there any trace of 
 perforation. 
 
 181. Dysentery complicated with delirium tremens. — Abscess and cirrhosis of the 
 liver. — Denis L. Donahen, aged twenty-eight, a man of stout frame but of dissipated 
 habits, aften ten or twelve days' illness with dysentery, was admitted into the 
 European General Hospital on the 11th December, 1842. There was heat of skin, 
 full and frequent pulse, and considerable tenderness about the ccecum. He was bled 
 to twelve ounces, had fifty leeches applied to the abdomen, and took calomel with a 
 fidl opiate. The following day he was tremulous, and the dysenteric symptoms 
 continued. On the 14th he was in a state of delirium tremens, and there was dis- 
 tinct induration at the site of the ccecum. On the loth the symptoms of delirium 
 tremens had passed away but the dysentery continued. He was treated chiefly with 
 free opiates without amendment ; and on the 29th, to the dysenteric symptoms was 
 added occasional uneasiness of the right hypochondrium shoeting to the shoulder. 
 This state persisted with occasional febrile symptoms, collapsing features and declining 
 strength, and he died on the 4th January. 
 
 Inspection ten hours after death. — Abdomen. — The omentum adhered firmly to the 
 coecum, and the transverse colon was rather contracted. The liver was in a state of 
 cirrhosis, and several small abscesses projected from its convex surface, and there was 
 a larger one, at the thin edge of the liver, of which the walls were in part formed by 
 the omentum. 
 
 Section II. — Congestion of the Liver. — (Edema. 
 
 The facts which it is important to remember in regard to this 
 pathological state are, the three degrees of congestion described 
 by Mr. Kiernan: the first confined to the hepatic vein, the second 
 implicating the portal capillaries in part, the third involving all 
 the portal capillaries. Thus the varieties of mottling frequently 
 observed on the incised surface of the liver are caused. 
 
 The two first of these degrees are liable to be produced by 
 cardiac or pulmonary disease obstructing the ready return of the 
 venous blood to the heart. 
 
 Consequent on the altered balance of the circulation and the 
 deteriorated blood in malarious fever, congestion of the portal 
 capillaries, leading to enlargement of the organ and derangement 
 of function, is apt to occur. This pathological state has been 
 already alluded to in connection with the subject of fever, and the 
 
HEPATIC CONGESTION. 427 
 
 caution has been given not to mistake this condition co-existing 
 with fever, for hepatitis.* 
 
 It is a favourite theory with some, that blood vitiated by the 
 absorption of matters from the intestinal canal is a common cause, 
 and affords a ready explanation of certain biliary derangements. 
 That, consequent upon blood altered in quality being conveyed to 
 a secreting structure, the processes between that blood and the 
 cells — in other words, secretion — may be impaired and capillary 
 congestion result, is accordant with present physiological doctrine. 
 But f that the food of the middle and upper classes of society, 
 taken in excess, is liable to generate an immense variety of noxious 
 matter, capable of absorption by osmotic force, is surely a state- 
 ment unsupported by sufficient proof. 
 
 In ordinary digestion the assimilable portion of the food is 
 absorbed in the upper parts of the alimentary canal, while its fcecal 
 residuum with the excreta from the surface of, or poured into, the 
 intestinal canal, are passed onwards for rejection. When dela}^ed 
 in the large intestine, that portion of the contents which is absorb- 
 able by osmotic force is removed and the density of the residual 
 mass is increased, while the fluid part which has been absorbed is 
 carried to the portal blood ; but no evil results, simply because 
 that which is noxious has been left behind, and that which has 
 been absorbed is innocuous. 
 
 Why should it be otherwise in the instance of excess ? Then 
 the undue quantity of fcecal residuum is hurried through the canal 
 and speedily ejected. Instead of there being greater likelihood 
 under these circumstances of absorption into the portal blood of 
 
 * " Congestion of the liver " is at present a common phrase often however used, 
 very vaguely, and without any attempt to ascertain by percussion, whether the organ 
 is enlarged or not. Increased size of the liver is a condition of its congestion, and un- 
 less this exists, the assertion that there is congestion of the liver is hardly justifiable. 
 
 A persistent, enlarged and friable state, caused by congestion or other change of the 
 large parenchymatous viscera — the liver and spleen — of the abdomen is also important 
 in reference to questions of medical jurisprudence. For example, rupture of an 
 enlarged spleen and speedy death by haemorrhage, caused by slight and apparently 
 inadequate external injm*ies, is not a very unusual occurrence in India. Four such 
 cases are recorded by Mr. Heddle, in the 1st volume, " Medical and Physical Society's 
 Transactions," Bombay. The only instance which has come under my own observation 
 was that of police constable, who had strained himself in playing cricket. He was 
 admitted into the European General Hospital on the 1st February, 1840, with uneasy, 
 full abdomen and oppressed breathing, and died on the following day. After death the 
 cavity of the abdomen was found to contain four imperial pints of dark-coloured 
 blood, in part coagulated, which had proceeded from a laceration, an inch and a half in 
 length, on the inner siu-face of the spleen. 
 
 f Dr. Budd, " Diseases of the Liver," second edition, p. 61. 
 
428 LABDACEOUS AND FATTY LIYEE. 
 
 the so-called noxious matters, there must be less, for they are de- 
 layed a much shorter time in relation with the structures which 
 are supposed to absorb. That excess in eating and drinking de- 
 ranges the digestive functions, those of the liver included, is very 
 true ; but that this effect is usually caused by the direct transmis- 
 sion of noxious matters of food, by the portal blood, from the 
 intestine to the liver, is for the reasons just assigned, an impro- 
 bable theory. 
 
 (Edema of the Liver — is a pathological state with which I was 
 unacquainted till I met with the following case. This condition 
 is not noticed by Rokitansky, and the only mention of it to which 
 I am at present able to refer, is in the Library of Medicine.* 
 There it is said that oedema of the liver, uncombined with inflam- 
 mation, has often been observed ; but by whom is not stated. 
 
 182. Remittent fever, oedema of the liver. — Cassim Ibrahim, aged thirty-six, admitted 
 after ten days' illness, on the 6th February, 1857. The skin was hot and dry, the 
 breathing hurried, general tremors, sordes on the lips, the tongue dry and florid, the 
 pulse frequent and small, no abnormal cardiac sounds. The exhaustion increased, and 
 he died in twenty-four hours. 
 
 Inspection fifteen hours after death. — The white tissues were tinged yellow. No 
 abnormal vascularity or effusion in the head. The lungs healthy, with exception of 
 considerable oedema, and dark redness of the bronchial mucous membrane. The heart 
 was healthy. The liver, of dark olive colour, reached two inches below the right ribs, 
 and touched the point of the eighth left rib. It weighed four pounds four ounces, 
 and when cut, and gently pressed, serous fluid oozed freely from the surfaces, six 
 ounces were collected. The parenchyma broke down readily under the finger. The 
 incised surfaces presented a dark olive colour, with brown intermixture, but not the 
 mottled redness of congestion. There was commencing Bright's disease of both 
 kidneys. The mucous membrane of the stomach and intestines was, with exception of 
 mottled redness of the former, healthy. 
 
 Section III. — Lardaceous and Fatty Liver. — Cancer, and, 
 Hydatid Formations. 
 
 Lardaceous Liver. — This state, termed by Dr. Budd scrofu- 
 lous enlargement of the liver, found in scrofulous, syphilitic, and 
 mercurial cachexia, is, I believe, very similar to that caused by 
 malaria. I have already, when treating of hepatic enlargement 
 consecutive on intermittent fever, stated my own limited infor- 
 mation on this subject, and what seem to me the chief desiderata 
 in its further investigation. 
 
 Fatty Degeneration of the Liver. — The etiology and pathology 
 of this morbid state in India are subjects for future inquiry; for 
 
 * Vol. iv. p. 180. 
 
CANCER OF THE LIVER. 429 
 
 it is probably more common than recorded facts have yet proved 
 it to be. This, and all allied processes which imply perversion of 
 nutrition, of great interest in all countries, are particularly so in 
 India, where, for reasons elsewhere adverted to (p. 154), the ten- 
 dency to degenerative action, is, in all likelihood largely developed. 
 The reader will find a full exposition of the present state of patho- 
 logical knowledge on scrofulous enlargement and fatty degenera- 
 tion of the liver in Dr. Budd's work.* 
 
 Cancer of the Liver. — Judging from the considerable space 
 allotted to descriptions of this morbid state in works on the patho- 
 logy of the liver, it would seem that it is not of unfrequent occur- 
 rence in European countries. 
 
 It is certainly rare in India, and therefore, clinically speaking, 
 it is undesirable that it should fill a prominent place in the mind 
 of the practitioner in that country. 
 
 The following is the only case which has come under my ob- 
 servation : — 
 
 183. Treated for supposed dyspeptic symptoms. — Numerous cancerous tubera dis- 
 St minated throughout the liver. — One had opened into the stomach. — Chayia Raggia, a 
 Hindoo fisherman, of fifty years of age, a resident of Caranja near Bombay, and using 
 spirituous liquours habitually, was, not much reduced in flesh, admitted into the 
 clinical ward, on the 11th July, 1849, under the head "Dyspepsia." The abdomen 
 was flaccid, and without induration. The 'tongue was clean and moist. He com- 
 plained of pain at the epigastrium extending up the sternum coming on in parox- 
 ysms three or four times in the day, generally, he thoxight, when the stomach was 
 empty. The paroxysms were attended with flatulence and a sense of burning and 
 acidity of stomach which were relieved by firm pressure, and also, he said, by the 
 use of spirits. He had suffered more or less from these symptoms for four years. 
 During his stay in hospital the urine was frequently examined, but gave no indications 
 of albumen. He continued under treatment till the 29th July, when he was dis- 
 charged relieved. He returned to the hospital several times, and was treated for his 
 dyspeptic symptoms as they were termed. The last admission was on the 24th 
 November, 1850. There was pain at the epigastrium, with distinct induration extend- 
 ing in a direction below the margin of the right ribs. The alvine discharges were 
 clay coloxired. On the 10th December there was vomiting of dark-coloured fluid, under 
 which he sank and died. 
 
 Inspection twelve hours after death. — The liver enlarged, chiefly the right lobe. 
 From different parts of both the convex and concave surfaces there projected in relief 
 circumscribed white elevations of various size, from a pea to an olive. These, when cut 
 into, were found to be white, indurated, circumscribed tubera. There were also 
 numerous similar nodules in different parts of the substance of the liver in size from a 
 pea to a small orange. Some of the large ones were softened at their centres into a 
 pulpy matter, almost of the consistence and colour of pus, which under the microscope 
 exhibited the granular cellular appearance of the eneephaloid cells. The intercurrent, 
 portions of the liver were natural in appearance and consistence. The concave surface 
 of the left lobe adhered to the surface of the stomach near to the pylorus, and 1 he 
 
 * For further remarks on fatty degeneration of the liver and fatty liver, see 
 note, page 9. 
 
430 HYDATIDS IN THE LITER. 
 
 inner surface of the stomach at the site of adhesion presented a cup-like depression 
 involving the substance of the liver, the evident consequence of the opening of a tuber 
 into the stomach. Both kidneys, on removing the capsule, presented a buff mottled, 
 somewhat granular appearance, and on incision the cortical portion was pale buff, and 
 encroached on the tubular. There was some degree of hypertrophy of the left ven- 
 tricle of the heart, and some thickening of the mitral valve. 
 
 Hydatid formations in the liver are also rare in India. I have 
 met with only three cases. Two occurred in natives, and in both, 
 echinococci were present in great abundance. The subject of one 
 of these two cases was a negro sailor, a native of Muscat, admitted 
 into the clinical ward with fulness of the right false ribs, and a 
 dull prominent swelling reaching to the eighth left rib, and to near 
 the umbilicus. There was also fever and dysentery. The history 
 was imperfect, but from, the hepatic enlargement, the fever and 
 dysentery — the diagnosis was hepatic abscess. He died ten days 
 after admission, and after death a large hydatid sac was found in 
 the right lobe of the liver, containing five pints of clear colourless 
 fluid with floating acephalocysts and echinococci ; and numerous 
 nodules of lymph deposit, some softening into pus, were scattered 
 throughout the left lobe. There was sloughy ulceration of the 
 large intestine. The diagnosis was therefore correct, though in 
 complete, and the inference from the enlargement erroneous. 
 
 The third case is detailed below — it occurred before the atten- 
 tion of the profession had been called to the general presence of 
 echinococci in the hydatid sac. The subject of it was a soldier 
 of the loth Hussars, lately arrived from Europe — so that the 
 hydatid in this case as well as that in the Muscat sailor were not 
 of Indian origin. 
 
 184. Phthisis pulmoncdis. — Licngs tuberculated, hydatid sac in the abdomen, also in 
 the liver, — Peritoneum studded with miliary transparent tubercles. — Edward Colling- 
 ridge, Her Majesty's 15th Hussars, aged twenty-two, had been troubled with a pectoral 
 affection during the voyage, and was admitted into the European General Hospital, on 
 the 10th November, 1839. He was pale, sallow, and had frequent dry cough. Tuber- 
 cular deposition in the lungs was suspected. On the 3rd December the abdomen was 
 tense and full, with sense of fluctuation. There was constant hectic fever with 
 increasing emaciation, and he died on the 2nd January. 
 
 Inspection twelve hours after death. — Body much emaciated. Head. — There was a 
 thin veil of serum between the archnoid and pia mater on the convex surface of the 
 brain. The substance of the brain was soft. Chest. — There was a pint of serum in 
 the sac of each pleura. The anterior part of the lungs was emphysematous, and 
 miliary tubercles were disseminated throughout. The posterior part of the upper lobe, 
 and almost the whole of the lower lobe of the right lung, were impermeable from 
 tubercular infiltration ; in places there were tubercular masses, the size of a pigeon's 
 egg, but generally it was intermixed with the red parenchyma, and presented the 
 pariegated appearance (when incised) of shell marbles, in which red and white arc the 
 predominating colours. The posterior part of the left lung was cedematous, but there 
 was little tubercular infiltration. The heart was healthy. Abdomen. — The intestines 
 
AFFECTIONS OF THE GALL-BLADDEK. 431 
 
 were displaced, and the central part of the abdominal cavity was occupied by a 
 hydatid sac which completely filled the pelvis, rose over the promontory of the sacrum, 
 and reached to the margin of the left lobe of the liver. This sac was filled with many 
 pints of hydatids, transparent and clear, ranging from a marble in size to a large 
 orange ; there was also a great quantity of yellow membranous shreds, the evident 
 teguments of dead hydatids. In the left lobe of the liver were two sacs, each the size 
 of a small orange, also filled with hydatids. The intestines were of a dark leaden 
 colour, and generally contracted. The mesentery, and much of the peritoneal surface 
 of the intestines, and also the omentum, were studded closely with miliary tubercles, 
 about the size of a mustard seed ; and to these the small red ramifications of vessels 
 very frequently extended. The stomach was small. The kidneys healthy. The 
 examination was not further pursued. 
 
 Section IV. — Inflammation of the Gall-Bladder and Biliary 
 Ducts. — Distention of the Gall-Bladder. — Biliary Calculi. 
 
 • 
 
 My observations supply very little information on these affections. 
 The cases of jaundice complicating remittent fever, detailed at 
 page 98, do not countenance the idea of inflammation of the 
 mucous lining of the biliary ducts being a common cause of jaun- 
 dice ; and if I may judge from my own experience, inflammation of 
 these structures, as well as of the gall-bladder, is not of frequent 
 occurrence. 
 
 A case (185) of inflammation * of the gall-bladder, associated 
 with abscess in the liver, is subjoined ; also two cases of distention 
 of the gall-bladder, previously referred to.f In association with 
 the two last cases, 42 and 43 may also be considered. 
 
 185. Hepatitis. — Abscess.— Inflammation of the external and internal surface of the 
 
 gall-bladder. — Sudden collapse, continuing with varying symptoms for several days. 
 
 John Mclnnes, aged thirty-three, had been employed as an engineer. After ten days' 
 illness with hepatitis, he was admitted into the European General Hospital on the 
 12th April, 1841, with the disease unsubdued. On the 20th there was unexpected 
 collapse with vomiting. He continued, till his death on the 30th, with occasional 
 vomiting, hiccup, pidse frequent, and fading in strength. Latterly abdomen full, with 
 pain shifting from place to place. 
 
 Inspection. — There were two abscesses in the right lobe of the liver. There was a 
 small quantity of sero-purulent effusion in the abdomen, with tender adhesions of the 
 convolutions of the intestine to each other, and firm adhesion of the liver to the con- 
 cavity of the ribs. The gall-bladder was moderately distended, its peritoneal surface 
 was of bright red colour, and adhered to the colon ; the lining membrane was also of 
 bright red colour, and the contents consisted of tenacious mucus in places almost 
 
 * I find, in my notes of fatal cases of officers, one of a stout corpulent man of thirty- 
 four years of age, who suffered frequently from pain of the hepatic region, and clay- 
 coloured evacuations. After six weeks' illness with these symptoms, treated freely 
 with general and local blood-letting and calomel, he died exhausted. The liver was 
 found much enlarged, mottled, and readdy lacerable. The gall-bladder was small, 
 and filled with calculi, from a pigeon's egg to a pea in size, but without bde ; the 
 mucous membrane was red and livid, with sphacelated patches. 
 
 t Page 413. 
 
432 AFFECTIONS OF THE GALL-BLADDER; 
 
 membranous in character ; a probe passed through the duct met with resistance. The 
 mucous coat of the stomach was lined with adhesive mucus, and presented a rosy tint, 
 but was unchanged in structure. 
 
 186. Fever, with jaundice. — Gall-bladder distended, seemingly from inflammation of 
 the common duct. — Little improvement from treatment. — Jamsetjee Sapoorjee, a Parsee 
 carpenter, of fifty-five years of age, following his occupation in the Government dock- 
 yard, and habitually using spirits, was admitted into hospital, on the 24th June, 
 1852, ill with intermittent fever, complicated with jaundice. On the 2nd July, a 
 pyriform indistinctly fluctuating swelling was observed below the margin of the 10th 
 right rib. It was about an inch and a half in length and an inch in breadth, and was 
 dull on percussion, but not painful. There was pain increased by pressure at the margins 
 of the seventh and eighth ribs, also felt in a direction inwards from them. There was 
 no swelling or abdormal dulness elsewhere. The alvine discharges were pale, and the 
 urine tinged with bile. Leeches and small blisters were applied over the tender part. 
 Quinine combined with taraxacum and rhubarb or aloes was given, also alkalies and 
 diuretics ; but he benefited little by the treatment, and left the hospital on the 8th Sep- 
 tember, wnh the swelling unchanged. 
 
 187. Tlie gall-bladder, distended, reached to the umbilicus. — Gastritis. — Colon 
 contracted. — A negro cook, of fifty years of age, a native of the island of Cayenne, 
 resident for some years in France, and latterly in Jamaica, had suffered at different 
 times from illnesses, the nature of which he eoidd not clearly explain ; they seemed, 
 however, to have affected chiefly the abdominal viscera. This individual arrived in 
 Bombay about the middle of December 1835, and complained occasionally of irregular 
 action of the bowels, and the tongue was generally thickly coated. These complaints, 
 though relieved by the exhibition of mercurial purgatives, recurred towards the end 
 of December, and were attended with pain of the margin of the right false ribs, 
 relieved by leeches. From the 1st January to the 20th he suffered more or less from 
 irritability of stomach, irregular and torpid action of the bowels, frequently colicky 
 pain, but without distention or tenderness of the abdomen. The tongue was thickly 
 coated, the pulse was natural, the skin was scaly and dry, but of natural appearance. 
 Various purgatives with anti-spasmodics, anodynes, enemata, &c, were freely used. 
 On the 20th the matter vomited was dark-coloured and offensive ; there was tender- 
 ness roimd the umbilicus, and pressure there induced vomiting. From this time the 
 irritability of stomach became distressing ; vomiting was excited by speaking, and by 
 all ingesta ; the matters ejected were watery, foetid, and sometimes tinged with blood. 
 There was trifling pain of the epigastrium ; the pulse became rapid, and feeble, and 
 the skin morbidly hot ; there was subsultus tendinum and low delirium ; the abdomen 
 was collapsed, and the action of the bowels irregular ; and during the last days of life 
 there was occasional tenesmus. He died on the 28th of January. 
 
 Inspection five hours after death. — Abdomen. — The lower part of the thorax was 
 contracted, so that the liver and stomach were pushed more towards the umbilicus 
 than is natural. The gall-bladder was distended, and extended two inches beyond 
 the edge of the liver ; it passed over the hepatic flexure of the colon, and was opposed 
 to the right edge of the umbilicus ; the gall-ducts were natural. The stomach was 
 moderately distended, the mucous lining of the cardiac end was dotted red and 
 softened ; that of the body and pyloric end thickened, and presenting a mammillated 
 surface. The small intestine was empty, pale, and contracted. The large intestine 
 was throughout of small calibre, with frequent and considerable contractions, chiefly 
 in the transverse and descending portions ; but there was no thickening of the coats ; 
 the prevailing tint of the inner surface was dark grey, occasionally merging into 
 streaks of grey black, with here and there dark red patches. There was in places 
 softening of the mucous coat, and cicatrices of former ulcers were apparent, but the 
 i races ofthe most recent inflammatory action were in the sigmoid flexure of the colon, 
 and the commencement of the rectum. 
 
JAUNDICE. 433 
 
 Biliary calculi have seldom come under my notice in post 
 mortem examinations in India, and I cannot bring to my recollec- 
 tion above three or four cases of individuals suffering from the 
 symptoms characteristic of obstruction of the ducts from this 
 cause. 
 
 These results accord with Dr. Budd's experience in the Dread- 
 nought Hospital among men returned from India. But he justly 
 adds, and the remark applies in part to my own field of inquiry, 
 "It is, however, not fair to judge from these men, who were sailors 
 and had probably great immunity from gall-stones, on account 
 merely of their seafaring life." To this may be added that they 
 were also, for the most part, men at a period of life of acknow- 
 ledged little liability to this affection. 
 
 Dr. Budd states that gall-stones are common in the cancerous 
 diathesis. Judging from my own experience, as well as inquiry 
 from others, both cancerous degeneration and biliary calculi are 
 rare in India compared with other countries. 
 
 It may be, that the circumstance of my pathological investiga- 
 tions having been chiefly carried on among males, is another 
 reason why biliary calculi have not frequently come under my 
 notice. 
 
 If the proclivity of the female sex to the formation of gall-stones 
 be due to the sedentary life which they lead, the affection ought 
 to be common among those females in India who lead secluded 
 lives. My opportunities of witnessing disease in these classes in 
 Bombay have not been unfrequent, yet I cannot call to my recol- 
 lection a single case of jaundice or of other symptoms that could 
 be attributed to the passage of gall-stones. 
 
 The inference to be drawn from these remarks is, that there is 
 still room for further research on the formation of biliary calculi in 
 India. 
 
 Section V. — Jaundice. — Pathology.— Causes. — Treatment. 
 
 Though this symptom of hepatic disease has been, from its 
 prominent character, long familiar to medical men, we are still 
 imperfectly acquainted with its proximate causes. These, as at 
 present believed, ma) T be stated to be — 
 
 1. Obstruction of the hepatic or common duct by viscid mucus 
 or gall-stones, and by external pressure of enlarged lymphatic 
 glands, the head of the pancreas, gravid uterus, loaded colon, or 
 other mechanical influences of a similar nature. When obstruction 
 
 F F 
 
434 JAUNDICE. 
 
 has continued for some time, the hepatic cells become destroyed, 
 their place being taken by granular amorphous matter; and 
 the liver, losing its firmness, becomes soft, flaccid, and pulp} r . 
 When the obstruction has become permanent, death takes place 
 by a slow process of exhaustion and emaciation. Jaundice under 
 these circumstances is caused by re-absorption of bile. 
 
 2. Destruction of the hepatic cells, independent of obstruction 
 in the ducts. This is the yellow atrophy of Eokitansky. It is 
 characterised by reduced size and a flaccid, pulpy state of the 
 liver, with absence of the nucleated cells. It is attributed to causes 
 affecting the blood-mass as the poison of fever, of serpents, &c. 
 The course is sometimes rapid, attended with adynamic febrile 
 phenomena, delirium, and coma.* This state of the liver has been 
 treated of at some length by Dr. Budd, and he countenances 
 the idea that it may at times affect the organ partially, follow 
 a slower course, and terminate in recovery. The jaundice thus 
 arising is generally believed to be the consequence of suppressed 
 secretion. 
 
 3. Congestion is another proximate cause of jaundice, perhaps 
 partly by absorption, partly by suppression. 
 
 The notes of forty-five cases in which jaundice had been present 
 are before me : of these, twenty-seven have been already adverted 
 to as complicating remittent fever (p. 98) ; thirteen were entered 
 as simple jaundice, but from the attendant pyrexial symptoms 
 eight of them might have been more correctly classed with the 
 
 * This form of jaundice has also been fully considered by Frerichs in his " Klinik 
 der Leber Krankheiten." The greater prevalence of this severe and generally fatal 
 form, in females, is shown by facts referred to both by Budd and Frerichs. The 
 former alludes to eleven cases of which eight were females ; the latter to thirty-one 
 cases of which twenty-two were females. Frerichs further mentions that one half of 
 the twenty-two females were pregnant. 
 
 In twenty-eight of Frerichs' cases, death took place in the first week in 13 ; in the 
 second week in 6; in the third in 5, and in the fourth in 4. In twenty-three carefully 
 observed, the spleen was enlarged from congestion in 19, normal in 3, and small in 
 one. The ages of the thirty-one cases were — 
 
 6 . . . from 
 20 . 
 3 . 
 
 2 . 
 Of eleven cases referred to by Budd, the ages werc- 
 
 3 . 
 
 3 . 
 1 
 
 4 . 
 
 Of the four, between 10 and GO — two were males, and the third male was between 
 20 and 30. 
 
 10 to 
 
 20 
 
 20 „ 
 
 30 
 
 30 „ 
 
 40 
 
 40 „ 
 
 60 
 
 10 to 
 
 20 
 
 20 „ 
 
 30 
 
 30 „ 
 
 40 
 
 40 „ 
 
 60 
 
TAUTOLOGY. 435 
 
 twenty-seven febrile cases. The five remaining cases were of 
 hepatic abscess. Ten of the febrile cases * and the five of hepatic 
 abscess proved fatal. 
 
 My investigations do not support the opinion that obstruction 
 of the ducts by inflammation of their lining membrane is a common 
 cause of jaundice, for the traces of inflammation have not been 
 found in any of the fatal cases ; and it is fair to infer that this state 
 was not generally present in the successful ones, even though pain 
 at the right costal margin had been complained of. In only three 
 cases was there satisfactory evidence of mechanical obstruction of 
 the hepatic or common duct : the cause in two f was a lumbricus ; 
 in the third \, not fatal, it was possibly biliary calculus, and this 
 is my only case which can be fairly related to this obstructing 
 cause. In seven § there was enlargement of the lymphatic glands in 
 the course of the common duct, but it is very doubtful whether, in 
 these cases, it was sufficient to cause obstruction by pressure : at 
 all events, distention of the ducts behind was noticed in only one.|| 
 
 In six H of the fatal cases, inflammation of the mucous membrane 
 of the duodenum was observed, and it is reasonable to infer that it 
 may also have been present in a proportion of the recovered cases 
 characterised by tenderness at the margin of the right ribs. 
 
 I am unable to explain the relation which duodenitis bears to 
 jaundice. It may be that they are only coincident sequences of 
 one antecedent. As already stated, the usual theory of extension 
 of inflammation from the duodenum to the common duct is not 
 supported by my cases. May it be that from a protective sym- 
 pathy (if I may be allowed the expression), the bile is pre- 
 vented from coming in contact with the inflamed surface of the 
 duodenum ? 
 
 In none of my fatal cases was yellow atrophy of the liver 
 noticed. It is true that the microscope was used in only three 
 instances, but in the others the appearances of the organ, as 
 described, do not accord with those characteristic of this lesion. 
 It is moreover fair to infer that yellow atrophy was also absent 
 in all the recovered cases, though in some of them drowsiness and 
 tendency to coma had been well marked 
 
 The opinion entertained by Dr. Budd, that some cases of jaun- 
 dice may be accounted for on the supposition of the existence of a 
 partial yellow atrophy, and that of recovered cases some may be 
 of this nature, does not seem to me very probable ; because, 1. The 
 
 * Cases 36—45. f 38, 137. $ 186. § 36—39, 42, 44, 173. || 36. 
 
 If 36, 37, 40, 42, 43, 45. 
 
 F F 2 
 
436 JAUNDICE. 
 
 suspended function of only portions of the liver is generally 
 insufficient to occasion jaundice, as is proved by the rarity of its 
 occurrence in hepatitis. 2. A general blood-cause is not likely to 
 operate partially. 3. As regards the recovered cases the inference, 
 from a review of the whole subject, is against the supposition. 
 
 Such, then, are my reasons for concluding that there is still 
 room for further careful investigation of the proximate causes of 
 jaundice, and that much which has been written on the subject is 
 merely hypothetical.* 
 
 The exciting and predisposing causes of jaundice are also a 
 subject of much interest. Three of my cases occurred in the 
 guards of an opium convoy, proceeding from Marwar to Bombay, 
 exposed to fatigue and to elevated temperature. They are a class 
 of people frequently addicted to the habitual use of opium. 
 
 * The precise constituents of the bile, — whether only the pigment, or the acids 
 also, — present in the blood and urine in jaundice, are not yet determined. lam 
 indebted to Dr. Parkes for the following statement on the present state of this question 
 as regards the urine. 
 
 " The changes in opinion respecting the presence or absence of the bile acids in 
 icteric urine have been considerable, and even now the subject is very obscure. 
 
 " Before the experiments of Strecker had elucidated the composition of the bile, 
 Thenard and Orfila believed they had found the so-called ' resinous bodies ' in the 
 urine. Subsequently, however, it seemed to be acknowledged that though the bile 
 acids could be sometimes found, this was uncommon, and that they were generally 
 absent- in the urine of icterus (Lehmann ; Gorup-Besanez; Scherer). It has been 
 therefore surmised either that these acids are destroyed in the system or that in icterus 
 the liver ceases to form them, although it continues to produce pigment. Frerichs 
 and Staedeler («) however advanced a most remarkable hypothesis, viz. that in jaun- 
 dice the bile acids are converted into bile pigment. Into their reasons for advocating 
 such a conversion it is not necessary now to enter, as they do not seem to have won 
 many adherents. The fact on which their hypothesis was based (viz. the deficiency 
 of bile acids, and the presence of bile pigment in the icteric urine), has been disputed 
 by Kuhne (b), who by the employment of another method believes he has succeeded 
 in proving that bile acids, or rather their derivatives (choloidinic acidi or dyslisin?) 
 can really be found in the urine. If Kuhne's experiments can be relied upon, 
 they would imply that the formation of glycin (and perhaps of taurin) in the liver 
 is impeded in jaundice, but that chobc acid is still formed, and that there is no 
 conversion of bile acid into pigment. Kuhne believes he has shown that benzoic arid 
 does not form hippurie acid in cases of jaundice, owing, he presumes, to the absence 
 of glycin. 
 
 "Still more lately, Folwarczny (c) has repeated Kuhne's experiments, and does not 
 confirm them. In four cases of jaundice he examined the urine in the same manner 
 as Kuhne, and found no bile acid. He also gave benzoic acid and found hippurie 
 acid in the urine, as in health. The question is then yet doubtful and a stricter 
 investigation is still required. - ' 
 
 (a.) Midler's Archiv. 18.56, p. 55. 
 
 (&.) Vjrchow's Archiv. fur Path. Anat. x. p. 310. 
 
 (<?.) Wien Zeitsehrift : 185*9. Neue Folge ii. p. 15. 
 
rATHOLOGY. 437 
 
 Fatigue, heat, opium-eating, — are these common predisposing 
 or exciting causes of jaundice? 
 
 The Bombay Fusileer Eegiment, after many months' active ser- 
 vice in the field, which terminated with the dispersion of Shere 
 Sing's army, were encamped, at the end of March 1849, in front 
 of the Khybur Hills, near Jumrood. They remained under canvas 
 till the 7th of May. The ground was badly selected, being partly 
 on the banks and partly in the bed of a mountain torrent which 
 divided the hospital from the rest of the Hues, and which, on more 
 than one occasion, nearly swamped the whole of the sick and com- 
 pletely cut off all access to them. The tents were crowded one 
 upon another, and the place soon became filthy in the extreme, 
 and very offensive. The slime deposited by each subsiding flood, 
 and the dead, putrid, and unburied camels, deposited all around, 
 produced the most offensive odours and a plague of flies, which 
 effectually prevented rest of any kind or anywhere from sunrise to 
 sunset, or the enjoyment of a single meal. Fortunately during 
 this time the weather had not been very hot. Dr. Arnott, from 
 whose interesting report * of the Fusileer Regiment this description 
 is taken, thus continues : — 
 
 " The effects on the men of change from the active, regular and excited life of 
 a campaign, to the sedentary, inactive life and looser habits of a standing camp, 
 soon became apparent in their diminished relish for their meals, their predisposition 
 to indigestion, jaundice, and in the prevalence of nausea and vomiting after meals, 
 which, during the time we lay at Jumrood, affected nearly every man and officer of 
 our regiment, and, indeed, I bebeve almost every man of the force. The complaint, 
 for complaint it was, and a very annoying one too, though not dangerous, I admit, I 
 could not account for in a manner satisfactory to myself. The natives, as they always 
 do, attributed it to swallowing flies, and some became converts to this opinion ; they 
 no doubt did sod and corrupt every article of diet or whatever else was left for the 
 shortest period exposed ; and if anything could give one an idea of the third plague 
 inflicted on the land of Egypt in days of old, it was here reabsed in perfection. Many 
 attributed the complaint to the presence of antimony in the water, as it is found in the 
 hills from which the streams issue, but none covdd be detected in it ; and I considered 
 that the real cause lay in the new life and habits we had entered upon. The disease 
 was characterised by no peculiar symptoms besides those mentioned. There was 
 nausea most frequently in the middle of, or immediately after, a meal, suddenly fol- 
 lowed by vomiting, till the whole contents of the stomach were ejected ; and the 
 feeling of nausea continued for some time afterwards, but gradually subsided, very 
 probably to return again, however, at the following meal. 
 
 "In the matter ejected there was seldom anything either bilious or acid, and the 
 bowels were in a natural state, or perhaps rather confined. This state of things might 
 occur once, or might recur frequently, and then the men woidd apply at the hospital for 
 an emetic or a dose of physic, but seldom to be admitted. From not being able to retain 
 anything on the stomach, and consequently from want of due sustenance, the men felt 
 languid and low-spirited, but no other permanently bad effects resulted from it ; and 
 
 * " Transactions, Bombay Medical and Physical Society," 1st Series, No. 10, p. 28. 
 
438 JAUNDICE. 
 
 after we moved back towards Peshawur, on the 7th May, there was scarcely a case 
 of it. 
 
 "Icterus. — Subsequently to this disease, and, as it appeared to me, proceeding from 
 the same causes, cases of jaundice became very frequent, amounting in the nine months 
 we lay at Peshawur to no fewer than thirty-four admissions against two in the corre- 
 sponding period of the previous year. They were characterised by the usual appearances 
 of yellowness of the skin and eyes, high-coloured urine, obstipation, and clay-coloured 
 stools, want of appetite, languor, &c. An emetic was abnost uniformly given on 
 admission; cathartics dady, and most frequently mercury was given to ptyalism. 
 Under this treatment they all did well, though occasionally a considerable degree of 
 debility remained for some time afterwards, which was treated with aperient bitters, 
 alkaline medicines, tonics, and mild nutrient diet." 
 
 The European troops employed in the expedition to the Persian 
 Gulf, in 1857, suffered, at Mohamarah and Bushire, in the month 
 of April, from nausea and vomiting, just as the Fusileers did at 
 Jumrood. The 14th Dragoons returned from Persia to Kirkee 
 towards the end of May, and in the month of June ten cases of 
 jaundice were admitted into hospital. Of the men selected 
 as healthy in the first week of June to accompany a force to 
 Aunmgabad, four became affected with jauudice. The disease 
 yielded readily to treatment. 
 
 Treatment. — The uncertain state of the pathology of jaundice 
 necessarily affects the treatment. 
 
 A preliminary question before commencing the treatment of 
 jaundice, is, whether we have to do with a liver previously 
 healthy, or affected with congestion, cirrhosis, or other organic 
 change. 
 
 Whenever tenderness at the margin of the ribs is present, we 
 may infer the existence of congestion of the liver, or inflammation 
 of the duodenum or adjacent structures, and conclude that these 
 conditions are related, in some way or other, to the jaundice ; anil 
 that their removal by leeches and counter-irritation ought to be a 
 leading indication of cure. 
 
 To increase excretion from the intestinal surface is also an object 
 to be held in view, and it may be effected by such means as aloes, 
 rhubarb, and saline cathartics ; used, however, with caution, in 
 order that inflammation of the duodenum, or adjacent structures, 
 when present, may not be increased, and that in cachectic 
 individuals dysenteric symptoms may not be excited. 
 
 The expediency of the cholagogue action of mercury is an 
 important question in the treatment, and from the obscurity which 
 involves the proximate cause of jaundice, it is often difficult to 
 determine. If the existence of a mechanical obstructing cause be 
 suspected, then to stimulate the secreting action of the liver must 
 
TREATMENT. 439 
 
 be injurious. If there be a general destruction of the hepatic 
 cells, is mercury likely to reconstruct them ? If we accept the 
 theory of a partial cell destruction, then will mercury, if given, 
 not rather affect the healthy cells and leave the destroyed ones 
 uninfluenced ? 
 
 These are perplexing questions, and all that we can do in prac- 
 tice is to follow those principles which under the circumstances 
 seem to be most reasonable. So long as symptoms of gastro-enteric 
 inflammation are present we must use mercurials very cautiously, 
 and trust chiefly to local depletion and counter-irritation, the 
 combination of taraxacum with alkalies and ipecacuanha, and 
 mild saline purgatives, as the potassio-tartrate of soda. 
 
 When the inflammatory symptoms have been removed, and the 
 jaundice persists unchanged, or when evidences of inflammation 
 have not been present, and the constitution is not much impaired, 
 then two or three grains of calomel, or of blue-pill, or chalk and 
 mercury, may be occasionally combined with aloes or rhubarb. 
 
 To give large doses of calomel forms no part of the treat- 
 ment of jaundice, unless we except the early stages of occa- 
 sional cases in plethoric Europeans, in whom there is good reason 
 for suspecting a congested and stagnant condition of the portal 
 circulation. t 
 
 The error, to which I have already on several occasions alluded, 
 of confounding the cholagogue action with the constitutional 
 effect of mercury, has been frequently committed in the treat- 
 ment of jaundice. The induction of mercurial influence in this 
 disease is unsupported by any rational argument with which I am 
 acquainted. 
 
 When that state of constitution in which, on general principles, 
 we abstain from the use of mercurial remedies, co-exists with 
 jaundice, we may use some of the other milder means which are 
 believed to exercise a similar action on the liver, as taraxacum, 
 alkalies, kydrochlorate of ammonia, nitric acid internally, and 
 nitro-muriatic acid externally. 
 
 It should be further remembered, as previously stated in refer- 
 ence to jaundice complicating remittent fever, that saline diuretics 
 are often given with great advantage ; and, as a rule of practice in 
 this disease, it should also be recollected that time is required for 
 the removal of the bile from the blood, and that we may err by too 
 great haste or too active interference. 
 
 H4 
 
440 BILIOUS DIAEIUICEA AND CHOLERA. 
 
 Section VI. — On Increased and Defective Secretion of Bile. 
 
 Increased Secretion. — That bilious diarrhoea and cholera may 
 attack Europeans not long resident in India, after injudicious 
 exposure and excesses in eating and drinking, is true, but that they 
 are common affections under any other circumstances is not 
 confirmed by experience.* 
 
 Excess of biliary secretion is a rare disorder in the European 
 who lives with ordinary prudence in India, and in the native it is 
 hardly ever observed. The chief importance of bilious cholera is 
 the risk of confounding it with epidemic cholera. The diagnosis 
 of the two affections has been stated in general terms at p. 213. 
 The mistake is not likely to occur to a careful inquirer. The 
 pathology of bilious cholera is very simple. From excess of the 
 constituents of bile in the blood, and active determination of blood 
 in the portal capillaries, an undue quantity of bile is secreted, and 
 as a necessary consequence is speedily ejected. 
 
 The leading indication of treatment is to palliate the discomfort 
 by diluents, to allay the vomiting by effervescing draughts, with a 
 few minims of tincture of opium, and the external use of sinapisms, 
 and to watch for symptoms of prostration, and then give opium 
 more freely, as well as stimulants. After the primary symptoms 
 have ceased, gastro-enteritis may follow, and require to be treated 
 on ordinary principles, by leeches, alkalies, ipecacuanha, opium, and 
 perhaps mild mercurials. 
 
 The question whether, at the commencement, the discharge of 
 bile ought to be increased or not by the cholagogue action of 
 mercury, will arise. If the subject be a robust European, if the 
 tongue be much coated, and there is tendency to jaundice, or un- 
 easiness of the hepatic region, with signs of enlargement of the 
 liver, then it will be of advantage to give ten grains of calomel 
 with a grain of opium, to be repeated or not, according to cir- 
 cumstances ; and the effervescing draught may be made slightly 
 aperient by the addition of small doses of the potassio-tartrate of 
 soda, or other saline cathartic. 
 
 '■• Subsequently to the expression of this opinion, the following statement of Dr. 
 Marshal] came under my notice: — 
 
 " It may be observed, that the cholera morbus of the systematic writers, a complaint 
 which is supposed t<> arise from an inordinate secretion of bile, very rarely occurs in 
 Ceylon, either among European residents or the indigenous inhabitants.*' — Notes on the 
 Medical Topography and prevailing Diseases of Ceylon, p. 115, by Henry Marshall, 
 Staff-Surgeon to the Forces. 
 
DEFECT OF BILE. 441 
 
 Defect of biliary secretion, characterised by clay-coloured alvine 
 discharges, — a state to which the name torpor of the liver has been 
 given, — is sufficiently common in India. 
 
 Torpor of the liver is an unsuitable term, for it expresses a 
 pathological theory which is probably erroneous, and suggests a 
 system of treatment which is often injurious. 
 
 The symptoms are white-coloured alvine discharges, often formed 
 and not passed with more than usual frequency, a sense of languor, 
 depression and anorexia, and a pale but little coated, tongue, 
 without jaundice. This derangement occurs for the most part in 
 adults, cachectic and anaemic from malarious influence, prolonged 
 exposure to elevated temperature, abuse of mercurial or other 
 depressant remedies. Mental anxiety is in these states of con- 
 stitution sometimes the exciting cause. Anaemic children are 
 also liable to this affection, and in Bombay it is observed in them 
 more towards the close of the hot season than at any other period 
 of the year. 
 
 That this condition proceeds from torpor of the liver is an im- 
 probable theory. There is absence of bile in the intestinal canal, 
 but also absence of it in the blood (jaundice). The just inference 
 from these facts, is, not that the liver, specially, is inactive, but that 
 the metamorphosis of waste tissue into the excreta of bile is not 
 duly carried on in the blood. All the attendant phenomena point 
 to languid general assimilation and excretion, and the leading 
 indication of cure is, not to stimulate the liver by cholagogue re- 
 medies, but to lessen the cachectic state by appropriate regimen and 
 tonics. 
 
 While holding these opinions on the pathology of this affection*, 
 I would caution against neglect in inquiring into the state of the 
 liver ; for a pre-existing defect of the organ, congestive or organic, 
 will necessarily favour a more early development of the symptoms, 
 and when existing ought to receive due consideration in the treat- 
 ment. 
 
 We shall best treat this derangement by a suitable adjustment 
 of diet, of which animal food should form a part. In two cases 
 the use of strong coffee two or three times in the day, seemed to be 
 beneficial, and in one it restored the secretions to a healthy state, 
 
 * Ansemic European children, sent at the close of the hot season of Bombay to 
 Poona at the commencement of the rains, or to Mahubuleshwur at the end of October, 
 are very apt, unless there be great attention to the temperature and action of the skin, 
 to be affected with clay-coloured alvine discharges. Under these circumstances the 
 presence of some degree of congestion of the liver is a probable event, and should 
 always be looked for. 
 
442 DEFECT OF BILE. 
 
 after various preparations of taraxacum had been freely used and 
 failed. It is worthy of further trial, but the coffee must be 
 genuine and fresh. Should observation confirm this impression, the 
 result will probably be explained on Liebig's theory of the identity 
 of caffeine and the principle of bile. Along with appropriate 
 regimen, such remedies as quinine, bitter infusions, iron in small 
 doses, or dilute nitric acid should be used. Change to a more 
 temperate climate will be of benefit, but considerable and sudden 
 reductions of temperature should be avoided. Under all cir- 
 cumstances external cold or damp must be guarded against by 
 suitable clothing. 
 
 If deficiency of bile be truly related to anaemic or cachectic 
 states, then it may be predicted that under a rational sanitary sys- 
 tem and better therapeutic principles, it will cease to be familiar, 
 as now, to the practitioner in India. 
 
 Though the use of cholagogue remedies has not been distinctly 
 admitted, yet reflection will suggest that the milder members of 
 the class may occasionally be beneficial. It is reasonable to sup- 
 pose that even with an improving condition of the blood, the 
 hepatic cells, in consequence of suspension of function, may evince 
 a want of readiness in assuming it again, and that special remedies 
 may be useful under these circumstances. Whether this theory be 
 just or not, still I believe that the inference drawn from it is prac- 
 tically correct, viz., that though any but the most guarded use 
 of mercurials is sure to be injurious, we may always look for 
 benefit from such means as taraxacum, coffee, and the external 
 application of diluted nitro-muriatic acid by sponging or stupes. 
 
 Children with deficiency of biliary secretion are very predisposed 
 to dysentery ; but in this fact there is probably nothing more than 
 an illustration of the general predisposing influence of anaemic and 
 cachectic states. 
 
443 
 
 CHAP. XVII. 
 
 ON PERITONITIS, ILEUS AND COLIC. 
 
 Section T. — Peritonitis. — Pathology. — Plastic and sero-puri- 
 form Exudations related to Diathesis. — Chronic Tubercular. — 
 Chronic not Tubercular, and not Consecutive on Acute. — 
 Treatment. 
 
 In the chapters on Dysentery and Hepatitis it Las been shown that 
 acute general peritonitis, secondary on the advanced stage of 
 dysentery, or the formation of hepatic abscess — but independent 
 of perforation or rupture, — is not an uncommon event in the 
 course of those diseases in India, and is, in all probability, favoured 
 by constitutional states. A secondary partial protective peritonitis 
 is likewise not unfrequent. 
 
 But acute idiopathic general peritonitis in a sthenic diathesis, 
 independent of traumatic causes, is a rare form of disease in India, 
 as in other countries. In the notes of my own practice there is 
 not a single illustrative case. On examining my memoranda of 
 fatal cases of sick officers, I find seven of peritonitis, which is in 
 the ratio of 2-25 per cent, of the deaths from all causes. But of 
 these seven there are only three which can be regarded as idio- 
 pathic and sthenic. Two of them occurred in officers consequent 
 on exposure to cold after fatigue in the heat of the day. The 
 third was caused by excesses in eating. 
 
 It is of interest to note carefully all fatal cases of traumatic 
 general peritonitis, for they may demonstrate the morbid changes 
 which result from this inflammation in persons of good diathesis, 
 and afford more precise knowledge than we can otherwise obtain, 
 of the length of time requisite for their development. Much in- 
 terest also attaches to those slighter wounds, which though pene- 
 trating the abdomen — as proved by slight visceral protrusion — 
 and followed by distinct peritonitis, are amenable to judicious 
 
444 peritonitis. 
 
 treatment. They are so, because the tendency of inflammation 
 uuder circumstances of moderate injury and good diathesis is not 
 to extend, but to be restricted to the neighbourhood of the wound, 
 and to yield to the repeated use of leeches, opium, warm water 
 stupes, and complete repose: I have seen several cases which 
 illustrate the truth of this observation. Three fatal cases of 
 traumatic peritonitis* are subjoined : — 
 
 188. General peritonitis from a penetrating wound of the liver. — Considerable 
 effusion of serum in the head without symptoms. — James Harrison, aged twenty-eight, 
 born in India, tall, and of moderate strength, was admitted into the European General 
 Hospital on the night of the 22nd October, 1838. He stated that, whilst in a state of 
 intoxication, he had stabbed himself.* On the left side of the epigastrium there was a 
 wound about an inch long, filled with charcoal and oil, but apparently not deeper than 
 the muscles. It was attended with considerable tenderness of the abdomen. Twenty 
 ounces of blood were taken from the arm, and a purgative enema was exhibited. On the 
 morning of the 24th he still complained of general tenderness of the abdomen, attended 
 with considerable fulness. The pulse was 120 and compressible; the tongue was 
 covered with a thin yellow fur ; there was present a short cough, from which he had 
 suffered for some days previously ; there was, however, neither vomiting nor difficulty 
 in micturition. One hundred leeches were applied to the abdomen, and in the evening, 
 the symptoms, having somewhat increased, twelve ounces of blood were taken from 
 the arm, and seventy-two leeches were repeated to the abdomen ; the warm bath was 
 directed to be used, and pills of calomel and opium to be given at bed-time. On the 
 25th he was considerably relieved ; but on the evening of the 26th the symptoms of 
 peritonitic inflammation were again on the increase ; a large blister was applied to the 
 abdomen, and a turpentine enema exhibited. On the 27th the pulse was 120 and 
 feeble, the countenance anxious, and there was occasional vomiting. An attempt was 
 made to induce the action of mercury on the system by inunction, and the internal 
 exhibition of calomel and opium. The pain was never very acute, but the symptoms 
 progressed, and he died at 10 p.m. of the 28th. 
 
 Inspection nine hours after death. — Body stout; abdomen distended. — Abdomen. 
 On tracing the wound, it was found to penetrate transversely the lower edge of the 
 sixth rib on the left, side also, the entire of the cartilage of the seventh rib, about a 
 quarter of an inch from its junction with the other cartilages. The wound passed 
 through the diaphragm and through the left lobe of the liver, and was about half an 
 inch in its long diameter. The intestines adhered to the abdominal parietes, and the 
 convolutions to each other ; and among the adhesions there was much extravasation 
 of dark bloody serum. In the pelvis, between the rectum and bladder, and in the 
 right iliac region, there was much dark coagulated blood. All the intestines were dis- 
 tended with air; but, with the exception of the lymph effused on the peritoneal 
 surface they were healthy. The liver was pale coloured. The mucous coat of the 
 stomach was thickened, but otherwise healthy. Chest. — The lungs were emphyse- 
 matous. In the lower lateral part of the left side of the chest there were flakes of 
 lymph effused on the costal pleura, and blood extravasated in small quantity under- 
 neath the pleura of the diaphragm. Head. — There was considerable effusion of 
 serum between the pin mater and arachnoid membrane, and at the base of the skull; 
 also considerable venous congestion of the posterior lobes of the brain. 
 
 189. Fracture of both thigh hones. — Abdomen bruised. — Death in fifty-f'Ur 
 hours from peritonitis. — General redness and effusion of lymph on the peritoneal sur- 
 
 * The knife was shown to me on the following morning ; it was a blunt, somewhat 
 rusty, worn, table carving knife. 
 
TRAUMATIC. 445 
 
 faces. — A pint of turhid serum in the cavity. — John Birch, aged twenty-two, of the 
 ship Cornea was brought to the General Hospital at 4^- p.m. of the 5th March, 
 1842. It was stated that he had just fallen from the yard-arm of the ship on deck ; 
 both thigh bones were fractured about the middle of the shaft ; the abdomen was 
 bruised and tender to the touch; and the breathing was oppressed and attended with 
 sense of sinking. He passed an indifferent night, and on the morning of the 7th the 
 tenderness and tension of abdomen had increased, and the pidse was feeble. Fomen- 
 tations and enemata were used. Towards evening the tension of the abdomen had in- 
 creased, and there was pain of left side complained of, with oppressed breathing. 
 Pulse small, 120. He died at 10 p.m. 
 
 Inspection twelve, hours after death. — Purple sugillations on the posterior part of 
 the trunk. The abdomen distended. Chest. — The right lung adhered firmly to the 
 costal pleura. In the left sac of the pleura about six ounces of red-coloured serum 
 were effused. The lungs and the heart were healthy. Abdomen. — The intestines 
 were distended with air. The external surface of all the intestines was of a brown red 
 colour. The omentum was matted over the intestines, and adhered to them by bands 
 of friable lymph, and similar adhesions existed between their convolutions. In the 
 cavity of the abdomen there was about a pint of brown turbid serum effused. The 
 liver and spleen were healthy. The mucous coat of the stomach was healthy. 
 
 190. Wound of the abdomen with protrusion of intestine. — Vascularity of, and 
 lymph-exudation on the peritoneum and the protruded intestine. — A man was brought 
 to the Native General Hospital at 9 a.m. of the 24th February, 1845, with a consider- 
 able portion of the small intestine, and a part of the attached mesentery, protruding 
 from a wound between the umbilicus and margin of the right ribs, to the right of the 
 mesial line. It had been inflicted by himself about three hours before. The intestine 
 was of a bright red colour. The wound was small, and it was enlarged with the view 
 of reducing the intestine. But, in consequence of the opposition and struggles of the 
 individual, reduction coidd not be effected. The following morning, at 7 a.m., the 
 protruded intestine, now consisting of several convolutions, was covered with a toler- 
 ably thick layer of friable red-eokrared lymph, which united the protruded convolutions 
 to each other. 
 
 Remark. — Thus, assuming the intestine to have been healthy before, we find active 
 vascularity in the course of three hours after protrusion, followed bj- effusion of a layer 
 of lymph in twenty-four hours — a process, however, which must have commenced 
 many hours earlier. I do not find the date of death in my notes, which were made 
 merely to record the periods of vascularity and exudation. 
 
 When attention is turned from peritonitis in individuals of good 
 constitution, characterised by exudation of plastic Lymph, to that 
 form in which puriform or sero-puriform effusion predominates, 
 we shall always find this difference of result attributable to con- 
 ditions of diathesis. 
 
 In the first of the three cases * about to be narrated, the special 
 character of the cachexia does not appear, — the patient is merely 
 stated to have been long ill. The second is related to parturition ; 
 and the third is a case of circumscribed purulent effusion, probably 
 due to cachexia from intemperance. These, however, form but a 
 small portion of the cases of this nature which, at different times, 
 have come under my observation. There is reason for believing 
 that among the cachectic natives received into general hospitals 
 
 * Cases 191 to 193. 
 
446 PERITONITIS. 
 
 in India, death is not unfrequently hastened by the access of aplas- 
 tic peritonitis, overlooked during life in consequence of the latency 
 of the symptoms. I have more than once seen patients, under 
 these circumstances, sink with cooling skin, collapsing features, 
 thready pulse, and no suspicion of peritonitis; yet examination 
 after death has proved its existence. When, in cachetic states, 
 unexpected prostration, unexplained by discharges, comes on, we 
 shall do well to direct our attention to the peritoneum. 
 
 191. Peritonitis. — Purulent effusion into the cavity of the abdomen. — Lymph general 
 on the peritoneal surfaces. — Robert Piper, aged sixteen, seaman, ship Oriental, after 
 having been unwell for a long time, chiefly with recurring constipation of the bowels, 
 was admitted into the General Hospital on the 9th August, 1842. The abdomen was 
 uneasy on pressure, but quite supple. Till the 16th he continued complaining of oc- 
 casional pain of abdomen, and had generally an evening accession of fever. Leeches 
 were applied two or three times ; the bowels were kept open with laxatives, and an 
 attempt was made to control the febrile accessions by the exhibition of quinine. On 
 the 17th, the tenderness of abdomen was increased, aud the pulse rose to 120, and 
 was irritable. On the 19th, to the pain was added fulness and tenderness of abdomen, 
 which had considerably increased by the 21st with occasional vomiting; and pyrexia! 
 symptoms were generally present. Leeches were again had recourse to, followed by 
 blisters, and an attempt was made to induce the constitutional effect of mercury. On 
 the 28th, wandering delirium commenced. The other symptoms persisted with in- 
 creasing failure of strength, and he died on the 2nd September. 
 
 Inspection fifteen hours after death. — Body emaciated. Abdomen distended. In 
 the abdomen there was about a pint of pus ; and the interior surface of the parietes, 
 the omentum, and the external surface of the small intestine were more or less coated 
 with a thin layer of lymph. The body was not further examined. 
 
 192. Peritonitis after parturition, but probably caused by blows. — Mary Anne, a 
 native Christian, of twenty-three years of age, was admitted into hospital, on the 26th 
 November, 1848. She stated that she had been affected with diarrhoea for about a 
 month. That three days before admission she had given birth to a child which had 
 died : that two and a half hours before admission she had been kicked on the chest 
 and abdomen. There was tenderness of the abdomen about the umbilicus, the ex- 
 tremities were cold, the pulse 120 and thready, the countenance collapsed. She was 
 treated with ammoniated stimulants and opium, sinapisms and fomentations. She 
 continued in the sunken state as on admission, with frequent vomiting and little 
 vaginal discharge, and died on the 28th. 
 
 Inspection seventeen hours after death. — The abdomen was considerably distended : 
 there were no marks of bruises on the external surface. There was general redness, 
 with Ivmph effusion on the peritoneal surface of the small intestine, the omentum was 
 matted to the fundus of the uterus, and there was about a pint of purulent effusion in 
 the pelvis. The uterus, upwards of six inches long and four wide, rose like a flaccid 
 bag above the pubes, inebned to and occupied the right iliac fossa. There was lymph 
 on its peritoneal surface, but no redness or purulent infiltration of its structure. The 
 inner surface as well as upper part of the vagina was lined with grey and black 
 pultaceous adhesive matter with gangrenous fcetor, and the lining membrane when 
 exposed by removal of the adherent exudation presented a red colour. The mucous 
 membrane of the colon showed numerous circular ulcers. 
 
 193. Partial peritonitis l< ad 7 ng to formation of a large circumscribed purulent sac. — 
 Dewjee Gunnoo, a Hindoo horse-keeper, of twenty-five years of age, using spirits oc- 
 
TUBERCULAR. 447 
 
 casionally, was, after two months' illness, admitted into the clinical ward, on the 18th 
 August, 1851. He was a good deal reduced. The countenance was anxious, and the 
 respiration thoracic. A large, prominent, distinctly circumscribed, somewhat elastic, 
 and obscurely fluctuating swelling occupied the abdomen. It extended from the ensi- 
 fonn cartilage almost to the pubes. It engaged more of the right than of the left side 
 of the abdomen. The right boundary was a vertical line dropped from the ninth rib, 
 but the left a line passing obliquely from the seventh rib to the left of the umbilicus, 
 and reaching the right iliac fossa. The swelling was dull throughout on percussion, it 
 was tender on pressure, and pain was increased by decubitus on the left side. No 
 abnormal chest signs. The pulse was small, the bowels were regular. He stated that, 
 two months before, he had noticed a small swelling below the margin of the right ribs 
 unattended by paiu, that twenty-five days before admission this swelling, subsequent 
 to the action of a purgative, had disappeared, but it reappeared after eight or nine 
 days, and was situated more in the direction of the umbilicus, and since had gradu- 
 ally increased to its present size. He further added that he attributed his complaint 
 to pressure made by some friends, a month before admission, for the purpose of re- 
 lieving pain that existed there. He was under treatment till the 3rd September, when 
 he died. During his stay in hospital there were irregular febrile exacerbations, with 
 night sweats, and the swelling increased in size, and became more tense, and promi- 
 nent, and painful. His friends would not permit a post mortem examination, but 
 they did not object to the introduction of a trocar and canula, which were inserted a 
 little above, and an inch and a half to the right of the umbilicus. On removing the 
 trocar about half an ounce of reddish-coloured fluid escaped through the canula, and 
 on making a good deal of pressure on the tumour, aboxit eight ounces of flaky pus, 
 mixed with coagula of dark-looking blood, were slowly drawn off. It was necessary, 
 frequently, to clear out the canida, as it became stopped up with the flakes of pus. The 
 tumour, after the removal of the pus, had not diminished much in size, but had be- 
 come much softer. 
 
 Remark. — Many years ago I saw a case similar to this, both in situation and size, 
 in an old Hindoo tailor, in company with Dr. Bird. At the urgent entreaty of the 
 patient the fluid, of dark -red colour, was drawn off by a small trocar. The operation 
 perhaps rather hurried the fatal issue. 
 
 Chronic Tubercular Peritonitis is an interesting and well-under- 
 stood form of disease. I find among my cases four * of tubercular 
 peritonitis. Two in Europeans, with tubercular deposit in the 
 lungs, and two in natives without this complication. In one of the 
 Europeans f the intestines were firmly adherent to each other, 
 and tubercular deposit was intermixed with the organised tissue. 
 In the second European \ the tubercles were miliary and semi- 
 transparent, without adhesions, and with very little serous effusion. 
 The appearance presented in this case by the tubercles on the 
 diaphragmatic peritoneum of the right side was of interest ; they 
 were compressed by the liver into flattened patches, instead of 
 standing in granular relief as elsewhere. I do not find this effect 
 of pressure mentioned by any author, and yet some, Dr. West for 
 example, particularly allude to the diaphragm and the surface of 
 the liver as common seats of granular tubercular formation. 
 
 * Cases 194 to 197. t 194. [ 195. 
 
448 PEBITONITIS. 
 
 In both natives there was abundant serous effusion, and the 
 disease had been considered to be ascites. In one * the effusion 
 disappeared consequent on an attack of cholera. In my re- 
 marks annexed to this case, attention has been called to the evi- 
 dence which it affords that the peritoneum, studded with tubercles, 
 is still fitted for absorption ; and to the fact, that the supply of 
 fluid derived from a peritonitic and pleuritic effusion delayed the 
 fatal result. 
 
 In the other native f case there is a feature of diagnostic import- 
 ance. The diagnosis of peritonitic effusion from ovarian dropsy, 
 by percussion, is now well understood: that in the former, we 
 generally have clearness of the uppermost surface of the swelling ; 
 in the latter, dulness all over. 
 
 Dr. Watson directs attention to two exceptional conditions which 
 in peritoneal effusion may occasion dulness throughout as in ova- 
 rian dropsy. 1. When the distention is so great as not to ad- 
 mit of the floating intestines reaching the surface of the fluid. 
 2. When the intestines are fixed down by adhesions. Case 196 
 points to a third cause, viz., a contracted state of the intestinal 
 canal in an asthenic person who, for some time previously, had 
 used very little food. This explanation, suggested to my mind 
 before death, was confirmed by dissection. The uniform character 
 of the swelling and the history forbad the belief in ovarian dropsy. 
 
 194. General peritonitis. — The lungs studded with crude tubercles. — The mesenteric 
 glands tuberculatcd. — The end of the ileum, the caecum, and colon ulcerated. — Consider- 
 able (fusion in the head. — Daniel Rumbell, aged twenty-two, of slight habit, a marine 
 on board Her Majesty's sloop Cruizer, was admitted into the European General Hos- 
 pital on the 19th December, 1838. During the six previous months he had suffered 
 from frequent attacks of catarrh excited by slight exposure to cold, and latterly at- 
 tended with cedematous swelling of the feet. His general health had also become much 
 impaired. He was debilitated and emaciated, and complained of pain at the epigas- 
 trium, and across the lower part of the chest, also of dyspnoea and dry cough. The 
 pulse was generally frequent, and there were profuse nocturnal sweats. On admission 
 into hospital pain across the epigastrium, increased by pressure and full inspiration, 
 was complained of; the tongue was florid but not furred ; there was thirst, but no 
 vomiting. He complained of occasional dry cough, and the pulse was 96, of good strength. 
 During the thirteen first days of his residence in hospital, attention was chiefly directed to 
 the abdomen, which was moderately distended and tense, with, on one or two occa- 
 sions, an obscure sense of fluctuation. There was also generally tenderness on pn 
 bnl al no time acute. The tongue was usually florid, and every evening there was a 
 distinct febrile exacerbation. The abdomen was leeched and blistered, and on one 
 occasion ten ounces of blood were taken from the arm. Small doses of calomel and 
 opium were given, but the mouth did not become affected. On the 2nd of January, 
 tea and uneasiness across the chest were complained of, and sibilous and sub- 
 crepitous rales were audible on the anterior part. The feet became cedematous, and 
 
 * Case 197. t 196. 
 
TUBERCULAR. 
 
 449 
 
 the pulse increased in frequency and lost in strength. A blister was applied to the 
 chest with relief; two grains of pulv. scillee, in combination with a grain of calomel, 
 half a grain of ipecacuanha, and a similar quantity of opium, were given thrice daily. 
 The urine was examined, but found not coagulable. On the 4th of January there was 
 diarrhoea for the first time during his stay in hospital, it recurred from time to time ; 
 the evening febrile exacerbations persisted ; the pulse became feebler ; emaciation 
 increased, and he died on the 15th. The pectoral symptoms were not, with exception 
 of on the 2nd of January, much complained of. 
 
 Inspection four hours after death.— Body emaciated. Head. — There were about 
 three ounces of serum in the cavity of the head. Chest. — The liver had encroached 
 on the cavity of the chest to the level of the third rib on both sides, and the heart was 
 in consequence placed more transversely than is natural. The pericardium contained 
 several ounces of serum. Both lungs adhered firmly to the costal pleurae ; and in both, 
 there was abundant deposition of crude grey tubercles, with emphysema. Abdomen. — 
 There was no distention. The peritoneal lining of the parietes, and all the viscera, 
 with the omentum, were firmly united by adventitious adhesions. Between the layers 
 of these adhesions there was serum in some places, and in others nodules and masses of 
 firm, almost schirrous lymph, frequently of tubercular form. The liver was much en- 
 larged and firm, and the cut surface presented a white mottled appearance. The 
 spleen was also enlarged, its texture was firm, and part of the edge was matted to the 
 left lobe of the liver by means of a thick mass of lymph. The mesentery was much 
 thickened, and when cut showed the glands enlarged, and in many places under- 
 going tubercular degeneration. The mucous lining of the stomach was of a pale 
 rosy tint, and softened. The mucous coat at the end of the ileum for the extent of 
 several feet presented large transverse ulcerated bands. Some of which, on the 
 separation of the peritoneal adhesions, opened into the cavity of the abdomen. The 
 coecum was in a similar state of ulceration, but the transverse part of the colon was 
 undiseased. The right kidney was healthy. The left was of chocolate-red colour, i 
 195. Extensive ulcer on the groin. — Miliary tubercles in the lungs and underneath 
 the peritoneum throughout its whole extent. — Follicular ulceration of the large intestine. 
 — Three ounces of serum in the cavity of the cranium. — JSo head symptoms. — Charles 
 Sutherland, aged twenty-four, a seaman, of fair complexion and strumous habit, was 
 first admitted into the hospital on the 16th October, 1838, affected with extensive 
 ulceration of the left groin, and of the under and upper part of the thigh of the same 
 side. This affection was of several months' duration, and was attributed to a venereal 
 sore, with which he had been affected some time previously. He remained in hospital 
 without improvement till the 17th January, when being impatient from the tedious 
 nature of his illness, and at the want of success attending the treatment, he was dis- 
 charged at his own desire. He was re-admitted on the 17th February, having been 
 during his absence from hospital under the care of a Hakeem in the bazaar, who had 
 used various applications, and given internal remedies, in consequence of which the 
 mouth had become affected. At this second admission the ulcer on the groin had a 
 more unhealthy appearance, its edges being ragged and irregular; that on the thigh 
 had become double its former size, and had also irregular ragged edges. Sarsaparilla 
 and hydriodate of potass were prescribed and continued for some time, and the ap- 
 plications to the ulcers wore frequently varied. The ulcers did not improve in 
 appearance, the general health declined, and on the 9 th April he first complained of 
 cough with scanty expectoration. The cough continued more or less troublesome, 
 chiefly so during the three weeks immediately succeeding its first appearance. The 
 ulcers were generally stationary, sometimes, however, for a few days assuming a more 
 healthy appearance, and then again relapsing. The strength declined ; night sweats 
 became troublesome, the cough ceased; and on the 19th June diarrhoea commenced, 
 and was more or less urgent, and attended with florid tongue, till the period of death 
 on the 15th July. 
 
 g a 
 
450 PERITONITIS. 
 
 Inspection six hours after death. — Body emaciated ; abdomen collapsed. Head. — 
 There was no tnrgeseenee of the vessels, and there were about three ounces of serum 
 at the base of the skull. Chest. — There were adhesions of the upper lobe of the right 
 lung to the anterior parietes, and opposed to these adhesions there was a crude tuber- 
 culous nodule the size of a walnut. The lowest lobe of the right lung was moderately 
 congested with frothy serum. The upper lobe of the left lung was healthy; the 
 lowest part of the lower lobe was in a state of red hepatisation, and at the upper part, 
 and immediately below the pleura, there were miliary tubercles deposited. The heart 
 was healthy. Abdomen. — There were about fixe ounces of clear serum in the cavity 
 of the pelvis. Over the peritoneal lining of the lateral part of the abdomen, of the 
 pelvis, and of much of the intestines, there was a blush of ramified redness, and the 
 tunic was studded in these places with isolated miliary tubercles, transparent, none 
 larger than a pin's head, and many smaller; in many instances they seemed to con- 
 stitute the termination of a vascular ramification. Underneath the peritoneal Kning of 
 the diaphragm where opposed to the liver there was a similar tubercular deposition, 
 but here, instead of standing in relief, it was compressed into flattened patches — a 
 modification evidently caused by the resistance of the liver, because, on the left side 
 of the diaphgram, where there was no resisting object, the tubercles stood out in relief as 
 elsewhere. These appearances where much more developed on the right than on the left 
 side of the abdomen. The mueous coat of the stomach was dotted dark red at the cardiac 
 end, but it was healthy in texture; towards the pylorus it was mammillated and 
 thickened. The liver was pale and mottled. The mucous coat at the end of the 
 ileum was vascular and studded with mucous glands. The mucous coat of the colon 
 and rectum was studded with ulcerated follicles, and in some cicatrisation had 
 commenced. Here and there there were patches of reddish lymph, with occa- 
 sionally a yellow central point like a tubercle. The mesenteric glands ranged in 
 size from a pea to a horse bean, bxit they were not tuberculated. The kidneys were 
 healthy. 
 
 196. Chronic peritonitis. — Tubercular. — Much effusion, and comphte dulness on 
 percussion. — Eamni Penack, aged fifty, a Hindoo female, much emaciated, was ad- 
 mitted on the 28th July, 1852. The abdomen was swollen, tense, fluctuating, dull all 
 over on percussion. The dulness rising to the fourth rib on both sides. The feet and 
 legs were cedematous; the rest of the chest was resonant, and vesicular respiration 
 was distinct. The sounds of the heart were natural. There was no increased heat 
 of skin. Pulse small, and very easily compressed. Tongue coated brown in the 
 centre; urine scanty; bowels confined for five or six days. She stated that twenty 
 days before admission there had been pain below the ribs, and that eight days after- 
 wards the abdomen began to swell, and was attended by difficulty of breathing. She 
 died at 3 p.m. of the 30th. 
 
 Inspection seventeen hours after death. — Abdomen. — About fourteen pints of turbid 
 yellowish serum were found in the sac of the peritoneum. The intestines were in 
 general much contracted, and occupied the left lumbar region, but were not fixed by 
 adhesions. On the surface of the intestines here and there slight redness was seen. 
 Studding the mesentery and the inner surface of the abdominal walls, chiefly at the 
 hypogastric region, and also the pelvic viscera (bladder, rectum and ileum), were 
 numerous miliary tubercles, ranging from the size of a mustard-seed to a small pea, 
 and situated in the subserous tissue. Firm adhesions connected the under surface of 
 the right lobe of the liver to the upper ends of the righl kidney. The liver was 
 smaller than natural, but did not feel indurated when incised. The gall-bladder was 
 full of bile. The kidneys were somewhat smaller than natural, and externally mottled 
 red and white, finely granular, and presenting numerous serous cysts. One of the 
 cysts in the righl kidney, when laid open, was found to contain puriform matter, 
 which showed under the microscope broken-down pus corpuscles. The cortical portion 
 
TUBERCULAR. 451 
 
 of both kindeys defective. Lungs healthy ; heart healthy. There was atheromatous 
 deposit on the aortic valves. 
 
 197. Effusion in chest and abdomen. — Access of cholera. — Disappearance of the 
 effusions. — Bright' s disease of the kidney and tubercular peritonitis. — Moobnrick 
 Nuseel >. an African, of fifty-eight years of age, was admitted into the clinical ward on 
 the 10th of September, 1849. He was somewhat emaciated ; the abdomen was swollen, 
 tense, and fluctuating, and somewhat tender on pressure. On the left side of the chest 
 there was dulness below the level of the third rib, varying with change of posture, 
 accompanied with absence of vocal thrill, and the heart's impulse was most distinctly 
 felt to the right of the sternum. There was no febrile disturbance observed, but he 
 complained of nausea and abdominal distention and discomfort after eating. The 
 pidse was small, of natural frequency. The tongue not coated, but somewhat florid at 
 the tip, and the bowels occasionally relaxed. He stated that he had been ill fifteen 
 days, and that the uneasiness and fulness of abdomen had come on gradually during 
 that period. On the loth and 19th the urine was examined; its specific gravity was 
 about 1020, and it gave no traces of albumen witli heat and nitric acid. On the 20th, 
 the occasional diarrhoea from which he had suffered since admission, passed into dis- 
 tinct cholera, and he died on the 26th. The rice-water-like discharges continued 
 more or less abundant till the 23rd. The pulse became feebler, but remained distinct 
 till shortly before death. The surface of the body was sometimes cold, at others re- 
 gained its natural temperature. The urine was passed scantily on the 23rd and 25th. 
 Drowsiness first showed itself on the evening of the 21st, and he became quite comatose 
 before death. On the 21st the fulness and tenseness of the abdomen were much 
 lessened ; the thoracic dulness extended no higher than the fifth rib, and the heart's 
 impulse was less to the right of the sternum. On the 25th the abdominal fulness and 
 the thoracic dulness had almost entirely disappeared, and the heart's impulse was 
 most distinct between the third and fourth ribs of the left side, an inch from the 
 margin of the sternum. 
 
 Inspection twelve hours after death. — Chest. — There was not any serous effusion 
 found in the sac of the left pleura, and the left lung was soft and crepitating. Two 
 or three bands of firm adhesion connected the inner surface of the lung to the pericar- 
 dium. The right lung was also soft and crepitating, and united by old adhesions to 
 the costal pleura. There were no traces in the costal or pulmonary pleura of recent 
 inflammatory action. A larger than normal portion of the heart was to the right of 
 the mesial line. There were opaque patches here and there on the surface of the 
 heart. A slight degree of dilatation of the left ventricle, and of thickening of the 
 mitral valve, was observed ; the right ventricle, and the aortic valves, were healthy. 
 Abdomen. — The whole of the peritoneal covering of the anterior parietes was closely 
 beset with granular deposits, each granule was about the size of a small pin's head. 
 Similar deposit was also present on the peritoneal surface of the intestines, and the 
 convolutions were closely and firmly adherent to one another, and, in places, here and 
 there, to the anterior parietes chiefly below the umbilicus. The concave surface of the 
 liver adhered to the stomach, and to the hepatic flexure of the colon, and also by old 
 and firm adhesions to the diaphragm. There was no serous fluid in the cavity of 
 the abdomen. The liver was harder than natural, resisting to the knife, and granular. 
 The left kidney was considerably enlarged and flabby ; and when incised the sur- 
 face showed, chiefly in the body of the organ, considerable encroachment on the 
 til mlar portion by a pale buff finely granular structure. The external surface, on 
 removal of the capsule, presented a finely mottled appearance (red and yellow). A 
 similar state of the right kidney existed, in greater degree. The Head was not ex- 
 amined. 
 
 Remarks. — This case occurred at a time when cholera was prevalent. It present* 
 several points of considerable interest. The abdominal effusion, co-existing with a 
 
 G G 2 
 
452 PERITONITIS. 
 
 pleuritic effusion, was due in all probability to the kidney disease, not to the pre-exist- 
 ing, and probably not recent, tubercular peritonitis. The incomplete collapse, and the 
 long course of the cholera attack, are to be attributed to the replacement, from the 
 pleuritic and abdominal effusions, of the -water of the blood lost in the intestinal 
 discharges. It shows that endosmosis and exosmosis may go on freely from a serous 
 surface studded with grey granular deposit. It is an instance of this deposit present 
 in the peritoneum, but absent in the lungs. 
 
 Chronic peritonitis consecutive on an acute attack, and tuber- 
 cular peritonitis, chronic in its character from the commencement, 
 are well known to pathologists. But I apprehend that idiopathic 
 peritonitis, not tubercular, yet chronic from its outset, is not a form 
 of disease very generally recognised. 
 
 Mr. Scott, now Inspector-General of Hospitals of the Bombay 
 Army, at the time Surgeon of the 10th Regiment Bombay Native 
 Infantry, called attention*, in 1842, to a very interesting form of 
 disease which he correctly designated " Chronic Peritonitis." 
 
 The regiment was stationed at Aden at a time when, from 
 defective arrangements, a scorbutic taint was prevalent among the 
 native classes there, and rheumatic affections were also common. 
 
 The disease in question was most prevalent at the commence- 
 ment of the cold season, and the symptoms, as observed in twenty- 
 nine cases, were of the following nature : — There was uneasiness 
 on pressure, or a sense of pricking or heat about the umbilicus 
 with anorexia, distention after eating, and subsequently vomiting. 
 The urine was scanty and high coloured, but there was no febrile 
 heat. So little importance did the sepoys attach to these symp- 
 toms, that, in some cases, they had been present for a week or two 
 before application was made for admission into hospital. Then 
 signs of effusion into the abdomen succeeded at varying periods. 
 Sometimes the men did not report themselves ill till effusion had 
 commenced ; and in others, the effusion began to appear three or 
 four days after admission. In some there was jaundice and en- 
 largement of the liver. A few cases, treated at the commencement, 
 after the true nature of the disease had been determined, are be- 
 lieved to have recovered; but all in whom effusion had taken 
 place, died within a month from its appearance. A post mortem 
 examination was made in three cases. In all, the liver was hard 
 and granular, the peritoneum was opaque ; and in two there 
 were extensive deposits of coagulable lymph among the intestines. 
 The kidneys were healthy. 
 
 There can be no doubt that the disease was chronic peritonitis. 
 Mr. Scott attributed it to a rheumatic diathesis which prevailed to 
 
 * "Transactions, Bombay Medical and Physical Society," No. 6, p. 153. 
 
ILEUS AND COLIC. 453 
 
 a considerable extent. His words are: " Perhaps what excites 
 rheumatic pains in the muscles and joints of one man, fixes on the 
 peritoneum in another, and creates this complaint." 
 
 When we bear in mind that Mr. Scott's report was written at a 
 time when diathetic disease did not occupy the place in pathology 
 which has since been accorded to it, and when little notice was 
 taken in medical writings of rheumatic pneumonia, pleuritis, or 
 bronchitis, it must be allowed that the words just quoted are con- 
 ceived in a spirit of happy suggestion. 
 
 I would only further add that Rokitansky, and probably other 
 pathologists also, recognise a rheumatic form of peritonitis. 
 
 On the treatment of peritonitis, generally, I shall be very 
 brief. 
 
 Of the utility of general and local blood-letting, the use of opium, 
 and gentle mercurial influence in the early stages of idiopathic 
 peritonitis in a good constitution, there can be no question ; but it 
 must be recollected that the proportion of this form of the disease 
 is very small. There can be no doubt that the too ready asso- 
 ciation of antiphlogistic remedies with the name peritonitis has 
 been attended with injurious consequences in practice. 
 
 General peritonitis, secondary on other serious forms of abdomi- 
 nal disease, or idiopathic in cachectic constitutions, ought not to be 
 treated by much blood-letting, or mercury. It is true that in 
 these forms the chances of recovery are very limited ; but they 
 should not be still lessened by injudicious treatment. There ought 
 not, in these conditions of peritonitis, associated as they generally 
 are with marked collapse, to be any hesitation in setting antiphlo- 
 gistic means altogether aside, and in trusting to opium, — after the 
 manner recommended by Dr. Stokes, — with rubefacients, and 
 stimulants to sustain the failing pulse. 
 
 In the chronic forms of the disease we shall have further to keep 
 in view the character of the diathesis, and the means, gently 
 eliminatory or other, which science may suggest for its removal or 
 improvement. The injury often caused by active purgatives, in 
 the treatment of peritonitis, is well enforced by Dr. Watson in his 
 excellent lectures, and is I apprehend, now universally assented to. 
 
 Section II. — Ueus and Colic. 
 
 Setting aside cases of strangulated hernia, the instances of ileus, 
 which have come before me, are few in number. 
 
 The first of the two following cases came under my observation 
 
 G G 3 
 
454 ileus. 
 
 at Kirkee, in the hospital of the 4th Dragoons, and is of the form 
 depending upon paralysis of muscular fibre, consequent on com- 
 mencing inflammation (enteritis), which Dr. Abercombie has so 
 well illustrated in his writings. In the second, a portion of the 
 small intestine was strangulated by old adhesions resulting from 
 former peritonitis. To Mr. Carter I am indebted for the notes and 
 the opportunity of inspecting the morbid appearances of a case 
 which had come under his care. In this the obstruction was from 
 colloid-cancerous degeneration of the sigmoid flexure. It is the 
 only instance of malignant disease of the alimentary canal which 
 has come under my notice. 
 
 198. Hens, with granular effusion on the inner surface'' of the ileum. — Biliary calculi. 
 — Mrs. Horton, aged thirty-seven, admitted into the hospital of the 4th Light 
 Dragoons, September 6th, 1832. A few months in India. Had been for some 
 years subject to occasional pain in the abdomen, with constipated bowels; good 
 health in the intervals. Had an attack some months ago in Bombay, also another 
 about ten days since, from which she recovered under the use of purgatives and 
 leeching. In the course of the day of admission, had been affected with violent pain 
 of abdomen ; belly tender. Little vomiting. Actively treated, leeched, blistered. 
 Some dark-coloured stools procured after the use of active purgatives and enemata. 
 Pain undiminished, insensibility; moaning and sinking on the 7th. Died early on 
 the 8th. 
 
 Inspection six hours after death. — Abdomen distended and tense, the integuments 
 loaded with fat ; a small quantity of serum in the cavity of the peritoneum. On tie 
 incisions being made, the intestines protruded, distended with gas and fluid. The 
 ileum externally, principally at its most dependent parts, was dark red, and vascular, 
 with very slight and partial exudation of flakes of lymph. There were old firm ad- 
 hesions at the upper part of the ascending colon, which connected it firmly to the 
 whole surface of the gall-bladder, and to the thin edge of the right lobe of the liver. 
 The gall-bladder shriveled, contained no bile, but was filled with small angular earthy 
 concretions. In portions of the descending colon and sigmoid flexure there were eon- 
 tractions for some extent, but no unnatural condition of the tissues. The lower end 
 of the ileum to a considerable extent, also the coscum, were laid open. Where the 
 peritoneum was discoloured, there the inner surface of the ileum presented a similar 
 discoloration, and there more especially, and elsewhere also, for the extent of about two 
 feet, there was effusion on the inner coat of the ileum of fine granules, forming an 
 aspect as if a moist surface had been sprinkled with fine sand : this effusion, with the 
 thin mucous tunic, peeled easily off with the nail. The large intestine also, in part 
 distended, contained, as well as the small, thin light-coloured feculence; no scybalous 
 matter, no obliteration of the cells of the colon. The upper part of the descending 
 colon was marked with red dotted softened patches of the mucous membrane ; in the 
 contracted portion no disease of the tissue. Liver somewhat dark in colour, otherwise 
 pretty healthy. Uterus of natural size, with some vascularity of its peritoneum; but 
 no exudation. 
 
 199. Ileus. — Strangulation of part of the intestine bjf old peritonitic adhesions. — A 
 lady, aged twenty, of very delicate habit, the subject, it was said, of abdominal in- 
 flammatory attacks at different times in early life, had for some time been suffering 
 from diarrhoea. On the morning of the 26th July the bowels had been relaxed, and 
 to check this an opiate was given. About 3 p.m. was seized with excruciating pain of 
 abdomen, with much prostration, cold skin, anxiety, and frequent vomiting. This 
 
colic. 455 
 
 continued during the night, and the pain was relieved by friction and pressure. Seen 
 by me, with Dr. Burn, on the 27th at 2 p.m. From the period of the attack no action 
 of the bowels had taken place, though enemata had been freely used for this purpose. 
 When seen, the abdomen tender and tense, the pain was increased by pressure and 
 the slightest motion ; pulse 120, easily compressed. Thirty-six leeches were applied, 
 and Dover's powder, with hydrarg. cum creta, given. At 5 p.m. she had borne the 
 leeching well ; the pidse was rather more developed ; tenderness and pain of abdomen 
 continued, and just above the pubes, and inclining towards the right iliac region, there 
 was an irregular knotty induration perceptible. The pain was constant, but it increased 
 in paroxysms from time to time with eructations, but no return of vomiting Five 
 dozen leeches were applied. Seen at 9 p.m. The pain and tenderness of abdomen 
 were very little alleviated, pulse upwards of 120, and very feeble. No discharge from 
 the bowels, and she was anxious and exhausted. Opium one grain, calomel two grains, 
 every third hour. 28th, 6 a.m. Had dozed much during the night. Pulse very 
 feeble. The tenderness of abdomen and tenseness continued ; no evacuation. The 
 opium was directed to be continued without the calomel, and an enema to be exhibited 
 in the course of the day. 5 p.m. The vomiting recurred, and was frequent. The 
 exhaustion had been great, and the paroxysms of increased pain frequent. Some dark 
 fecident matter was brought away with the enema. Now skin cold ; pidse thready ; 
 features collapsed ; breathing hurried. Stimulants were given. She died about 7 p. m. 
 Intelligence entire to the end. 
 
 Examination fourteen hours after death. — Abdomen tense. Not much distended; 
 The omentum vascular, adhered to the convolutions of the small intestine, dipped into 
 the pelvis, and was adherent there. A dark reddish tint of the surface of the small 
 intestine generally, and the stomach also at its great arch, was observed. On separa- 
 ting the tender adhesions of the convolutions of the intestines, and raising them from 
 the pelvis, very dark-red effusion was found to the extent of about ten ounces, and a 
 portion of the small intestine to the extent of about two feet was observed to be in 
 a perfectly black state. Over this the omentum was in part matted, but the greater 
 part of the dark-coloured portion of the intestine had sunk into the cavity of the pelvis. 
 On examination it was found that this portion of the intestine had been strangulated. 
 A ligamentous band passed from the free end of the appendix vermiformis to a part 
 of the mesentery. The side of one convolution (about six inches from the ileo-ccecal 
 valve) was united to another by a firm ligamentous band not more than quarter of an 
 inch in length. The ring thus formed was about two inches in diameter. The strangu- 
 lated portion of intestine had passed through this ring, and the size of the ring had 
 been lessened, by part of its circumference and its diameter, having been compressed 
 by the band connected with the appendix vermiformis. But of the exact manner of 
 the strangulation I was not quite certain. The part strangulated was a portion of the 
 ileum commencing a few inches above the ring which has been described.* 
 
 Ordinary colic from some casual error of diet is not uncommon 
 both in Europeans and natives, and is in general readily cured by 
 a purgative combined with an anodyne. 
 
 M. Boudin remarks f that " colique vegetale " is not alluded to in 
 the first edition of this work, and adds, that when he questioned 
 me on the subject I seemed astonished at the name. Doubtless 
 
 * Case 86 may be referred to in connection with that now detailed. 
 
 t "Traite de Geographie et de Statistique Medieales," par J. Ch. M. Boudin. 
 Vol. ii. p. 377. His words are, — "Nous ajouterons meme, qu'ayant tout recemment 
 interroge M. le professeur Morehead sur la colique vegetale, le seul nom de la maladie 
 parut l'etonner beaucoup. 
 
 c c 4 
 
450 COLIQUE VEGETALE. 
 
 this impression is correct, as the name was then new to me, and 
 I find on a careful perusal of the interesting description in M. 
 Boudin's work, that the disease is also unknown to me. 
 
 It is said to occur in greatest degree in French ships, particularly 
 steam vessels, in the proximity of tropical coasts. It is observed 
 much less frequently, and in a milder form, on shore. It attacks 
 several individuals at a time, and consists of recurring paroxysms 
 of severe colic, succeeded by emaciation, tremors, paralysis, delirium, 
 and convulsion. The mortality is considerable, and the occurrence 
 of cerebral symptoms always indicates a fatal result. The water, 
 the wine, the provisions, and the circumstances of crews thus 
 affected, have been carefully examined, without the slightest 
 evidence of the presence of lead. The disease has therefore been 
 attributed to a miasmatic poison. 
 
 It is difficult to explain why this form of colic is unknown in 
 India in English troops, or, as I believe, in the crews of English 
 ships in tropical seas. The statement in M. Boudin's work, that 
 English surgeons in Bombay receive a large number of patients 
 affected with this form of colic from Scinde and the Persian Gulf, 
 is certainly erroneous.* The European General Hospital is the only 
 hospital in Bombay for the reception of sick sailors, and with the 
 occurrences in this hospital I have been familiar for the last 
 twenty years. 
 
 I quote, in connection with this subject, the only case of lead- 
 colic which has come under my observation, and this chiefly on 
 account of the morbid appearances found after death. 
 
 200. Colica-Pictonum. — The colon was much distended and displaced. — Dmth. with 
 head symptoms. — Only slight serous effusion at the base of the skull. — W. Keilly, of 
 twenty-eight years of age, a seaman in moderate condition, a painter by trade, who 
 had at different times, after working with paint, been affected with severe colic. The 
 last attack was about two years before he came under observation, and it continued 
 for eight months. On the 5th of May, 1839, he came to the General Hospital in a 
 state of intoxication. He was affected with vomiting, and complained much of pain 
 at the epigastrium ; his hands were tremulous and the bowels constipated. He had 
 lately been engaged in painting the ship to which he belonged. The pulse was feeble, 
 the skin damp. The pain and constipation were relieved by the warm bath and tur- 
 pentine enemata, but they recurred from time to time, with vomiting, during his stay 
 
 * The words are, "Les ehirurgiens Anglais de Bombay, dit M. Lemarie (these 
 MontpeHier, 1851), reeoivent un grand nombre des maladea atteints de colique secho 
 des postcs et des batiments du Sind et du Golfe Persique ; ceux de Calcutta de la 
 navigation du Gange et du Golfe de Bengale." I am not entitled to speak with the 
 same confidence respecting Calcutta, but I have very little doubt that here also there 
 is some misapprehension. The experience of the medical officers of the steam vessels 
 of the Oriental and Peninsular Company would be of value on this question. 
 
COLICA riCTONUM. 457 
 
 in hospital, and were attended with retraction of the wrists, and convulsive movement 
 of the fingers. On the 8th, 9th, and 10th, he had several convulsive fits, followed by 
 moaning, restlessness, and incoherence ; accompanied with a cold, damp skin, a quick 
 and feeble pulse. On the 11th and 12th he was delirious, and death on the latter day- 
 was preceded by drowsiness. He was treated with opiates, stimulants, blisters, and 
 purgatives. 
 
 Inspection fifteen hours after death. — Head. — An ounce and a half of serum was 
 effused in the cavity, the greater portion at the base of the skull ; the substance of the 
 brain and the membranes were in their natural state. Chest. — The lungs were healthy 
 and collapsed. The heart was soft in its texture. Abdomen.— The whole of the large 
 intestine was dilated and varied in calibre from about two to tliree inches. The trans- 
 verse colon coursed along the margin of the right false ribs, concealed the liver, reached 
 to the ensiform cartilage, thence coursed downwards at the margin of the left false 
 ribs, thence passed directly upwards to the diaphragm, opposite to the apex of the 
 heart, thence turned downwards and formed the descending colon ; the distended 
 sigmoid flexure occupied the hypogastric region and reached to the umbilicus ; the 
 coats were natural, perhaps thinned, and there was much thin feculence in the gut ; 
 the mucous follicles were here and there enlarged. The stomach was contracted and 
 concealed by the colon ; at its cardiac end, there were dark, extravasated patches, 
 elsewhere the coat was mammillated, but there was no softening. The small intestine 
 was contracted, The liver was paler than natural. The kidneys were healthy. 
 
458 AFFECTIONS OF THE STOMACH. 
 
 CHAP XVIII. 
 
 AFFECTIONS OF THE STOMACH. 
 
 Section I. — Gastritis, Acute and Chronic. 
 
 Acute Gastritis. — In my remarks on remittent fever *, it is stated 
 that bright redness of the mucous membrane of the stomach is 
 occasionally found after death, in the fevers of plethoric Europeans 
 in whom irritability of the stomach had been present during life ; 
 but this condition is probably rather congestive than inflaminatorv. 
 
 In my notes of fatal cases of small-pox there is one in which 
 symptoms of acute gastritis were present during life, and the 
 characteristic morbid appearances were found after death ; but 
 with this exception, all the other cases of acute gastritis which 
 have come under my observation have been instances of irritant 
 poisoning. 
 
 Poisoning by arsenic, with suicidal or criminal intent, is unfor- 
 tunately common iu India, as is well known to medical officers 
 connected with native general hospitals. 
 
 I have the notes of several before me, but I shall be satisfied 
 with the narration of two, selected not only as illustrative of the 
 symptoms and morbid appearances of acute gastritis, but also of a 
 a remark previously made relative to the diagnosis of cholera.f In 
 the absence of a faithful history, the following case, in a season of 
 epidemic cholera, might very readily have been taken for one of 
 that disease : — 
 
 201. Poisoning by arsenic, admitted in the stage of collapse, after the active symp- 
 toms of gastritis were passed. — Furdonjee Jewajee, a Parsee liquor seller, of thirty 
 years of age, was brought by his friends to the hospital at 7 a.m. on the 28th February, 
 1851. He was said to have taken arsenic at 2 a.m.. and at the same time half a bottle 
 of brandy. He vomited frequently, and the ejected matters contained Wood. Ho 
 had also been frequently purged. On admission \u- was drowsy and restless, and the 
 conjunctivae were vascular, the skin cold the pulse imperceptible, and the tongue some- 
 
 * Tage 93. f Page 211. 
 
ACUTE GASTRITIS. 459 
 
 what florid. Ho complained of pain of the loins, but not of the abdomen. He died at 
 eleven o'clock. 
 
 Inspection four and a half hours after death. — Rigor mortis present. The heart 
 contained liquid blood, and there was concentric hypertrophy of the left ventricle. 
 The stomach contained about seven ounces of dark liquid blood. The mucous mem- 
 brane was throughout of bright red colour, abundantly studded with dark red points 
 of extravasated blood. There were patches of viscid mucus here and there, with 
 white particles intermixed. Liqiiid blood flowed from the vessels of the dura mater, 
 as it was divided. The pia mater was congested. The substance of the brain was 
 redder than natural, and showed many bloody points. 
 
 Analysis. — Some of the white gritty particles from the mucous membrane of the 
 stomach, heated with black flux in a test tube, gave a grey metallic ring. This por- 
 tion of the tube, heated in a large tube, gave on its sides deposit of a white sublimate, 
 which was dissolved in boiling distilled water ; tested with the ammonio-nitrate of 
 silver, it gave a canary-yellow precipitate, with the ammonio-sulphate of copper, 
 a bright green precipitate, and with a stream of sulphuretted hydrogen, a yellow solu- 
 tion. 
 
 202. Poisoning from arsenic in which symptoms of narcotism were prominent at the 
 commencement. — A Hindoo goldsmith, of about thirty years of age, was brought to the 
 Jamsetjee Jejeebhoy Hospital on the morning of the 21st May, 1847, at 6 a.m. He 
 had been picked up by the police on the public street. He was comatose ; his pupils 
 were dilated, the breathing was natural, the pulse frequent. There was no appearanco 
 of injury, and no emaciation or sign of long-continued sickness. As he was being 
 lifted from the cart in which he had been conveyed to the hospital, he vomited a little 
 bilious matter. Nothing was known of his history. Cold affusion was used to the 
 head, and an emetic of ipecacuanha and carbonate of ammonia was given. The emetic 
 acted readily, and he became sensible. He vomited several times during the day, and 
 was purged two or three times, the evacuations consisting of gelatinous-looking mucus. 
 Towards evening the pulse had become very feeble, the breathing hurried, the thirst 
 and anxiety considerable, with occasional retching. He died about five o'clock a.m. 
 on the 22nd instant. The only statement he made was, that he had eaten some sweet- 
 meats the night before he was brought to the hospital. The residt of the coroner's 
 inquest was, that he had taken poison himself. 
 
 Inspection six hours after death. — The body was in good condition. Abdomen. — ■ 
 There was a general blush of redness over the peritoneal covering of the stomach and 
 small intestine, but no effusion into the sac of the peritoneum. The stomach was 
 opened and found to contain about six ounces of a dark watery fluid with mucous sedi- 
 ment, partly tinged with blood, and containing some white gritty particles. There was 
 general redness of the mucous lining of the stomach, characterised towards the cardiac 
 end by a dark patch-like arrangement; and towards the pyloric end there was a dark 
 and more diffused redness leading to an almost black patch about three inches long, 
 and two in short diameter, raised somewhat above the general level, and abraded in 
 part of its surface. There was dark redness in patches of the mucous lining of the 
 duodenum, and a general blush with increased secretion of mucus on that of the 
 jejunum, and of the ileum and crecum. The thoracic viscera were healthy, there was 
 slight congestion of the vessels of the pia mater of the brain. For the following note 
 of the analysis of the contents of the stomach I am indebted to Dr. Giraud : — 
 
 "About four ounces of a mucous flocculent fluid taken from the stomach, containing a 
 few minute white brittle particles. These particles, weighing about the tenth of a grain, 
 were sublimed in a tube into a white crystalline ring ;— this, with the part of the tube 
 on which it was deposited, being placed in a reduction tube with charcoal powder, gave 
 a steel grey metallic ring, which, on being heated in a wide tube, was reconverted 
 into a white crystalline sublimate. By Reinsch's process metallic deposition on copper 
 
460 CHRONIC GASTRITIS. 
 
 was obtained from the above-mentioned fluid ; this yielded a white crystalline subli- 
 mate, which on solution in water gave the characteristic effects of arsenious acid 
 with ammoniaco-nitrate of silver, ammoniaco-sulphate of copper, and sulphuretted 
 hydrogen. By the foregoing processes arsenious acid and metallic arsenic were ob- 
 tained from the white particles found in the fluid of the stomach ; and from the fluid 
 itself metallic arsenic was procured, and made to pass through its various compounds 
 of arsenious acid, arsenite of silver, arsenite of copper, and orpiment." 
 
 Remark. — The interest in this case consists in the strongly marked narcotic symp- 
 toms shown on admission into hospital. It was viewed then as a case of narcotic 
 poisoning, and treated as such. Subsequently its nature was sufficiently evident. A 
 circumstance, not noted in the case, attracted my attention when the narcotic symp- 
 toms were present. There was a fixed frown on the countenance, an expression of 
 suffering not usual in simple narcotism, and to which probably more importance as a 
 diagnostic sign should have been attached. 
 
 Chronic Gastritis. — A review of the fatal eases of disease now 
 before me, and partly detailed in this work, show that some degree 
 of chronic inflammation of the mucous membrane of the stomach 
 is frequently observed in persons addicted to excesses in drinking, 
 — indicated by streaked or dotted redness, generally at the cardiac 
 end of the stomach, associated with softening, or a hypertrophied 
 and mammillated state of the tissue.* 
 
 Ulceration of the gastric mucous membrane has not been 
 frequently met with by me t ; and the same remark applies to 
 fibrous growths in the sub-mucous tissue. A small fibrous tumour 
 is mentioned in case 50. I have also notes of the history of a 
 soldier of the 4th Light Dragoons whom I saw in the hospital at 
 Kirkee in 1837 in a state of great emaciation. He died shortly 
 afterwards. The pyloric orifice of the stomach was so contracted 
 by cartilaginous thickening as barely to permit the passage of a 
 quill. Vomiting had only been occasionally present, and in conse- 
 quence of the pale colour of the evacuations the disease had been 
 considered hepatic, not gastric. 
 
 I have not met with a single case of malignant disease of the 
 stomach, though the occurrence of two or three in the higher 
 classes of Europeans, in the practice of others, has come to my 
 knowledge. My own observation in India would lead me to infer, 
 that malignant growths generally are of infrequent occurrence. 
 
 * Though a remark pertaining rather to the symptoms of cerebral irritation, it may 
 be well even here to allude to the risk of mistaking the irritability of stomach sympa- 
 thetic with cerebral affection, for that symptomatic of gastric inflammation. In respect 
 to children, caution on this point is well understood, but it is also necessary in regard 
 to adults. I have known cases of cerebral determination from undue exposure to the 
 sun, in which the vomiting was so prominent as to tend to overshadow the uneasiness 
 of head, the flushing of countenance, the restlessness, and tendency to mental confu- 
 sion, and to divert attention from the true seat of the disease. 
 
 f Cases 89, 90. 
 
GLOSSITIS. 461 
 
 Whether the circumstance of their having come rarely under my 
 notice is to be attributed to absolute infrequency, or to my field 
 of inquiry not having extended to the classes and the periods of 
 life most susceptible of malignant disease, I am unable to deter- 
 mine.* 
 
 Section II. — Glossitis. 
 
 This serious disease is of very rare occurrence. I have met with 
 only two cases. The first in a sthenic soldier of the loth Hussars. 
 The half of the tongue was affected ; but the organ was so swollen 
 as to fill the mouth, protrude between the lips, and cause appre- 
 hension for the result. Eecovery took place under the use of 
 general blood-letting. 
 
 The second case occurred in February 1846, in a very asthenic 
 native child, who was brought to the dispensary of the Jamsetjee 
 Jejeebhoy Hospital for relief. Both sides were affected, and the 
 swollen tongue protruded from the mouth and completely prevented 
 deglutition. Leeches and superficial scarifications were used with- 
 out relief. The child was so reduced that the bleeding consequent 
 on free incisions was dreaded, and yet the symptoms had become 
 very urgent, I pencilled the tongue freely with nitrate of silver. 
 On the following clay the swelling was much reduced. The 
 caustic was again used, and nothing further was necessary to 
 perfect the cure. 
 
 I have alluded to the subject of glossitis that I might record the 
 efficacy of the nitrate of silver in this case. It is a practical fact 
 well worthy of being borne in recollection. 
 
 * As connected with the pathology of the stomach, I would alhide to a pecidiar case 
 of injury which came under my observation in the European General Hospital in 1839. 
 A sailor was violently squeezed between the bidwark of a steam vessel and a tense 
 cable which passed across the epigastrium. When received into the hospital, an hour 
 after the accident, there was an ecchymosed mark distinct on the epigastrium and op- 
 posed part of the spine. There was much collapse. He vomited some dark-coloured 
 blood. After reaction there was much tenderness of abdomen, hurried respiration, 
 but no return of vomiting. He died twenty-four hours after admission. After death, a 
 pint of dark fluid blood was found in the left pleura : a large rent, through which three 
 fingers coidd be passed, existed at the posterior part of the left side of the diaphragm, 
 near to the spine. No fracture of the ribs. In the pelvis and neighbourhood of the 
 kidney there was a pint of dark fluid blood. Transversely across the centre of the 
 great arch of the stomach there was a strip of the mucous membrane above an inch in 
 breadth, torn froni the subjacent coat, hanging loose with lacerated edges. 
 
462 DYSPEPSIA. 
 
 Section III. — Dyspepsia. — General reflections on Pathology 
 and Principles of Treatment. 
 
 Though " dyspepsia " occupies a prominent place in hospital 
 returns, it is my intention to treat very briefly the train of symp- 
 toms to which this term has been applied. By dyspepsia, or 
 indigestion, is meant more or less of such symptoms as anorexia, 
 nausea, vomiting, epigastric distention and pain, gaseous and 
 watery eructations. Much has been written on this affection, but 
 the question may be suggested, whether the tendency of elaborate 
 disquisitions on dyspepsia has not been to obstruct the progress 
 of enlarged views in pathology and rational doctrines in thera- 
 peutics. 
 
 Indeed, I venture to predict, that the time is not very distant, 
 when consequent on advancing generalisations in pathology, the 
 term dyspepsia will be removed from our nosologies, just as 
 dyspnoea has already been. 
 
 That, consequent on inflammation of the mucous membrane, or 
 organic lesion of the stomach, the taking of food will be followed 
 by more or less of the symptoms called dyspeptic, may be readily 
 allowed. Gastric inflammation and organic lesion should be treated 
 in accordance with the general principles applicable to their class, 
 adapted to the diathesis of the individual affected. 
 
 My present remarks, however, are not intended to apply to 
 dyspeptic s}unptoms thus arising, but as they occur independent 
 of inflammation or organic disease, — the form of dyspepsia called 
 functional. 
 
 In the first chapter of this work, and in other places also, much 
 importance has been attached to diathesis in its bearing on etiology 
 and therapeutics, and to no affection is this principle more justly 
 applicable than to the so-called disease — functional dyspepsia. 
 
 In the most robust constitution, great excess in eating will be 
 followed by imperfect digestion with its attendant phenomena, but 
 here the pathology is clear and the indication of cure self-evident. 
 These, however, are not the circumstances under which functional 
 dyspepsia usually occurs. It is among the asthenic and cachectic 
 that it is generally met with. In these states of defective assimi- 
 lation of food to blood and blood to tissue, or of blood vitiated by 
 mal-assimilation, retained excretion, or reception of external in- 
 jurious agencies, the stomach partakes in the infirmity of the 
 whole system, its functional power is enfeebled, and that quality 
 
DYSPEPSIA. 463 
 
 and quantity of food which in vigorous health would be digested 
 with ease, is followed by indigestion. 
 
 Then there are associated with these dyspeptic symptoms, 
 phenomena which indicate derangement of other organs, as irre- 
 gular action of the heart, headache, restless nights, muscular and 
 mental languor, depressed spirits, irritable temper, morbid alvine 
 discharges, constipated bowels, urine vitiated with urates, phos- 
 phates, or oxalates, &c. In this assemblage of deranged actions 
 the dyspeptic symptoms are prominent, because the functions of 
 the stomach are frequently called into exercise, the phenomena of 
 derangement are well marked, the act of placing food into the 
 organ is voluntary and often injudiciously performed. This pro- 
 minence of the indigestion naturally tends to favour the belief 
 that the other co-existing disorders are sequences of it. It may 
 be admitted that as the function of the stomach is essential to re- 
 covery from asthenic and cachectic states, its frequent derangement 
 must tend to increase these states with all their attendant evils ; 
 and thus in a limited sense the continuance of the other derange- 
 ments may be said to be consequent on the persistence of the 
 dyspepsia. 
 
 But this is not the large and practical view of the relation of all 
 these events to each other. 
 
 The deranged digestion, circulation, assimilation, secretion, 
 nervous and muscular functions, are conditions of the diathetic 
 state, which, when developed, tend mutually to aggravate each 
 other ; but still they are all equally traceable to the causes which 
 induced the asthenia or cachexia, and are only to be permanently 
 cured by the removal of these causes and by the substitution of 
 the causes of health. 
 
 The truly essential practical consideration in the treatment of 
 functional dyspepsia, is to determine the causes of the asthenia or 
 of the cachexia, to remove the individual from the sphere of 
 their influence, and to place him in circumstances favourable to 
 health. 
 
 The conditions of health may be summarily stated to be : relief 
 from mental care and anxiety, a pure atmosphere, nutritious food 
 in quantity adapted to the power of the stomach, exercise in the 
 open air always short of fatigue, attention to the functions of the 
 skin by ablution and suitable clothing, cheerful occupation, due 
 amount of sleep, and avoidance of excessive evacuations. Under 
 these influences the dyspeptic symptoms and their associated 
 derangements will gradually disappear; but if these influences 
 
464 DYSPEPSIA. 
 
 be overlooked and neglected, there cannot be restoration to 
 health. 
 
 But this statement does not comprise all the resources of the 
 medical art. The progress to recovery may be smoothed and 
 hastened by various remedies, as sedatives, alkalies, tonics, alter- 
 atives, eliminants. It is not my object to enter here into the 
 details of these means ; they are well set forth in systematic works 
 on disease and on Materia Medica, and their powers and applica- 
 tions should be carefully investigated by the clinical student ; for, 
 when the circumstances of the patient do not admit of change of 
 scene and relaxation from occupation, or when the cachexia has 
 become irremediable, these remedies, with the adjustment of diet, 
 are unfortunately the only means by which relief may be obtained. 
 
 My present purpose has been to enforce the doctrine that these 
 gastric and associated derangements are very generally induced by 
 neglect of the conditions necessary to health, and are only to be 
 permanently recovered from by a suitable adjustment of the vital 
 stimuli, on which health depends, and without due attention to 
 which it cannot be maintained or restored. 
 
 Articles of the Materia Medica, when the conditions of health 
 are attended to, conduce to the cure, but in many instances are 
 not essential to it. When the conditions of health are neglected, 
 articles of the Materia Medica, judiciously used, may alleviate 
 discomfort and suffering, but they are insufficient of themselves 
 to effect recovery, and are liable, in unskilful hands, to prove 
 injurious.* 
 
 It is from reflections such as these, that I have ventured 
 to hint that elaborate treatises on dyspepsia tend to interfere 
 with en]arged views in pathology and rational doctrines in thera- 
 peutics; and to predict that the term, at no remote period, will 
 be used merely to express a symptom, not a disease. 
 
 I am very sensible that in these remarks I have laid myself open 
 to the charge of inculcating trite and very simple principles, yet 
 they can hardly be deemed uncalled for. It is, in fact, to the 
 neglect of these obvious truths which lie upon the very surface of 
 our science, that are due the exaggerated pretensions of partial 
 systems of treatment, and the attempts to throw discredit on 
 rational medicine. 
 
 * It would be easy to enlarge upon the evils which have resulted, and the discredit 
 which has attached, to the profession of medicine, in consequence of the excessive and 
 habitual use of purgative and mercurial medicines in India, as in other countries, in the 
 treatment of the symptoms called dyspeptic. I would fain hope that the subject is 
 now well understood. 
 
465 
 
 CHAP. XIX. 
 
 on bkigiit's disease of the kidney and albuminous urine. 
 
 Section I. — Prevalence of Bright's Disease in the hospital- 
 frequenting classes of the natives of India, 
 
 In the year 1849 I first called the attention of the Medical and 
 Physical Society of Bombay to Bright's disease of the kidney, as 
 occurring in the hospital-frequenting classes of the native popula- 
 tion of Bombay; and subsequent experience has confirmed my 
 belief, that the morbid states to which the name of this eminent 
 physician has been given, are as common in these classes of the 
 community in India as in European countries. 
 
 I have before me the notes of fifty-eight cases which have been 
 under my care in the clinical ward in the course of six years: 
 thirty proved fatal, and twenty-eight were discharged, of whom 
 nineteen were improved, and nine had received no benefit from 
 treatment. These, however, form but a part of the admissions 
 for this disease into the Jamsetjee Jejeebhoy Hospital during 
 this period. Many cases have come under the observation of 
 other medical officers in other wards of the hospital ; and there is, 
 in the following circumstance, evidence that many more must 
 have passed through the hospital unrecorded. During these six 
 years 782 patients have been admitted under the head "Cachexia;" 
 and of these 493 have died. This is 12 per cent, of the total 
 hospital deaths. The term cachexia is used in the hospital 
 register when the imperfect history of previous illness, or the short 
 time which has elapsed between admission and death, has pre- 
 vented the discovery of the character of the cachexia, or of the 
 existence of important organic disease. It is not to be doubted 
 that a proportion of this class has been affected with Bright's 
 disease. Indeed, if the relation which these structural changes of 
 the kidney have to processes of degeneration be recollected, and, 
 
 H ii 
 
466 bright's disease of the kidney. 
 
 at the same time, the fact of the greater prevalence of asthenic and 
 cachectic types of disease in warm climates be borne in mind, then, 
 not only an equal, but a greater frequency of this affection in 
 India, may be assumed as the fair inference from a review of all 
 the attendant circumstances. 
 
 In respect to the occurrence of Bright's disease in Europeans in 
 India, my dissection reports show that it was not unfrequently 
 noticed by me in the European General Hospital. At that time, 
 however, my attention was more given to other subjects of 
 pathology; and I therefore believe that my observations at that 
 period do not indicate the full proportion of this disease in the 
 classes who resort to that hospital. Of its frequency in European 
 regimental hospitals in India I am unable to speak ; but I need 
 hardly observe that in this, as in all other questions of pathology 
 relating to European soldiers in India, the comparison is between 
 them and soldiers elsewhere, and not between them and the civil 
 population of European countries. I am also without satisfactory 
 facts respecting this disease in officers, civil servants, and others of 
 the higher classes of Europeans in India. Of the 311 fatal cases 
 of officers, of which I have notes, Bright's disease is mentioned in 
 only three, and these were subsequent to the year 1849. These 
 data, however, as bearing on this question of pathology, may be 
 set aside as inconclusive ; for it is very evident that the attention 
 of medical men in India has been, till very lately, imperfectly 
 directed to its investigation. 
 
 The remarks which I am about to make have been chiefly sug- 
 gested by the fifty-eight clinical cases now before me, viewed 
 in connection with the statements and opinions advanced by 
 European writers. They may be arranged under the heads — 
 1. Pathology. 2. Causes. 3. Symptoms and Treatment. 
 
 Section II. — The Relation of Brighfs Disease to Albuminous 
 Urine stated. — The Morbid Anatomy and Pathology of the 
 Fluids. — Pathology of the Secondary Affections. — The 
 Urcvmic Theory. — The Proximate Cause of Albumen in the 
 
 Urine. 
 
 Albuminous urine ma} 7 occur independent of structural change 
 of the kidney, caused by cold applied to the surface of the body, 
 when the eliminating and sensory functions of the skin are in an 
 abnormal condition. Under these circumstances, the urine is 
 scanty, more or less tinged with the hsematosin of the blood, and 
 
TAUTOLOGY. 467 
 
 abounds in albumen, depending on an excessive afflux of blood to 
 the capillaries of the kidney, with, it may be, an increase of the 
 epithelial cells of the uriniferous tubes. But this state is tran- 
 sient, and may readily be removed by appropriate treatment : it 
 has been most generally observed secondary on scarlatina. 
 
 Albuminous urine occasionally exists in connection with forms of 
 fever, independent of renal disease. The albumen is then present 
 in small quantity, only for a few days, and disappears with the 
 febrile disturbance.* The history, the condition of the patient, the 
 fact, ascertained by frequent and careful examination, of the disap- 
 pearance of the albumen, will always suffice to distinguish these 
 cases. 
 
 The various morbid states to which the term Bright's disease has 
 been applied are characterised by urine, more or less albuminous, 
 at some period or other of their progress. This condition of the 
 urine is generally persistent throughout the entire course of the 
 disease ; but occasionally the albumen is absent from the urine for 
 varying periods, and such cases may usually be distinguished from 
 transient albuminuria, related to a febrile state, by the history, the 
 condition of the patient, and the fact that the urine from which the 
 albumen has disappeared is generally in abnormal quantity, and of 
 density too low to be explained by the increase of watery consti- 
 tuent alone. 
 
 The prevailing opinions on the morbid anatomy of Bright's dis- 
 ease may be summarily expressed in the following terms : — 
 
 1. The kidney, when enlarged, is so: (a) from accumulation of 
 epithelial cells, or of more or less degenerate lymph, in the inte- 
 rior of the tubuli of the cortical portion ; (b) from exudation, ex- 
 ternal to the tubuli of the cortical portion, in the areolar matrix of 
 the organ. The greater or less redness, and the various degrees of 
 mottling, depend upon the proportion and situation of the blood 
 present in the capillaries of the kidney at the period of observation. 
 
 2. When the kidney is small, granular, and indurated, it is 
 so : {a) from collapse and cohesion of the sides of the tubuli of the 
 cortical portion consequent upon the removal of pre-existing accu- 
 mulations ; (b) from atrophy of the cortical structure consequent 
 on pressure from the contractile organisation of pre-existing caco- 
 plastic deposit in the areolar matrix. 
 
 There has been much discussion in regard to the relative im- 
 portance of deposit, external or internal to the tubes, and to the 
 
 * The presence of albumen in the urine, from the existence of blood or pus in tin 1 
 secretion, is apart from my present subject) and does not call for remark in this place. 
 
 H H 2 
 
468 bmgiit's disease of the kidney. 
 
 nature of the deposit. Into these questions I shall not enter, but 
 merely observe that there is one fact common to all — viz., that 
 they tend to destruction of more or less of the secreting structure 
 of the organ. 
 
 The following fifteen cases will illustrate the general features of 
 the disease in the natives of India. They show the kidneys en- 
 larged in five, of natural size in two, small in four, lobulated in 
 six, and mottled in five. The encroachment of the cortical on the 
 tubular portion is noted in ten, and small cysts were present in 
 the kidney in two. 
 
 203. A diver by occupation. — Anasarca, ascites. — Urine of low density and albuminous. 
 ■ — Dilatation of the right ventricle of the heart. — Hypertrophy and dilatation of the left. — ■ 
 Kidneys enlarged, lobulated, in a state of yellow gran ular degeneration. — Suliman Seedee, 
 a Mussulman, twenty-five years of age, an inhabitant of Zangibar, and resident in Bombay 
 about a month. He had followed the occupations of a diver and a blacksmith, used spirits 
 and ganja habitually, and opium occasionally. About five years before he came under ob- 
 servation, he was the subject of dropsical symptoms for about ten days, which made their 
 appearance after he had been engaged in his occupation of diver. There was no recur- 
 rence of them till about five months before his admission into the clinical ward, on 
 the 7th March, 1849. Then they had been preceded by febrile symptoms, coming on 
 frequently with chills, not terminating by sweating, and attended with scanty urine. 
 On admission there was general anasarca and ascites, the respiration was somewhat 
 hurried, and dry bronchitic rales were heard in different parts of the chest ; the im- 
 pulse of the heart was rather increased, but the sounds were natural ; uneasiness of 
 the loins ; urine copious, and passed frequently ; the pulse of good strength ; no 
 febrile heat; the bowels regular, and the tongue moist and clean. He continued 
 under treatment till the 24th April, when he died. During the first month the urine 
 ranged in quantity from forty to eighty ounces and upwards in the twenty-four hours, 
 was clear and pale, sometimes alkaline, at others neutral, and always gave a consider- 
 able flocculent deposit by heat and nitric acid. The dropsical symptoms were sta- 
 tionary ; a sense of uneasiness across the chest was frequently complained of, attended 
 with some degree of dyspnoea, cough, and crepitous rale in both dorsal regions. On 
 the 17th April precordial uneasiness was complained of, and there was increased dul- 
 ness over the region of the heart, with accelerated action and confused sounds. The 
 pulse was very small ; and now the urine was reduced to nine ounces ; the dropsical 
 symptoms, the dyspnoea, and asthenia increased ; and diarrhoea was superadded. He 
 became somewhat drowsy, and died the 24th April. The treatment consisted of 
 diaphoretics, diuretics, and purgatives ; rubefacients, antimonials, and on two occa- 
 sions leeches were used for the chest affection, and latterly stimulants were exhibited. 
 Inspection seven hours after death. ■ — Chest. — The pericardium contained eight 
 ounces of serous fluid ; the cavities of the right side of the heart were dilated and 
 filled with blood ; the left ventricle was also dilated, and its walls hypertrophied ; 
 the valves were all healthy; the inner surface of the aorta near to the arch was 
 roughened from yellow deposit. The lower lobes of both lungs adhered to the costal 
 pleurse firmly, posteriorly; and a considerable part (more of the right lung) of these 
 lobes was iii a state of red hepatisation. Abdomen. — Serous effusion, but to no great 
 amount, was present in the cavity of the abdomen. The liver was enlarged, indurated, 
 and its incised surface mottled. Both kidneys wire slightly enlarged, and somewhat 
 lobulated; their surface, when denuded of the capsule, was mottled dark red and 
 yellow, and was granular. The kidn#ys? when vertically incised, showed much granular 
 degeneration, — the surface being mottled red and yellow, granular, with confusion of 
 
rATKOLOGT. 469 
 
 the tubular and cortical structures. This state was most marked in the central part 
 of the right kidney ; it was more diffused in the left one. In both, in one or two 
 places, there was tubular structure, not encroached upon ; but the cortical portion 
 external, showed commencement of yellow granular deposit. 
 
 204. Dropsical symptoms. — Urine of low density and albuminous. — Bronchitis, 
 diarrhoea, 2^riostitis, erysipelas, as secondary affections. — Kidneys large, and in a 
 state of yellow granxdar and fatty degeneration. — An opium eater. — Hurrichund, a 
 Hindoo writer, of thirty years of age, a native of Cutch, and resident in Bombay for 
 about seven months, was the subject of primary and secondary syphilis about five 
 years before he came under observation, but no traces of the disease were present. He 
 admitted that he had been in the habit of eating opium to the extent of twenty-five 
 grains daily for about four years, and that he occasionally drank spirits. About four 
 months before his admission into hospital he had been affected with dropsical swel- 
 lings, which had disappeared without any medical treatment. About a month before 
 admission he had experienced pain in the lumbar region, and the dropsical symptoms 
 had returned. He was admitted into the clinical ward on the 22nd April, 1849. 
 There was cedema of the lower extremities ; the abdomen was full, but without 
 distinct fluctuation. The respiration was calm ; there was no dulness on percussion 
 of the chest. The sounds of the heart were natural, but an occasional crepitus mixed 
 with the vesicular respiration in the dorsal regions, chiefly the left. The pulse was 
 soft, the skin cool, the tongue moist, the bowels were reported to be regular, the urine 
 copious, and the pain of the lumbar region, formerly complained of, had ceased. On 
 the 24th the urine was amber-coloured, of specific gravity 1/007, and gave an abundant 
 flocculent deposit under heat and nitric acid. Dm-ing the seven months that he was 
 under treatment the quantity of urine passed was noted daily, and there are upwards 
 of sixty observations on the character of the secretion to be found in the diary of the 
 case. The urine fluctuated a good deal in quantity ; it was seldom less than twenty 
 ounces in the twenty-four hours, and during the months of June and July very gene- 
 rally amounted to about five pints. Whether this great flow of urine was due to the 
 diuretic remedies which he was at the time using, or to the influence on the cutaneous 
 surface of the cold damp air of the monsoon season, is doubtful. For the most part, 
 the specific gravity of the urine ranged from T003 to 1-012 ; and it was always very 
 albuminous. To the low density of the urine there were several exceptions, chiefly in 
 the month of May, when the urine was about twenty ounces in quantity : on these 
 occasions the specific gravity ranged from 1-018 to 1-030, and then the urine was 
 generally of a deep brown colour, and very albuminous, and sometimes febrile symp- 
 toms were present, Throughout the course of treatment the dropsical symptoms were 
 more or less present, Bronchitic symptoms were also at times complained of, at 
 others diarrhoea, sometimes dysenteric in character. There were also periostitis of 
 the sternum, and erysipelas of the left thigh, in the month of October, with febrile 
 symptoms, which tended much to increase the asthenic state. Febrile symptoms 
 recurred about the 10th November, attended with occasional delirium; the dropsical 
 effusions increased, and he died, with much hurry of the respiration, but without 
 distinct coma, on the 12th November. The dropsical state was treated with diapho- 
 retics and diuretics, and the other indications, as they arose, were attended to. 
 
 Inspection eight and a half hours after death. — The body swollen from anasarca. 
 Chest. — There were about seven pints of clear serous fluid effused into the sac of the 
 right pleura, and about one pint into that of the left. The right lung was compressed 
 against the spinal column, did not crepitate on pressure, but was soft and tough ; the 
 left lung was crepitating. There was no redness, or other trace of inflammatory action, 
 observed in any part of the pleura. There were about three ounces of clear serous 
 fluid in the sac of the pericardium, but no redness of the membrane, or other trace of 
 inflammation. The heart was of smaller size than natural, and the mitral valves were 
 
 H II 3 
 
470 bright's disease of tiie kidney. 
 
 somewhat thickened. Abdomen. — There was about a pint of serum in the cavity of 
 the abdomen. The liver, not enlarged, was in the first stage of hepatic congestion. 
 The spleen was enlarged. Both kidneys were increased in size, the left one most so — 
 it weighed eleven ounces, and the right one eight ; both were somewhat lobidated, 
 externally mottled red and yellow, but not granular. On incising the kidneys, the 
 cortical portion of both was in increased proportion, was mottled red and yellow, and 
 was somewhat granular and fatty in appearance ; the tubular portion was encroached 
 upon, but was quite distinct. Head. — The vessels of the pia mater were somewhat 
 injected, and there was slight serous effusion into the sub-arachnoid space. 
 
 205. Gastro-cntcritis, anasarca, and ascites. — Urine of low density and, albuminous. 
 — Paracentesis. — Death from peritonitis. — Kidneys small, in a state of yellow granular 
 degeneration. — Imam Khan, a Mussulman Hakeem, of thirty years of age, a native of 
 Dowlutabad, and resident in Bombay for two years and a half. He was in very indi- 
 gent circumstances, and often very badly supplied with food ; was in the habit of 
 smoking ganja and tobacco, but did not use spirits. For about eleven days before his 
 admission into hospital he suffered from fever and dysentery. He was admitted into 
 the clinical ward on the 25th June, 1S19. He was reduced in flesh; the respiration 
 was calm ; there was no dulness of the chest ; and vesicular respiration was general 
 and unmixed. The abdomen was collapsed, tender, slightly resistant, and an indu- 
 rated enlargement was perceptible for two inches below the margin of the left ribs. 
 The skin was of natural temperature, the tongue rather florid at the tip and edges, 
 the pulse small and easily compressed ; he complained of frequent calls to stool, and 
 the evacuations, passed with griping and straining, were said to contain blood and 
 mucus ; he also suffered from occasional vomiting after eating. At first attention was 
 directed to the removal of the dysenteric symptoms. As these improved, bronehitie 
 symptoms appeared ; and on the 11th July there was puffiness of the face and cedema 
 of the feet. The urine was now examined, and was found to be of pale amber colour, 
 of specific gravity 1'00-i, and albuminous. It was frequently examined during his 
 illness, and varied a good deal in quantity, frequently above forty ounces in the 
 twenty-four hours, and latterly often below twenty, the specific gravity ranging from 
 1"004 to I/O 18, and the presence of albumen always clearly indicated. Diarrhoea suc- 
 ceeded an alleviation of the bronehitie symptoms, continued present for several weeks 
 in succession, and often in an aggravated degree ; the dropsical symptoms increased ; 
 there was troublesome dyspnoea ; the abdomen swelled, and became tense and fluctu- 
 ating. Paracentesis was had recourse to on the 9th December, and fourteen pints of 
 clear serous fluid, of specific gravity l - 006, and giving a copious deposit under nitric 
 acid, were drawn off. On the 11th there was general tenderness of abdomen, with a 
 very feeble pulse. This increased, and he died on the 12th. 
 
 Inspection eleven hours after death. — Head. — There was considerable serous effusion 
 in the cavity of the arachnoid and in the sub-arachnoid space. The vessels of the pia 
 mater were congested ; and there was about an ounce of serum in the ventricles of the 
 brain. Chest. — There was about a pint of reddish serum in the sacs of the pleura. 
 Both lungs collapsed and crepitated ; the right lung was in part adherent to the costal 
 pleura, but the left was free. The heart was contracted and smaller than natural ; the 
 valves were healthy, and there was no hypertrophy of the walls. About two ounces 
 of serum were found in the sac of the pericardium. Abdomen. — About ten pints of 
 serum in the cavity of the abdomen. The peritoneal covering of the small intestine 
 iied in some places a dotted red appearance, and shreds of recent coagulable 
 lymph were found upon its surface and between the convolutions of the intestine, 
 causing tender adhesions of the convolutions to each other, and to the parietes of the 
 abdomen. The peritoneal aspect of the trocar wound was cicatrised, and there was 
 no greater trace of inflammatory action around it than elsewhere on the peritoneum of 
 the anterior wall. The convex surface of the liver adhered to the diaphragm by a 
 
PATHOLOGY. 47 1 
 
 thin layer of lymph ; the organ was smaller and harder than natural, and yet presented 
 appearances of congestion. The kidneys were smaller than natural, and each weighed 
 three ounces. On removing the capsule the surface appeared of a pale Luff-colour, 
 mottled red and granular. On incising the right kidney the cortical part was also of 
 pale buff colour, with a mottling of red; it was slightly granular, and in parts en- 
 croached considerably on the tubular portion. The left kidney presented much the 
 same appearance as the right, with this exception, that the cortical portion was pale, 
 and the tubular less red. 
 
 206. Anasarca and ascites. — Urine of low density and albuminous. — Was eight times 
 tapped. — Kidneys in a state of yellow granular degeneration. — Ahmed Senna, a Mussul- 
 man beggar, thirty years of age, a native of Scinde, and originally a cowherd. About 
 three years before he came under observation he suffered from fever while in Scinde, 
 and was subsequently on several occasions affected with cederuatous swelling of the feet 
 and ankles. He denied being addicted to the use of spirits, and stated that he had 
 never taken them till two months before admission, when he was advised to do so, 
 moderately, for the relief of the dropsical symptoms. He was in the habit of smoking 
 tobacco, but not of eating opium. Four years before admission he had been the sub- 
 ject of syphilis, for which he had been salivated. He was admitted into hospital on 
 the 28th September, 1849. There was general anasarca, and the abdomen was mxich 
 swollen, tense, and fluctuating. He was under treatment in hospital till the 19th 
 January, 1851. Throughout this period the urine was generally less than twenty 
 ounces in the twenty-four hours, was pale, of specific gravity (varying with the 
 quantity) from 1-007 to 1-015, and giving a flocculent deposit, more or less copi- 
 ous, under heat and nitric "acid. From the 10th October, 1849, to the 10th No- 
 vember, 1850, he was eight times tapped, and about one hundred pints of fluid, in 
 all, evacuated. After the first tapping it was discovered that the spleen was much 
 enlarged, reaching beyond the umbilicus in the median line, and as low as the crest of 
 the ilium ; but after the latter tappings it was found to have considerably decreased in 
 size. In the months of July and August, 1850, he suffered from diarrhoea, sometimes 
 dysenteric in character ; and during this time the fluid re-accumulated slowly in the 
 abdomen. He died from exhaustion, and without coma. The treatment was very- 
 varied, consisting of purgatives, diuretics, with tonics and stimulants, but without any 
 advantage. The operation of tapping was in each instance performed at the patient's 
 urgent request, to relieve the discomfort attendant on the distention of the abdomen. 
 
 Inspection. — Abdomen. — There were about twenty-six pints of serous fluid in the 
 sac of the peritoneum. The diaphragm was pushed up by the effusion, as high as the 
 interspace between the third and fourth ribs. The liver was much reduced in size, 
 and was suspended by its ligaments, separated by a considerable interspace from the 
 concave surface of the diaphragm. Bands of old adhesions united the lower part of 
 the right lobe of the liver to the diaphragm. After detaching the liver from its con- 
 nections, it weighed twenty- eight ounces ; the external surface was pale, and its peri- 
 toneal covering opaque ; the surface was also granular, chiefly that of the left lobe ; the 
 tissue, when incised, appeared dense and compressed, and pale, — but had none of the 
 lobulated appearance of cirrhosis. The body of the gall-bladder adhered to the 
 duodenum. The spleen was of about the natural size, weighed eleven ounces, and its 
 capsule was opaque and thickened ; its texture was very indurated, and its incised 
 surface appeared red, and abundantly studded with white spots and streaks of fibrous 
 tissue. At the upper end the fibrous constituent was so abundant as to form 
 a pale indurated nodule, of about the size of a pigeon's egg. The left kidney was 
 larger than the right, and weighed about four ounces. On removing its capsule, the 
 surface appeared somewhat lobulated, mottled red and yellow, and granular; when 
 incised, it presented a surface also mottled red and yellow, but not granular; the 
 tubular portion was encroached upon by the cortical, chiefly at the central parts ; at 
 
 u n 4 
 
472 bmght's disease of the kidset. 
 
 the upper end there was a cyst, of about the size of a pea. The right kidney weighed 
 three and a half ounces ; the external and internal appearances were very similar to 
 those of the left, but more marked in character. The colon was contracted, and the 
 small intestine was gathered together in the centre of the abdominal cavity. Chest. 
 — The right lung was firmly adherent to the costal pleura, but its texture was spongy 
 and crepitating ; the left lung was also healthy. The heart was of about the natural 
 size, and weighed eight ounces ; there were some opaque patches on the surface of the 
 right ventricle ; the aortic and mitral valves were healthy. 
 
 207. Anasarca and ascites. — Urine of low density and very albuminous. — Sunk 
 under diarrhwa. — The kidneys in a state of yellow granular degeneration. — The 
 mucous coat of the colon and ileum with dotted red patches and, granular deposit. — A 
 spirit drinker. — Cirrhosis. — Shaik Abdoola, a Mussulman sailor, of thirty years of age, 
 addicted at one time to the excessive use of spirits, but not to opium or other narcotic 
 drug, had for two months before his admission into hospital, on the 28th May, 1850, 
 suffered from frequent vomiting, and latterly from oedema of the feet and legs. He 
 was received into the clinical ward on the 15th June, when the abdomen was some- 
 what full, soft, and with an indistinct sense of fluctuation, but without any induration 
 below the margin of either ribs. The feet and legs were also cedernatous, the respira- 
 tion was calm, the sounds and impulse of the heart were natural, and there was no 
 dulness on percussion of the chest ; the pulse was small and soft, the tongue moist 
 and clean. He was the subject of a large reducible scrotal hernia of the left side, 
 which had commenced three years previously. He continued under treatment till the 
 27th June, when he died. The urine in the twenty-four hours was generally above 
 fifty ounces, was clear amber-coloured, of specific gravity from 1*007 to 1*012, and 
 very albuminous. He became affected with diarrhoea, which increased, and caused 
 death by asthenia. The treatment was chiefly directed against the diarrhoea. 
 
 Inspection. — The body was emaciated. Head. — There was some serous fluid effused 
 in the sub-arachnoid space. Chest. — The lungs were collapsed and crepitating ; the 
 heart small in proportion to the body. Abdomen. — The large intestine generally was 
 contracted, — its coats were thickened. The omentum was contracted, and matted 
 over the colon. The inner surface of the large intestine was rugous and irregular, 
 dark grey coloured, variegated of different shades, with bright red patches, and spots 
 here and there, chiefly in the ccecum ; the mucous coat had a granular appearance, 
 and was firmly adherent to the subjacent coat. For a foot and a half the inner surface 
 of the lower end of the ileum presented the same appearance as the large intestine ; 
 above, for about three feet, the inner surface of the ileum was rugous, of a dark red 
 colour, with grey granular patches here and there. The portions of the ileum just 
 described occupied the large scrotal tumour. The stomach was contracted, and the 
 mucous coat was rugous, of dark grey colour, with some dark red patches, and covered 
 with adhesive mucus. The liver was granular externally, and hard under the scalpel ; 
 the left lobe was very small. The left kidney was larger than the right, — its external 
 surface was mottled red and yellow, the cortical portion buff-coloured and granular. 
 The red colour of the tubular portion was quite distinct. The right kidney presented 
 me appearances as the left. The spleen was small, and denser than natural. 
 
 208. Anasarca with ascites. — Urine of low density and generally albuminous. — Died 
 
 Kid,,/,/* .<t. mil. with cysts and excess of cortical portion. — Cirrhosis. — Thrice 
 
 admitted. —Antonio de Souza, fifty-five years of age, a Portuguese inhabitant of Goa, but 
 
 al in Bombay for about eight years, and occupied as a servant in a baker's shop. 
 
 For many years he had been in the habit of drinking about three ounces of spirits 
 
 daily; was the subject of incomplete paralysis of the right arm from his boyhood; 
 
 but, with this exception, had enjoyed g I health till about three weeks before his 
 
 ion into the hospital, on the 19th February, 1819, when he had become, con- 
 
PATHOLOGY. 473 
 
 sequent on exposure to cold, he believed, the subject of intermittent fever, which after 
 fifteen Jays was followed by dropsical symptoms. 
 
 State on Admission.— Be was somewhat emaciated, but with general anasarca, and 
 the abdomen full and fluctuating. The respiration was somewhat hurried, and there 
 were dry and moist bronchitic rales general on both sides of the chest, obscuring 
 the sounds of the heart. The pulse was feeble and somewhat frequent, the tongue 
 slightly coated, but moist, and the skin of natural temperature. During his stay in 
 hospital, the urine ranged in quantity from twelve to thirty ounces, was generally 
 clear, sometimes of acid, at others of alkaline reaction, of specific gravity from 1-007 
 to 1-017, and very generally gave a scanty flocculent deposit with heat and nitric 
 acid : this deposit, however, was sometimes absent. He continued in hospital till the 
 loth March, when he was discharged, at his own desire, with the dropsical symptoms 
 somewhat less, and the bronchitic rales considerably decreased. He was treated with 
 stimulant diuretics, of which squills was generally a constituent, and also at one time 
 the ferri-potassio tartras ; rubefacient applications were also used to the chest, He 
 applied for readmission on the 27th March. The emaciation and the dropsical symp- 
 toms had much increased ; the respiration was more hurried and oppressed, and the 
 cough more urgent ; the pulse was very feeble, and the urine very scanty. Under 
 the use of eight grains of sesquicarbonate of ammonia, a drachm of spiritus fethens 
 nitrici, with camphor mixture every third hour, and four ounces of arrack daily, and 
 an adequate diet, he speedily began to improve. The pulse gained somewhat in 
 strength, the breathing became less oppressed, the urine increased to sixty ounces and 
 upwards in the twenty-four hours, and the dropsical symptoms gradually lessened. 
 On the oth April the acetate of potass was substituted for the sesquicarbonate of 
 ammonia. The urine still increased, and the dropsical symptoms had altogether 
 disappeared by the 10th April ; on the 13th, quinine and the muriated tincture of 
 iron were substituted for the diuretic ; and he was discharged on the loth, at his 
 earnest request. The urine was in general clear, sometimes alkaline, of specific gravity 
 from 1-006 to 1-017, and was, except on one or two occasions, unaffected by heat or 
 nitric acid. He was admitted again into hospital on the 23rd October, 1849. The 
 face was puffed, the feet and legs oedematous, the abdomen swollen. He complained 
 of cough and mueo-puriform expectoration. Sounds of the heart natural, impulse 
 feeble. He stated that since his discharge from hospital he had used spirituous 
 liquors moderately, had been to Goa, and been exposed to the inclemencies of the 
 weather, to which he attributed the return of the dropsical symptoms, as well as irre- 
 gular febrile accessions, to which he was also subject. The pulse was very feeble ; 
 the asthenic and bronchitic symptoms increased. He became comatose on the 29th, 
 and died on the 30th. The urine, during the time he was under treatment on this 
 last occasion, ranged in density from 1-011 to 1-013, and was albuminous. 
 
 Inspection twenty hours after death. —Head.— The vessels of the pia mater were 
 congested, and there was more than the normal quantity of serum in the sub-arachnoid 
 space, but none in the ventricles. On incising the brain, numerous bloody points 
 appeared, but no softening was observed. Chest. — The lungs adhered firmly to the 
 costal pleura, and to the diaphragm, and when incised gave out much sero-puriform 
 fluid on pressure. The substance was crepitating, and the mucous membrane of the 
 bronchial tubes was of dark red colour. The heart was well covered with fat, chiefly 
 over the left ventricle ; the right ventricle was somewhat dilated ; the left slightly 
 hypertrophied ; no disease of the valves, but the ascending aorta was somewhat 
 dilated with opaque deposit, in parts ossific, on its inner surface. Abdomen. — There 
 was about a pint and a half of clear serum found in the cavity. The liver was some- 
 what smaller than natural, with some degree of irregularity on its external surface, 
 mottled dark red, and indurated in texture under the knife. The kidneys were 
 smaller than natural. In the cortical portion of the left kidney there were two cysts, 
 each of about the size of a small bean, but no distinct granular degeneration was 
 
474 eright's disease of the kidney. 
 
 found in any part. The cortical part of the right kidney was mottled red and buff on 
 its surface, and it somewhat encroached on the tubular portion, but it was not granu- 
 lar, and there was an appearance of commencing cysts in some places. 
 
 209. Febrile symptoms, followed by anasarca, ascites, and dysenteric symptoms. — Urine 
 of low density and albuminous. — Death by coma. — The kidneys in a state of yellow 
 granular degeneration. — The mucous membrane of 'the large intestine ulcerated, and with 
 granular exudation. — Elepa, a Hindoo shopkeeper, of fifty years of age, an inhabitant of 
 Hydrabad, in the Deccan, but for twenty -five years resident in Bombay ; not addicted 
 to the use of spirituous liquors. He stated that about two months before he came under 
 observation he left Bombay, in good health, on a pilgrimage to Nassick ; that about 
 fifteen days after his arrival there, he, consequent on exposure to wet, became affected 
 with febrile symptoms and diarrhoea, followed by cedenia of the feet and legs. He was 
 admitted into hospital on the 29th July, 1850, feeble, and reduced in flesh; the feet 
 and legs were cedematous ; the abdomen full, and with distinct sense of fluctuation ; 
 there was no dyspnoea or sign of disease of the lungs or heart ; the pulse was small 
 and thready. The day after his admission the urine amounted to fourteen ounces, 
 was pale, neutral, of specific gravity 1-010, and gave a copious flaky deposit under 
 nitric acid, but less under heat ; and such continued to be its character whilst 
 he was under treatment. On the 8th August, dysenteric symptoms set in, and he died 
 on the 17th August, having been very drowsy for twenty-four hours before death. 
 
 Inspection twelve hours after death. — Head. — There was slight turgescence of the 
 vessels of the brain, but the substance of the organ was of natural consistence. Chest. 
 — There were old adhesions on both sides, but chiefly on the right, and the base of 
 this lung was also adherent to the diaphragm. There were about two ounces of fluid 
 found in the cavity of the pericardium. The heart was small, but healthy in structure. 
 Abdomen. — There were about two pints of clear serous fluid in the sac of the peri- 
 toneum. The liver was of natural size and consistence, but its incised surface showed 
 the presence of congestion in the second degree ; upon its external surface there were 
 two or three opaque puckered patches of cartilaginous consistence. The spleen was 
 smaller than natural, and its substance healthy. The left kidney was somewhat 
 larger than the right, and on removing the capsule the external surface presented a 
 granular appearance, and was somewhat mottled. When incised, the cortical portion 
 was found to encroach upon the tubular, which was here and there of a dark red 
 colour, and arranged in distinct bundles. The right kidney was smaller in size, and 
 presented very much the same appearance as the left, with the addition of two or three 
 small cysts, of about the size of a split pea. The apices of some of the papillae were 
 also somewhat indurated, and fibrous in appearance. The rectum was contracted, and 
 its mucous membrane was thickened, and presented irregular ulcerations, the surfaces 
 of which were covered with a deposition of granular lymph. The mucous membrane 
 of the descending colon and sigmoid flexure was also ulcerated, but the ulcers were 
 more follicular in character. The mucous membrane of the remaining portion of the 
 large intestine was attenuated, and there were transverse striae of vascularity seen, 
 apparently an early stage of the inflammatory action, which in the rectum had passed 
 on to ulceration and granular exudation. 
 
 210. Vesicular emphysema of both lungs. — Displacement of the heart. — Dilatation 
 and hypertrophy of the ventricles. — Atheromatous deposit, with idecration, in the 
 aorta. — Granular degeneration of the kidneys. — Urine once noted, albuminous. — 
 Dropsy. — Rawogee Canojee, a Mahratta gardener, of fifty years of age, resident for 
 twelve years at I'arell, was admitted into hospital on the 15th October, 1850, affected 
 with dyspnoea ami oedema of the lower extremities. He had been ill for two years, but 
 no account is given of the nature of his illness. The chest, including the precordial 
 region, was preternaturally resonant ; there was faint respiration, and sonorous and 
 eibilous rales ; the impulse of the heart was most distinct at the scrobiculus cordis, 
 
PATHOLOGY. 475 
 
 and there the sounds were distinct, and no murmurs were audible. The dropsical 
 symptoms increased, and also the dyspnoea, and he died on the 4th November. The 
 urine passed during the night after admission was sixteen ounces, of specific gravity 
 1-005, and unaffected by heat and nitric acid. After the 24th it became more scanty 
 —about ten ounces in twenty-four hours ; it was of specific gravity 1-020, and gave a 
 turbid deposit under heat and nitric acid. 
 
 Inspection sixty hours after death. — Chest. — Both lungs were emphysematous, and 
 rose beyond the margins of the chest; they were soft and spongy. The -heart was 
 displaced downwards and towards the right side. Firm adhesions connected parts of 
 the surface of the heart to the pericardium, and there were opaque patches on other 
 parts of the heart's surface. The heart was enlarged from dilatation with hypertrophy 
 of the right ventricle, and hypertrophy with dilatation of the left. There were coagula 
 of blood in the left auricle and right ventricle. There was slight opaque deposit 
 towards the attached margin of the mitral valve. The aortic valves were healthy; the 
 inner coat of the aorta, from its commencement, and throughout its thoracic portion, 
 was closely studded with variously-sized patches of atheromatous deposit. At the origin 
 of the left carotid and subclavian arteries the deposit was ossific in character, and the 
 inner coat was ulcerated Jo the extent of a quarter of a rupee piece. Abdomen. — The 
 left kidney was small, the surface pale yellow, granular, in places lobulated, and the 
 tubular portion was distinctly encroached upon by the cortical, chiefly at its central 
 parts. The right kidney was of the natural size, but presented the same abnormal 
 appearances as the left. 
 
 211. Admitted in an advanced state of disease. — Hepatisation of both lungs. — Circum- 
 scribed pleuritic effusion of the right side. — Kidneys enlarged, and hi a state of yellow 
 granular degeneration. — Urine not tested. — Balloo Eagoo, aged forty, a Maratha, a 
 native of Poona, but resident in Bombay for ten years, was admitted into the Jamsetjee 
 Jejeebhoy Hospital on the 1st October, 1849, affected with diarrhoea and oppressed 
 breathing. He had been ill a month, but was unable to give any connected account 
 of his illness. On the oth October, Atmarain Pandurang, at the time an intelligent 
 student of Grant College, now a graduate, made the following note of the physical 
 signs : — " Kespiration short and hurried ; the whole of the posterior and lateral part 
 of the right side of the chest is duller than natural, and here bronchial sounds, mixed 
 with mucous rale, are heard under the stethoscope ; elsewhere on this side of the chest, 
 and in the whole of the left side, the resonance was natural, and puerile respiration 
 mixed with mucous rale is audible. There is equal movement of the two sides of the 
 chest, and the dulness noticed does not vary by change of position. The vocal thrill 
 is distinct on both sides." He died on the 7th. 
 
 Inspection fifteen hours after death. — Chest. — The inner edge of the right lung 
 adhered firmly to the pericardium, and its anterior surface from the first to the sixth 
 rib, adhered to the costal pleura by old firm adhesions. Below the foiu-th rib the ad- 
 hesions did not extend externally beyond the nipple, but above that rib they were 
 general to the lateral and posterior costal parietes, as well as to the anterior. There 
 were about thirty ounces of sero-puriform fluid in the sac of the right pleura, chiefly 
 between the base of the lung and diaphragm, and between the costal pleura and the 
 lung, below the level of the fourth rib. The costal and pulmonary pleurae were there 
 covered with flaky lymph, forming, in parts, friable bands which extended across the 
 effused fluid. The liver was displaced by the effusion, and projected below the 
 margins of the right ribs. The right lung was, in great part, in a state of red 
 induration, in parts passing into grey infiltration. The left lung adhered firmly to 
 the costal pleura ; the lower lobe was in a state of red induration ; the upper cre- 
 pitating, but oedematous. The kidneys were both enlarged and flabby, appearing 
 mottled externally on the removal of the capsule, and on incision considerable encroach- 
 ment of the tubular portion by pale yellow, slightly granular substance was evident. 
 
476 height's disease of the kidney. 
 
 212. TJie subject of intermittent fever, followed by bronchitis, and slight anasarca. — 
 Urine of low density, and very albuminous. — Moria Pheena, a Hindoo labourer, of 
 fifty years of age, an inhabitant of Benares, but for four or five years employed as a 
 labourer at Aden, which place he left about eight months before admission into 
 hospital: he had been addicted to the use of opium — ten grains daily for about eight 
 years; he smoked ganja occasionally, but did not take spirituous liquors. He was 
 admitted into the clinical ward on the 20th June, 1851 : he stated that he had been 
 the subject of intermittent fever about four months before, succeeded by cough, with 
 copious expectoration, some oedema of the arms and feet, and subsequently with swel- 
 ling of the abdomen. On admission he was a good deal reduced ; the abdomen was 
 somewhat full, and obscurely fluctuating, and there was slight oedema of the legs, 
 scrotum, and fore-arms, with puffiness of the face; the lungs and heart showed 
 no signs of disease on percussion and auscultation ; there was no induration detected 
 in the abdomen ; the pulse was small and feeble ; tongue moist ; the bowels rather 
 confined ; no pain of loins. He continued under treatment up to August 7th, with 
 no change in his state. The urine ranged in quantity from thirty to seventy ounces in 
 the twenty-four hours, in specific gravity from l'OOo to 1*015, was generally clear, 
 of pale lemon colour, neutral, and giving a copious floceulent deposit with heat and 
 nitric acid. The urine being free, and the dropsical symptoms slight, it was thought 
 advisable to try whether any impression could be made on the degeneration of the 
 kidney by cod-liver oil : he took it to the extent of an ounce, and latterly an ounce 
 and a half daily, and at the same time quinine was used twice daily in three-grain 
 doses ; but there being no improvement in the urine, or in his general state, these 
 remedies were omitted, and the syrup of the iodide of iron was substituted. This 
 was not followed by any amendment, and Dover's powder and the occasional use of 
 the warm bath were had recourse to, with lessening of the cedema of the feet. He 
 continued under treatment till the 22nd October, when he left the hospital, bavin-* 
 derived little or no benefit from treatment. He was again seen on the 21st December, 
 much in the same state as on discharge. From this time he was lost sight of till the 4th 
 April, 1853, when he was re-admitted into hospital with feeble pulse, coldish skin, puffed 
 face, cedematous feet, full abdomen. The urine, scanty and very albuminous, became 
 almost entirely suppressed, and he passed into a drowsy state, and died on the 17th. 
 
 Inspection sixteen hours after death. — Head. — There was much opaque granular 
 thickening of the arachnoid membrane, at the situation of the glandulse Pacchioni. 
 There was increased serous effusion in the sub-arachnoid sjjace, and there was about a 
 drachm of fluid in each lateral ventricle. The substance of the brain was healthy. There 
 were about three pints of reddish-coloured serum in the sac of the left pleura. The 
 left lung was compressed against the spine, and both costal and pulmonary pleurae were 
 thickened by granular lymph deposit. The right lung was cedematous, but healthy 
 in other respects. The heart did not present any abnormal appearance. The left 
 kidney was small, lobulated, granular, and pale externally. Internally the cortical 
 part encroached much on the tubular, particularly at the centre. The right kidney 
 not so pale, was more granular on the surface than the left, but in other respects Mas 
 in the same state. The liver was congested in the second degree. 
 
 213. Febrile symptoms and dropsy after exposure to cold and wet. — Traces of albu- 
 men in tin' urine, slight throughout, finally disappeared. — Addicted t<< the occasional 
 use of spirits mid opium.— Finally sunk under inert using asthenia. — Granular 
 degt ru ration of the kidneys. — Shaik Isood, a Mussulman horsekeeper, of eighteen years 
 of age, a native of Kattyawar, apparently somewhat weak in mind, and using opium 
 and spirits occasionally, was on the voyage to Bombay, two months before he came 
 under observation, for two days exposed to cold and wet. After this he began to suffer 
 from irregular febrile symptoms, generally commencing with chills, and the feet and 
 
TAUTOLOGY. 477 
 
 legs became swollen. On admission into the clinical ward on the 24th August, 1851, 
 the face was puffed, and there was some degree of oedema of the body and the extremi- 
 ties, but no swelling or fluctuation of abdomen. No signs or sj-mptoms of pulmonic or 
 cardiac disease, or of enlargement of any abdominal viseus. The pulse was small, the 
 bowels confined, and the urine free. On the 26th the urine had been thirty ounces in 
 the preceding twenty-four hours, was of pale amber colour, neutral, and specific 
 gravity 1-015, and became slightly turbid, by heat and nitric acid. He was treated 
 with Dover's powder five grains, quinine two grains, ipecacuanha half a grain, every 
 fourth hour for four times. This was continued, with the occasional use of warm 
 baths, and one dose of castor-oil, till the 2nd September. There was generally 
 sweating after the bath, the febrile symptoms ceased to recur, the dropsy lessened. 
 The urine from thirty to fifty ounces, specific gravity 1*011 to T015, now showed a less 
 degree of turbidity under heat and nitric acid. The same treatment, with substitution 
 of six grains of nitre for the quinine, was continued tiU the 8th, when the dropsical 
 sjmiptoms were gone, and the urine, unchanged in other respects, ceased to give traces 
 of albumen. The warm bath was still occasionally used, and fifteen miliums of the 
 tincture of the sesquichloride of iron was now substituted for the powders. He con- 
 tinued in the clinical ward till the 12th October, gaining strength slowly, but without 
 return of fever or of dropsical symptoms, and with the urine free of albumen. There 
 was occasional!}' turbidity by heat, but it disappeared with effervescence, on addition 
 of nitric acid. Latterly, ten minims of the compound tincture of iodine had been 
 added to the tincture of iron. From this date he continued in another ward of the 
 hospital, till the 5th April, without any regidar record of the symptoms. Then 
 imbecility of mind is noted, with occurrence of febrile disturbance, painful swelling of 
 the left lower extremity, and pain of loins. He was with difficulty persuaded to keep 
 his urine, which on the 11th was reported to be clear and high coloured, of specific 
 gravity l - 020 and almost unaffected by heat, but showing a dark brown colour on ex- 
 cess of nitric acid. On the 15th, uneasiness of the cardiac region was complained of, 
 and the pidse was weak and irritable : no signs of cardiac disease were detected. He 
 now became affected with diarrhoea ; sank rapidly, and died on the 17th. 
 
 The inspection after death was made by Dr. Forbes Watson, the Curator of the 
 Museum, and the following note is abridged from his description. 
 
 Inspection. — Head. — On removing the scalp, a small ideerous opening was detected 
 over the right parietal protuberance. Opposite to it the bone was absent for the space 
 of a circle an inch in diameter. The foramen was found to be filled with dense fibrous 
 tissue, about quarter of an inch in thickness, and adherent pretty firmly to the dura 
 mater. At this situation the brain felt less elastic, but did not present any abnormal 
 appearance. Chest. — Slight adhesions existed between the left pleural surfaces at 
 their lower part, but otherwise no disease of the lungs. The heart was healthy. 
 Abdomen. — The liver rather increased in size; the external surface rouo-h, and the 
 surface of an incision mottled. The mucous membrane of the large intestine, and of 
 the ileum, about Peyer's glands, was more vascular than natural. The size of the kid- 
 neys is not noted. On removing their capsules, the surface was granular, and of brick- 
 red colour, and the texture was friable. These appearances were more remarkable in 
 the left kidney. A section showed encroachment of the cortical on the tubular portion 
 and some fat was found in the pelvis, about the mammary processes. A portion of the 
 healthy tubular part adjoining the cortical was examined under the microscope. The 
 tubuli were distinctly made out in several parts, but only an occasional fat molecule 
 detected. The cortical part showed mxdtitudes of granular cells, and an occasional fat 
 granule. 
 
 214. — Dropsical symptoms with diarrhoea, following exposure to cold and int. 
 
 Urine very albuminous. — Drowsiness co-existing with sinking pulse, removed by , 
 
 lanfs, did not recur. — Diath by exhaustion. — Kidneys large and granular. Spirit 
 
 drinking not admitted. — Abdoolla, a Mussulman Lascar, of thirty-five years of age, 
 
478 bmght's disease of the kidney. 
 
 and in indigent- circumstances, abstaining, according to his own statement, from the 
 use of opium and spirits. Three months before he came under treatment had suffered 
 from oedema of the feet, removed by the remedies used, and oue month before his 
 admission on the 16th September, 1851, into the clinical ward, he, consequent on ex- 
 posure to wet and cold, became affected with diarrhoea, uneasiness of the right iliac 
 region and loins, oedema of the feet and scanty urine. On admission, he was con- 
 siderably reduced. The feet and legs were cedematous. The abdomen somewhat full, 
 but without fluctuation. No signs or symptoms of pulmonic disease. The impidse of 
 the heart was feeble, but the sounds normal. Hepatic dulness reached half an inch 
 below the the margin of the ribs. The pulse was small. The tongue clean but glazed. 
 The bowels relaxed. The urine scanty, high-coloured and very albuminous. He con- 
 tinued under treatment till the 23rd October, when he died. Throughout the diarrhoea, 
 with more or less abdominal uneasiness, persisted. From the 26th September, febrile 
 symptoms began to appear, and frequently recurred. On the 22nd September the 
 pulse became very small, and there was drowsiness, which, removed by stimidants, 
 did not again return. The urine, examined daily, was sometimes of brownish tint, at 
 others amber coloured. At first the quantity was below twenty ounces. After the 
 1st October it ranged from twenty to thirty ounces. The specific gravity was always 
 below 1*018. The albumen was throughout very copious, often filling half the tube, 
 and latterly there was some degree of bronchitis. He died exhausted, without coma. 
 He was treated with quinine and opium and stimulants. 
 
 Inspection seven hours after death. — Chest. — About one pint of serum was found in 
 the left, and half a pint in the right cavity of the pleura. The middle lobe of the 
 right lung was somewhat emphysematous, and firmly adherent to the costal pleura by 
 old adhesions. The rest of the lungs was healthy and crepitating, excepting the 
 upper part of the upper lobe of the left lung, which was compressed. Abdomen. — 
 About two pints of serous fluid were found in the cavity. Firm adhesions connected 
 the convex surface of the liver to the diaphragm. The peritoneal surface presented 
 generally an opaque appearance, and the surface of the viscus was of a yellowish (not 
 mottled) colour. The right lobe was larger than natural. When incised the surface 
 had also a general yellow colour, was not mottled, and had a smooth appearance. Its 
 texture was rather soft. The mucous membrane of the ileum was healthy. No 
 enlargement of Peyer's glands or ulceration anywhere. In the mucous membrane of 
 the large intestine, viz., part of the transverse, and the whole of the descending, colon, 
 the sigmoid flexure, and rectum, numerous small, circular, follieidar ulcers were seen 
 scattered here and there ; some completely cicatrised and others in process of ciatrisa- 
 tion. No ulceration could be detected in the ascending colon or in the ccecum. The 
 right kidney was very large ; it weighed six and a half ounces. When divested of its 
 capsule it presented a somewhat lobulated, granular surface, of a generally buff 
 colour, with small red patches here and there. When vertically incised, the cortical 
 portion presented also a buff mottled granular surface, encroaching upon the tubular 
 portion, chiefly at the central parts. The tubular portion, where not destroyed, was 
 distinct and of a reddish colour. The left kidney was similar in colour and appear- 
 ance to the right, both externally and when incised, but there was more of encroach- 
 ment upon the tubular portion by the buff granular cortical part. It weighed seven 
 ounces. Under the microscope a small portion scraped from the yellow granular sub- 
 stance showed an amorphous granular appearance. No oil globules. 
 
 215. Syphilis, primary and secondary. — Mercurial influence. — Slight dropsy. — 
 Albuminous urine, pain of loins, dysentery. — Fatal. — Bright' s disease. — Ulceration 
 and granular (.nidation mi intestinal mucous membrane. — Cirrhosis. — A cretified guinea- 
 worm encysted between the right lung and the pericardium. — Shaik-Hussain-Adam, 
 a .Mussulman drummer, a na1ivo of Madras, of thirty-five years of age, and using 
 spirits habitually to the extent of two ounces daily, suffered from primary syphilis, for 
 
PATHOLOGY. 479 
 
 which he was salivated fire years before he came under observation. From this time, 
 however, till six months ago, his health had been good; then he experienced irregular 
 febrile accessions, with much pain of the limbs, particularly of the tibise. For these 
 symptoms he was received into the hospital ; and while under treatment, orchitis 
 came on, the 21st June, 1853, relieved by leeches, succeeded on the 25th by pain of 
 loins and scanty urine, which on examination was found to be albuminous. He was 
 transferred to the clinical ward on the 28th. Reduced in flesh, with cedema of the face 
 and feet, pulse of moderate volume and jerking ; no signs of cardiac disease, but bron- 
 chitic rales were audible in different parts of the chest. The liver was felt below the 
 ribs, and the spleen was enlarged. The pain of loins, testes, and joints continued. There 
 was slight heat of skin, with venous murmurs above the middle of the clavicles. The 
 appetite was impaired, and he vomited occasionally. On the 1st July the urine was 
 fourteen ounces, of Hght amber colour, and gave a deposit with heat and nitric acid. 
 Under the occasional use of the warm bath, infusion of chiretta and diluted nitric 
 acid, or the tincture of the sesquichloride of iron, there was lessening of the dropsical 
 symptoms and some degree of general improvement up to the 15th, when dysenteric 
 symptoms began to show themselves, and an abscess to form in the left natis, 
 associated with frequent febrile accessions. Under these complications he sank without 
 drowsiness, and died on the 27th July. The vomiting had been troublesome 
 throughout. The urine had ranged from sixteen to thirty-eight ounces, specific gravity, 
 1-007 to 1-012, and was always albuminous. 
 
 Inspection nineteen hours after death. — There was not any effusion into the sac 
 of the peritoneum. The kidneys weighed about four ounces each. The external 
 surface was mottled red and white. The cortical portion encroached upon the tabular, 
 and the latter was in some places indistinct, and in others spread out and ex- 
 panded. The liver weighed 2 lb. 6 oz. There was much atrophy of the left lobe, and 
 the external surface had an irregular puckered aspect. The mucous membrane of the 
 end of the ileum ascending, transverse, descending colon and rectum presented a 
 mottled brown and red granular appearance. There was extensive sloughy idceration 
 of the mucous membrane of the coecum, and the tissue around was dark red, almost 
 black in colour. Peyer's glands were not enlarged. The pleural and pericardial sacs 
 were free of effusion. The lungs were crepitating but did not collapse. Between the 
 inner surface of the middle lobe of the right lung and the pericardium, and connected 
 to both by areolar tissue, there was an indurated tubular-looking body about three 
 inches long, and much convoluted at one end. It resembled a guinea-worm. The 
 large bronchial tubes contained frothy mucus, and their lining membrane was vascu- 
 lar. There was congestion of the left lung. The heart was abnormally small — 
 concentric hypertrophy of the left ventricle — no disease of the valves. 
 
 Remark. —The cretified guinea- worm, situated between the lung and pericardium, 
 is of interest. It is not unusual to find them in this state in subcutaneous areolar 
 tissue in the dissecting-room of Grant Medical College. 
 
 216. Dysentery, dropsy. — Albuminous urine, with fat globules, in an old spirit 
 drinker and opium eater. — Fatal. — Ulcerated intestines. — Kidneys enlarged. — Fatty 
 degeneration. — Baldeen Pectum, aged sixty, a Hindoo barber, a native of Lucknow, 
 and residing for the last twenty years in Bombay, drinking spirits freely in his early 
 youth, and using opium occasionally in more advanced age, became affected with 
 diarrhoea six months, followed by scanty urine and dropsical symptoms one month, 
 before admission into hospital, on the 27th September, 1853. He was emaciated. The 
 countenance was anxious and puffed. The upper and lower extremities were (Edema- 
 tous. The abdomen resistant, and uneasy on pressure in the course of the colon. The 
 diarrhoea persisted. Had cough, but no signs of cardiac disease. The pidse was 
 hardly perceptible and the skin coldish. On the 2nd eight ounces of urine of light 
 amber colour, and specific gravity 1-010, gave a copious white precipitate by heat and 
 
480 bright's disease of tiie kidney. 
 
 nitric acid. He continued to sink under the diarrhoea, and died on the 8th October 
 without coma. The urine continued albuminous and scanty, and showed epithelial 
 cells and abundant fat globules under the microscope. 
 
 Post mortem examination three hours after death. — Body emaciated. Chest. — 
 There were firm old adhesions of the lungs on botli sides all around. The right lung 
 was very cedematous, in parts hepatised, and broke down under the fingers. The left 
 lung was spongy and crepitating. There was about an ounce of fluid in the cavity of 
 the pericardium. Heart diminished in size. The cavities were contracted and the 
 valves healthy. On the anterior surface of the right ventricle there was an opaque, 
 white, membranous patch the size of quarter of a rupee. Abdomen. — There 
 were about eight ounces of turbid serum in the cavity of the abdomen. The in- 
 testines collapsed. The peritoneal surface of the intestines had an opalescent ap- 
 pearance ; but no trace of inflammation was observed on the peritoneal surface of the 
 anterior wall of the abdomen. There were large ulcerated patches here and there on 
 the mucous membrane of the large intestine, evidently consequent on the separation of 
 sloughs. About a foot of the mucous membrane of the ascending portion, and the 
 commencement of the transverse colon, was in a dark grey and sloughy state. Similar 
 disease was observed in the ccecum and also at the end of the rectum. There was 
 redness of the mucous membrane of the ileum, as well as other parts of the small in- 
 testine ; but no softening or ulceration observed. The stomach was distended, 
 reached across the abdomen into the right hypochondriac region, and occupied half the 
 space between the margins of the right false ribs and the right crest of the ileum. The 
 mucous membrane of the stomach was healthy. The liver was not enlarged. It was 
 of a dark brown colour both externally and internally. The right kidney weighed 
 eleven ounces ; externally it was of a pale yellow colour and lobulated ; when incised, 
 thesiu-face presented, for the most part, a pale yellow granular appearance ; the tubular 
 portion had disappeared, except at the ends of the kidney, where there remained two 
 or three bundles of bright red colour. The left kidney weighed nine ounces, and the 
 morbid appearance was the same as that of the right kidney, with the exception of the 
 tubular portion, which was more abundant and still present in the body of the organ. 
 The scrapings of the surface, placed under the microscope, showed epithelial cells 
 abounding with fat globules, similar to those observed two days before death in the 
 urine. The spleen was somewhat increased in size, and the structure was found to be 
 firm and hard on incising it. 
 
 217. Dropsy. — Albuminous urine. — Death from dysenteric symptoms. — Kidneys cn- 
 larged, with fatty degeneration. — Redness in patches of the intestinal mucous lining. — 
 Habits not known. — Chimajee, a Hindoo horsekeeper, of thirty years of age, and of 
 whose habits there is no note, after two months' illness, was admitted into hospital on 
 the 4th June, 1852. The face was puffed, the feet and legs cedematous, and the abdo- 
 men tumid and fluctuating. He also suffered from febrile symptoms. The urine was 
 scanty, of specific gravity TO 17, and gave a copious flocculent deposit with heat and 
 nitric acid. It was tested several times and always found to be albuminous. He be- 
 came affected with diarrhoea, lost strength rapidly, and died on the 17th June, without 
 head symptoms. 
 
 Inspection thirteen hours after death by Mr. Carvalho. — Chest. — Both lungs were 
 Collapsed. The whole of the middle lobe of the right lung and the posterior part of 
 the first and third lobes were in a state of red hepatization and easily lacerable. 
 There was congestion of the posterior parts of the left lung, but no hcpatisation. The 
 hear! was normal in size and structure. Abdomen. — The liver was about the natural 
 size and of normal structure. The mucous membrane of the lower end of the ileum, 
 and of the whole of the colon, was of dark grey colour, with streaked patches of rednei s 
 here and there, chieflyat the end of the ileum and rectum. No ulceration, thickening, 
 or enlargement of the follicles. Both kidneys were considerably enlarged. The 
 
PATHOLOGY. 4S 1 
 
 right weighed eleven and a half ounces, the left eleven, when denuded of their 
 capsules. Both, when incised, presented a similar appearance. The cortical substance 
 was found considerably augmented, pale yellow, fatty-looking, and encroaching 
 much on the tubular structure which was of reddish colour. Under a cursory 
 examination with the microscope numerous fat globules were apparent. The spleen 
 was somewhat enlarged in size. 
 
 Under the continuance of Bright's disease, the quality of the 
 blood is changed. The albumen and the red corpuscles decrease, 
 the water increases, and an excess of urea is present. The urine 
 may be defective, normal, or increased in quantity; and may 
 contain varying proportions of albumen, be deficient in urea, and 
 of diminished density. 
 
 Dropsy is of frequent occurrence. Some degree of anasarca and 
 ascites was present in forty-six of my cases. The effusion may 
 take place under two sets of circumstances. 1. In the early 
 stages of the disease, while yet there is no deficiency of blood in 
 the system, from the decided application of cold to the sur- 
 face of the body. 2. In advanced stages, when cachexia is 
 apparent, the blood watery, and all the actions of the system 
 manifestly enfeebled. The occurrence of dropsy in these latter 
 conditions is also very generally favoured by abstraction of heat 
 from the surface of the body. My cases chiefly, though not 
 exclusively, illustrate this second form. 
 
 In estimating the relation of dropsy to Bright's disease, we must 
 not lose sight of the fact, that the structural changes throughout a 
 considerable part of their progress are unattended by this symptom. 
 Cases observed by me in the European General Hospital and re- 
 ported in the chapters on Fever, Dysentery, and Hepatitis, con- 
 firm this truth. 
 
 The relation of Bright's disease to head symptoms — drowsiness, 
 coma, convulsion — has been much dwelt upon by all observers in 
 European countries, and is supposed to substantiate a pathological 
 theory. 
 
 Head symptoms — drowsiness, or coma — were present in eight 
 of my cases. In four * there was general exhaustion sufficient to 
 explain these symptoms. In one (214) the drowsiness was not at 
 the close of the disease, but some days previously, associated with 
 failing pulse, and removed by stimulants. In two there were febrile 
 symptoms of that kind, which not unfrequently lead to drowsiness 
 and coma, irrespective of kidney disease. In one (203) there was 
 complication of heart disease to which the head symptoms were as 
 fairly chargeable as to the affection of the kidney. 
 
 * Of these, three, 208, 209, 212, are detailed. 
 I I 
 
482 bright's disease of the kidney. 
 
 Nor do my cases confirm the opinion, that when head symptoms 
 take place, they may be explained by the existence of intercranial 
 serous effusion. I have already shown* that increased serous 
 effusion in the cranium, without head symptoms, is a common 
 occurrence in India ; and of my twenty post-mortem examinations 
 of Bright's disease, there are three (204, 205, 207) in which 
 increased intercranial effusion existed without head symptoms. 
 
 The relation of Bright's disease to structural change of the 
 heart, has also been much insisted on. Not only has valvular 
 disease been observed, but hypertrophy of the left ventricle f , 
 without affection of the valves or of the aorta, has also been 
 noticed, and regarded in the theoretic pathology of this disease. 
 Complication of cardiac disease existed in six of my cases, and 
 in one the aorta alone was affected. In two % of the six cases 
 there was aortic disease, but the subject of one had followed the 
 occupation of a diver, and the heart affection, more particularly 
 the dilatation of the right ventricle, was probably as much due to 
 this as to the aortic lesion. In one (210) of the six cases, there 
 were old pericardial adhesions, and considerable emphysema of the 
 lungs. In three there was disease of the mitral valve, and the 
 subjects of two had formerly suffered from rheumatism. I have 
 not met with a single instance of simple hypertrophy of the left 
 ventricle. My observations, then, do not show a very frequent or 
 evident relation between cardiac and renal disease ; and a similar 
 inference may be drawn from the facts stated by me in a subse- 
 quent chapter on pericarditis and organic affections of the heart. 
 As bearing on this question, I would refer to two of my cases, in 
 which an anaemic cardiac murmur was present. That this symp- 
 tom should occasionally occur in a disease characterised by deterio- 
 rated blood is very probable, and the fact suggests a caution lest 
 anaemic be mistaken for organic murmur ; an error the more likely 
 to arise when the mind of the observer is fully preoccupied with 
 the idea, that disease of the heart is a very frequent sequence of 
 Bright's disease of the kidney. 
 
 Various other secondary affections have been observed in the 
 course of this disease — as pleuritis §, pericarditis, bronchitis, 
 
 * Chapter on Remittent Fever, p. 90. 
 
 t Dr. Bright, in the First Volume of Guy's Hospital Reports, records this state of 
 22 cases in 100. 
 
 \ Cases 203, 208. 
 
 § The relation of puriform pleuritis and peritonitis, secondary on hepatic al 
 to the cachexia of Bright's disease, has been already suggested in the chapter on He- 
 patitis, p. 359. 
 
PATHOLOGY. 483 
 
 pneumonia, peritonitis, cirrhosis, diarrhoea, and dyspeptic symp- 
 toms. Of all these, occasional instances have come under my 
 notice. 
 
 The morbid actions in the kidney which lead to disorganisation 
 by deposits internal or external to the tubuli, and their ulterior 
 changes, may be fairly attributed to a degenerate state of the pro- 
 cesses by which constituents of the blood, in the renal capillaries, 
 are assimilated to tissue, or appropriated to secretion. This 
 abnormal action may be dependent on a pre-existing altered con- 
 dition of the blood, the precise nature of which is unknown, but 
 which forms part of those states of the system to which the 
 terms "asthenic" and "cachectic" are applied. The morbid 
 changes in the kidney will doubtless be favoured by the capillary 
 circulation becoming the seat of inflammation. It is very pro- 
 bable that, when the structural lesion has taken place apart 
 from well-marked cachexia, inflammatory action has been an 
 operative condition. 
 
 The opinion that the organic change of the kidney is the result 
 of a blood-poison seeking for local elimination, is altogether 
 hypothetical, and hardly accordant with the fact of relation to 
 various and different cachectic conditions which even a toxcemic 
 theory of disease must attribute to separate poisons. 
 
 That the dropsical, cerebral, cardiac, and other secondary affec- 
 tions are dependent upon urcemia, is another favourite pathological 
 theory. It is sufficiently plausible, and may ultimately prove 
 correct ; but I cannot avoid the conclusion, that it has been in- 
 ferred from very insufficient premises, and too hastily and generally 
 adopted. It may be admitted that when a part of the secreting 
 structure of the kidney has become unfit, excess of urea in the 
 blood, and defect in the urine, are probable sequences ; but at the 
 same time it should be borne in mind, that when an important 
 organ becomes gradually unfit for function, then all the other 
 actions of the system gradually harmonise with this defect. The 
 lungs slowly unfitted by tubercular deposit, or the liver by cirr- 
 hosis, does not lead to excess of carbonic acid, or 01 bile in the blood, 
 but to an anaemic state of the general system. The blood is by 
 degrees reduced to the quantity which these imperfect organs are 
 capable of depurating. For a similar reason, when the kidney 
 becomes gradually disabled, it follows that there will be defect of 
 urea in the urine, but by no means, necessarily, excess of this 
 excretion in the blood. On the contrary, the inference from 
 analogy is, not that there will be excess of urea in the blood, 
 
 I I 2 
 
484 bright's disease of the kidney. 
 
 but that the blood will be brought down to that quantity which 
 the kidney is competent to purify. 
 
 But chemistry has detected urea in excess in the blood in 
 Bright's disease. On this point the questions may be put : («) what 
 proportion do the cases, in which the blood has been analysed by 
 competent inquirers, bear to the total number of cases of Bright's 
 disease which have been clinically studied? (b) Has care been 
 taken, in selecting cases for analysis, to discriminate the recent 
 from the advanced, the rapidly from the slowly-occurring struc- 
 tural lesions? (c) There are cachectic states from malaria, scurvy, 
 mercury, syphilis, insufficient food, &c, in which the secondary 
 affections, noted in Bright's disease, also occur. What amount of 
 information do we possess in respect to the proportion of urea in the 
 blood and in the urine, in these varied and frequently-occurring 
 conditions? (d) Moreover, the cerebral and dropsical symptoms 
 do not usually take place in chronic cases till the advanced 
 stages of the renal affection have arrived. When dropsy occurs 
 earlier, it, as well as many of the other secondary phenomena, may 
 be removed by treatment and remain absent for months or years. 
 Yet all this time the urine is albuminous, and in theory there is 
 uraemia, but why is the poison quiescent ? 
 
 Frerichs, appreciating this latter difficulty in regard to the 
 secondary nervous affections, has propounded the theory that urea 
 does not, while in that state, exercise a poisonous influence, but 
 only after decomposition and formation into carbonate of am- 
 monia. This theory, to be good for anything, will require to be 
 extended in its application to all the other secondary affections 
 which pathologists have, equally with the head symptoms, attri- 
 buted to uraemia. 
 
 It is consequent on reflections such as these that I have ven- 
 tured to suggest that the uraemic theory of the secondary affec- 
 tions of Bright's disease has been too hastily adopted, and on data 
 altogether insufficient for the logical affirmation of an important 
 pathological doctrine. 
 
 The facts as they now stand relative to the kidney-degeneration 
 itself, and the secondary affections which attend on it, seem to 
 me merely to afford another illustration of that general law on 
 which I have already so frequently insisted, viz., that structures 
 in cachectic states are apt to be injured and unfitted for function 
 by degenerate processes of assimilation ; and that, when this occurs 
 in an important organ, the effect must be to aggravate the cachexia 
 by reducing the blood and the actions dependent on it to a degree 
 
PATHOLOGY. 485 
 
 proportionate to the impairment of the organ. Further, that in 
 cachectic states, various secondary affections are apt to arise, under 
 the influence of slight, sometimes even without appreciable, ex- 
 citing causes.* 
 
 That special structural changes may, at some future time, be 
 proved to be related to special cachexia? is very probable ; but this 
 advance in science can only be achieved by time and a far more ex- 
 tended range of investigation than has as yet been applied to these 
 subjects. The hasty generalisations, too characteristic of patho- 
 logical inquiry of late years, serve to retard sure and steady pro- 
 gress, and to detract from the philosophy of medical research. 
 
 Having in view, in the remarks which have just been concluded, 
 the uraemic doctrines which have been applied to the pathology 
 of the secondary affections of Bright's disease, I have confined my 
 observations to the supposed alteration of the blood in respect to 
 the proportion of urea ; but the blood is also said to be defec- 
 tive in its proportion of albumen, in the ratio of the excess 
 of the albumen in the urine, (a) It may perhaps be inquired 
 whether, in thus relating the loss of albumen in the blood to 
 the gain of albumen in the urine, sufficient attention has been 
 given, in the cases submitted to analysis, to the fact of presence or 
 absence of dropsical effusion ; for surely when dropsy is present, 
 deficiency of albumen in the blood may more fairly be attributed 
 to its presence in the effusion than to its transudation into the 
 urine, (b) Again, is it not likely that deficiency of albumen in the 
 blood will be found equally characteristic of other dropsies as of 
 renal dropsy ? (c) Further, is it not probable that much of the 
 deficiency of albumen in the blood may be attributable to the co- 
 existing anaemic state ? (d) In a word, pathologists in explaining a 
 defect of albumen in the blood in Bright's disease, seem to lay 
 
 * That when an important organ is structurally unfit, the co -existing cachexia may 
 favour one secondary affection rather than another, is very true and very intel- 
 ligible. In malarious and scorbutic cachexise, secondary dysentery or dropsy are 
 sufficiently common, but when certain structural changes of the liver co-exist, there is 
 still greater liability to secondary dysentery and ascites, in consequence of the obstruc- 
 tion to the portal circulation. When heart disease co-exists with cachexia, general 
 dropsical effusions more certainly take place. When we recollect the function of the 
 kidney in regulating the proportion of water in the blood, there need be no difficulty 
 in understanding why a cachexia, attended with certain structural changes of this 
 organ, should have more of secondary dropsical affections than cachexias unassociated 
 with this structural change ; but I am unable to appreciate the necessity of calling in 
 the aid of a special toxceinia, in explanation of the dropsy of Bright's disease, more 
 than in that of the many other pathological states with which this symptom is also 
 often associated. I shall have to return to the subject of dropsy in a subsequent chap- 
 ter, which may be considered in reference to my observations now made. 
 
 I I 3 
 
486 BRiaHT's DISEASE OF THE KIDNEY. 
 
 chief weight upon one event — albumen in the urine — to the 
 exclusion of other co-efficient events — dropsical effusion, and 
 general anasmia. 
 
 The supposed accordance of the latest theory of urinary secre- 
 tion, and albumen in the urine in Bright's disease, is certainly not 
 exempt from difficulty and doubt. In regard to normal secretion 
 it is assumed that the peculiar arrangement of the capillaries of 
 the Malpighian bodies leads to an abrupt retardation in the velo- 
 city of the current of the blood passing through them ; by which, 
 and by the aid of cilia, facility is given to the escape, by transuda- 
 tion, of the water of the blood from the Malpighian capillaries. It 
 escapes without albumen. In regard to the presence of albumen 
 in Bright's disease, it is argued that defect of the processes be- 
 tween the blood external to, and the epithelial cells internal to, 
 the cortical tubuli, leads to retardation of the blood in the Mal- 
 pighian bodies behind; hence transudation of the serum of the 
 blood takes place, just as obtains in a dropsical effusion from 
 venous obstruction. We are further told that after a time under 
 this deranged action the walls of the Malpighian capillaries be- 
 come thickened.* In the early stages of the disease when the 
 urine is scanty, and the Malpighian capillaries, we may assume, as 
 yet unthickened, this explanation of the proximate cause of albu- 
 men in the urine is perhaps satisfactory. But when we refer to 
 the advanced stages, when the urine is more than normal in quan- 
 tity, and the walls of the Malpighian capillaries are said to be 
 thickened, the explanation fails to convince, for it is not in accord- 
 ance with the theory of normal secretion. In Bright's disease 
 with excess of urine there must be a continuous current through 
 the capillaries as in the healthy state ; but in the latter we have a 
 condition of the capillary walls more favourable to transudation, 
 yet the albumen is retained, and only transudes when the condi- 
 tion of the capillary walls is, from hypertrophy, less favourable for 
 the process. It seems to me, however, that this difficulty rather 
 invalidates Mr. Bowman's theory of the function of the Malpighian 
 bodies than the explanation of the albuminous urine ; for in order 
 to complete the theory of urinary secretion, advanced by this dis- 
 tinguished physiologist, is it not necessary to show some reason 
 why, under circumstances described as so favourable to transuda- 
 tion, the albumen is retained during the process which is supposed 
 to take place normally in the Malpighian capillaries ? Is there 
 
 * "On the Diseases of 1 lie Kidney : " London, 18-52. By George Johnson, M.D., 
 p, 240. 
 
CAUSES — PREDISPOSING AND EXCITING. 
 
 487 
 
 any other instance of free transudation, through, thin capillary 
 Avails, in which the water of the blood is not accompanied by a 
 portion of the albumen ? 
 
 Section III. — Etiology. — Scarlatina not influential in India. — 
 Relation to Caste, Age, Occupation, Habits, Season. — Cold 
 an exciting cause sometimes of the Kidney Disease, gener- 
 ally of the Secondary A feet ions. 
 
 The frequent occurrence of dropsy, with albuminous urine, during 
 convalescence from scarlatina, and the history of occasional cases of 
 Bright's disease in European countries, have suggested the idea 
 that scarlatina may be related, as a cause, to Bright's disease. 
 This may be true of these countries, but it cannot be of India ; for 
 I have elsewhere * stated that there, scarlatina, if not altogether 
 unknown, is undoubtedly very rare. 
 
 The native population of Bombay is very varied and fluctuating, 
 and includes all castes, and the inhabitants of different and widely 
 separated countries. This is well shown in the following classi- 
 fication of my fifty-eight cases of Bright's disease. 
 Hindoos, 19 — natives of the following districts : — 
 
 Bombay 
 Concan 
 
 . 4 
 
 . 2 
 
 Mooltan 
 Benares 
 
 
 
 
 . 1 
 
 1 
 
 Deccan 
 
 . 2 
 
 Lueknow ... .1 
 
 Cuteh . .-. 
 Jeypoor 
 
 . 1 
 . 1 
 
 Country not stated . . 7 
 
 Mussulmans, 22 — from 
 
 
 
 Bombay 
 Concan 
 
 . 2 
 . 1 
 
 Scinde 
 Mooltan 
 
 
 
 
 2 
 
 1 
 
 Deccan 
 
 2 
 
 Khorassan 
 
 
 
 
 1 
 
 Cuteh 
 
 . 1 
 
 Lueknow 
 
 
 
 
 1 
 
 Kattywar 
 Guzerat 
 
 . 1 
 . 1 
 
 Cabool 
 
 Arabia 
 
 
 
 
 1 
 1 
 
 Bengal 
 
 . 2 
 
 Africa 
 
 
 
 
 1 
 
 Madras 
 
 . 1 
 
 Not stated 
 
 
 
 
 3 
 
 Par sees, 8 — from Bombay and Surat. 
 Christians, 9 — chiefly Portuguese, from Goa. 
 
 From this statement it is evident, that the frequency of Bright's 
 disease in Bombay is not attributable to the influence on the 
 native resident population, of the example of the lower classes of 
 Europeans who frequent the port. It rather justifies the belief 
 that further inquiry will show that this disease prevails in certain 
 classes of the varied tribes and natives of Asia and Africa, as 
 well as of Europe. 
 
 * Chapter on Eruptive Fevers, p. 199. 
 114 
 
488 
 
 BRIGHT S DISEASE OF THE KIDNEY. 
 
 The ratio per cent, of these fifty-eight cases in the different 
 castes stands thus : — 
 
 Mussulmans 36 -9 per cent. 
 
 Hindoos 327 „ 
 
 Christians ....... 155 „ 
 
 Parsees 13"2 „ 
 
 But in order to determine whether these data suggest the pro- 
 bability of a greater prevalence in one caste than another, it is 
 necessary to show the ratio of the hospital admissions of these 
 castes. It is as follows : — 
 
 Hindoos 33-9 per cent. 
 
 Mussulmans 28-9 „ 
 
 Christians 16-2 „ 
 
 Parsees ....... 6 - 8 „ 
 
 On comparing these two ratios we find that they show the great- 
 est proclivity to Bright's disease in Parsees and Mussulmans. In 
 the ratio of castes to the hospital admissions, females are not 
 included ; but the women of all castes are 14 per cent. ; and of 
 the fifty-eight cases of Bright's disease, two were females, which 
 is 3*4 per cent. But these data do not justify any inference 
 relative to sex, because my clinical researches were pursued chiefly 
 in the male wards of the hospital. 
 
 In classifying my cases with reference to age, occupations, habits, 
 and season, the following results appear : — 
 
 AGES. 
 
 From 15 to 20 3 
 
 „ 21 „ 30 27 
 
 ., SI „ 40 16 
 
 „ 41 „ 50 ...... 8 
 
 „ 51 „ 00 2 
 
 Not stated 2 
 
 58 
 
 Baker . 
 Barbers 
 
 Beggars 
 Cooks 
 Coachmen 
 Diver 
 Hakeems 
 House painter 
 Labourers 
 Liquor sellers 
 
 CCVPA 
 
 TIONS. 
 
 1 
 
 Pilgrims 
 
 2 
 
 Sailors . 
 
 3 
 
 Servants 
 
 8 
 
 Sepoys . 
 
 8 
 
 Shopkeepers 
 
 1 
 
 Weavers 
 
 2 
 
 Writers 
 
 1 
 
 Women 
 
 7 
 
 Not stated 
 
 3 
 G 
 2 
 2 
 2 
 2 
 2 
 2 
 2 
 
 58 
 
CAUSES — rREDISrOSING AND EXCITING. 
 
 489 
 
 Spirit drinkers 
 
 Opium eaters 
 
 Ganja smokers. 
 
 Spirit drinkers and opium eaters 
 
 Spirit drinkers and ganja smokers 
 
 20 
 4 
 4 
 
 7 
 2 
 
 Spirits, opium, and ganja 
 Not stated .... 
 Denied use of spirits or narcotics 
 
 1 
 
 11 
 
 9 
 
 58 
 
 MONTHS OF ADMISSION. 
 
 6 
 
 August . 
 
 5 
 
 2 
 
 September 
 
 16 
 
 2 
 
 October 
 
 11 
 
 2 
 
 November 
 
 4 
 
 2 
 
 December 
 
 3 
 
 4 
 
 
 . — 
 
 1 
 
 
 58 
 
 January 
 February 
 
 March 
 
 April 
 
 May 
 
 June 
 
 July 
 
 The bearing of these facts on the etiology of Bright's disease 
 may be thus stated : — 
 
 1. The great number, forty-three, between the ages of twenty-one 
 and forty, is consistent with the opinion, that intemperate habits 
 are influential. 2. Seventeen occupations are named, but twenty- 
 nine of the cases are comprised under four, viz. : cooks, coachmen, 
 labourers, and sailors, all of which, more or less, involve exposure 
 to alternations of heat, cold, and wet, and imply habits usually more 
 or less intemperate. 3. The habits of only thirty-eight are stated, 
 but in these, the use of spirits, opium, or ganja, singly or com- 
 bined, is acknowledged. 4. Twenty-seven were admitted in 
 September and October, months in which neither cold nor wet 
 are influential as exciting causes of disease. But considering that 
 a very large proportion were not residents of Bombay, and that all 
 were admitted in advanced stages of the disease, the period of 
 admission into hospital has no bearing on the etiology. September 
 and October, the months immediately succeeding the rainy seasoD, 
 are those in which the influx of strangers is great, and to this cir- 
 cumstance the large number of admissions in these months is 
 doubtless attributable. 
 
 The inference from my cases is, that there exists a relation 
 between structural degeneration of the kidney, and the cachectic 
 states induced by the habitual use of spirits and narcotics. 
 
 They however afford no evidence of the influence of syphilis in 
 causing Bright's disease, because though a syphilitic taint is re- 
 corded of eleven cases, they all, with two exceptions, are also 
 included in the list of spirit drinkers, opium eaters, or smokers of 
 ganja. 
 
 Malaria is a fertile source of cachexia in India, and conduces, 
 
490 bright's disease of the kidney. 
 
 as we have already found, to degeneration of structure in the liver 
 and spleen. It is interesting to inquire whether this influence is 
 also exercised on the kidney. It is difficult to separate the effects 
 of malaria from the other causes already named, for they are often 
 combined together. It is, therefore, sufficient to note, that, in 
 nineteen of the fifty-eight cases, the influence of malaria on 
 the system is clearly recorded. 
 
 That inflammation, though by no means essential, is often oper- 
 ative in producing the structural lesions of this disease, is probably 
 true. If so, we may expect occasional evidence of the ordinary 
 exciting causes of inflammation acting as the exciting causes of 
 Bright's disease. Therefore, we can be at no loss in understanding 
 how this disease may, in some instances, be clearly traceable to the 
 influence of external cold. Indeed, the functional relation of the 
 skin and the kidney might lead us to anticipate that interruption 
 of the actions of the former (more particularly if previously dis- 
 ordered), by reduction of its temperature, may be followed by 
 inflammation or other derangement of the latter. 
 
 So much, then, in regard to the causes of the renal disease. 
 We have next to inquire into those of the secondary affections. I 
 shall not again advert to the question of uraemia; for I have 
 already expressed my opinion that it ought to be regarded as still 
 sub judice ; the more so, as the phenomena of the disease are, for 
 practical purposes, sufficiently explainable on certain general well- 
 understood pathological principles. That a more intimate know- 
 ledge of deranged actions ought to be earnestly sought for, is not 
 denied ; but a practical art, such as medicine, is as likely to be 
 damaged, as advanced, by uncertain science ; and it is therefore 
 well not to set aside useful and safe, though incomplete principles, 
 for others which, though full of promise, are still hypothetical, and 
 may lead us into errors of practice. 
 
 In the cachectic state, associated with Bright's disease, there is 
 ample explanation of the predisposition which exists in the system 
 to become affected with inflammatory and other forms of disease. 
 In this cachectic state, as in others, of which I have previously 
 treated, the deranged actions are very generally excited by the 
 application of external cold to the surface of the body. In regard- 
 ing cold as an exciting cause of the secondary affections of Bright's 
 disease, we must remember the lessened capacity for the generation 
 of animal heat in cachectic states; and when our inquiry has 
 reference to tropical countries, we have also to recollect the relation 
 of heat- generating power to climatic temperature. Further, in 
 
SIMITOMS. 491 
 
 respect to the class of individuals from which my experience in 
 Blight's disease has been chiefly derived, there is, in inadequate 
 clothing and insufficient habitations, another circumstance favour- 
 able to the abstraction of heat from the surface of the body. On 
 referring to my cases for confirmation of the influence of cold as an 
 exciting cause, I find that the dropsy has been attributed to cold or 
 wet by the patients themselves in seven instances, and that it 
 occurred in sixteen others at times when the heat-abstractino- 
 conditions of the cold or rainy season were operative. 
 
 Section IV. — Symptoms. — Referable to the Kidney. — Condi- 
 tion of the Urine. — Treatment. — Of the Kidney Disease. — 
 Of the Secondary Affections, chiefly the Dropsical Effusions. 
 
 Symptoms. — In cases in which the scanty, high-coloured, and 
 very albuminous character of the urine rendered probable the 
 existence of preternatural, inflammatory, or other afflux of blood 
 to the kidneys, this inference has been further confirmed by the 
 presence of more or less uneasiness in the lumbar region, with 
 sometimes nausea and vomiting. But in the large proportion of 
 my own observations this has not been the character of the urine, 
 and pain of loins has not been a common symptom. 
 
 The disease has generally been indicated in my cases by the 
 occurrence of dropsy in cachectic individuals, suggesting inquiry 
 into the state of the urine. In order to the detection of this 
 disease, the safe practical rule is, that in all asthenic or cachectic 
 states — whether simple or complicated — we ought to search for 
 Bright's disease of the kidney by examining the urine, just as in all 
 cases of rheumatism and of idiopathic fever we search for peri- 
 carditis and pneumonia by percussion and auscultation. Indeed, 
 I have previously remarked that in asthenic and cachectic states 
 the clinical rule should be invariably observed of determining, 
 by the application of all the diagnostic means at our command, 
 the presence or absence of local disease ; for, without this pre- 
 liminary step, the prognosis will be needlessly uncertain, and the 
 treatment vacillating and unsafe. My present remark, in re- 
 ference to Bright's disease, is merely an application of this 
 general rule. 
 
 In all the cases in which the urine was carefully examined, its 
 albuminous character and low density have been well marked. It 
 has been, for the most part, of jale amber or lemon colour, clear 
 
492 lright's disease of the kidney. 
 
 and neutral, varying in specific gravity from 1*003 to 1*018.* In 
 quantity it has generally ranged from twenty to forty ounces in 
 the twenty-four hours ; and in cases beyond these limits it has 
 more frequently exceeded forty ounces than fallen short of twenty. 
 My earlier cases occurred before much attention had been given to 
 the microscopic character of the urine ; but in the later ones the 
 characteristic tube casts, epithelial debris, and oil globules, were 
 frequently observed. 
 
 Treatment. — The treatment resolves itself into that which is 
 appropriate for the disease of the kidney, and that which conduces 
 best to the removal of the several secondary affections. 
 
 "When uneasiness of the loins, scanty, very albuminous, and 
 high-coloured urine, indicate excess of blood in the kidney, then 
 local depletion from the loins by cupping or leeches, the use of the 
 warm water, vapour, or hot air bath, the removal of constipation, 
 and confinement to bed, are appropriate and efficacious means of 
 cure. When the state of constitution is such as to contra-indicate 
 loss of blood, much diaphoresis, or other evacuation, then dry 
 cupping, a moderated use of baths, and a greater attention to warm 
 clothing, is the modification of treatment required. By these 
 means the lumbar uneasiness will disappear, and the urine will 
 gradually become more copious and of lighter colour. The per- 
 sistence or not of albumen will depend upon whether the excess of 
 blood has been in a kidney previously healthy, or affected with 
 structural degeneration. 
 
 In cases in which freedom from lumbar pain, and a flow of pale 
 urine, of normal or increased quantity, point to the absence of ex- 
 cess of blood in the kidneys ; but in which the presence of albumen 
 and a low specific gravity of the urine, generally with a co-existing 
 cachectic state, prove the existence of structural degeneration, the 
 indication of cure as respects the kidney, is to promote, moderately, 
 the function of the skin by great attention to clothing, and to en- 
 deavour to lessen the general cachexia by well-adjusted tonic 
 regimen and remedies. The cases observed by me have been 
 chiefly of this nature, and the remedies which have seemed to me 
 most efficacious, have been 'preparations of iron, combined with 
 (j a in i ne, in instances in which the influence of malaria was sus- 
 pected." 
 
 * The specific gravities are noted as observed with a urinometer, graduated for a 
 temperature of 60°. These observations have been made at a mean temperature of 
 about SO ; and maybe sufficiently corrected by an addition of 2° to each specific 
 gravity. 
 
TREATMENT. 493 
 
 Though by this course of treatment we can hardly hope to remove 
 the structural degeneration when fairly established, yet we may 
 expect to check its progress, and lessen the predisposition to attacks 
 of the secondary affections. Moreover, though we may not be 
 sanguine enough to anticipate the restoration of structures already 
 degenerate and changed ; still there is surely no more likely method 
 of effecting an object so desirable, than by that regimen and those 
 remedies which tend best to re-induce normal assimilation to blood 
 and to tissue. 
 
 In noticing the treatment of the secondary affections, I shall 
 consider first the dropsical effusions, as being the most frequent, 
 and perhaps the most important, of them. When dropsy comes on 
 early in the disease, it is generally accompanied with the symptoms 
 which indicate excess of blood in the kidney, and will be best 
 removed by the means already recommended as most appropriate 
 for this state, viz., local blood-letting, the warm or vapour bath, 
 attention to the bowels, and confinement to bed. When dropsy, 
 as is most frequently the case, occurs in the more advanced stages 
 of the disease associated with a cachectic state, and not characterised 
 by scanty urine and lumbar uneasiness, then the following rules of 
 practice may be observed : — 
 
 1. Attention to the functions of the skin by warm clothing, and 
 the occasional use of the warm bath, is a ruling indication in the 
 management of all the forms of dropsy. 
 
 2. When the effusions, from situation or degree, are not of a 
 nature to interfere much with the functions of important organs — 
 as the lungs, the heart, or the kidneys themselves — the treatment 
 of the dropsy simply resolves itself into that adjustment of regimen 
 and tonic remedies, which is most likely to ameliorate the nutritive 
 condition of the blood. With improvement in the general system, 
 the dropsical effusion will disappear. 
 
 3. When the dropsy, from situation or extent, interferes with the 
 functions of important organs, the reduction of the effused fluid 
 by evacuation from the blood becomes an important indication 
 in the treatment. The channel of elimination must be selected 
 according to the circumstances of individual cases. 
 
 4. When there is no evidence of gastro-intestinal irritation, eva- 
 cuation by purgatives holds out the greatest prospect of speedy 
 relief — bitartrate of potass combined with jalap or gamboge, and 
 elaterium, are the most useful remedies of this class. In asthenic 
 states, complicated with dropsy, purgatives may probably be given 
 to a degree which would be unsafe in similar states of constitution 
 
494 leiqht's disease of the kidney. 
 
 unattended by dropsy, because the effusion is a ready source of 
 supply to the blood of that fluid which has been eliminated from 
 the intestinal surface.* But risk from the use of purgatives in 
 the dropsy of Bright's disease rests on the fact of the proclivity 
 which obtains in this, as in all other cachectic states, to muco- 
 enteritis, from the application of irritants to the mucous sur- 
 face. This difficulty is very likely to arise in tropical countries, 
 and in my own practice it has proved very generally obstructive to 
 the use of this class of remedies. 
 
 5. When purgatives are contra-indicated, then we may select 
 between evacuation by diaphoresis or diuresis. If there be no con- 
 gestion of the kidney to remove, I doubt whether much will be 
 gained by evacuation by the skin. Indeed, in those cases of dropsy 
 with renal congestion, in which determination to the skin in general 
 acts so beneficially, the good effected is not by diaphoresis, but by 
 the restoration of improved circulation and secretion in the kidney 
 itself. The frequent use of the warm bath must tend to increase 
 the cachexia ; therefore, in the kind of cases of which I now treat, 
 diaphoresis, beyond that which is involved in my first rule, is 
 inexpedient. 
 
 6. "When there are no symptoms of excess of blood in the kidneys, 
 when purgatives are contra-indicated, when the dropsical symptoms 
 are such as to call for speedy removal, — then we must use com- 
 binations of diuretics, as the acetate of potass, with tincture of 
 squills and of digitalis, and spiritus aetheris nitrici. The addition 
 of the potassio-tartrate, or other salt of iron, or of quinine, is often 
 very useful. When the state of the constitution suggests the use 
 of stimulants, the sesquicarbonate of ammonia may with advantage 
 be substituted for the acetate of potass. 
 
 7. I have already said that, when the dropsy is not present to 
 that extent which interferes with important functions, evacua- 
 tion from the blood is not required ; for the effusions will disap- 
 pear under attention to the state of the skin, and improvement in 
 the condition of the general system. And it may now be added, 
 that when, under these circumstances, the intestinal discharges 
 and the quantity of urine are adequate, we are likely to do harm 
 by the use of evacuant remedies, for they tend to increase the 
 asthenia. 
 
 * In the chapter on Peritonitis I have narrated a case (197) in which cholera came 
 on in the course of Bright's disease, with dropsy, and in which I attributed the Blow 
 of the cholera to the fad thai thelosstothe blood by intestinal discharges was 
 supplied from the fluid of the dropsical effusions. 
 
TREATMENT. 495 
 
 8. While appropriate evacnants are being used in those cases in 
 which the degree of the dropsy calls for reduction by evacuation, 
 great attention must, at the same time, be given to the regimen, 
 and to the tonic or stimulant remedies, which may be indicated for 
 the correction of the diathesis. Success in the treatment of such 
 cases will be commensurate with the skill and steadiness with 
 which these two indications are simultaneously carried out. 
 
 It is unnecessary to explain the details of treatment of the 
 secondary inflammations in Bright's disease. They must be con- 
 ducted with reference to the state of the constitution, the improve- 
 ment of which must also be kept in view as a leading indication in 
 the management of the case. Hence the great importance of 
 ascertaining, in respect to all asthenic inflammations, whether they 
 are co-existent or not with structural degeneration of the kidney. 
 The only secondary inflammation which I shall notice, in conse- 
 quence of the frequency of its occurrence in India, is d} T sentery. 
 The treatment must be conducted in accordance with those princi- 
 ples which I have already elsewhere so fully exj)lained, combined 
 with much attention to warmth of the surface of the body. 
 
 To conclude. In Bright's disease, as in other structural degenera- 
 tions, for the restoration of which the powers of the animal sj^stem 
 are inadequate, we have impressed upon us the importance of care- 
 ful inquiry into the causes, with the view of preventing their action. 
 It is thus, in respect to these forms of disease, that we shall best 
 apply the resources of medical science in prolonging life. 
 
 It may seem that by making no reference in my remarks on 
 treatment to the uramric theory, and the therapeutic principles 
 which it naturally suggests, the value of medical art has not been 
 fully appreciated. I would, therefore, on this question of practice, 
 express my belief that, in the present state of the science, the only 
 conditions which justify the use of eliminant remedies are excess of 
 vascular action, adequate amount of blood and diminished excre- 
 tion ; and that the eliminant should be selected with reference to 
 the excretion which is most markedly defective. 
 
 Some degree of asthenia or cachexia is always present in the 
 chronic forms of disease supposed to be dependent on an abnormal 
 materies in the blood ; and attention to the amount and variety of 
 elimination which is involved in a well-adjusted tonic regimen, 
 holds out, it seems to me, a better and a safer j)rospect of benefit 
 from the therapeutic principle in question, than the empiric use of 
 special eliminant medicines. A well-adjusted tonic regimen im- 
 plies a just attention to pulmonary, cutaneous, alvine, and urinary 
 
496 bp.ight's disease of the kidney. 
 
 excretion. It aims, also, at bringing about increased activity of 
 those actions by which food is assimilated to blood and blood to 
 tissue ; and every step of success towards this end must improve 
 the structural fitness and other functional conditions of excreting 
 organs, and lead to augmented excretion. Increased excretion is 
 a necessary sequence of increased assimilation. That these are 
 sound principles of practice, in the present uncertain state of the 
 pathology of blood diseases, cannot, I think, be questioned ; but I 
 venture to go further than this, and to predict, that even with that 
 greater knowledge of blood poisons and of excretions which chemi- 
 cal science has yet to confer on pathology, these principles will still 
 prove applicable and essential. 
 
497 
 
 CHAP. XX. 
 
 ON ABNORMAL STATES OF TIIE URINE. 
 
 Section I. — Preliminary Pathological Remark. — A want of 
 Information in respect to the Normal Condition of the Urine 
 in India. 
 
 Albuminuria has, in the last chapter, been related to transient 
 congestion, or to structural degeneration, of the kidney : the 
 proximate cause is therefore supposed to exist in the secreting 
 organ itself. But there are other abnormal conditions of the urine 
 occurring without structural change of the kidney, whose proximate 
 cause is believed to reside in derangements of primary or secondary 
 assimilation : the precise nature, however, of these derangements 
 is unknown. But before noticing these abnormal states of the 
 urine, a preliminary question suggests itself for consideration, — In 
 what respect does the normal condition of the urine in warm 
 climates differ from that in cold ? 
 
 In the months of July, August, October, and November 1852, 
 and in February and March 1853, Mr. Sebastian Carvalho, an in- 
 telligent graduate of Grant College, while officiating as one of the 
 medical officers of the Jamsetjee Jejeebhoy Hospital, conducted a 
 series of observations on the urine of five healthy Hindoo Ward 
 boys, with the view of determining the normal quantity and specific 
 gravity of the secretion. The average quantity amounted to about 
 forty-two ounces in the twenty-four hours, and the specific gravity 
 was found to range from 1-007 to 1*016.* But on other questions 
 
 * In my remarks on the urine in Bright's disease of the kidney, I stated the specific 
 gravity observed in my cases to range from L003 to L018; or, when corrected for 
 temperature, from 1*005 to l - 020. The normal specific gravity, as deduced from Mr. 
 Carvalho's observations, does not accord with this. The inference I believe to be 
 simply this — that further and more extended investigation is necessary, in order to 
 establish a trustworthy standard of the normal state of the urine both in Europeans 
 and natives in India. 
 
 K K 
 
498 ABNORMAL STATES OF THE URINE. 
 
 relative to the quality of the urine, no light has been thrown by 
 these observations. They were submitted by Mr. Carvalho to the 
 Grant College Medical Society, and a summary statement of them 
 has been published.* I have already f expressed my belief that all 
 the solid excreta are considerably less in India than in colder cli- 
 mates; and the investigations just referred to, so far as they go, 
 tend to strengthen this opinion in regard to the mine. 
 
 Section II. — Chylo-serous Urine. — Short Notice of its Pathology 
 
 and Treatment. 
 
 This term has been applied to urine of a milky, opaque 
 appearance, coagulating on the application of heat or addi- 
 tion of nitric acid, and sometimes spontaneously. The opacity 
 depends upon fatty matter, the coagulability by heat on albumen, 
 and that which occurs spontaneously on the presence of fibrine. 
 This abnormal state of the urine has been generally noticed in 
 association with more or less asthenia or cachexia, and has been 
 attributed to faulty assimilation, and not to disease of the kidney ; 
 because, in the few instances of which post mortem appearances 
 are recorded, this organ has been found healthy; and, on the 
 other hand, restoration to health, with coincident normal urine, has 
 not been infrequent. ProutJ had met with thirteen cases of this 
 disease ; and as seven of them occurred in residents of hot climates, 
 it was inferred that the affection was probably more common in 
 tropical than in temperate countries. Still it cannot be viewed as 
 of frequent occurrence in India. There is the case of a female 
 reported § by Dr. H. H. Goodeve; also one | of a female observed by 
 Dr. Pearse, with a careful chemical analysis by Professor Mayer. 
 These are the only recorded Indian cases with which I am ac- 
 quainted. My personal knowledge of the disease is limited to 
 eight cases. The first, made known to me at Belgaum in 1830, 
 occurred in an European officer's wife. The urine coagulated spon- 
 taneously into a white gelatinous mass: with the termination of 
 this case I am not acquainted. The second was observed by me 
 about 1839, in the European General Hospital at Bombay. The 
 
 * "Transactions, Medical and Physical Society of Bombay," now series, No. 2. 
 
 f Page 4. 
 
 % "Nature and Treatment of Stomach and Renal Diseases," 4th edition. 
 
 § " Transactions, Medical and Physical Society of Calcutta," vol. viii. 
 
 || " Transactions, Royal Medical and Chirurgical Society," vol. xxxiv. 
 
CHYLO-SEROUS HEINE. 4 'J 9 
 
 subject was a young female born in India, of European parents, 
 and the wife of a warrant officer of the garrison. She was pale and 
 feeble, the urine was white and spontaneously coagulated into a 
 jelly-like mass.* Much variety of treatment was adopted without 
 benefit. This patient left the hospital, and was lost sight of for 
 about two years, when I accidentally met her in the ward visiting 
 a friend. She had lost her pallid appearance, and was in good con- 
 dition. I inquired into her state of health ; but so completely had 
 the former abnormal condition of the urine passed from her mind, 
 that the object of my questions was not at first readily understood. 
 It appeared that after leaving the hospital she had gone to Scinde 
 to join her husband, who was on duty there. Her general health 
 improved, and the urine became normal without the use of medi- 
 cines of any kind. 
 
 The remaining six cases are annexed in detail to these remarks ; 
 three of them occurred in Parsees, one in the clinical ward, and 
 two communicated to me by Mr. Dossabhoy Bazunjee, a zealous 
 graduate of Grant College. The fourth was observed in a Hindoo 
 by Mr. Carvalho. The fifth is extracted from Mr. Balchrishna 
 Chintoba's report of the Poona Charitable Dispensary for 1858. 
 The sixth occurred in a Portuguese servant, under my own 
 observation. 
 
 I shall not speculate on the nature of the faulty assimilation 
 by which fatty and proteine principles, instead of being normally 
 appropriated, are excreted with the urine. Albuminous and chylo- 
 serous urine would seem to differ simply in this, that in the former, 
 albumen is the only proximate principle present, whereas in the 
 latter, albumen, in greater quantity, is associated with fat and fre- 
 quently with fibrine. There is in the chylo-serous urine a more 
 complete transudation of organic constituents of the blood on the 
 free surface of the uriniferous tubes. Though it may probably be 
 added that urea is deficient in albuminous, but not in chylo-serous 
 urine ; yet it may be doubted whether investigation has been suffi- 
 ciently extensive in both affections to justify an assertion so positive. 
 
 There is good reason for relating both derangements to cachectic 
 states, that is, to mal-assimilation. In Bright's disease, degenerate 
 proteine and fatty principles are deposited in the structures of the 
 kidney, and albumen transudes with the urine. In chylo-serous 
 urine the proteine and fatty principles are separated from the 
 blood at the kidney, with the urine, and no part is left behind to 
 clog and destroy the structure of the organ. In both affections 
 proximate principles unsuited, from some cause or other, for their 
 
500 ABNORMAL STATES OF THE URINE. 
 
 normal purposes, are carried to the kidney. In the one they are 
 partly deposited in the organ to the injury of its structure, and are 
 partly removed with the urine. In the other all are removed with 
 the urine, none are deposited in the kidney. Such, I think, is 
 the view which, in the present state of pathology, we are justified 
 in taking of the points of resemblance and difference between 
 these two diseases. Why, in the one, the same principles are all 
 excreted, and in the other partly deposited in the kidney, is 
 one of the many questions which pathology has yet to determine. 
 I would further remark, that the doubts which I ventured to ex- 
 press, relative to the generally received explanation of the proxi- 
 mate cause of albuminous urine in Bright's disease, are increased 
 by the fact of the greater albuminous transudation which takes 
 place in chylo-serous urine. 
 
 On treatment a very few remarks will suffice. The indica- 
 tion is to remove the cachectic state, in other words, to correct the 
 error of assimilation ; and six of my cases distinctly show, that all 
 means having this object in view failed till suitable change of air 
 was enforced. The balsams, lytta, diosma, gallic acid, prepara- 
 tions of iron and other remedies supposed to have special influence 
 on the urinary organs, have signally failed — a further proof that 
 the proximate cause of the disease is not to be sought for there. 
 
 218. Urine thick, white, opaque, coagulating with heat and nitric acid. — No improve- 
 ment under the use of varied remedies. — Recovery by attention to the general health, 
 chiefly to change of air. — A Parsce, of twenty-one years of age, following the occupa- 
 tion of English clerk, of temperate habits, never the subject of syphilis, but of weak 
 constitution, consulted Mr. Dossabhoy Bazunjee on the 13th October, 1851. There 
 was no indication of pulmonary or cardiac disease, but the pulse was feeble, the appe- 
 tite impaired, and he attributed his feeble health to close application to study. He 
 was also the subject of reducible femoral hernia of the left side. He stated that for six or 
 seven days he had been voiding thick, white opaque urine, without, however, frequent 
 calls to micturate. This state of the urine had been attended with pain of the loins 
 and limbs, but no distinct fever. He had never suffered thus before. The urine, on 
 being examined, was found to be white, thick, and opaque, of specific gravity l - 040, 
 and gave a copious white flocculent deposit under heat, and on the addition of nitric 
 acid. He was treated with creosote and tincture of the sesquichloride of iron, and 
 plain nourishing food ; a rubefacient liniment of turpentine oil, liquor ammonia', and 
 olive oil was applied to the loins. This treatment was followed till the 29th October, 
 by which time lie had gained in flesh, the pulse had improved in strength, the un- 
 easiness of loins was less; the urine, for the most part unchanged in character, was, 
 however, occasionally clear, of amber colour, slightly acid, and unaffected by heat and 
 nitric acid. The same treatment was continued, with exception of the liniment to the 
 loins ; and on the 1st November he went to the seaside at Breach Candy, and resided 
 four days with ;i friend. There lie improved in general health, the mane also became 
 dear, and remained so for four days after his return home to the Fort of Bombay. 
 On the iit'tli day the urine was clear in the morning, but in the middle of the day had 
 become white and opaque as before* Mr. D. Bazunjee recommended a longer resi- 
 
CHYLO-SEROUS URINE. 501 
 
 dence at Breach Candy, but another practitioner undertook to cure him by other 
 means. The infusion of diosma, balsam of copaiva and aperients, with restricted diet, 
 were freely tried. He became emaciated and feeble, and the urine remained unchanged. 
 About the 15th December he again became a patient of Mr. D. Bazunjee, and I 
 was asked to see him in consultation. The tincture of the sesquichloride of iron, 
 with tincture of lytta, was prescribed. He improved in flesh and strength, but the 
 urine continued white, thick, and opaque. And on the 14th March he again went to 
 Breach Candy, and remained there for two and a half months. In ten days the urine 
 became clear. He returned home on the 1st June in good health, and afterwards con- 
 tinued so. While at Breach Candy he took no medicine, and lived on good food 
 without any particular restriction. 
 
 219. Urine, thick, white, opaque, coagulating with heat and nitric acid. — No improve- 
 ment from medical treatment. — Recovery from change of air. — On the 1st May, 1852, 
 a Parsee, of forty-five years of age, of stout frame and temperate habits, never the 
 subject of syphilis, nor under the influence of mercury, but generally in the enjoyment 
 of good health, consulted Mr. Dossabhoy Bazunjee. No visceral disease could be 
 detected ; but he complained that his urine was white, thick, and opaque, and that 
 the calls to micturate were generally six times in the night and four in the course of 
 the day. He had suffered thus for five months, and had been treated with balsam of 
 copaiva and various other remedies, with some relief. The urine, when examined, 
 was found to be of high density, and to give a copious floccident deposit under heat 
 and nitric acid. Mr. D. Bazunjee prescribed creosote, without benefit ; then tincture 
 of the sesquichloride of iron, with tincture of iodine, tincture of lytta, galhc acid, and 
 sulphuric ether were in succession tried, with as little success. On the 15th July 
 medicine was omitted, and change of air recommended. This advice he coxdd not 
 follow for twenty days, during which time the urine continued unchanged. About 
 the middle of August he went to reside at Negaon. He remained there for a month, 
 became quite well in fifteen days, and has continued in good health since his return home. 
 
 220. Urine opaque and white, occasiojially coagulating spontaneously. — Recovery 
 from change of air. — A Hindoo clerk, of twenty- three years of age, attended the 
 Jamsetjee Jejeebhoy Hospital, as an out-patient, from the 21st May to the 1st July, 
 1851. He was under the care of Mr. Sebastian Carvalho, to whom I am indebted for 
 the following information. Five years before he had been affected with white opaque 
 urine, which continued for two months, — then ceased, he thought, not from the reme- 
 dies used, but gradually and spontaneously. He remained well till eight months and 
 a hah? before he came under observation at the hospital, when the urine suddenly 
 became opaque and niilky, but without pain of loins or fever. On admission the 
 urine was milk-like, of specific gravity 1-012, and gave a copious eoagulum by heat 
 and nitric acid ; and the rest of the urine was left clear. Blood and mucus were also 
 present, and subsided to the bottom of the vessel. Latterly the urine spontaneously 
 separated into a coaguluni and a pretty clear fluid ; it was frequently passed with 
 pain, and obstructed by coagula in the urethra. His only other complaint was of 
 weakness. He was treated with tonics without benefit. He ceased attendance that 
 he might avail himself of change of air, from which he is reported to have soon reco- 
 vered, and after his return to have continued in good health. 
 
 221. Urine milky, coagulating by heat and nitric acid, becoming clear by addition of 
 sidphuric ether.— No improvement from treatment. — Change of air recommended. — 
 Result not known. — Coverjee Maneckjee, a Parsee schoolboy, of sixteen years of age, 
 and temperate habits, but in feeble health, was admitted into the clinical ward on the 
 12th December, 1852. With exception of slight bronchitis, he was free from thoracic 
 or abdominal visceral disease. He stated that, six months before admission, his urine 
 had begun to be scanty, and that two months ago it had assumed a milky appearance. 
 There was also pain of loins. The urine was passed without pain, except occasionally 
 
 K K 3 
 
502 ABNORMAL STATES OF THE URINE. 
 
 from urethral obstruction by coagula. He continued under observation till the 2nd 
 January. The imne was of milky appearance, coagulated with heat and nitric acid, 
 lost its turbidity by addition of sulphuric ether, ranged in quantity from twenty-five 
 to forty ounces, and was of specific gravity from 1-022 to 1-030. He was treated with 
 gallic acid, phosphate of soda, and creosote, without the least benefit, and was dis- 
 charged with a recommendation to proceed to Surat for change of air. The result is 
 unknown. 
 
 222. Chylo-serous urine removed by change of air. — Junardhun Kesho, a Hindoo 
 clerk, of twenty-one years of age, applied at the Poona Dispensary. He was in 
 reduced health, and on the 17th September, 1858, passed a pint of curdy urine, of 
 specific gravity 1-012, giving a cloudy deposit with heat and nitric acid. There was 
 no fever nor syphilitic taint. He was treated with gallic acid, then with the tincture 
 of the sesquichloride of iron ; but the iirine continued opaque, with a brick-red tint. 
 He went for change of air on the 22nd, and on the following January was reported 
 well, and the urine natural. 
 
 223. Chylo-serous urine removed twice by change of air. — Antone , a Portuguese 
 
 butler, about forty-five years of age, left Bombay for Goa in May 1854, after having 
 been for some months the subject of chylo-serous urine, with occasional fever and 
 generally impaired health. During the voyage the urine began to clear, became 
 normal, continued so at Goa, and he returned to Bombay in perfect health in about a 
 year and a half. After about a year's residence in Bombay, the chylo-serous urine, 
 impaired health, and occasional fever returned ; and he went again to Goa in May 
 1857. The urine became clear on the voyage, and continued so when I last saw him, 
 on the 3rd November, 1857, five days after his second return to Bombay. 
 
 Section III. — Saccharine Diabetes. — Infrequent in India. — 
 
 Diuresis. 
 
 In this abnormal state of the urine we have another illustration 
 of disease depending on faulty, primary, or secondary assimilation ; 
 differing, however, from that which has just been considered, in 
 that the defect is in the processes by which the non-asotised 
 principles of food are converted to their purposes of usefulness in 
 the system. The result is, that sugar exists in excess in the 
 blood, and is excreted with the urine ; hence the great abundance of 
 this secretion, its saccharine quality, and its high specific gravity. 
 
 For details on these points, and on the cachectic phenomena 
 which are associated with saccharine diabetes, I must refer 
 to the many excellent treatises which have been written on this 
 disease. 
 
 Prout, during the period in which he had seen only thirteen 
 cases of chylo-serous urine, witnessed 500 of diabetes. From 
 this fact some idea may be formed of the comparative frequency 
 of the two affections in European countries. The number of cases 
 of diabetes in India, of which I have had personal knowledge, 
 amounts to six. The first occurred about the year 1836, in the 
 Hindoo Jemadar of the Governor's escort at Dharpooree, in the 
 
SACCHARINE DIABETES. 503 
 
 Deccan. This officer died two or three months afterwards. Another, 
 in the person of a Mahomedan gentleman of advanced age, about 
 whom I was consulted in 1854, by Mr. Atmaram Pandurang. The 
 remaining four cases are narrated in this section : three, two males 
 and one female, were Parsees ; the fourth was a native of Groa. 
 I have no reason for supposing that in the experience of others, 
 diabetes has been found a more common disease than it has proved 
 to be in my own. Prout was disposed to relate diabetes to mala- 
 rious influence. The infrequency of the disease in India is not in 
 conformity with this opinion; nor does it countenance the idea 
 that abuse of mercury, or syphilitic taint, have much to do with 
 the etiology of diabetes. When we recollect that numerous classes 
 subsist chiefly on cereals and other vegetable food, we, in theory, 
 might anticipate that diabetes would be a more common disease 
 in India than in those countries in which animal food is more 
 generally consumed. This, however, does not seem to be the case. 
 Such facts tend to show that much of the pathology of saccharine 
 diabetes is still unknown. 
 
 224. Diabetes. — Symptoms improved somewhat under the use of creosote and muriate 
 of morphia. — Muncherjee Ruttonjee, a Parsee cook, of twenty-eight years of age, whilst, 
 on his return from China, about twenty-three months before he came under observation, 
 landed at Singapore, and there, without appreciable cause, for the first time experienced 
 extreme thirst and frequent desire to micturate. Since that time both these symptoms 
 have continued and increased. After his return from China, he resided for three months 
 in Bombay ; then proceeded to his native town, Surat ; and, after a residence there of 
 about eight months, he again set off for China, unrelieved of his complaint. Twenty days 
 before admission into the clinical ward, on the 9th March, 1850, he had returned from 
 China to Bombay. He was a good deal emaciated, was affected with urgent thirst and 
 dryness of the fauces, and micturated frequently and copiously. The gums were swollen 
 and the teeth loose, the appetite was keen, the tongue dryish and slightly florid at the 
 tip, and the bowels rather slow. The skin was of natural temperature, and dry ; the 
 pulse 100, of tolerable volume, and soft. There were no signs of pulmonary or 
 cardiac disease. The abdomen was full, but soft, without uneasiness or abnormal 
 dulness. He complained of a general sense of weakness, slept badly, from uneasiness 
 in the course of the tibiae, burning in the soles of the feet, and frequent calls to pass 
 his urine. He stated that the urine increased in quantity after oleaginous articles of 
 food and vegetables, and that when voided on the same place for two or three succes- 
 sive days, the spot appeared as if whitewashed. He was unable to assign any par- 
 ticular cause of the complaint ; but a sister had died,* after two years' illness, with 
 similar symptoms. No other member of his family, however, had been thus affected. 
 Much variety of medicine had been used, and he had been salivated about a year 
 before admission. He continued under observation till the 4th April. The urine was 
 generally of amber colour, and of specific gravity from 1"035 to 1-040. On admission 
 twenty-four pints were passed during the night ; but it gradually decreased, and after 
 the 14th March ranged from seven to three pints in the night. The thirst lessened, 
 and he improved somewhat in appearance. He was treated chiefly with creosote in 
 two-minim doses thrice daily, a draught with the solution of the muriate of morphia 
 at bed-time, and the occasional use of the hot-air bath. The diet consisted of milk, 
 eggs, mutton, with succulent vegetables. 
 
 K K 4 
 
504 ABNORMAL STATES OF TIIE URINE. 
 
 225. — Diabetes. — No improvement from preparations of iron, permanganate of potass, 
 and opium. — Ruttonjee Dhunjeebhoy, aParsee sweet-meat seller, of twenty-five years 
 of age, and using spirits to the extent of two ounces daily, was admitted into the clinical 
 ward on the 10th October, 1853. He w r as much reduced and complained of pain of loins, 
 weakness of the lower extremities, and frequent micturition. The countenance was 
 anxious, the pulse small, and slightly jerking; the skin of natural temperature, and 
 dry ; the tongue thinly coated, and somewhat florid at the tip ; the gums slightly 
 swollen, and tender ; and the bowels confined. With exception of an occasional 
 bronchitic rale, there was no sign of pulmonary or cardiac disease. The abdomen was 
 retracted and free of induration or dulness. He rested badly at nights. He stated 
 that he had suffered from dysenteric symptoms for about two years, for which much 
 variety of treatment had been unsuccessfully followed till three months ago, when he 
 was treated in the hospital with opiates and stimulants, and the dysenteric symptoms 
 •were removed. Then, for the first time, he observed an increase in the urine, and 
 attributed it to the remedies which had been used. These, he said, had caused thirst, 
 and led him to drink much water. On the 12th eight pints of urine had been passed 
 during the night ; it was clear, of pale amber colour, neutral, of specific gravity 1-033, 
 and on addition of sulphate of copper, liquor potassse, and application of heat, a 
 yellowish brown precipitate was thrown down. He continued under treatment till the 
 7th November. The urine ranged from three to eight pints in the night, and con- 
 tinued of high specific gravity. The asthenia increased. He was discharged at his 
 own earnest desire. He was treated first with preparations of iron and opium, and 
 then the permanganate of potass was substituted for the iron, and a diet of eggs, mutton, 
 and a limited portion of bread, and two ounces of arrack daily was given. 
 
 226. Diabetes. — Not improved by treatment. — Sorabye, a Parsee female, of twenty- 
 six years of age, much emaciated, and affected with boils, was, after a year's illness, 
 admitted into hospital on the 20th May, 1850. The tongue was florid. The pulse 
 feeble and quick. The urine ranged from six to twelve pints, and was of specific 
 gravity from l - 030 to 1-036, and yielded sugar on evaporation. The thirst was urgent, 
 and the appetite voracious. Opium, quinine, creosote, and Dover's powder were used, 
 and a diet of milk, eggs, chicken, and little bread was given. She gained somewhat 
 in flesh, and the tongue was less florid, but in other respects was at the time of her 
 discharge, on the 29th July, in the same state as on admission. I saw her again in 
 the month of October, when the symptoms remained unchanged. 
 
 227. — Diabetes. — No improvement from permanganate of potass, or from creosote 
 alone, but marked benefit from addition of opium. — Cosmo de Souza, a native Christian, 
 of forty-five years of age, an inhabitant of Goa, a cook by occupation, and habitually 
 using spirits, was admitted into the clinical ward on the 10th November, 1852. He 
 was reduced in strength, the pulse was small and jerking. He complained of dimness 
 of vision, sleepless nights, frequent and copious micturition. The tongue was moist 
 and clean, the bowels slow, the appetite keen, and the thirst urgent. No signs of 
 thoracic or abdominal disease. He stated that these symptoms had first made their 
 appearance at Belgaum five j'tears before, and had persisted with little intermission. 
 The urine on the 12th was five pints, of specific gravity 1-033, and gave a scanty brown 
 precipitate with sulphate of copper and liquor potassse. The patient seemed to have 
 discovered, and alluded to, the sweet taste of his urine. He continued under treat- 
 ment till the 21st December, when he was discharged at his own request ; the urine 
 having decreased to about fifty ounces, mid specific gravity to 1-022; his general state had 
 also improved. He was again seen on the 28th December, and the urine was examined. 
 It was of specific gravity 1-025, and gave merely a trace of sugar with Trommer's 
 test. He was afterwards scon on the 24th January, when the specific gravity of the 
 urine was T028, and a considerable In-own precipitate was thrown down with the 
 sulphate of copper and liquor potassse. During his stay in hospital he was treated 
 
URIC, OXALIC, AND PIIOSrHATIC DIATnESIS. 505 
 
 first -with permanganate of potass without improvement, then with creosote, also without 
 any change in the urine ; but on the addition of a grain of opium at bed-time, the 
 urine decreased from 100 to 60 ounces, and during the twenty days that he sub- 
 sequently continued in hospital ranged from forty to eighty ounces. He had full diet, 
 but without any special arrangement. 
 
 Diuresis. — Cases of abundant limpid urine, of low specific 
 gravity, are occasionally, though rarely, observed in India. I re- 
 collect two well-marked instances of this affection. The first, a 
 European, employed in the government remount stables, who, 
 about the year 1837, consulted me for this affection, and for par- 
 tial amaurosis of one of his eyes. The urine was very copious and 
 limpid, and was about 1-005 or lower in specific gravity. The 
 abnormal state of the urine, unaffected by medical treatment, after 
 a time reverted to its normal standard, and some improvement 
 took -place in the amaurosis. This individual is still (1860) in 
 Bombay, and for many years subsequent to the period adverted to 
 has enjoyed good health. 
 
 The second case was of an Indo-Briton, who applied at the 
 Jamsetjee Jejeebhoy Hospital, towards the end of 1853. The 
 urine was very copious, of low specific gravity, and gave no traces 
 of sugar. He was much emaciated and out of health. I have no 
 notes of the particulars of this case, or of its further course. 
 
 Section IV. — Uric, Oxalic, and Phosphatic Diathesis. 
 
 The presence of insoluble urates, oxalates, and phosphates in the 
 mine, is also a consequence of faulty primary or secondary assimi- 
 lation, sometimes due to error in the quantity or quality of the 
 food, at others to defect in the processes themselves. The sub- 
 ject has of late years received much attention, and the risk 
 is, that too much importance may be attached to the ascer- 
 tained facts, both in reference to pathology and therapeutics. 
 The probability is, that further investigation of the morbid 
 states of the urine in India will lead to results similar in 
 kind to those which have already been obtained in European 
 countries. 
 
 These abnormal conditions of the urine may be practically con- 
 sidered from two points of view. 
 
 1. As leading to the formation of urinary calculi, and all their 
 attendant evils. The opinion at one time entertained that these 
 were of rare occurrence in India, has been long since disproved in 
 Bengal, by the experience of Burnard, Brett, Twining, Darby, 
 
506 ABNORMAL STATES OF TIIE URINE. 
 
 Cole, and many skilful lithotomists, graduates * of the Bengal 
 Medical College; in the Nizam's territories, by Dr. W. C. Maclean ; 
 and in Bombay, by Peet, Ballingall, Kitchie, and Bhawoo Dajee.f 
 
 * Of the many skilful lithotomists trained in the Eengal Medical College, I would 
 name Earn Narain Doss, the present teacher of surgery in the military class of the 
 college, as the most conspicuous. He has performed the operation above two hundred 
 times with good success. Also Mr. C. E. Eaddock, who has communicated an in- 
 teresting report of his cases of lithotomy in the 4th number of the "Indian Annals of 
 Medical Science." 
 
 f On this subject I quote the following extract from my retrospective address to 
 Grant College Medical Society for the year 1857 : — 
 
 " Mr. Bhawoo Dajee, in continuation of a former paper published in the 2nd number of 
 the 2nd Series of the ' Transactions of the Medical and Physical Society,' communicated 
 five additional cases of lithotomy. In four the operation was performed by the author ; 
 in one by Mr. Narrayen Dajee. Two were of Mahomedans, three of Hindoos. The 
 ages of three ranged from 7 to 10 ; of the remaining two the ages were 55 and 60. 
 In all, the symptoms of calculus had been present from 3 to 6 years ; in all the opera- 
 tion was successful. The calculi extracted weighed from 3 to 4^ drachms. But neither 
 in the six cases previously reported, nor in those now under notice, is there any account 
 given of the chemical composition of the calculi. 
 
 " Mr. Sadashew Hemraj contributed three cases of lithotomy successfully performed 
 at Bhooj. Two in children 4 years of age ; one of 12. The composition of the calculi 
 is not stated. The same defective information exists relative to 41 of the 50 calculi 
 now in the Grant College Museum. 
 
 " The etiology of urinary calculus is imperfectly understood. It is, therefore, very 
 important that, in the investigation of this form of disease, information should be 
 carefully sought in regard to all points which may serve to elucidate the causes which 
 produce it. It is very desirable that the place of birth and of residence, varieties in 
 modes of life from habits of caste or difference of circumstances, and the chemical 
 composition of the calculi, should be inquired into and recorded. Mr. Bransby Cooper, 
 in the year 1851, in a paper published in the 7th volume of the 2nd series of Guy's 
 Hospital Eeports, relative to the cases of lithotomy performed by Mr. Coles of the 
 Bengal army in the Punjaub, remarks on the importance of determining whether a 
 relation existed between the climate and peculiar systems of diet and the composition 
 of urinary calculi ; and he throws out the suggestion, that iu theory it may be ex- 
 pected that in India, where vegetable food is more exclusively used by large numbers 
 of the people, a greater proportion of oxalate of lime calculi would be found to exist. 
 "With the view of setting before you the results which may be deduced from existing 
 records of Indian calculous disease, I have referred to the several sources of information 
 within my reach. There are cases recorded, with chemical analysis, in the ' Transac- 
 tions of the Medical and Physical Society of Calcutta,' by Burnard, Spry, Twining, Brett, 
 and Darby ; in Guy's Hospital Eeports by Coles ; and in the catalogue of the Grant 
 College Museum there is an analysis by Dr. "Watson of nine calculi extracted by Dr. 
 Kitchie at Mooltan. The cases adverted to amount to 77. Eleven consisted of uric 
 acid, or urate of ammonia; 48 of uric acid associated with oxalate of lime or phos- 
 phates ; 7 of oxalate of lime alone ; 7 of oxalate of lime and phosphates ; one of phos- 
 phates alone. 
 
 "Dr. Simpson, of Tirrhoot, in the 3rd number of the 'Indian Annals of Medicine,' 
 gives the analysis of L86 cases, with a mortality of 4'8 per cent. He makes no allusion 
 to mixed calculi, but classes them all under the heads of orates, phosphates, oxalates. Of 
 the first 70 ; of the second G8 ; of the third 42 ; which gives a per-centage of 40 - 8 urates ; 
 3G-6 phosphates; 22 - G oxalates. 
 
URIC, OXALIC, AND HIOSrilATIC DIATIIESIS. 507 
 
 2. As indications of mal -assimilation, the urates being often 
 related to excess of food and sthenic states, the oxalates and 
 phosphates to asthenic and cachectic states. They are signs of 
 deranged actions, very useful to note in practice, but often serving 
 merely to confirm an inference already sufficiently evident from 
 other symptoms. They indicate the propriety of the regimen and 
 remedies which are calculated on general principles to remove the 
 deranged constitutional states on which they depend. They do 
 not indicate the use of chemical remedies with the view of altering 
 the state of the urine, unless the formation of urinary calculus be 
 apprehended ; and, then even, such remedies are not entitled to 
 rank higher than temporary palliatives. 
 
 The presence of blood, pus, and mucus in this secretion, in their 
 relation to disease of the urinary organs, and the decomposition of 
 urea, is well understood and need not be described in this work. 
 
 "Mr Ruddock, Sub-Assistant Surgeon of the Bengal Sen-ice, in the 4th number of 
 the 'Indian Annals of Medicine,' reports 77 cases of lithotomy, with a mortality of 67 
 per cent. ; but he is silent on the chemical composition of the calculi. 
 
 "These data show that uric acid entered into the composition of 135 out of 263 
 calculi ; but this is, doubtless, far short of the truth, for it is very improbable that Dr. 
 Simpson's 68 phosphates and 42 oxalates were, all of them, free of uric acid. 
 
 " In Dr. Golding Bird's work there is an analysis of 374 calculi in Guy's Hospital 
 Museum. Uric acid entered into the composition of 269. So far, then, as inquiry 
 has as yet gone, there are no grounds for believing that oxalate of lime calculi occur 
 in greater proportion in the natives of India than in those of England, yet the 
 question cannot be viewed as settled without more extended and more careful investi- 
 gation." 
 
 Since these remarks were written, Mr. H. Vandyke Carter, Professor of Anatomy 
 and Physiology, Grant Medical College, has carefully analysed the urinary calculi in 
 the Museum and arrived at the following conclusions : — 
 
 " 1. That in the Bombay Presidency the proportion of calculi having oxalate of 
 lime for their nucleus, or wholly composed of it, is about twice as great as in Eng- 
 land, taking for comparison certain standard collections there. 2. That the propor- 
 tion of calculi having uric acid, or a urate for their nucleus or entire substance, is 
 considerably less in India than in England ; in the former, urate of ammonia calculi 
 are somewhat more frequent than uric acid calculi : the opposite is the case in Eng- 
 land. 3. That the number of calctdi wholly composed of earthy phosphates, or having 
 them for a nucleus, is proportionately much fewer in India than in England : the dif- 
 ference being chiefly owing to the rarity of mixed phosphates in the former." * 
 
 * " Transactions, Medical and Physical Society of Bombay," No. 5, New Series, p. 147. 
 
508 
 
 CHAP. XXI. 
 
 ON PNEUMONIA. 
 
 Section I. — Pneumonia. — Rare in Europeans in Bombay. — 
 Asthenic Form common in Natives. 
 
 Pneumonia is a rare disease in Europeans in Bombay. I am un- 
 able for the six years of my own service in the European General 
 Hospital to separate the admissions of pneumonia from those of 
 bronchitis and pleuritis: they have all been recorded in the 
 hospital returns under the head " Thoracic Inflammations." The 
 register of admissions might supply the means of subdivision, but 
 it is not at present within my reach. On referring to my a Cases * 
 illustrative of the Pathology of the Diseases of Bombay," chiefly 
 observed in the European General Hospital, I find only eight of 
 pneumonia, and five of them were consecutive on measles. Of the 
 three other cases, one occurred in a dissipated clerk serving in a 
 public office, and the attack came on obscurely during a series of 
 successive days of intemperance ; the second in a seaman suffering 
 from delirium tremens ; the third in a warrant officer of the garri- 
 son, terminated in red and grey induration, with several gangrenous 
 excavations. In the returns of the European General Hospital for 
 the succeeding ten years, from 1844 to 1853, kindly supplied to 
 me by Dr. Stovell, twenty-two admissions of pneumonia are re- 
 corded : of these, two died. On examining my notes of cases of 
 sick officers, it appears that of 1,699 cases which passed under my 
 review, only five of pneumonia are noted: four of these proved 
 fatal ; in one there was a gangrenous excavation, and in the 
 remaining three the disease had passed on to induration or he- 
 patisation. 
 
 In respect to the natives of India, however, the results are very 
 different. In them pneumonia, of asthenic type, is sufficiently 
 
 * " Transactions, Medical and Physical Society of Bombay," 1st Series, Nos. 2, 6, 7. 
 
ETIOLOGY. 509 
 
 common. Mr. Allen Webb has published * an account of this 
 disease, as observed in 1845, at the dispensary of Cawnpore, in 
 the upper provinces of Hindostan, by Dr. Edward Goodeve; and in 
 the jail at Midnapore, in Bengal, by Mr. Green, in the same year. 
 Mr. Webb had also himself frequently observed pneumonia in 
 natives in the lower belt of the Himalayan range. During the six 
 years, from 1848 to 1853, 313 admissions of pneumonia took place 
 in the Jamsetjee Jejeebhoy Hospital. Of these 103 were under my 
 immediate care in the clinical ward; and the following remarks 
 will chiefly relate to the pathological and therapeutic deductions 
 which these cases have suggested. 
 
 Seventy-six of the cases were of primary pneumonia, and 
 twenty-seven f were of pneumonia complicating intermittent or 
 remittent fever. 
 
 In the chapter on Remittent Fever it was stated that primary 
 pneumonia, and that which complicates malarious fever, would 
 be considered together. When this arrangement was originally 
 adopted, it seemed to me that questions relative to the pathology, 
 symptoms, and treatment of inflammation of the lungs might 
 arise, in the consideration of which a comparison of the two 
 forms might be found useful. In the observations which I am 
 about to make I shall use the term primary pneumonia in its 
 generally received sense ; while for convenience sake, I shall de- 
 signate by the term febrile, the pneumonia which complicates 
 intermittent and remittent fever. In this restricted sense, then, 
 the word febrile, when applied to pneumonia, has been used in 
 this chapter. 
 
 My comments on these clinical cases have been arranged under 
 the heads— 1. Etiology. 2. Pathology. 3. Symptoms. 4. Treat- 
 ment. 
 
 Section II. — Etiology. — Relation to Sex, Age, Caste, Habits 
 Constitution, and Season. 
 
 Sex. — The question of the influence of difference of sex in pre- 
 disposing to pneumonia is not affected by these cases — they were 
 all of males. 
 
 Age. — The greater or less prevalence and mortality of this dis- 
 ease at different periods of life is a subject of interesting inquiry ; 
 
 * "Pathologia Indica," by Allan Webb, B. M. S., 2nd edition: Calcutta, 1848. 
 t Of these, twenty-three complicated remittent fever, and four intermittent fever. 
 
510 PNEUMONIA. 
 
 but the class of inmates of the Jamsetjee Jejeebhoy Hospital is not 
 calculated to advance it. They are chiefly adults, and consist for 
 the most part of day-labourers, peons, cart-drivers, domestic ser- 
 vants, and sailors. Many of them are natives of other parts of the 
 country, resorting to Bombay, for a season, in pursuit of the 
 means of subsistence. They are generally individuals in the vigour 
 of life. Of the subjects of the present cases, fifty-seven were 
 between the ages of twenty-one and thirty ; twenty-two between 
 thirty-one and forty ; eleven between ten and twenty ; and nine 
 above forty. 
 
 Caste. — The castes from which these patients were selected 
 have been, with one exception, Hindoo, Mussulman, and native 
 Christian: there were forty-nine Hindoos, forty Mussulmans, 
 and thirteen native Christians. This is about the ratio of the 
 total hospital admissions of these several castes. In this state- 
 ment, then, there is no evidence of liability to pneumonia being 
 caused by peculiarities in the customs of these different classes. 
 Yet there is an interesting fact observable in these cases, which is 
 probably related to caste-customs. The mortality among the 
 Hindoos and Mussulmans has been about one in three ; that of the 
 native Christians not quite one in six. On referring to the 
 duration of the disease before admission, I find that of the seventy- 
 one recovered cases, only twenty were admitted within five days of 
 the commencement of the attack : of these, nine were native 
 Christians. From this statement it is a fair inference, that 
 though pneumonia has been as prevalent among native Christians 
 as the other two castes, yet it has been much more successfully 
 treated, in consequence of their earlier application for relief.* 
 
 Habits and state of constitution. — The state of constitution 
 and the habits of these patients, have in all probability assisted in 
 causing the disease. Of one hundred and one individuals whose 
 state of constitution on admission is noted, sixty-three were 
 asthenic, and the condition of thirty-eight is stated to have been 
 good or tolerable. Of the asthenic patients, about one in three 
 died ; of the others about one in four. 
 
 The habits of seventy-seven are stated : of these, forty-six ad- 
 mitted that they were in the practice of using spirituous liquors ; 
 thirty-one denied it. 
 
 Seasons. — On referring to the total hospital admissions of pri- 
 
 * That the difference of the rate of mortality from pneumonia in Christians extends 
 to all forms of disease is shown by the fact — that the general hospital mortality is, 
 in Hindoos, 19'48, in Mussulmans, l.j-oG, and in Christians, y - 93. 
 
ETIOLOGY. 
 
 511 
 
 mary pneumonia during the six years to which these remarks 
 relate, it is found that in the year 1849 the number was one-third 
 more than the average of the other years. On comparing the 
 monthly admissions for the whole period, it appears that in the six 
 months from December to May, the admissions were 182; but 
 in the six months from June to November, they were 131 — a 
 difference of fifty-one in favour of the -winter and spring. These 
 results are deduced from the consideration of 313 cases. 
 
 In M. Grisolle's elaborate work on pneumonia, there is a table 
 which exhibits the months of admission in Paris of 296 cases. 
 It will be useful to compare these two statements *, with the view 
 of determining to what extent there is correspondence or difference 
 in the seasons of greatest prevalence of pneumonia in the climates 
 of Paris and Bombay. In both we find the disease more common 
 in the six months from December to May than in those from June 
 to November. But the difference is more marked in one climate 
 than in the other: in Paris it is 190, in Bombay fifty-one. When 
 the month of November is excluded, and the admissions in the two 
 places from June to October are compared, it appears that in Boin- 
 ba} T they amount to one hundred, in Paris to thirty-one. 
 
 There is, then, in Bombay, a greater proportion of admissions 
 in summer and the first half of autumn than in Paris. The reason 
 is evident. June, July, August, and September are the monsoon 
 months in Bombay — the season of the periodical rains. We have 
 at this time wet, a moist atmosphere, and high winds, as causes of 
 reduction of the temperature of the surface of the body. 
 
 These remarks have had reference to friirua/ry pneumonia. But 
 when we regard the periods of admission of the twenty-seven cases 
 of febrile pneumonia, we find that the greatest monthly number 
 
 * The statements in detail are subjoined: — 
 
 January 
 
 February 
 
 March 
 
 
 
 3ombay. 
 30 . 
 39 . 
 32 . 
 
 
 
 Paris 
 20 
 40 
 47 
 
 April . 
 May . 
 June . 
 
 
 
 21 . 
 27 . 
 23 . 
 
 
 
 62 
 
 40 
 
 8 
 
 July . 
 August 
 September 
 October 
 
 
 
 9 . 
 18 . 
 21 . 
 29 . 
 
 
 
 13 
 3 
 5 
 2 
 
 November 
 
 
 
 . 31 . 
 
 
 
 22 
 
 December 
 
 
 
 33 . 
 
 
 
 34 
 
 313 
 
 296 
 
512 PNEUMONIA. 
 
 was in July. When we compare the six months from June to 
 November with those from December to May, we find that the 
 admissions in the former amounted to twenty-two, in the latter 
 only to five. The difference between the seasons of greatest pre- 
 valence of primary and febrile pneumonia in Bombay would seem 
 to be well marked. The explanation is clear. Primary pneumonia 
 is most common in the cold months of the year ; but febrile pneu- 
 monia, on the other hand, is necessarily most common in the 
 months in which malarious fevers chiefly prevail. This fact is 
 important, as it tends to facilitate the diagnosis of the two forms, 
 and affects the principles of treatment. 
 
 Causes assigned. — The patients generally have not attributed 
 the attack to any particular cause. Nine traced it to cold or wet, 
 eight to fatigue and exposure, and ten to blows more or less re- 
 cently received. When we consider the season of greatest pre- 
 valence of the primary form, the occupations of the inmates 
 of the hospital, their exposure to vicissitudes of weather, their 
 scanty clothing, and defective habitations, we are justified in 
 regarding reduction of the temperature of the surface of the body 
 as the common exciting cause of pneumonia in India, as else- 
 where. 
 
 Section III. — Pathology. — Preliminary Question relative to the 
 affected Capillaries. — Rate of Mortality. — Duration of Illness 
 before Admission. — Stage of the Disease. — Which Lung most 
 frequently affected. — Period of Residence in Hospital. — State 
 of the Lung on Discharge. — Morbid Anatomy. 
 
 Preliminary Remarks. — The first question which naturally 
 arises, relative to the pathology of pneumonia, is the deter- 
 mination of the precise seat of the inflammation. I do not 
 mean, whether the walls of the pulmonary air cells or their 
 connecting areolar tissue are the structures affected : this, 
 though much discussed by pathologists, has never appeared to me 
 a very important or difficult point to establish. If in inflam- 
 mation of mucous and serous membranes we generally find that 
 the deranged action tends to extend to arid cause exudation in the 
 areolar tissue subjacent to them, it is improbable that inflamma- 
 tion of the pulmonary cell-wall can exist without tending to ex- 
 tend and to cause exudation in the areolar tissue which connects 
 the cells together, as well as into the cells themselves. The ques- 
 tion to which I allude is, whether the capillaries of the bronchial 
 
PATHOLOGY — GENERAL REMARKS. 513 
 
 arteries, or those of the pulmonary artery, are the seat of inflam- 
 mation. The answer appears to me simple and evident. If we 
 adopt the opinion, at present generally received, that inflammation 
 is an altered state of the nutritive processes of the affected part, 
 depending upon something faulty in one or other of the conditions 
 of normal nutrition, then the capillaries concerned in inflamma- 
 tion must necessarily be only those which circulate, in their normal 
 state, arterial blood for purposes of nutrition. The capillaries of 
 the bronchial arteries are the nutrient vessels of the visceral pleura, 
 of the mucous lining and other structures of the bronchial tubes, 
 and of the connecting areolar tissue of the constituent parts of the 
 lung ; and we can hardly avoid the conclusion that they are also 
 the nutrient vessels of the pulmonary cell-walls. These capil- 
 laries are unquestionably those involved in visceral pleuritis, and 
 in bronchitis ; and when we regard the frequent relation of these 
 affections to pneumonia, it is reasonable to conclude that the 
 same kind of capillaries are concerned when the inflammation is 
 of the pulmonary cell-walls, and of the areolar tissue which con- 
 nects the cells to each other.* 
 
 The capillaries of the pulmonary artery, on the other hand, 
 convey venous blood to the air cells, for distribution on their wails, 
 in order that the physical process of endosmosis and exosmosis 
 may take place between the gases of the blood and the atmospheric 
 air. It does not seem probable that the blood in these capillaries 
 takes any part in the nutrition of the cell-walls. It is, therefore, a 
 just conclusion that these capillaries and their blood cannot be 
 agents in the altered state of nutrition of the pulmonary cell-walls, 
 and their connecting areolar tissue, which we designate by the 
 term pneumonia. Though the capillaries of the pulmonary artery 
 are not the capillaries directly engaged in inflammation, yet their 
 deranged action has much to do with the pathology of pneumonia. 
 
 The phenomena which attend on the first inspiration after birth, 
 on asphyxia, vesicular emphysema, and other pathological states of 
 the lungs, teach us the following facts : — 
 
 1. That the pulmonary capillary circulation is contingent on 
 
 * I am, of course, aware that some physiologists hold that the blood in the pulmo- 
 nary capillaries, passing into the arterial state, becomes nutrient of the cell-walls. 
 The subject is not susceptible of demonstrative proof; but surely the argument from 
 analogy supports the opinion that the bronchial are the nutrient capillaries. It seems 
 to me quite as reasonable to suppose that the blood flowing in the channel of the aorta 
 is nutrient of its walls, as that the arterialised blood of the pulmonary capillar;.- is 
 nutrient of the tissues around it. Both bloods are flowing in their respective channels 
 with objects in view, special and not related to the nutrition of the tissues imme- 
 diately adjoining to them. 
 
 L L 
 
514 PNEUMONIA. 
 
 the processes between the blood in the pulmonary capillaries and 
 the air in the pulmonary air cells being in action. 
 
 2. If this aeration of the blood is impeded from want of suf- 
 ficient air or from thickening of the cell-walls, or the cells 
 becoming filled with liquid or solid deposits, the pulmonary 
 capillary circulation on such cell-walls becomes languid, and soon 
 stops : — the blood distends the vessels, and stagnates in them. 
 Now, additional blood is no longer sent into the branches of the 
 pulmonary artery which conduct to these defective cells; but it 
 passes in excessive quantity into adjoining branches, to be con- 
 veyed to the capillaries of adjoining healthy cells, in order that 
 it may be aerated there. If, however, the blood thus sent in ex- 
 cessive quantity to these adjacent healthy cells be greater than 
 their extent of surface can readily aerate, dyspnoea is caused. 
 Short and hurried respirations merely express the fact that all the 
 cells of the lungs are not admitting air, and that the diminished 
 extent of surface thus arising is being compensated for by the 
 greater frequency of the respiratory acts. Difficulty of breathing 
 is only experienced when there is want of harmony between the 
 quantity of blood in the vascular system and the extent of the 
 effective pulmonary surface. 
 
 Let us now endeavour to apply these principles to the pathology 
 of the disease before us. 
 
 When the pulmonary cell-walls become somewhat thickened 
 from the turgescent state of the bronchial capillaries, and when 
 secretions are present in the cells, in the degree which interferes 
 with, but does not altogether prevent, the admission of air, then 
 we may believe that some degree of aeration is still carried on, 
 that the pulmonary capillaries become somewhat distended, and 
 that the circulation of the blood is impeded in them, but as yet 
 is not altogether obstructed. Such I believe to be the condition 
 of the lung in the first stage of pneumonia. The inflammation 
 continues, the thickening of the cell-walls increases, the inflam- 
 matory deposits take place in greater abundance into the cells, 
 and now the aeration of the blood at these cells is physically 
 impracticable : the pulmonary capillaries become turgid with stag- 
 nated blood, and the circulation in them becomes altogether ob- 
 structed. Such I believe to be the state of the lung in the second 
 stage of pneumonia: its spongy structure has become solid; the 
 solidification depending, in part, it may be assumed, on inflamma- 
 tory exudation into the crlls, in part also, however, on the stag- 
 
TATUOLOGY — EATE OF MORTALITY. 515 
 
 nated blood in the close-set meshes of the pulmonary capillaries. 
 This latter condition of consolidation is not stated with sufficient 
 prominence by pathological writers on this disease. It explains 
 well how the consolidation of the lung sometimes takes place 
 rapidly, and how it sometimes is very speedily removed. It 
 is evident that if part of the consolidated condition has de- 
 pended on pulmonary capillaries turgid with blood stagnated, 
 but not coagulated, and aeration becomes re-established in the 
 affected cells by reduction of the inflammation, then this stagna- 
 ting blood will at once be set in motion, and the consolidation 
 that depended upon it be speedily removed. 
 
 My belief, then, is, that the capillaries of the pulmonary artery 
 are not the inflamed capillaries of pneumonia; but that conse- 
 quent on inflammation of the pulmonary cell-walls, the action of 
 the pulmonary capillaries becomes deranged in the manner ex- 
 plained. This derangement constitutes the danger of pneumonia, 
 as of all other forms of pulmonary disease. Moreover, the de- 
 ranged action of the pulmonary capillaries takes a part in pro- 
 ducing the striking morbid appearance of the lung in pneumonia 
 — I mean its hejmtisation. 
 
 In this view of the pathology of pneumonia, we have also a 
 satisfactory explanation of the relation between hypostatic con- 
 solidation of the lung, and the hepatisation of pneumonia. In 
 hepatisation, there is in the pulmonary capillary turgescence 
 which is present, the condition of hypostatic consolidation; but 
 there are also, in addition, the consolidating conditions derived 
 from the direct products of inflammation. 
 
 These are not mere idle speculations, for, as we shall presently 
 find, they have an important reference to symptoms, as well as to 
 questions of treatment. The subject is analogous to that which 
 has been previously discussed, relative to the capillaries engaged 
 in hepatitis.* 
 
 Rate of Mortality. — There were 76 cases of primary pneu- 
 monia. Of these 24 died — a mortality of nearly 29 per cent.,f if 
 two cases fatal from cholera be excluded. \ 
 
 * Page 325. 
 
 t In my subsequent statements regarding the rates of mortality, I shall not exclude 
 these cholera cases. 
 
 | It will be observed, that the tabular statement at the end of this chapter gives 
 for the total hospital admissions of pneumonia a mortality of 38"6 per cent. This is 
 in part explained by the supposition that there may have been cases admitted in such 
 an advanced and hopeless state of disease as to be unsuited for clinical instruction, 
 
 L L 2 
 
516 TNEUMONIA. 
 
 There were twenty-seven cases of febrile pneumonia : of these 
 eight died ; in two the fatal result was caused more from co-exist- 
 ing meningitis than pneumonia; yet, in estimating the rate of 
 mortality of this form, we may not exclude any of the usual con- 
 tingencies of malarious fever. The rate of mortality of the febrile 
 cases was not quite 30 per cent. 
 
 The rate of mortality of primary pneumonia has been nearly as 
 high as that of the febrile form : hence we are probably justified in 
 assuming that this inflammation, complicating malarious fever, is 
 not so severe as when it occurs in its primary form. Were it other- 
 wise, the mortality of the febrile form would be higher, for in it we 
 must always attribute death, in part, to other conditions of idio- 
 pathic fever as well as to the pneumonia. 
 
 But 29 per cent, seems a large mortality from primary pneu- 
 monia. We have already found in the diatheses of a large propor- 
 tion of the patients one condition favourable to high mortality 
 from disease. Still it is very necessary, with the view of satisfac- 
 torily testing the success or failure of treatment, to inquire into the 
 following points : — 
 
 1. The duration of illness before admission. 
 
 2. The stage of the disease on admission. 
 
 3. The extent and part of the lung affected. 
 
 4. The length of time under treatment before recovery or 
 death. 
 
 5. The state of the lung on discharge, in the cases discharged 
 from hospital. 
 
 Duration of illness before admission. — The following tabular 
 
 and therefore to have been excluded from my selection for the clinical ward. Allow- 
 ance must also be made for errors of diagnosis, liable to occur in large hospitals served 
 by different medical men often overtasked with duty. This latter observation, pro- 
 bably more or less true of all countries, is correct of civil and military hospitals in 
 India — more especially in seasons of unusual sickness, or amid the distractions and 
 labours of active service. It is also particularly applicable to those forms of disease — 
 of the chest for example — in which much care, time, and patience are required to 
 establish the diagnosis with that precision and accuracy of which the present state of 
 the science is capable. 
 
 I am most desirous of impressing on the Indian practitioner the injury which is 
 likely to result to pathology and therapeutics, by applying to their elucidation data 
 which are unsuited for the purpose. The least reflection must convince any one that 
 there is little in common between the figured statements of disease in hospitals, as 
 usually compiled, and the results of the scrutiny of a series of attentively considered 
 and carefully recorded clinical cases. Most certainly nothing in common, but the use 
 of fig-ires, between pathological and therapeutic deductions, from military and naval 
 hospital statistics, ami the inferences from the numerical method as practised by Louis 
 and those who are truly his followers. 
 
PATHOLOGY RATE OF MORTALITY. 
 
 517 
 
 statement exhibits the duration of illness of the patients before 
 admission. 
 
 Duration of Illness of Patients before Admission. 
 
 
 Recovered. 
 
 Died. 
 
 
 1 to 5 days .... 
 
 
 
 Total. 
 
 Primary 
 
 Febrile- 
 
 Primary. 
 
 Febrile. 
 
 17 
 
 3 
 
 1 
 
 1 
 
 22 
 
 6 to 10 „ 
 
 18 
 
 8 
 
 8 
 
 — 
 
 34 
 
 11 to 15 „ 
 
 6 
 
 6 
 
 4 
 
 2 
 
 11 
 
 16 to 20 „ 
 
 
 
 — . 
 
 1 
 
 3 
 
 9 
 
 21 to 30 „ 
 
 2 
 
 2 
 
 2 
 
 2 
 
 8 
 
 31 and upwards .... 
 
 4 
 
 — 
 
 8 
 
 — 
 
 12 
 
 
 Total . 
 
 103 
 
 The mortality of the 'primary form, admitted within five days 
 from the commencement of illness, was 5'5 per cent. The single 
 fatal case occurred in a Parsee of intemperate habits ; was in the 
 second stage, and complicated with pleuritic effusion and albu- 
 minuria. 
 
 The mortality of the febrile form, admitted within five days 
 from the commencement of illness, was 25 per cent. The single 
 fatal case occurred in an individual affected with fever and bron- 
 chitis : pneumonia came on subsequently, and proved fatal seven- 
 teen days after admission. 
 
 The mortality of primary pneumonia, admitted between six and 
 ten days from the commencement of illness, was 30 per cent. In 
 seven of the eight fatal cases the disease was in the second stage on 
 admission. In four the pneumonia was double, and in three of 
 them the disease was in the second stage, in one in the first. 
 
 Of the eight cases of febrile pneumonia, admitted between six and 
 ten days from the commencement of illness, none proved fatal. 
 
 The mortality of both forms, admitted above ten days from the 
 commencement of illness, was nearly 47 per cent. 
 
 When we regard all the admissions of primary pneumonia, 
 within ten days from the commencement of illness, the rate of 
 mortality is found to be 20 per cent. But when we consider the 
 febrile cases from the same point of view, the mortality falls to 8 
 per cent. Yet for the periods above ten days, the mortality of 
 both forms is the same, — 47 per cent. The lower mortality of 
 febrile pneumonia, within ten days from the commencement of 
 illness, is of interest : it seems to show that the pneumonia does 
 not come on till some time after the commencement of the fever. 
 It is, therefore, probable, that in all the cases of febrile pneumonia 
 
 r. l 3 
 
518 PNEUMONIA. 
 
 admitted within ten days from the commencement of illness, the 
 pneumonia has generally been either in the first stage, or only 
 passing into the second. 
 
 Stage of the Disease. — Of the primary form eight were in the 
 first stage. Of these two died ; in one the pneumonia was double, in 
 the other it was complicated with much bronchitis in a man of 
 sixty years of age. 
 
 Sixty-four cases of primary pneumonia were admitted in the 
 second stage. Of these twenty-seven were double, thirty-four were 
 single, and confined to part of a lung, and three were of one entire 
 lung. If we class together the cases of double pneumonia and 
 those of one entire lung in the second stage, we find that the mor- 
 tality was 36-6 per cent. ; but the mortality of single pneumonia 
 in the second stage, involving only part of a lung, has been 17*6 
 per cent. The mortality of the aggregate admissions of primary 
 pneumonia in the second stage, has been 26*5 per cent. 
 
 Four admissions of primary pneumonia took place in the third 
 stage : all were fatal. 
 
 Of the febrile form, five cases were admitted in the first stage: 
 one proved fatal, admitted after twenty days from the commence- 
 ment of the fever, complicated with muttering delirium and 
 drowsiness. 
 
 Twenty-two of this form were admitted in the second stage. Of 
 these, fourteen were double, eight single. The mortality of the 
 former was 35 per cent., of the latter 25 per cent. 
 
 Lung affected. — In comparing the frequency of pneumonia in 
 the lung of the different sides, and in the different parts of the 
 lung, I shall class the primary and febrile forms together. Of 
 both lungs (double pneumonia) there were forty-six cases, with 
 a mortality of 32-6 per cent. Of the right lung there were 
 thirty-nine cases, with a mortality of 33-3 per cent. Of the 
 left lung there were eighteen cases, with a mortality of 22-2 per 
 cent. Of the cases in which the right lung was affected, the entire 
 organ was involved in three : this did not occur in any of the in- 
 stances in which the disease was confined to the left side, there- 
 fore, when these three cases are deducted, the mortality for the 
 right side is reduced to 25-3. 
 
 In regarding these rates of mortality, we must always bear in 
 mind that they relate to a series of cases of which the admissions in 
 the first stage were only about 13 per cent. 
 
 In this statement the proportion of double pneumonia appears 
 much greater than has usually been observed. This is, in part. 
 
PATHOLOGY. 519 
 
 owing to the two forms having been classed together. Of the 
 twenty-seven cases of febrile pneumonia, we had the disease double 
 in seventeen. When we consider the primary form alone, we find of 
 double pneumonia twenty-nine ; of the right lung thirty-three ; 
 of the left lung fourteen. This is still an unusual proportion 
 of double pneumonia. 
 
 When we direct our attention to the part of the lung affected in 
 these cases, it appears that in seventy-nine the lower or middle parts, 
 or both, were engaged, and of these the mortality was 26 per cent. 
 In fifteen cases the upper lobe was affected, and of these the mor- 
 tality was 26 per cent. In nine the entire lung, double or single, 
 was affected, andthe rate of mortality was 77 per cent. 
 
 The greater liability of the lower part of the lung to become 
 affected with pneumonia is well shown in these cases. The great 
 mortality of the disease when an entire lung is involved also ap- 
 pears ; but the opinion that pneumonia of the upper part of the 
 lung is more fatal than that of the lower, is not confirmed by these 
 cases. It was believed by Louis, that individuals above the age 
 of fifty were more liable to pneumonia of the upper lobe than those 
 of earlier periods of life: but eleven of my fifteen cases were under 
 the age of thirty-one.* 
 
 * Subsequent observation in India has tended to confirm my opinion that pneumonia 
 of the upper lobe is more frequent than is generally supposed, is not more dangerous, 
 and is not most common in individuals above the age of fifty. It also shows that, 
 in India at least, there is a greater liability to error of diagnosis between pneumonia 
 and phthisis in their second stages, than would exist under the generally received 
 opinion that pneumonia is seldom exclusively in the upper lobes. I am satisfied that 
 a too ready belief in the common opinion has led me, on more than one occasion, to 
 diagnose phthisis in the second stage instead of pneumonia in the second stage. 
 
 The subject is so important, that I do not hesitate to submit a short summary of 
 the additional cases which have come under my notice since the remarks in the 
 text were written ; the aggregate thus amounts to twenty-one eases. 
 
 1. Bapoo Eawa, a Maratha, twenty-five years of age, admitted with remittent fever 
 attended with delirium, on the 5th December, 1856. There was cough. Dulness and 
 coarse crepitus were detected in the right infra-clavieular region on the 11th, and 
 phthisis was diagnosed. The fever ceased. The dulness lessened, and he was dis- 
 charged on the 16th December without any trace of disease in the right infra-clavicular 
 region. 
 
 2. Chota Padrcn, aged twelve, was, after three days' illness, admitted on the 5th 
 January, 1857. He was out of condition, there was much fever with pain of limbs. 
 The dorsal regions were examined, and no pulmonary disease detected. Continuance 
 of febrile exacerbation with cough led to a more thorough examination, and on the 
 7th there was ftmnd dulness of the left infra-clavieular, mammary and axillary regions 
 with bronchial respiration. Acetate of ammonia and nitre were given, and water com- 
 presses applied to the affected regions. The febrile symptoms lessened, crepitus ap- 
 peared in the dull regions, and on the 22nd the state of the upper part of the left lung 
 was normal and he was discharged well on the 31st. 
 
 I. L 4 
 
520 PNEUMONIA.. 
 
 Residence in hospital. — In considering the duration of residence 
 in hospital, let us separate the recovered from the fatal cases. 
 
 Of recovered cases, twelve primary and two febrile were dis- 
 charged within ten days ; twelve primary and eleven febrile between 
 eleven and twenty days; thirteen primary and three febrile between 
 twenty-one and thirty days ; fifteen primary and three febrile above 
 thirty-one days. 
 
 There were fifty-seven cases discharged at different periods above 
 ten days ; eighteen of them, indeed, above thirty-one days. From 
 this statement we may infer, that though pneumonia in the second 
 stage is frequently recovered from, yet a considerable time is gene- 
 rally required to ensure the restoration of the lung to a healthy or 
 useful state. 
 
 Of the fatal cases, fourteen primary and five febrile died within 
 ten days from admission, three primary and two febrile between 
 eleven and twenty days, two primary and one febrile between 
 twenty-one and thirty days, and five primary upwards of thirty- 
 one days. The fact of nineteen of the thirty-two fatal cases 
 having proved fatal within ten days of admission shows the ad- 
 vanced stage at which a great portion of them must have come 
 
 3. Rama Itoo, a Hindoo, aged thirty, after six days' illness, was admitted on the 4th 
 January, 1S58, with duhiess, bronchial respiration, and crepitus of the left infra-clavi- 
 cular, mammary and scapular regions. There was also crepitus in the right infra- 
 seapular region. Under the use of quinine, stimulants, nourishment, and a water 
 compress to the chest, the cough and fever lessened, the duhiess and bronchial respira- 
 tion decreased, and he left the hospital contrary to advice on the 12th. at which time 
 there was no fever nor cough, biit the defective resonance and the bronchial respiration 
 on the left side were not altogether gone. 
 
 4. Pestonjee Dorabjee, a Parsee, aged forty, had been in hospital two or three times 
 with fever and suspected tubercles in the upper right lung, but after discharge he had 
 gained so much in flesh as to remove the suspicion of phthisis. He was re-admitted 
 on the 4th February, 1857, with remittent fever. The tongue was florid at the edges, 
 and there was occasional vomiting and cough. On the 7th there was duhiess and im- 
 perfect respiration in the right infra-clavicular region, with bronchial respiration and 
 crepitus in the scapular region. On the ninth the physical signs were the same, and 
 the sputa had a faint rusty tinge. The fever continued for two days with some delirium 
 and slight jaundice, then lessening of the fever and cough, and on the 12th there was 
 coarse general crepitus in the right infra-clavicular region. On the 14th the dulness 
 was less and the crepitus was being replaced by vesicular respiration. The fever no 
 longer recurred. He gradually improved and was discharged on the 23rd March in 
 good flesh, without cough, and with normal resonance and breath sounds in the right 
 infra-clavicular region, 
 
 o. Mahadoo Sawnut, a Mahratta sepoy of the Gth Regiment, Bombay Infantry, 
 aged twenty-two, was admitted into hospital at Poona, on the 15th April, 1859. He 
 had feverwith marked remissions ami exacerbations. The chi st was examined on the 
 17th, but nothing abnormal was detected. On the 19th the fever continued, the re- 
 spiration was hurried, .-11111 wandering delirium was present. I saw this patient for the 
 
PATHOLOGY. 521 
 
 under treatment. It confirms the direct statement made on this 
 point in a former part of these remarks. 
 
 State of lung on discharge. — Seventy-one cases were discharged 
 from hospital. Of fifty-one cases of primary pneumonia the lung 
 was quite* restored in thirty-three, improved in thirteen, not im- 
 proved in five, and in one not recorded. Of nineteen febrile cases 
 the lung was restored in sixteen, improved in two, and in one not 
 recorded. 
 
 When we class the two forms together, we find that sixty-two 
 were admitted in the second stage, and only nine in the first stage. 
 It has appeared that in forty-nine of the discharged cases the lung 
 was restored. If we deduct from these the nine cases admitted 
 in the first stage, we have of sixty-two cases of pneumonia in 
 the second stage forty recoveries. Of the remaining twenty-two 
 the lung was improved in fifteen, not improved in five, and not 
 recorded in two. 
 
 Morbid anatomy. — There was a post-mortem examination made 
 in fifteen of the twenty-four fatal cases of primary pneumonia, and 
 in seven of the eight fatal cases of febrile pneumonia. 
 
 In eleven of the cases the solidified lung was in a state of 
 
 first time on the morning of the 20th, on the occasion of my weekly visit to the 
 hospital, and was struck with the hurried breathing and defective movement of the 
 left side. The subclavian, mammary and scapular regions of that side were dull, and 
 bronchial respiration was present. I called the attention of the medical officer to the 
 pneumonia in the second stage, complicating fever, which he had overlooked. A few 
 leeches were applied, and quinine, with one grain of calomel and antimonial powder, 
 was given every second hour, and sesquicarbonate of ammonia in the intervals. On the 
 21st the sputa, previously tenacious, had become less so, the respiration less hurried, 
 but the delirium still occasional. -On the 23rd, the respiratory murmur began to 
 return ; and on the 28th, when I again saw him, the dulness was gone and the 
 respiration quite restored. He was discharged on the 1st May._ This case shows 
 very forcibly the importance of frequent systematic auscultation and percussion in 
 remittent fever in natives of India. The medical officer in this instance was a gentle- 
 man of much intelligence, and in general quite alive to the importance of these 
 methods of investigation, but in this case he had been satisfied with one cursory ex- 
 amination on the second clay after admission. 
 
 6. John Dias, aged thirty, a cook, after five days' illness, was admitted, on the 18th 
 December, 1857, with fever, slight jaundice, delirium, adhesive yellow-tinged sputa, 
 and solidification of the left lung, chiefly noted in the axillary and scapular regions. 
 He died on the 14th, and on inspection the whole of the left upper lobe was in a state 
 of grey hepatisation, with friable lymph on its pleural siu-face. The upper part of the 
 lower lobe from above downwards passed from grey into red hepatisation, and the thin 
 part of the base of the lung was spongy and crepitating. The right lung was healthy. 
 There was commencing Bright' s disease. This was a case of pneumonia commencing 
 in the upper lobe, and passing downwards. 
 
 * By this I mean that the removal of the dulness on percussion, and return of the vesi- 
 cular respiration, indicated that the lung had become permeable and fit for function. 
 
522 PNEUMONIA. 
 
 induration, either red or grey. This condition, compared with 
 readily lacerable hepatisation, occurs iu this hospital in a greater 
 proportion even than this series shows : it is related to asthenic 
 states, to a protracted course, and not unfrequently to advanced 
 period of life. True hepatisation, on the other hand, usually 
 occurs in better states of the constitution, and after a more rapid 
 course : in the febrile form it has existed in greater proportion than 
 induration. Of the seven cases of febrile pneumonia there was he- 
 patisation in five, and induration in two ; whereas in the fifteen cases 
 of primary pneumonia there was induration in nine, and hepati- 
 sation in six. Whether the grey induration is to be regarded as an 
 advanced stage of the red or brown, or a distinct variety from the 
 commencement, has been a question : these cases rather counte- 
 nance the former view. Tubercular deposit was observed in only 
 one case, a febrile one : it was in small quantity in the upper lobe 
 of the left lung. 
 
 In three of the cases — two primary, and one febrile — the he- 
 patisation, in places, occurred in nodules : the pneumonia had been 
 in part lobular ; but in all there were also hepatised portions of 
 considerable extent. There was no reason for supposing that these 
 instances of lobular pneumonia were dependent on jtysernia: they 
 were more probably cases in which bronchitis had passed into 
 pneumonia, for in all of them increased redness of the bronchial 
 mucous lining was well marked. 
 
 Though there are no cases of pysemic pulmonary abscesses in 
 this series, yet several have been observed in the hospital. Pyaemia 
 will be considered in a subsequent chajDter. 
 
 Pleural adhesions have generally proved the co-existence of 
 pleuritis, more or less recent. The absence of pleuritis occurs, 
 more frequently in febrile than in primary pneumonia: of 
 the seven fatal cases of the former, examined after death, it is 
 distinctly stated that in two of them there were no traces of 
 pleuritis, and yet in both there was much red hepatisation of 
 the lung. 
 
 Thick cacoplastic membranous, almost cartilaginous, deposits 
 were found in one or two cases, connecting the surfaces of the 
 pleura together. One case seemed to show that the deposit takes 
 place in the first instance on the surface of the pulmonary pleura, 
 and advances to some degree of thickness, before it forms adhesion 
 with the opposed costal pleura. In the case referred to, the an- 
 terior part of the upper lobe of the right lung adhered to the costal 
 surface by a thick membranous, almost cartilaginous, layer ; while 
 
rATIIOLOGY. 523 
 
 on the same part of the left lung there was an opaque membranous 
 deposit, but no adhesion. 
 
 Bronchitis, to greater or less extent, has also been noticed as a 
 frequent complication : it occurred in greater proportion in the 
 febrile form. 
 
 Cavities were found in the lungs in five* cases. They ranged 
 in size from a small orange to a split pea. In all there were 
 several cavities : they existed both in the upper and lower lobes, 
 and had formed in the midst of grey induration. In case 228 
 the different stages of the process were well shown ; in it, scattered 
 in the grey induration, were dark-red points, from the size of 
 a pin's head to that of a hemp seed ; and there were also 
 cavities from the size of a split pea to that of a pigeon's egg, with 
 an inner surface, moist, and of dark-red colour. In the grey in- 
 durated part, inflammatory stasis of blood had probably taken 
 place, here and there followed by molecular loss of vitality, hence 
 softening, liquefaction, and the formation of cavities at these 
 points : this seemed to me to be the process by which in two 
 of these cases the cavities had been formed. In the three others 
 the appearance of the cavities, the fcetor of their contents, or 
 of the sputa during life, indicated that the loss of vitality had 
 not been molecular merely, but of portions of tissue more or less 
 extensive: that the cavities had been formed by a process of 
 gangrene.f 
 
 * There was a sixth case, in which cavernous respiration was present ; but the body 
 was not examined after death. 
 
 f The occurrence of gangrene of the lung, unpreceded by inflammation, is not 
 common. There are two cases in my notes which seem to me to have been of this 
 nature. 
 
 The first was a marine of Her Majesty's ship Endymion, of twenty years of age. 
 He had suffered from adynamic remittent fever, and was under treatment for consecu- 
 tive dysentery. Chest. — The lungs did not collapse, the anterior parts were inflated, 
 the posterior (Edematous. On the posterior part of both lungs there was a green dis- 
 coloured portion, which broke down readily under the knife, and gave out much green- 
 ish frothy serum. The cellular tissue was plainly disorganised, and the serum seemed 
 to have been contained in a small cyst, rather than in the natural tissue of the lung 
 (gangrene with serous effusion into the cellular tissue of the lung, not preceded 1 y 
 condensation of that portion of the lung). No hepatisation of any part of the lungs. 
 Heart healthy. Abdomen. — The stomach, much distended, occupied the entire space 
 between the ensiform cartilage and umbilicus; its mucous coat was lined with adhe- 
 sive mucus, and presented throughout a dusky rosy tint, without softening. The liver 
 was rather enlarged, olive-green in colour, and mottled ; no abscess. The transverse 
 portion of the colon was opened ; the mucous coat presented numerous ulcers in diffe- 
 rent stages, many of them cicatrising. Spleen natural ; kidneys healthy. 
 
 The second occurred in a destitute Mahomedan pilgrim, of fifty years of age, with 
 puffed face, cedematous feet, short and hurried respiration, puriform sputa, some degree 
 
524 PNEUMONIA. 
 
 In none of the five cases in which cavities existed was tuber- 
 cular deposit observed in the lungs: three of them are here 
 detailed: — 
 
 228. Pneumonia, extensive of right lung. — Grey induration with cavities formal in 
 the upper lobe by molecular gangrene. — Pandoo Gunnoo, a Hindoo, of thirty-five years 
 of age, a native of Carlee, following the occupation of a peon, and not addicted to the 
 use of spirits, was, after fifteen days' illness with fever, cough, pain of back and loins, 
 admitted into the clinical ward on the 5th September, 1849. He was emaciated. The 
 respiration was hurried. There was dulness of the subclavian and lateral regions, and 
 of the whole posterior part of the right side of chest, greatest in degree in the supra- 
 spinous and dorsal regions. In all these situations occasional subcrepitus was heard, 
 with blowing respiration under the clavicle and under the spine of the scapula. In 
 the left side of chest no abnormal sign was detected ; but the respiration was puerile 
 in parts. The sounds and impulse of the heart were natural. There was elastic and 
 uneasy fulness of the abdomen, above the umbilicus. The feet were (Edematous. The 
 skin was above the natural temperature. The pidse was small and somewhat frequent. 
 The tongue was slightly florid at the tip and coated posteriorly. The voice was hoarse, 
 and the breath very fetid. On the 8th the chest was again carefully examined : under 
 the acromial end of the right clavicle and in the axilla, the respiration was cavernous, 
 sometimes almost amphoric, and pectoriloquy was distinct. In the right lateral and 
 dorsal regions the respiration was bronchial, with occasional crepitus and subcrepitus 
 in the former. He continued under treatment till the 21st, when he died. There was 
 hectic fever, frequent hard cough, with grey puriform sputa. Diarrhoea supervened 
 on the 16th, and hastened the fatal issue. He was treated with anodynes chiefly till 
 the diarrhoea came on, when acetate of lead with opium was given. 
 
 Inspection six hours after death. — The larynx and trachea were healthy. Chest. — 
 The left lung was crepitating and inflated : there were old adhesions between the 
 inferior lobe and the costal pleura and diaphragm. The right lung adhered firmly 
 on all sides to the parietes of the chest : the upper lobe was in a state of grey indura- 
 tion with many irregular excavations ; the largest was situated ne"ar the apex, of the 
 size of a small egg, and another, somewhat smaller, existed at the lower and. outer part ; 
 the excavations in process of formation were surrounded by a dark-red layer, and the 
 contents of all consisted of dark grey, sero-puriform, very fetid fluid ; the lower lobe 
 was in a state of grey hepatization, with the exception of its inner and lower half, 
 which was healthy and crepitating. Abdomen. — On opening the abdomen some fetid 
 gas escaped. Firm adhesions connected the anterior parietes to the omentum and 
 colon, which passed horizontally across the abdomen from one side to the other, just 
 above the umbilicus. The liver had contracted firm adhesions with the stomach, 
 diaphragm, and anterior parietes of the abdomen ; and its outer covering appeared to 
 be denser than natural. The structure was healthy. Besides the adhesion with the 
 liver, the stomach was also adherent to the spleen ; its mucous surface was not ex- 
 amined. The spleen was not enlarged ; it adhered on all sides to the diaphragm, 
 abdominal parietes, and the stomach. The left kidney was larger than the right ; 
 both were flabby, but of healthy structure. Other parts not examined. 
 
 of dulness of the right dorsal lateral and scapular regions, with occasional subcrepitus. 
 No albumen in the urine. Inspection. — Old adhesions united the posterior part of the 
 right lung to the walls of the chest. The posterior part of this lung, for about four 
 inches in length and three in width, was in a state of gangrene — reduced to a dark- 
 grey fetid pulpy state. The surrounding pulmonary tissue was in part healthy, in 
 part oedematous; but without trace of sanguineous engorgement or hepatization. 
 The heart was healthy. Two pints of serous fluid were effused in the cavity of the 
 abdomen. 
 
PATHOLOGY. 52 O 
 
 229. Grey, almost cartilaginous, induration of the lower part of the right lima, with 
 several excavations by process of gangrenous molecular softening. — The several stages 
 of the process well shown. — Bright' s disease of the kidney. — Pandoo, a Hindoo 
 labourer, a native of Coorla, of thirty years age, was, after three months' illness, ad- 
 mitted into the clinical ward on the 11th September, 18-18. He was much reduced, 
 affected with cough, puriform expectoration, and daily febrile accessions coming on at 
 irregular times. He had suffered thus for two months. He pointed to the right false 
 ribs as the seat of pain when he coughed, and this he believed to have been caused by 
 a fall from a horse some years before ; but he was wanting in intelligence, and not 
 distinct in his statements. The breathing was rather hurried, and the pulse feeble. 
 In consequence of disturbance from the cough, it was some days before a satisfactory 
 examination of the chest could be made. On the 17th, there was large mucous rale in 
 the right axilla. On the 27th, cavernous respiration in the right axilla, dulness of the 
 right seapida and dorsal regions, with occasional crepitus in the latter, were noted ; 
 also vesicidar respiration general on the left side, with occasional crepitus in the dorsal 
 region. On the third October, cavernous respiration, and pectoriloquy, were reported 
 in the right axilla, and at the inside of the inferior angle of the right scapula. Vesi- 
 cidar respiration was absent in the right lateral region, and bronchial sounds were 
 heard there. On the 8th, the right dorsal and lateral regions were completely dull, 
 and the signs of a cavity continued. There was very troublesome cough with copious 
 puriform expectoration and frequent, hectic fever. On the 13th October, the urine 
 gave a flaky deposit with heat and nitric acid, and on several subsequent occasions 
 also evinced traces of albumen. The feet became (Edematous', and he died on the 24th 
 October. Small blisters were applied to the right side of the chest. He was treated 
 with anodynes, expectorants, and tonics. 
 
 Inspection four hours after death. — Chest. — The left lung adhered firmly to the 
 costal pleura ; its upper lobe was emphysematous, but elsewhere it crepitated, was no- 
 where consolidated, and did not give out much fluid of any kind when incised. The right 
 lung adhered very firmly to the costal pleura at the lateral and dorsal parts ; also to 
 the diaphragm. The upper lobe was crepitating, with, at its very apex, an emphyse- 
 matous bulla, the size of a walnut. The third lobe was consolidated throughout, and 
 covered by a membranous layer of lymph, at least quarter of an inch thick at 
 the base of the lung, where opposed to the diaphragm. This lobe was in a state of 
 grey induration, almost cartilaginous when incised, but branches of the pulmonary 
 artery and veins and bronchial tubes could be traced ramifying through the indurated 
 substance. At the very edge and back part of this lobe there was about an inch square 
 of crepitating tissue, and at the upper part were several irregular excavations, the 
 largest the size of a pigeon's egg, with moist dark red walls, and membranous investing 
 tissue. They had the character of gangrenous excavations, but wanted the gangrenous 
 foetor. On making a vertical incision in the indurated lobe, below and somewhat 
 posterior to these excavations, there was found at the upper part another cavity, the 
 size of a small bean, with dark red sides ; and a little lower down, one the size of a 
 split pea. Still lower in the lobe there existed dark red spots distinct, isolated with 
 considerable interspaces, from the size of a hemp-seed to a pin's head, evidently the 
 first stage of what woidd have formed excavations. The heart was healthy. Abdonu n. 
 — The liver, enlarged, was not particularly examined. Both kidneys were somewhat 
 enlarged, the left most so, somewhat lobulated and mottled externally. When incised, 
 the surface of the cortical part presented a granular appearance, very streaked and 
 mottled red and buff, and some of the bundles of the tabular part were surrounded 1 >y 
 a distinct buff-coloured band. When examined through a lens, the surface of the in- 
 cision had a glistening fatty look. 
 
 230. Grey a ltd red induration of the upper lobe of the right lung with gangr 
 
 excavation. — Dulla, a Hindoo servant, a native of Sawunt Waree, using spirits habit- 
 
526 PNEUMONIA. 
 
 ually, was admitted into the clinical ward on the 27th February, 1849. He stated 
 that, three years before, he had been struck with the stock of a musket at the lower 
 part of the sternum, and that immediately afterwards he vomited blood. He soon 
 recovered from the effects of the injury, and did not then suffer from cough. On admis- 
 sion he was a good deal emaciated, had frequent cough, with copious mueo-puriform 
 sputa in roundish masses. The voice was hoarse, and the breath very fetid ; decubitus 
 was dorsal, and attempts to lie on the left side excited cough. He suffered from hectic 
 fever and diarrhcea. He had been affected with these symptoms for six weeks, and he 
 stated that his father, at an advanced age, had died of pulmonic disease. The respi- 
 ration was somewhat hurried and oppressed. There was didness on percussion of the 
 right subclavian, mammary, and lateral regions, decreasing from above downwards. 
 The respiration was bronchial in these dull regions, and the resonance of voice was 
 very distinct below the right clavicle and a little below and internal to the nipple. 
 The respiration was puerile on the left side, but there was no didness of that side, 
 nor any rales. He sank rapidly under the diarrhcea, and died on the 8th March. 
 
 Inspection five hours after death. — The left lung, with exception of a few hepatised 
 nodules the size of a horse-bean in the upper lobe, was soft and crepitated under 
 pressure. The upper lobe of the right lung was in a state partly of grey and partly 
 of red induration, and there was a gangrenous excavation at the apex the size of a 
 large orange. In the indurated parts adjoining the cavity, there were a few dark grey 
 portions the size of a bean (commencing gangrene). The two lower lobes were in a 
 state of red induration, with exception of the posterior thin edge of the third lobe, 
 which was soft and crepitating. The heart was healthy. The kidneys were normal. 
 The end of the ileum and the large intestine, as far as the ascending colon, were 
 opened : the mucous membrane was not ideerated. 
 
 In many of these cases, as may generally be noted when there 
 is solidification of a considerable part of a lung, a more or less 
 emphysematous or inflated state of the permeable parts of the lung- 
 was observed. 
 
 Bright's disease of the kidney was present in only three of the 
 twenty-two cases examined after death : in two of them there 
 was red hepatization, lobular in character in one, in the third case 
 there was grey induration, with cavities. On referring to my cases 
 of Bright's disease, it appears that pneumonia was present as a 
 secondary affection in five of twenty fatal cases. Of these, two were 
 in a state of induration, and three of hepatisation. Thus, then, 
 the observations made in this hospital tend to show a relation 
 between pneumonia and Bright's disease. 
 
 My investigations have not as yet confirmed the supposed 
 frequent relation between heart disease and pneumonia. Disease 
 of the heart was not present in any of the cases in this series, but 
 pneumonia was found in two of the seventeen fatal cases of cardiac 
 disease examined after death, and included in my remarks in a 
 subsequent chapter on disease of the heart. 
 
 In one case there had been circumscribed empyema of the right 
 side, and perforation of the under part of the middle lobe of the 
 lung at its fissure with the third lobe had taken place: this part of 
 
SYMFTOMS. 527 
 
 the middle lobe had formed the vault of the sac. The purulent 
 effusion had also opened into the pericardium, and excited peri- 
 carditis. In the left lung there was grey induration, and cavities 
 by softening. 
 
 The complication of pleuritic effusion, serous or puriform, was 
 observed in only two of the fatal cases of this series. One, just 
 adverted to, was circumscribed empyema and primary pneumonia. 
 The other was febrile : the effusion was of red-tinged serum. 
 These results, however, by no means express the frequency of this 
 complication. It was present in five of the recovered cases, four 
 primary, and one febrile ; and I have met with it in several other 
 cases at different times. Defective vocal thrill, the appearance 
 of a friction murmur as the dulness lessened, the presence of 
 crepitus at some period or other, and of sputa more or less copious, 
 have been the signs od which the diagnosis of this complication has 
 been determined. On the whole, my experience tends to confirm 
 the generally received opinion relative to the combination of pneu- 
 monia, and some degree of pleuritic effusion, — that the prognosis 
 is more favourable in the combined than in the separate affections. 
 We may believe that both commence simultaneously, and may 
 suppose that they mutually influence each other : the solidification 
 of the lung may limit the amount of the pleuritic effusion ; the 
 pleuritic effusion may limit the degree of the solidification of the 
 lung. The advance of the morbid change in both is thus checked, 
 and a greater tendency to restoration results. 
 
 Section IV. — Symptoms. — Fever, Pain, Dyspnoea, Cough, De- 
 lirium, Character of the Sputa. — Physical Signs. 
 
 Fever, not hectic in character, was observed in ninety-two cases, 
 viz., in all of the febrile form, and sixty-five of the primary. 
 
 The remittent * character of the fever was well marked in all 
 the cases of the febrile form. It was also distinctly observed in a 
 considerable proportion of the cases of primary pneumonia. The 
 remittent character of symptomatic fever is of frequent occurrence, 
 both in the medical and surgical practice of this hospital, and may 
 be regarded as a feature of symptomatic febrile disturbance in the 
 natives of India generally, more particularly in the asthenic. It is 
 of practical importance to watch for the remission, for reasons 
 to be explained when the treatment of pneumonia comes under 
 
 * I do not think it necessary to separate the four cases in which the fever was inter- 
 mittent in type. 
 
528 PNEUMONIA. 
 
 consideration. This remittent type of symptomatic fever probably 
 depends on the influence of malaria pre-existing in the constitution, 
 and is excited by local inflammation, just as intermittent fever may 
 be excited by exposure to cold in the same state of the system. 
 The inflammation is the exciting cause of the fever. The state of 
 constitution, previously engendered by the influence of malaria, 
 determines the type which that fever assumes. These views we 
 shall find are confirmed by the results of treatment. But whatever 
 the true explanation may be, the fact is undoubted that symptom- 
 atic fever in asthenic natives affected with pneumonia in Bombay 
 is in many instances markedly remittent in type.* So much so, 
 indeed, that it is frequently a difficult question of diagnosis to 
 decide whether the particular instance ought to be classed as pri- 
 mary or febrile pneumonia. 
 
 In determining this diagnosis, the following considerations have 
 chiefly influenced me, in respect to the febrile form : — 
 
 1 . The distinctness of the exacerbation and remission. 
 
 2. The history showing clearly that the febrile phenomena 
 had taken precedence by some days of the symptoms of pneumonia. 
 
 3. The state of the tongue, as regards fur, floridity, dryness. 
 
 4. The presence of much restlessness at night, with some 
 degree of delirium when the pneumonia was not far advanced. 
 
 5. The fever presenting adynamic phenomena. This was, 
 however, an occurrence only of the advanced stages : it was observed 
 in five of the cases of this series. 
 
 Attention to these circumstances will in general suffice to estab- 
 lish this diagnosis. Still, with patients admitted in the advanced 
 stages of disease, with imperfect histories of their previous illness, 
 difficulty will be occasionally experienced. 
 
 When the pneumonia has existed for some time in the second 
 stage, very generally, the cessation of the febrile disturbance 
 takes precedence for a time — longer or shorter, according to the 
 previous duration of the disease — of the restoration of the lung to 
 its healthy state. The discontinuance of the fever, when not re- 
 placed by that of hectic type, is usually attended by improvement 
 of the other symptoms, as by lessening of the cough and dyspnoea. 
 It is, however, to the physical signs that we must turn for infor- 
 mation regarding the real condition of the lung. In many cases — 
 nearly all of the febrile form, and in a considerable proportion of 
 the primary form it will be found that the cessation of the fever, 
 
 * Kemarks of a similar tenor have already been made at p. 74. I now apply them 
 to a particular disease, as previously (lone in respecl to hepatitis; p. 374. 
 
SYMPTOMS. 529 
 
 and the lessening of the cough and dyspnoea, are attended by a 
 corresoonding improvement in the physical signs. The dulness 
 becomes less, the bronchial respiration is gradually replaced by 
 vesicular murmur, the crepitus redux is sometimes heard, and after 
 a period more or less long the signs of complete recovery re- 
 appear. In other cases, however, of the primary form, in which the 
 lung has been for a longer time consolidated, we find that days 
 may pass before improvement in the general symptoms is followed 
 by signs of decrease of the consolidation : then these signs begin 
 to return, and by a slow process the lung is more or less com- 
 pletely restored. It is reasonable to assume, that though in these 
 latter cases the process of recovery is so slow as to require some 
 time before, by a lessening of the signs of consolidation, it gives 
 evidence of its being in progress, yet its commencement, or its 
 tendency to commence, is coincident with the termination of the 
 fever and the improvement in the other symptoms. These facts 
 have an important bearing on treatment as I shall presently 
 endeavour to show. 
 
 Hectic fever was noted in eight cases. They were all of the 
 primary form; five of them were cases in which cavities ex- 
 isted, and which proved fatal. Three of them were discharged 
 cases, two with the lung somewhat improved, and one with no 
 change. 
 
 Pain. — When we inquire into the frequency with which pain in 
 some part of the chest has been complained of, we find that it was 
 present in only forty: thirty-four of these were primary, which 
 is rather more than half of this form; five were febrile, which is a 
 little less than a sixth of this form. 
 
 The less complaint of pain in the febrile form accords with the 
 results noted under the head Morbid Anatomy. There, it is stated 
 that pleuritis was more frequently absent in the febrile than in 
 the primary form. 
 
 Pain beloiv the margin of the right false ribs was noticed in 
 thirteen cases : they were all of the primary form. In three there 
 was pain also at the margin of the left ribs. In six in which 
 there was pain below the margin of the right ribs, there was 
 also some degree of abnormal dulness on percussion in the same 
 situation. 
 
 In only one of these thirteen cases (a fatal one) was there reason 
 for connecting the pain with the existence of hepatic inflammation. 
 In this single instance abscess was found in the liver after death. 
 In my remarks on disease of the heart in a subsequent chapter 
 
 M M 
 
530 PNEUMONIA. 
 
 (page 592), it will appear that in six of thirteen cases of that 
 affection there existed pain and some degree of abnormal dulness 
 at the margin of the right ribs. This was attributed to conges- 
 tion of the liver, consequent on obstructed passage of the blood 
 through the heart. That congestion of the liver is also apt 
 to occur consequent on obstruction to the passage of the blood 
 through the lungs in extensive pneumonia, is an old observation 
 of pathologists. That it is correct, I believe, from having wit- 
 nessed a congested state of the liver after death in several cases of 
 pneumonia. 
 
 When pain below the margin of the right ribs is present in 
 pneumonia, associated with abnormal dulness, we shall generally 
 be right in relating it to hepatic congestion. The pneumonia may 
 be either of the right or the left side, but the hepatic congestion 
 probably indicates that it is extensive. 
 
 There are, however, other cases in which pain is experienced at 
 the margin of the right ribs, but which are unattended with ab- 
 normal dulness. In these the pain is probably sympathetic, like 
 that not unfrequently observed at the margin of the left ribs in 
 pericarditis. When the pneumonia is of the right lung, we shall 
 have this kind of pain, if present, at the margin of the right ribs ; 
 if the pneumonia, on the other hand, be of the left lung, the pain 
 will be at the margin of the left ribs. But we may expect to find 
 this symptom more frequently on the right side,, because pneu- 
 monia of the right lung is more common than that of the left. 
 This sympathetic pain was noticed in seven cases of the present 
 series : but my remarks are not grounded on these cases alone, for 
 the symptom has been noticed by myself and others in other cases 
 in the general wards of the hospital. 
 
 The occurrence of hepatitis secondary on pneumonia doubtless 
 occasionally takes place ; therefore, when pain is felt at the margin 
 of the right ribs, this fact should be borne in mind. Still, these 
 cases observed in India would seem to justify the opinion that 
 the co-existence * of these diseases is not common. It was noticed 
 in one only of 103 cases of pneumonia, and that in an instance in 
 which the event was unlikely to occur, for the pneumonia was 
 of the upper part of the left lung. But pain at the margin of 
 the right ribs, unconnected with hepatitis, has been observed in 
 twelve of the 103 cases. 
 
 * It musl be understood that I speak of hepatitis secondary on pneumonia: pneu- 
 monia secondary on hepatitis is more common. I do not nowallude to the co-existence 
 of these diseases taking place iu this latter order, but only in the former. 
 

 SYMPTOMS. 53 1 
 
 I have called attention to this symptom *, — and I shall follow 
 the same course in connection with heart disease, — in order that 
 an error in diagnosis may not be committed, and pnenmonia be 
 mistaken for hepatitis. This I have known to occur ; therefore I 
 am satisfied that the caution is not uncalled for. 
 
 Dyspnoea. — Some degree of shortness and hurry of the respira- 
 tory acts was noticed in ninety-one cases: of these sixty-seven were 
 primary, and twenty-four were febrile. Thus there remain nine 
 of the first form, and three of the second in which this symptom 
 was not noted. 
 
 Though some degree of dyspnoea has been observed in so many 
 instances, yet in the great proportion of them it was by no means 
 urgent, and in many might have been overlooked, had not the 
 cases, from the circumstance of being collected together for pur- 
 poses of clinical instruction, been submitted to careful investi- 
 gation and record. The reason why the dyspnoea was slight, 
 and might readily have escaped notice in many of these cases, is 
 sufficiently explained by the asthenic state of so many of the 
 affected. 
 
 The degree of dyspnoea in this disease is always an expres- 
 sion of the degree in which there is disproportion between the 
 amount of blood to be aerated, and the extent of the pulmonary 
 surface. 
 
 In an individual of sthenic constitution, in whom the blood is 
 abundant and the full extent of the pulmonary surface is required 
 for aeration, pneumonia of a small extent of lung will be attended 
 with marked dyspnoea. But when the quantity of blood has been 
 for some time reduced, as always happens in asthenic states, then 
 the full extent of the pulmonary surface is in excess of what is 
 necessary : part of it may become unfitted for function by pneu- 
 monia, and yet dyspnoea be hardly noticeable. In these statements 
 we have the explanation of the latency or obscurity of the symp- 
 toms of impaired function of the lungs in asthenic pneumonia. 
 
 AVhen the treatment of the sthenic forms of the disease comes 
 under consideration, we shall find that it is of importance to re- 
 member that dyspnoea indicates a want of proportion between the 
 quantity of the blood and the extent of the aerating surface ; and 
 that it may be lessened, or removed, in one or two ways — either 
 
 * It is hardly necessary to caution against the error of mistaking uneasiness at the 
 margin of the right riLs, •vrith dulness, consequent on displacement of the liver 
 froni plem-itic effusion, for the conditions to -which reference has been made in these 
 remarks. 
 
 M M 2 
 
532 PNEUMONIA. 
 
 by restoring the pulmonary surface to its structural fitness, or by 
 reducing the blood till it has become in proportion to the diminished 
 extent of that surface.* 
 
 Cough was present in ninety-eight cases, — seventy-two primary, 
 and twenty-six febrile. 
 
 The little urgency of the cough in pneumonia has been very 
 generally remarked by writers on this disease. The opinions which 
 I have ventured to express on the general pathology of pneumonia 
 seem to me to afford a ready explanation of this peculiarity. Cough 
 merely expresses the fact that there exists in the bronchial tubes some 
 obstacle to the free transmission of air to the cells beyond : it is a 
 forcible expiratory act, called into exercise to remove the cause 
 of the obstruction. It is reasonable to suppose that if the air cells 
 beyond become unfit for aeration, and the venous blood is no 
 
 * In some cursory notes on the thoracic inflammations in the European General 
 Hospital, presented by me to the Medical and Physical Society in May 1845, and 
 published in No. 6 of the "Transactions," the following remarks are made: — "Pneu- 
 monia is certainly a disease of infrequent occurrence in Bombay ; but it may not be 
 altogether misplaced to remark here, that partial and circumscribed pneumonia is by 
 no means a rare complication of the fevers to which natives are liable in the cold 
 season in the Deccan, and I believe in Guzerat. If the febrile symptoms persist 
 without intermission for two or three days, if the skin be dry, the tongue not furred 
 to the extent that might be expected, where the digestive organs are much deranged ; 
 then a careful stethoscopic examination will probably detect the existence of crepitous 
 rale in some part or other of the chest — most frequently in the neighbourhood of the 
 mammary region ; and this may be when there has been no complaint of pain, no 
 cough, and attention has not been called to any difficulty of respiration. In these 
 cases, attentive observation will detect an alteredexpression of countenance, not amount- 
 ing to anxiety, but which probably marks the implication of some important organ. 
 The person feels ill, but seems unable to explain to another the nature of his feelings ; 
 the body is inclined forwards, the lips are dry and parted, the respiration is somewhat 
 hurried, but often not more so than a general and uncomplicated febrile condition might 
 explain. The stethoscope will resolve the doubt, and the free use of tartar emetic, 
 combined with blood-letting, general or local, and blisters, according to circumstances, 
 will, if the disease has not been allowed to go too far, effect a cure, and prove the 
 accuracy of the diagnosis." These remarks were grounded on what I had seen of the 
 diseases of natives in former periods of my service in the Deccan, and on the Maha- 
 buleshwur Hills. My experience since in the Jamsetjee Jejeebhoy Hospital has cor- 
 rected my error in regard to the infrequency of pneumonia in Bombay. But my chief 
 object in reverting now to what I had previously written is, that I may have the oppor- 
 tunity of observing, that though there is nothing in my experience since at variance 
 with the tenor of these remarks on the obscurity and importance of febrile pneumonia, 
 yet we ought not to lay much stress on general symptoms such as those I have 
 detailed. In treating the malarious fevers of the natives of India, percussion and 
 auscultation of the chest should be invariably practised with daily regularity. It is a 
 practical rule quite as important in the management of this class of disease, as the 
 search for the signs of pericarditis and endocarditis is in the course of acute rheuma- 
 1 ism. lie is a careless observer of disease who finds himself taken by surprise by the 
 discovery of pneumonia in remittent fever, or pericarditis in acute rheumatism. 
 
SYMPTOMS. 
 
 533 
 
 longer sent to them, but, instead, to the healthy adjacent cells, — 
 then any obstruction existing in the tubes leading to the imper- 
 vious cells is no longer the same evil as when the cells were 
 efficient and blood was sent to them for aeration : hence there is 
 no longer the same demand for cough to clear them. The solidified 
 lung in pneumonia is in the state just described, and such seems 
 to me the best explanation of the little urgency of the cough in 
 this disease. 
 
 Delirium was observed in eleven cases. This symptom, when 
 present in primary pneumonia, occurs in the advanced stages : it 
 is of very unfavourable import. It was observed in three cases of 
 the primary form : they were all fatal, one with pneumonia of the 
 upper part of the left lung in the third stage with cavities, the 
 other two were double pneumonia in the second stage. 
 
 The remaining eight cases in which delirium, generally associated 
 with some degree of drowsiness, was noted, were of the febrile 
 form : in four there was recovery, and in four death. Therefore 
 this symptom, more particularly when occurring early in the 
 disease, and when not attended with adynamic phenomena, is 
 not of the same unfavourable import in febrile as in primary 
 pneumonia. 
 
 The character of the sputa. — The rusty adhesive sputa charac- 
 teristic of pneumonia were noted in only seventeen cases, — twelve 
 primary, and five febrile ; of these fourteen were recoveries, and 
 three proved fatal. In the other cases the sputa were untinged, 
 mucous, and more or less adhesive ; in a few cases none are re- 
 corded. 
 
 In seven cases red muco-puriform sputa are stated to have been 
 present : they were all of the primary form. Four proved fatal, 
 and in all of them there existed cavities in the lungs ; in two, 
 verified by post-mortem examination, but in two not examined 
 after death, cavities were believed to have been present, in conse- 
 quence of cavernous respiration having been recognised during 
 life. In three the patients were discharged: they were cases in 
 which hectic had been present ; in one there was no improvement of 
 the lung, but in two some degree of improvement had taken place. 
 In none of the three were cavities suspected to exist. From these 
 cases, then, and from another to which I shall presently advert, 
 the appearance of this character of sputa does not necessarily indi- 
 cate the existence of cavities in the lungs.* 
 
 * This is the red-tinged mueo-puriform sputa, to which I have already alluded in 
 my remarks on hepatic abscess, as occurring in states of asthenic pneumonia, and 
 
 
534 pneumonia. 
 
 Physical signs. — It is unnecessary that I should enlarge on a 
 subject now so well understood as the physical signs of pneumonia. 
 The accuracy of the statement relative to the stage of the disease 
 on admission, and the state of the lung on discharge, depends 
 on these signs. On this point I would merely observe, that ab- 
 normal dulness on percussion, bronchial respiration, with some de- 
 gree of crepitus in the adjacent parts, and presence of vocal thrill, 
 were the signs held to indicate the existence of the second stage ; 
 while disappearance of the abnormal dulness, and replacement of 
 bronchial by vesicular respiration (even though the latter continued 
 somewhat feebler than on the sound side) have been held to signify 
 that the lung had become restored to functional fitness. 
 
 There is one caution which it may be useful to make. The 
 frequency with which enlargement of the spleen is met with in 
 India, makes it necessary that we should be careful not to mistake 
 abnormal dulness of the left dorsal region, caused by it, for dulness 
 from hepatisation of the lung. 
 
 Section V. — Treatment. — General and Local Blood-letting, 
 Tartar Emetic, Mercury, Blisters, Quinine, Liquor Potassa 1 , 
 Stimulants. — Concluding Remarlts. 
 
 General blood-letting was held to be expedient in only three of 
 the 103 cases of pneumonia which form the subject of my present 
 remarks, and even in these it was adopted to a very limited ex- 
 tent. This fact shows clearly the general character of the consti- 
 tution of the persons affected, and the stage of the disease at 
 which they usually came under treatment. It is not to be ex- 
 plained on the supposition that I entertain peculiar views in re- 
 gard to the unsuitableness of general blood-letting in the treat- 
 ment of inflammatory disease. On the contrary I entirely agree 
 with those who think that a pulse above the natural frequency, 
 full and firm, associated with increased heat of skin, and co-exist- 
 ing with inflammation of an important organ, indicates the pro- 
 priety of general blood-letting. But we, at the same time, cannot 
 impress too firmly on our minds, that these are conditions of the 
 pulse which co-exist only with the early stages of inflammation in 
 individuals of sthenic constitution. Whilst thus, then, expressing 
 my belief in the efficacy of general blood-letting in appropriate 
 
 which is not to be distinguished, I believe, from thai which 1 formerly considered to 
 he pathognomonic of hepatic abscess having opened info the lung. I would refer the 
 reader to those observations (p. 383). 
 
TREATMENT. 535 
 
 circumstances, in the treatment of inflammatory disease, I am un- 
 able to concur in those views which regard it as a remedy peculiarly 
 appropriate in pneumonia. The opinion that blood-letting may be 
 carried to a greater extent in pneumonia than in other inflamma- 
 tions, rests, it may be supposed, on the observation of the great 
 relief to the dyspnoea which generally follows the loss of blood ; 
 and on the inference that this relief may be received as proof that 
 there has been a corresponding improvement in the inflamed lung. 
 Such an inference, however, may surely be erroneous. Dyspnoea, 
 as already explained, depends on a want of just proportion between 
 the quantity of blood in the vascular system, and the extent of the 
 pulmonary aerating surface. In pneumonia the extent of that sur- 
 face is lessened ; more blood is sent to the healthy part of the lung, 
 and dyspnoea results. By reducing, by venesection or other means, 
 the amount of blood circulating in the system, we necessarily re- 
 lieve the dyspnoea. But this may have been effected without any 
 improvement in the state of the inflamed part. Indeed, it is dis- 
 tinctly stated by Dr. Alison *, as a result of his clinical observa- 
 tion, that auscultation may indicate a continuance and even an 
 extension of the disease for a considerable time after the breathing 
 has been effectually relieved by blood-letting. Let us admit, then, 
 that blood-letting in pneumonia may afford relief on two distinct 
 principles : one common to it with other inflammations, the other 
 peculiar to itself, and related to the function of the organ. But it 
 by no means follows on this accoimt that the rules for its use 
 should in any respect differ from those which obtain in inflamma- 
 tion generally. Blood-letting, within certain limits, is a valuable 
 therapeutic means in certain states and stages of inflammation. 
 Carry it beyond these limits, use it in other states and stages of 
 inflammation, and it becomes injurious. This principle is equally 
 true of pneumonia as of other inflammations. "When the circum- 
 stances, as indicated by the pulse and skin and stage of disease, are 
 inappropriate, we may not use blood-letting in pneumonia merely 
 to relieve dyspnoea : this would be the mere palliation of a 
 symptom, purchased by increasing the tendency to death by 
 syncope. It would be as if in idiopathic fever complicated with 
 diarrhoea and stupor, we were to give full opiates and check the 
 former, with the certainty of increasing the tendency to death by 
 coma. 
 
 The statement made, with the view of inculcating free blood- 
 
 * " Outlines of Pathology," p. 281. 
 
 M M 4 
 
536 PNEUMONIA. 
 
 letting, by Andral*, and repeated by Dr. Watson f, that it is 
 useful in pneumonia on the principle applicable to all inflamma- 
 tions, and also on the principle in accordance with which the 
 exclusion of light is useful in ophthalmia, and rest in an inflamed 
 joint, is, I apprehend, in its latter part, of very doubtful accuracy. 
 If the opinions which I have ventured to express in a former part 
 of this chapter be correct, viz., that after the affected pulmonary 
 cells have, for a time, been the seat of inflammation, they become 
 unfit for function and no longer exercise it ; then blood-letting can 
 do no good to them, by relieving them from function, as the exclu- 
 sion of light and attention to rest do to the inflamed eye and 
 joint. It does good to the healthy cells by relieving them of part 
 of that excess of function which they had been required to assume. 
 But the only way in which the loss of blood can be of use to the 
 affected cells is by lessening the inflammation, in the way in which 
 other inflammations are lessened by the same means. The benefit 
 thus gained is augmented, not by the repose of these cells, but by 
 the resumption of function on their part setting the blood in their 
 pulmonary capillaries again in motion. 
 
 Local blood-letting. — Though there has been more scope for 
 the use of local than general blood-letting in these cases, still the 
 application of this means has also been limited in degree : not so 
 much as regards the proportion of instances as the extent to which 
 it was considered expedient to carry it. 
 
 In twenty-one of the cases cupping was used; in thirty-six, 
 leeches were applied. We have, then, an aggregate of fifty- seven 
 cases in which local blood-letting was practised : of these forty-six 
 recovered. 
 
 The total admissions within the fifth day from the commencement 
 of illness were twenty-two. Of these twenty recovered ; and in all 
 of them local blood-letting formed part of the treatment. 
 
 Between the sixth and tenth days there were thirty-four admis- 
 sions. Of these, twenty-six recovered : local blood-letting was used 
 in eighteen of them. 
 
 But if we confine our attention to primary pneumonia, this latter 
 statement gives too favourable an estimate of the success of treat- 
 ment. Of the twenty-six recoveries between the six and tenth days, 
 eight were of febrile pneumonia ; and I have already observed, that 
 though the fever had been of that duration on admission, the 
 pneumonia was probably of more recent origin. 
 
 * " Clinique Medical e," vol. ii. p. 378. 
 
 f "Lectures ou the Principles and Practice of Physic^" vol. ii. p. 91, 3rd edition. 
 
TREATMENT. 537 
 
 From these data, then, we are justified in concluding that 
 when pneumonia is seen within five days, or a little over it, even 
 in the classes to which the inmates of this hospital belong, local 
 blood-letting to some extent is an appropriate and efficacious 
 remedy. 
 
 Of the forty-six recovered cases in which local blood-letting 
 was used, there remain eight admitted above the tenth day of 
 illness. 
 
 Of the eleven fatal cases in which there had been local blood- 
 letting, three were admitted between the sixth and tenth day, and 
 eight above the tenth day, dating from the commencement of 
 illness. 
 
 It appears, that of forty-seven cases of pneumonia admitted 
 after the tenth day, local blood-letting was had recourse to in six- 
 teen. Of these forty-seven cases, twenty-five recovered, and local 
 blood-letting had been used in eight of them. We find, then, that 
 for pneumonia admitted after the tenth day, the scope for local 
 blood-letting is very limited ; for even in those for whom at the 
 time it seemed admissible, there were as many deaths as recoveries. 
 
 The principles which have been observed in directing local 
 blood-letting have been the symptoms and signs of pneumonia 
 existing with that condition of pulse and skin which, on general 
 therapeutic principles, justifies the use of this means. 
 
 To those, who, by clinical experience, have yet to become fami- 
 liar with the varying conditions of the pulse and their indications, 
 it may be said that in the natives of India, generally, we are not 
 likely to meet with the state of pulse and skin which indicates 
 local blood-letting, co-existing with a primary pneumonia of 
 upwards of ten days' duration. 
 
 Tartar emetic. — We have found that in these cases there was 
 little opportunity of practising general blood-letting. There has 
 been also, and for the same reasons, little opportunity of giving 
 tartar emetic in free doses. I am, however, from former experi- 
 ence, perfectly sensible of its efficacy in suitable cases. 
 
 This remedy, however, has been used to some extent * in sixty-six 
 of the cases : of these, forty-nine were recoveries, and seventeen 
 proved fatal. 
 
 Thirty-three of the recoveries were admitted under ten days' 
 illness, and in twenty-four of them local blood-letting had also been 
 used. Sixteen were admitted above ten days' illness : in five of 
 
 * From a sixth to half a grain every second, third, or fourth hour. 
 
538 raEUMONiA. 
 
 these tartar emetic was given alone, and in eleven it was combined 
 with quinine. 
 
 It may he inferred then, from these statements, that in many of 
 the recovered cases for which local blood-letting was considered 
 appropriate, the moderate use of tartar emetic was also held to be 
 indicated, and that it assisted the cure. That in some, in which 
 local blood-letting was had recourse to, tartar emetic was omitted, 
 either in consequence of co-existing gastro-enteric irritation, 
 or from the treatment with mercury having been preferred. 
 Further, that in some cases, for which local blood-letting was not 
 considered appropriate, tartar emetic was used, generally in 
 combination with quinine, on a principle to be subsequently 
 explained. 
 
 The principles which have been stated relative to local blood- 
 letting, may be also applied to this moderate use of tartar emetic, 
 viz., that those states of pulse and skin and symptoms, which 
 indicate the propriety of local blood-letting, justify the use of tartar 
 emetic, provided it be not contra-indicated by the presence of an 
 irritable state of the gastro-intestinal lining. But we may probably 
 go further than this, and say that, if we are careful to guard against 
 the tartar emetic causing increased evacuation from the bowels, we 
 may use it in instances of pneumonia with febrile disturbance, in 
 which the small volume and compressibility of the pulse are such 
 as to contra-indicate local blood-letting or other evacuation. We 
 may act thus because, by this cautious use of tartar emetic, we are 
 not adding directly to the asthenia ; and if by its use we can 
 reduce the degree of febrile disturbance, we thereby certainly lessen 
 an influence which tends rapidly to induce asthenia. 
 
 Mercury. — Calomel and opium were given with the view of 
 inducing mercurial influence, in twenty-one cases. Of these, twenty 
 were of the primary form, and the following remarks have exclu- 
 sive reference to them. 
 
 Fourteen were recoveries, six proved fatal. The constitutional 
 effect of mercury was produced in eleven of the recovered cases, 
 and in two of the fatal ones. In the remaining seven it was neces- 
 sary to omit the remedy, from some cause or other adverse to its 
 continuance. The cases in which mercury was used were in the 
 second stage of the disease. In the fourteen recovered cases, 
 seven were admitted within five days from the commencement 
 of illness, five between the sixth and tenth day, and two after the 
 tenth day. 
 
TREATMENT. 539 
 
 Of the eleven recovered cases in which mercurial influence was 
 induced, there was complete restoration of the lung in seven ; but 
 in four only improvement. Of the seven restored cases, four were 
 admitted within five days, and three between the sixth and tenth 
 day. Of the four improved cases, two were admitted within five 
 davs, and two above that period. 
 
 Let us now take eight of the cases in which mercury was used, 
 and regard them from another point of view. In three the com- 
 mencement of improvement in the lung was coincident with the 
 tenderness and swelling of the gums. In three the improvement 
 of the lung distinctly took precedence of the usual indications of 
 mercurial action. In two there was no improvement. 
 
 Let us now follow the six fatal cases in which mercury was given. 
 The two, in which mercurial influence was induced, had been ill 
 for upwards of twenty days before admission : in one of them 
 dysenteric s}anptoms with hectic fever came on, and in the other, 
 hepatitis ending in abscess. Of the four other fatal cases in 
 which it was necessary to discontinue the mercury, three were 
 admitted between the sixth and tenth da} 7 , and one within five 
 days. 
 
 Let us now address ourselves to the question, whether this series 
 of cases affords evidence favourable to the mercurial treatment of 
 pneumonia. 
 
 Of the seventy-one cases discharged from hospital, the lung was 
 restored in forty-nine, and improved in fifteen. Of the restored 
 cases seven had been brought under the influence of mercury,- and 
 forty-two had been cured without it ; and of these latter cases thirty- 
 seven had been admitted in the second stage. Of the improved 
 cases, in eleven the improvement was effected without mercury ; 
 they were all in the second stage. 
 
 It may, however, be objected to this statement that the febrile 
 cases have been included, while, with one exception, mercury was 
 only used in the primary form. 
 
 Let us exclude, therefore, from the discharged cases admitted 
 in the second stage those that were of the febrile form, and there 
 will remain twenty-five cases of restored primary pneumonia, 
 with eighteen of them cured without mercury ; and of improved 
 cases thirteen, with nine of them without mercury. Further, 
 let us recollect that, of the seven cured cases in which mercurial 
 influence had been induced, in three the improvement in the lung 
 commenced before the usual evidence of the action of mercury bad 
 
540 TNEUMONIA. 
 
 appeared ; it may, therefore, be argued that the improvement was 
 independent of this remedy.* 
 
 From a careful consideration of these facts, it must be acknow- 
 ledged that in these cases there is little evidence of the therapeutic 
 value of mercury in the treatment of pneumonia. Bat because 
 we have found little proof, in a particular field of practice, of 
 the advantage of this agent, it by no means follows that it may 
 not be expedient and useful under some circumstances of the 
 disease. These cases have borne no testimony to the efficacy of 
 general blood-letting, or the free use of tartar emetic, but the 
 utility of these means in suitable instances has not on this account 
 been called in question. Nor may we doubt the advantages 
 to be derived from mercury when the conditions are appropriate 
 for its use. It is most important that we should endeavour to 
 determine the states of pneumonia in which mercury is likely 
 to be beneficial, in order that we may have recourse to it only 
 in these, and abstain from it in those for which it is unsuitable 
 and injurious. 
 
 For the treatment of sthenic pneumonia in its first stage, or as it 
 begins to pass into the second, general blood-letting and the free use 
 of tartar emetic are, I apprehend, the appropriate remedies, because 
 we are almost certain, under such circumstances, of finding the full 
 and firm pulse, and the increased heat of skin, which indicate the 
 propriety of these measures. But when the disease has gone on, 
 and passed into the second stage, or has come under treatment 
 at this period, then, in addition to the degree of local blood- 
 letting and of tartar emetic indicated by the state of the pulse 
 and skin, we should give calomel and opium in such manner as 
 shall most safely effect a gentle mercurial influence. But when 
 the failing volume and strength of pulse, and reduction of the 
 temperature of the skin, indicate a deficiency of blood, and a 
 feebly acting heart, then, whether this state be consequent on 
 long duration of the disease, or on too antiphlogistic treat- 
 ment in a constitution originally sthenic, or co-exist with the 
 earlier stages of the disease in a constitution originally asthenic, 
 we must abstain from the use of mercury, because in this 
 condition of the blood, and of the heart, it will increase 
 the exhaustion : instead of favouring the removal of lymph- 
 
 * This argument has been generally used, but its force may be doubted. There is 
 nothing unreasonable in assuming that the mercury may have influence on the blood 
 and the diseased action which it is intended to remedy before it has been carried 
 to the degree of causing tender and swollen gums. 
 
TREATMENT. 541 
 
 deposits, mercury will favour their degeneration into pus or 
 sero-pus. 
 
 If I were asked to state a rule on this point of practice which 
 might be applied to clinical purposes, I should be disposed to 
 say that calomel and opium should only be given in the second 
 stage of pneumonia, in addition to tartar emetic ; but that 
 when the pulse and skin contra-indicate the use of tartar 
 emetic, mercury is also contra-indicated. In sthenic pneumonia 
 it will be found, that after the tenth or twelfth day this 
 remedy will no longer be appropriate; while, for the asthenic 
 form, it is altogether unsuitable. It not only increases the 
 asthenia, and favours softening or gangrene of the indurated 
 lung, but the calomel and opium are very apt to cause irrita- 
 tion of the intestinal mucous lining, and lead to dysentery 
 or diarrhoea : this is a most unfortunate complication of asthenic 
 pneumonia, and ought most carefully to be guarded against. The 
 result in several of the fatal cases of this series was hastened by 
 exhausting diarrhoea. 
 
 For the treatment of the second stage of the febrile form, 
 mercurial action is most inexpedient. We have, as I shall pre- 
 sently show, a more powerful agent in the sulphate of quinine. 
 
 Blisters. — Blisters have been used in eighty-two cases; of these 
 fifty-two recovered. It appears, then, that this remedy has been 
 had recourse to in a greater number of cases than any other of the 
 means which have been noticed. This has occurred, because 
 blisters are applicable to a greater variety of circumstances, — to 
 the more advanced stages of those cases in which local blood- 
 letting and antimony have been used, as well as to those for which 
 these means have been considered inappropriate. 
 
 This greater experience of the use of blisters might seem to 
 justify a positive opinion on their therapeutic value; but such 
 is not the case. It is difficult to come to a satisfactory con- 
 clusion on this point of practice. They are used in those more 
 advanced stages of disease in which we cannot look for marked 
 and speedy improvement from any remedies, and in which 
 we must be satisfied with steady, progressive, though slow 
 amendment. When the stage of pneumonia suitable for local 
 blood-letting has passed, blisters may be had recourse to with 
 some prospect of advantage. If applied too early in the disease, 
 they are apt to re-excite febrile disturbance and to be injurious. 
 If used in very asthenic states, they are sometimes followed by 
 troublesome ulceration, and the continued irritation thus arising 
 
542 PNEUMONIA. 
 
 does harm, by increasing the asthenia. For these reasons, then, 
 we must be cautious. The blisters in these cases have never been 
 larger than four inches square. The liquor lyttse has been the 
 preparation generally selected.* 
 
 Quinine. — The sulphate of quinine has been given in fifty- 
 six cases : of these thirty-seven were primary and nineteen 
 febrile ; of the former twenty-seven were recoveries, of the latter 
 fifteen. 
 
 In the treatment of febrile pneumonia, in addition to the local 
 blood-letting, tartar emetic and blisters, which the symptoms may 
 justify, quinine should be given in adequate doses during the 
 remission. It may be combined with tartar emetic. From five to 
 eight grains of quinine, with from one-sixth to one-fourth of a 
 grain of tartar emetic, given at intervals of two or three hours for 
 five or six doses, mil, in general, suffice to check and then stop the 
 febrile recurrences. When this effect on the febrile symptoms has 
 been produced, it will generally be found that improvement in the 
 pneumonia will at once commence ; and in a large majority of 
 cases, if the recurrence of the febrile state be prevented for some 
 days, the inflammation of the lung will be speedily removed. That 
 this is a therapeutic fact I am satisfied from the observation of 
 many cases. Indeed, I am not acquainted with anything more 
 striking and satisfactory in the whole range of rational therapeutics 
 than the progressive but speedy restoration of a hepatised lung, 
 co-existing with fever of remittent type, tuhen the exacerbations 
 been controlled by the adequate use of quinine. It is true 
 that small local detractions of blood, the application of small 
 blisters, and the use of quarter-grain doses of tartar emetic, have 
 been generally used at the same time ; but it is quite impossible 
 for any one familiar with disease, and the action of these means 
 in these degrees, to attribute the benefit chiefly to them, and 
 not to the prevention of the febrile exacerbation by the quinine. 
 But this is merely another illustration of a therapeutic principle 
 already explained, and inculcated in the chapters on intermittent 
 and remittent fever. 
 
 The same principle of treatment has been also applied to many 
 of the cases of prima/ry pneumonia in asthenic subjects. 
 
 In my remarks on " Symptoms," I stated that the symptomatic 
 fever of primary pneumonia in asthenic natives is not un frequent! 3 r 
 
 * Though confining my ol isters, I by n<> means undervalue other 
 
 derivants, as turpentine, sinapiems, dry cup] ing, and water compresses, Thelaetappli- 
 
 cation may be used with advantage in all st;iu' 8, 
 
TREATMENT. 543 
 
 distinctly remittent in type, and it seemed to me reasonable to 
 assume that it became so in consequence of the operative influence 
 of malaria. Actuated by these views I have latterly, in all cases 
 in which the remission was well marked, given quinine in com- 
 bination with antimony, in the same manner as in the febrile cases, 
 and very frequently with the same good effect ; though I think that 
 the improvement in the lung has taken place more slowly. It is 
 nevertheless true, that in some of the cases in which even the 
 remission has been well marked, we have met with disappoint- 
 ment ; the quinine failed to control the exacerbation. When this 
 occurs the remedy must be omitted, and the other usual means 
 appropriate for the case be trusted to. 
 
 Liquor potassce. — Some years since my attention was called to 
 the use of liquor potassae as a deobstruent remedy in the second 
 stage of pneumonia.* It has been used by me in many cases for 
 which mercury was considered unsuitable. It was given in doses 
 of from half a drachm to one drachm and a half every third or 
 fourth- hour in ten of the recovered cases of this series, and was in 
 general continued for several days. In some the proportion of 
 liquor potassse was diminished, and from six to ten grains of ses- 
 quicarbonate of ammonia were added, when the state of the pulse 
 indicated the propriety of a stimulant. The general impression 
 left on my mind was favourable to the use of liquor potassae ; but 
 this impression has not been confirmed by a careful consideration, 
 not only of this series of cases but also of all other hospital cases in 
 which it had been used. I can only find two, and they are not 
 satisfactory, in which quinine on the principle just explained was 
 not at the same time given. Being already satisfied of the thera- 
 peutic value of quinine in appropriate cases, I cannot feel sure of 
 that of the liquor potassse, when the two remedies have been given 
 at the same time. Further careful clinical observation is therefore 
 necessary to satisfy me of the deobstruent efficacy of liquor 
 potassa? in the second stage of pneumonia. The same remark 
 may be made of the internal use of iodide of potassium, and the 
 external application of the compound iodine ointment. I have 
 had recourse to both on several occasions, but am unable as yet 
 to offer any opinion on their utility. 
 
 Stimulants. — There often comes a period in the treatment of 
 pneumonia, and it may arrive very early in the asthenic form, 
 
 * I much regret that I am unaljle to refer to the publication in which the liquor 
 potassre -vras recommended. I omitted to make a note at the time, and I have been 
 unsuccessful in my secreh for it. It was in one of the periodicals.' 
 
544 PNEUMONIA. 
 
 when the failing pulse, the lowered temperature of the skin, and 
 the feeble expectorating efforts indicate the necessity for stimu- 
 lants. The earliest tendency to this must be watched for, and 
 stimulants be freely and assiduously given. The sesquicarbonate 
 of ammonia with tincture of squills, wine, and arrack, are the most 
 useful. At the same time chicken broth or beef tea must be 
 frequently administered; and sinapisms or warm turpentine applied 
 to the chest. By these means, if adopted in good time, cases 
 which appeared hopeless have been occasionally saved, more espe- 
 cially in youthful subjects. 
 
 Concluding Remarks. — In the review of these cases it has been 
 found that a large proportion of them came under treatment in the 
 second stage of pneumonia, and that when the disease was confined 
 to part of one lung, the rate of mortality was 17 per cent. lam 
 not acquainted with other recorded data exactly similar with 
 which to compare these results. But the impression on my mind 
 previous to my service in the Jamsetjee Jejeebhoy Hospital had 
 always been that pneumonia in the second stage was a more fatal 
 disease. 
 
 If, on the whole, success has attended the management of these 
 cases, it is very expedient to endeavour to explain all the princijales 
 in accordance with which it has been directed. In a previous part 
 of these remarks I have stated, that in many of the cases a con- 
 siderable time was required for the restoration of the lung ; and 
 that in many the cessation of the febrile symptoms and the relief 
 of cough and dyspnoea, were not at once followed by lessening of 
 the signs of consolidation of the lung, but that several days elapsed 
 before this began to appear. The efficacy of local blood-letting, of 
 tartar emetic, of occasional mercurial influence, of blisters, and of 
 quinine, has been acknowledged, and an endeavour has been made 
 to explain the principles on which these remedies have been re- 
 spectively used. But we do not find in these principles anything 
 that provides for the management of that period in the course of 
 the disease when there is persisting consolidation of the lung, with 
 little or no febrile disturbance, and little or no cough or dyspnoea, 
 yet I am satisfied that it has been on the proper treatment of this 
 condition of the disease that the successful issue of many of these 
 cases has depended. If so, then, it is necessary that I should ex- 
 plain what the nature of this treatment has been, and the principles 
 on which it has been conducted. In this state of the disease, the 
 pulse will be found to be of small volume, and easily compressed 
 
TBEATMENT. 545 
 
 This character of the pulse, with absence of febrile * disturbance, 
 at once indicates the appropriate method of cure. Antiphlogistics 
 of every kind, especially mercury, should be abstained from ; and 
 the tonic regimen and remedies best fitted gradually to increase 
 the quantity of blood, improve its condition, and strengthen the 
 action of the heart should be used. A light nutritious diet with 
 suitable stimulants, pure air, nitric acid, quinine, and preparations 
 of iron, are the means most suitable. 
 
 That at different periods in the history of medicine there have 
 been great errors in practice, is a truth which, with a view to future 
 improvement, we are bound to keep steadily before us ; and perhaps 
 no better illustration can be found than the wavering principles 
 which have characterised the practice of medicine during the 
 last twenty years and more. Those of us who were familiar with 
 practice at the commencement of this period must have wit- 
 nessed the destructive freedom with which antiphlogistic remedies 
 were not unfrequently applied ; and must be sensible that there 
 then was a very general disregard of tonic means. 
 
 When, on the other hand, we turn our attention to the present 
 state of practical medicine, we may discern a tendency to commit 
 the opposite error — to neglect antiphlogistic remedies and to 
 misapply tonics and stimulants ; to lose sight of great leading prin- 
 ciples, and to act too much under the guidance of a fragmentary, 
 and as yet very imperfect, knowledge of animal chemistry. 
 
 If this be true, it is peculiarly the province of those who have 
 practised during this period of vacillation and uncertainty, — who 
 have witnessed the advantages of the judicious use, and the evils of 
 the abuse, of antiphlogistics and tonics, — to endeavour to hold 
 the balance true between these two leading therapeutic principles, 
 by stating the impressions which these varied opportunities may 
 have left upon the mind. 
 
 Considerations of this nature induce me to explain, more 
 fully than may seem necessary, my reasons for attaching so much 
 importance, in certain states of pneumonia, to the decided inter- 
 mission of antiphlogistic, and the substitution of tonic treatment. 
 The principles which I am about to state are applicable, more or 
 less, to all inflammations. 
 
 It may be confidently affirmed, that when a tissue is inflamed, a 
 
 * I have not thought it necessary to notice those cases in which, with continuance 
 of consolidated lung, we hare hectic fever coming on, not cessation of the febrile dis- 
 turbance. Such cases must be managed on the ordinary principles observed in the 
 treatment of structural disease and co-existing hectic fever. 
 
 K N 
 
546 PNEUMONIA. 
 
 leading aim in its cure is the maintenance of a normal state of the 
 capillary circulation in the structures around. It matters not 
 whether the restoration is to consist merely in stagnating blood 
 being again set in motion, or in serous or lymph effusions being 
 absorbed, or in the organisation of lymph, or in the change of 
 lymph into pus with organisation of a bounding sac and processes 
 for the evacuation of the pus and the after reparation of the ab- 
 scess, or in the granulation and cicatrisation of ulcers. Which- 
 ever of these actions must be gone through before the inflamed 
 structure can resume its state of integrity, it should be a main 
 object in the management of all to bring about and maintain a 
 normal quantity, quality, and rate of movement of the blood in 
 the capillaries around and in the general vascular system. If 
 there be symptomatic fever, with a pulse full, firm, and frequent, — 
 the quantity, quality, and rate of movement, of the blood in the 
 capillary system are abnormal, and our means of correcting this 
 derangement are blood-letting and other antiphlogistic remedies. 
 But when the pulse becomes soft and of moderate volume, im- 
 provement in the inflammation by general antiphlogistic treat- 
 ment will cease, for under its use the pulse will become small and 
 compressible, indicating a quantity, quality, and rate of movement 
 of the blood in the capillaries around the inflamed part and in the 
 system generally, as adverse to restoration, by whatever processes 
 it is to be effected, as the opposite conditions of sthenic sympto- 
 matic fever : under these circumstances of inflammation we cannot 
 hope to do good, unless our regimen and remedies be decidedly 
 tonic. 
 
 These may seem very narrow principles, yet they are very useful 
 in practice. They may seem trite and simple, yet they are often 
 lost sight of under the seductive influence of transcendental theories, 
 inapplicable in the present state of the science. But, after all, 
 they reach further than at first may appear. 
 
 In the state of pneumonia to which reference is now being made, 
 mercury is an injurious deobstruent, for it spoils the quality and 
 lessens the quantity of the blood. But it is probable enough that 
 a deobstruent may yet be discovered free from this defect, and 
 therefore applicable to the treatment of this kind of consolidation 
 of the lung ; still a tonic influence on the blood, and on the heart, 
 must be a leading indication of cure, for unless there be an adeouate 
 capillary circulation immediately around the deposits, there can be 
 no absorption from the influence of any deobstruent. Again, the 
 idea that many inflammations are dependent on a materies morbl 
 
■STATISTICS. 
 
 547 
 
 in the blood is gaining ground as a pathological theory — very pro- 
 bably a true one ; if so, its elimination by the excreting organs may 
 become a chief object in the treatment. Still the maintenance of a 
 normal state of the capillary circulation by antiphlogistics or tonics, 
 as the case may be, must always be a leading aim, for without it we 
 can have no adequate action of the excreting organs, and conse- 
 quently no sufficient elimination from the blood. It would be easy 
 to multiply illustrations in proof, that whatever special therapeutic 
 indications may in after times arise in the treatment of particular 
 forms of disease, based on physiological or chemical facts as yet 
 undiscovered, there must always be the over-ruling principle of 
 maintaining, as far as practicable, a normal condition of the blood 
 and a sufficient capillary circulation general and local. This we 
 must endeavour to effect, in some forms of disease by antiphlogis- 
 tics, in others by tonics ; the state of the pulse, and of the general 
 system, determine the question. 
 
 Section VI. — Statistics of Pneumonia. 
 
 Table XXXV. — Admissions and Deaths, with Per-centage, from Pneu- 
 monia, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six Years 
 from 1848 to 1853. 
 
 
 
 
 1848 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 on total Ad- 
 missions. 
 
 Deaths on 
 total Deaths. 
 
 Jamiary 
 
 30 
 
 12 
 
 40-0 
 
 1-4 
 
 2-7 
 
 February 
 
 
 
 39 
 
 10 
 
 25-6 
 
 2-1 
 
 3-1 
 
 March . 
 
 
 
 32 
 
 17 
 
 531 
 
 1-5 
 
 4-4 
 
 April . 
 
 
 
 21 
 
 8 
 
 38-1 
 
 09 
 
 2-4 
 
 May . 
 
 
 
 27 
 
 14 
 
 51-9 
 
 1-2 
 
 4-8 
 
 June 
 
 
 
 23 
 
 6 
 
 26-1 
 
 11 
 
 1-9 
 
 July 
 
 
 
 9 
 
 5 
 
 555 
 
 0-4 
 
 1-6 
 
 Aua^ist . 
 
 
 
 18 
 
 7 
 
 38-9 
 
 0-9 
 
 21 
 
 September 
 
 
 
 21 
 
 8 
 
 38-1 
 
 1-01 
 
 2-5 
 
 October 
 
 
 
 29 
 
 15 
 
 518 
 
 1-3 
 
 4-4 
 
 November 
 
 
 
 31 
 
 4 
 
 12-8 
 
 1-4 
 
 1-2 
 
 December 
 
 
 
 33 
 
 15 
 
 45-5 
 
 1-4 
 
 3-8 
 
 Total 
 
 
 
 313 
 
 121 
 
 38-6 
 
 1-2 
 
 2-9 
 
 N N 2 
 
548 PLEURITIS. 
 
 CHAP. XXII. 
 
 ON PLEURITIS, BRONCHITIS, AND ASTHMA. 
 
 Section I. Pleuritis. — Symptoms, Causes, Pathology, 
 Treatment 
 
 Inflammation of the pleura is more common than that of the sub- 
 stance of the lung, because pneumonia seldom occurs without 
 co-existing pleuritis, and simple pleuritis is not an unfrequent 
 disease. 
 
 The admissions of pleuritis in the European General Hospital 
 for the ten years, from 1844 to 1853, amounted to sixty-eight, with 
 one death, whereas those of pneumonia did not exceed twenty-two, 
 with two deaths. The admissions of pleuritis into the Jamsetjee 
 Jejeebhoy Hospital during the six years, from 1848 to 1853, were 
 sixty-one, with nineteen deaths, a mortality of 31*2 per cent. The 
 cases treated by me in the clinical ward during the same period, 
 numbered twenty-five, and the deaths seven. The admissions of 
 pneumonia into the hospital and the clinical ward, during the same 
 period, were respectively 313 and 103. These data would suggest 
 that, in Europeans in India, pleuritis is more common than pleuro- 
 pneumonia, but that in natives the converse obtains : they 
 are, however, too limited to justify a general inference of this 
 kind. 
 
 The following brief observations have reference to the twenty-five 
 cases which formed a subject of study in the clinical ward. They 
 are arranged under the heads, Symptoms, Causes, Pathology, and 
 Treatment. 
 
 Symptoms. — >In cases admitted after the occurrence of pleuritic 
 effusion pain was not usually complained of; but inquiry into the 
 
SYMPTOMS— CAUSES, TATHOLOGY. 549 
 
 history generally led to the conclusion that this symptom had been 
 present at the commencement of the attack. Impaired respira- 
 tory movement of the affected side was noticed in all. 
 
 A distinct friction murmur was observed in ten cases. Its 
 most common situation was about the inferior angle of the scapula, 
 or in the lateral region. In eight the murmur was primary : I do 
 not mean that it occurred in that early stage which precedes 
 effusion, but that from the period of the disease and the degree 
 of co-existing dulness, it was judged not to be a redux friction 
 murmur. The redux murmur was noted in three cases : in two 
 it had not been present on admission, but had appeared as the 
 lessening dulness indicated absorption of the liquid effusion ; in the 
 third, the murmur was primary on admission, disappeared with 
 increasing effusion, but again reappeared in association with in- 
 creasing absorption. (Egophony was recorded in only one case of 
 pleuritis consequent on fracture of a rib. Bronchial respiration 
 was noticed in relation to the degree of effusion. Dulness on per- 
 cussion — more or less extensive, more or less complete — was 
 observed in every case. In some the shifting character was present, 
 in others it was absent. Defective vocal thrill generally co- existed 
 with the dulness. 
 
 In cases in which the effusion was considerable, the size of the 
 affected side was notably increased. In two of this class the 
 absorption of the fluid was followed by distinct contraction. In 
 the cases in which the effusion was in the left side — displacement 
 of the heart, in those of the right side — displacement of the 
 liver was noticed. 
 
 Causes. — Cold was doubtless the ordinary exciting cause. In 
 some, however, the affection was attributed to blows received in 
 squabbles, and in two to a strain while working. In two the 
 inflammation had probably depended on peculiarity of diathesis ; 
 in one who bad suffered from sypbilitic rheumatism, all the cha- 
 racteristic physical signs were present, and recovery took place ; in 
 the other, cachectic from intermittent fever and long the subject of 
 diarrhoea, the bowel complaint was checked, pleuritis of the left 
 side with effusion, dulness, absence of vocal thrill, and displacement 
 of the heart, took place, and was removed on recurrence of the 
 diarrhoea, but death resulted from exhaustion. 
 
 Pathology. — These cases show that when the constitution is 
 good, and the management careful, recovery may be expected 
 even though the physical signs have proved the existence, for 
 several successive days, of considerable effusion. The left side was 
 
 N N 3 
 
550 PLEUEITIS. 
 
 affected in fourteen cases, and the right in eleven. In none was 
 it distinctly double. The seven fatal cases, with one exception 
 already noticed, occurred in asthenic individuals, admitted in 
 advanced stages of effusion. In four a communication existed 
 between the effusion and the lung, as was proved in three by 
 examination after death ; in one by several small openings, in 
 another by a large opening into a gangrenous excavation, and 
 in the third by direct communication with the left bronchus. 
 In this last case there was also perforation by ulceration of 
 the second, fourth, and sixth intercostal spaces, with a fluctuat- 
 ing swelling in these situations, and partial absorption of the 
 costal cartilages. In that case, which communicated with the 
 gangrenous excavation, there was a second collection, the size of a 
 cocoa-nut, circumscribed between the base of the left lung and the 
 diaphragm. In the fourth case there was no inspection after death ; 
 but the character of the sputa, the tympanitic resonance on percus- 
 sion, and the amphoric respiration, had left no doubt that com- 
 munication existed between the lung and the pleural sac. 
 
 I have seen two cases of recovery by discharge of the contents of 
 a circumscribed pleuritic effusion through the lung. One, a Hindoo 
 lad, in whom, while under treatment for adynamic remittent fever, 
 pneumonia of the lower part of the left lung, as indicated by 
 crepitus and bronchial respiration, took place. This was followed 
 by circumscribed effusio of the upper part of the left side, 
 proved by great dulness and absence of breath-sounds, then, by 
 perforation of the lung, shown by the sputa, the tympanitic reso- 
 nance in the previously dull regions, and the presence of amphoric 
 respiration. There was gradual and slow restoration to health, with 
 permanent dulness of the upper part of the left side, very imper- 
 fect breath-sounds there, but no cognisable difference in the appear- 
 ance of the two sides. The second case was of a young European 
 female, of tubercular diathesis, who, after obscure pectoral symp- 
 toms, suddenly expectorated a large quantity of fetid pus. At this 
 stage of the affection I saw this patient. There were no signs of 
 consolidation, or cavities, of the upper part of either lung. About 
 the inferior angle of the left scapula, passing into the lateral region, 
 there was defective sound on percussion for a limited space, and 
 no breath-sounds. I concluded, not that tubercular excavations 
 existed in the lungs, but that a circumscribed pleuritic effusion had 
 opened into the lung. The opinion given, that gradual restoration 
 to tolerable health would take place, was verified. The expectora- 
 tion gradually ceased ; and when next I saw this patient, several 
 
TREATMENT. 551 
 
 years afterwards, there had been absence of pulmonic disturbance 
 for a long period. 
 
 The few cases which have formed the subject of these remarks, 
 suffice to prove that pleuritic effusion is not unfrequently circum- 
 scribed, and that a considerable extent of pulmonary surface — 
 generally its anterior part — may become adherent to the costal 
 pleura. The facts are important because they serve to qualify the 
 import, in diagnosis, of the situation and shifting nature of the 
 dulness, and the character of the breath-sounds. 
 
 Further, there are two cases before me in which the circumscribed 
 effusion existed between the anterior wall of the chest and the 
 anterior surface of the lung, and extended into the infra-clavicular 
 region, causing dulness and leading to the erroneous diagnosis of 
 tubercular phthisis. 
 
 Treatment. — The principles of treatment in pneumonia are also 
 applicable to pleuritis. Local blood-letting, small blisters, and 
 tartar emetic were the antiphlogistic remedies used in those cases. 
 Mercurial influence was induced in only one, but without benefit, 
 for the dulness continued when the patient was discharged. In 
 cases in which, from the state of constitution and the duration of 
 disease, it is reasonable to conclude that the existing effusion is 
 serous and removable, it must always be remembered that absorp- 
 tion is improbable before time has been allowed for the circulation 
 in the capillaries of the pleura to return to a normal state, and for 
 the exudations to become organised into areolar tissue. Whilst 
 waiting with this view, small blisters or other mild derivants may 
 be applied to the affected side. The further general treatment, 
 whether antiphlogistic, expectant, or tonic, will depend upon the 
 state of constitution, as explained in my remarks on the treatment 
 of pneumonia. But at this stage diuretic remedies also may 
 be used with advantage. In several of the cases now under 
 review, the decrease of the effusion, consecutive on an increased 
 flow of urine by diuretics, was well marked. Acetate of potass, 
 nitrous ether, and tincture of squills, were the remedies used. In 
 cases in which, from diathesis, duration of the disease, extent of 
 effusion, and hectic symptoms, empyema has become probable, the 
 general treatment must be regulated in accordance with the 
 principles applicable to a similar condition of the system, how- 
 ever induced. 
 
 A special practical question arises in the treatment of pleuritis, 
 viz., whether the effused fluid should be removed by paracen 
 or not. On this point I am without experience. Dr. Barlow, 
 
552 BRONCHITIS. 
 
 in his instructive " Manual of the Practice of Medicine," thus 
 remarks on this question of practice : — "In short, the ob- 
 jections to the operation may be thus summed up : where it is 
 safe and likely to be successful, it is unnecessary, but where it 
 seems to be called for by the permanence of the effusion, it is 
 more dangerous and generally unsuccessful." In estimating this 
 opinion, it should be borne in mind that it is grounded on 
 experience in a field — Gruy's Hospital, — in which this operation has 
 been practised on an extensive scale. Dr. Barlow is careful to 
 enjoin, that when the operation is considered expedient, it should 
 be performed in the manner recommended by Dr. Hughes and 
 Mr. Edward Cock, and to which I have already referred in my 
 remarks on the puncture of hepatic abscess.* 
 
 Section II. — Bronchitis. — Asthma. 
 
 Bronchitis. — The admissions from bronchitis into the European 
 General Hospital at Bombay during the ten years, from 1844 to 
 1853, have amounted to 223, and the deaths to fourteen, which 
 gives a mortality of 6*2 per cent, on the admissions, and shows that 
 the proportion of cases of this disease to the total sick treated in 
 the hospital has been, for this period, 1-77 per cent. 
 
 The number of sick from bronchitis in the Jamsetjee Jejeebhoy 
 Hospital for the six years, from 1848 to 1853, has been more than 
 double that from pneumonia. The admissions amounted to 707, 
 and the deaths to 57, a mortality of 8 -07 per cent. The ratio of 
 cases of bronchitis to total hospital sick, has been 2*7 per cent. 
 
 On instituting, in respect to bronchitis, the comparison, pre- 
 viously made regarding pneumonia, of the relative portion of 
 admissions at different periods of the year, it will be found that 
 there has been a great uniformity throughout the year. For 
 example : the admissions, from December to May, were 366, and 
 the deaths 29 ; those from June to November, were 341 and 28. 
 The probable inference from this statement is, that the rainy season, 
 included in the second half year, is as efficient an exciting cause of 
 bronchitis as the cold months of the first half year.t 
 
 * Page 410. 
 
 t For seventeen years, from 1837 to 1853, the "thoracic inflammations," doubtless 
 chiefly bronchitis, in the Byculla Schools, amounted to 518 with two deaths. For the 
 half year from December to May, the admissions were 227 ; from June to November, 
 291; but the greatest number in one month was in May, 85, — whereas, the number 
 in January was 21. I am unable to offer any explanation of the excess in May. It 
 has, however, not been uniform, because 4S of the 85, were in the Mays of 1840, 1844 
 and 1853, and none in 1841, 1847 and 1852. 
 
ASTHMA. 
 
 553 
 
 It is unnecessary to enter into questions of practical detail 
 relative to a disease so well understood. It is sufficient that the 
 practitioner applies to bronchitis in India the lessons of watchful- 
 ness and care, more especially in regard to young children, which 
 have been inculcated by European writers. 
 
 Asthma. — The term asthma has been used in its common 
 acceptation, to signify that pathological state compounded of varying 
 proportions of bronchitis, emphysema, and bronchial spasm. It is 
 sufficiently common in natives of India, more particularly in the 
 cold and wet seasons of the year. I have already * expressed my 
 belief that this disease is occasionally related to malaria as a cause, 
 and is then most successfully treated with quinine and preparations 
 of iron; and above all by a prolonged residence in a non-malarious 
 climate of suitable temperature. 
 
 Vesicular emphysema of the lungs is often present in great 
 degree, and is indicated by the well-known physical signs, of 
 altered form of the chest, increased resonance on percussion, faint 
 vesicular respiration with rhonchi, prolonged expiratory acts, dis- 
 placement of the heart and liver, accompanied with general 
 anasmia. 
 
 Section III. — Statistics of Bronchitis. 
 
 Table XXXVI. — Admissions and Deaths, ivith Per-eentage, from Bron- 
 chitis, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six Years 
 from 1848 to 1853. 
 
 
 
 
 1848 to 1853. 
 
 Monthly Averag 
 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Death on 
 total Deaths 
 
 January 
 
 66 
 
 5 
 
 76 
 
 3-1 
 
 1-1 
 
 February 
 
 
 
 00 
 
 3 
 
 5-4 
 
 2-9 
 
 0-9 
 
 March . 
 
 
 
 68 
 
 5 
 
 7-4 
 
 3-1 
 
 13 
 
 April . 
 May . 
 
 
 
 oo 
 
 
 
 91 
 
 2-6 
 
 14 
 
 
 
 69 
 
 6 
 
 87 
 
 3-1 
 
 2-1 
 
 June 
 
 
 
 49 
 
 5 
 
 102 
 
 23 
 
 1-6 
 
 July . 
 
 
 
 51 
 
 4 
 
 7-9 
 
 2-5 
 
 1-3 
 
 August . 
 
 
 
 43 
 
 2 
 
 4-6 
 
 2-2 
 
 0-6 
 
 September 
 
 
 
 66 
 
 4 
 
 6-1 
 
 3-2 
 
 1-3 
 
 October 
 
 
 
 60 
 
 4 
 
 6-6 
 
 26 
 
 1-2 
 
 November 
 
 
 
 72 
 
 9 
 
 125 
 
 3-3 
 
 27 
 
 December 
 
 
 
 53 
 
 
 
 0-9 
 
 23 
 
 1-3 
 
 Total 
 
 
 
 707 
 
 57 
 
 8-07 
 
 2-7 
 
 1-4 
 
 * Page 55. 
 
554 THTHISIS PULMONALIS. 
 
 CHAP. XXIII. 
 
 ON PHTHISIS PULMONALIS. 
 
 Section I. — Causes, Symptoms, Pathology, and Treatment, 
 
 In stating the result of my investigations, I shall keep in view the 
 researches of Louis, and other European writers on this disease. 
 
 During fifteen years, from 1838 to 1853, the admissions of 
 phthisis into the European General Hospital at Bombay, amounted 
 to 184, and the deaths to 79, a ratio of 0-93 per cent, on the total 
 hospital admissions, and 6 - l per cent, on the aggregate deaths. 
 
 The admissions of natives with phthisis into the Jamsetjee 
 Jejeebhoy Hospital, during the six years from 1848 to 1853, have 
 amounted to 445, and the deaths to 268, a ratio of 1*7 per cent, 
 on the total hospital admissions, and 6'5 per cent, on the total 
 deaths. But this statement does not fully represent the proportion 
 of phthisical disease in the inmates of this hospital. The remark 
 made at page 465, relative to the admissions registered under the 
 title " Cachexia " is applicable to phthisis pulmonalis, equally as to 
 Bright's disease. Seventy-nine cases of phthisis have been treated 
 in the clinical ward during these six years. Of these forty-two 
 proved fatal, and inspection after death 'was made in thirty-one. 
 
 I have also before me the reports of seventeen fatal cases, noted 
 during my service in the European General Hospital, and already 
 published.* In my notes of 311 fatal cases of European officers in 
 the Bombay Presidency, phthisis was the cause of death in eight. 
 
 I shall arrange the brief observations which these data suggest 
 under the heads : — 1. Causes. 2. Symptoms. 3. Pathology. 4. 
 Treatment. 
 
 Causes. — The erroneous opinion, at one time, entertained of the 
 rarity of phthisis pulmonalis in tropical countries, has been long 
 
 * "Transactions, Medical and Physical Society of Bombay," Nos. 2 and G. 
 
causes. 555 
 
 since corrected by the medical statistical reports of the British 
 army, and information from other sources. I have witnessed the 
 disease in Europeans, Indo-Britons, and in many of the Asiatic 
 races. Whether the access of phthisis is usually postponed to a 
 later period of life in warm climates, is a question which existing 
 data are insufficient to solve. Of nine European seamen who died 
 in the European General Hospital, seven were upwards of thirty 
 years of age, and one of them had attained the age of fifty-two. 
 Two European pensioners also died at the ages of fifty-three and 
 forty-nine. In respect to the eight fatal cases of officers; in three 
 the age was above thirty, in one it was twenty-three, in another 
 seventeen, and in three it is not recorded. The ages of seventy- 
 eight of the clinical cases of natives have been given ; four were 
 below twenty years of age, fifty-eight between twenty and forty, 
 fifteen between forty and sixty, and one upwards of sixty. 
 
 These facts probably tend to indicate a later development of the 
 disease in India than in European countries; but they are too 
 limited to suggest more than the expediency of further inquiry. 
 
 The admissions of phthisis into both hospitals have been pretty 
 equally distributed throughout the different months of the year, 
 with, however, a slight excess in favour of the half year from June 
 to November. For example, the admissions into the European 
 General Hospital and the Jamsetjee Jejeebhoy Hospital, for the 
 half year from December to May, were respectively 82 and 218; 
 whereas, for the half year from June to November, they were 102 
 and 227. The inference that the rainy season is unfavourable to 
 the course of phthisis, which may be drawn from this statement, is 
 confirmed by a remark made by Dr. E. H. Hunter relative to the 
 effect, on the health of Her Majesty's 2nd Eegiment, of change 
 from Poona to Bombay, at the commencement of the monsoon of 
 1836. Dr. Hunter says "all the phthisical cases began rapidly to 
 decline as the moist weather set in, and all proved fatal in the 
 course of the monsoon." * 
 
 Whether malarious cachexia favours the development of tuber- 
 cular disease, is a question of interest; and tropical countries 
 necessarily afford the best field for its investigation. In seven of 
 the seventy-nine clinical cases, attacks of intermittent fever were 
 reported to have preceded the pulmonary symptoms, and in four 
 others the febrile disturbance which co-existed with the phthisical 
 symptoms was rather malarious than hectic in character. Still 
 
 * "Transactions of the Medical and Physical Society of Bombay," No. 1, p. 23, 
 
556 rilTHISIS PULMONALIS. 
 
 these facts do not justify the supposition of a predisposition to 
 tubercular disease from malarious influence; for in the classes who 
 resort to hospitals in India, it is very likely that the admissions of 
 any other form of disease would evince evidence of the taint in a 
 proportion quite as great. Nor does my experience in India afford 
 any support to the opinion of Lancisi and others, that malaria is 
 preventive of pulmonary phthisis. 
 
 The data before me relate exclusively to males, and, therefore 
 do not show whether the greater prevalence of phthisis in females 
 than in males, established in respect to European countries, 
 obtains in India or not. 
 
 Symptoms. — The general symptoms and physical signs of 
 phthisis in India do not present any peculiarities.* Haemoptysis 
 had been present before admission in seventeen of the clinical 
 cases, and it was observed in three during the time they were 
 under treatment. In one of them the haemorrhage was consider- 
 able in quantity, and took place very shortly before death. A cavity 
 with red-tinged walls was found at the apex of the right lung, and 
 another the size of a walnut, filled with blood, existed at the upper 
 part of the left lung. Hoarseness of voice was present in eighteen 
 of the cases. 
 
 Pathology. — It has been supposed that phthisis runs a more 
 rapid course in warm than in cold climates, after it has fairly com- 
 menced. My cases are not of a nature to throw any light on this 
 question, for the record of the previous history is, in general, not 
 sufficiently precise, and probably unworthy of being fully depended 
 upon. Yet the general opinion may be safely hazarded, that in all 
 diseases which include destructive degeneration of structure and 
 co-existing hectic fever, the rapidity of the course will bear relation 
 to the number and degree of the debilitating influences to which 
 the individual is exposed. As in warm climates elevated tempe- 
 rature and malaria are causes of debility, additional to those ex- 
 isting in cold climates, it is a reasonable inference that, after tuber- 
 cular softening has fairly commenced, a fatal issue is likely to follow 
 sooner in a tropical than in a temperate climate. Moreover, as re- 
 
 * It has seemed to me that that the accuracy of diagnosis in cases, in which the 
 ordinary symptoms of cough, expectoration and dyspnoea are not well marked, is 
 sometimes prevented : — 1. Ey an emphysematous state of the adjoining pulmonary 
 tissues preventing dulness. 2. Many cavities, none sufficiently large or empty to 
 give a tympanitic sound on percussion, may Lessen dulness. 3. In cases of general 
 anremia, in which pulmonary expansion is diminished, there maybe slight infra-clavi- 
 cular dulness from defective expansion : this may suggest the suspicion of commencing 
 tubercular deposit, but it will disappear with the removal of the anaemia. 
 
PATHOLOGY. 557 
 
 spects phthisis pulmonalis, it should be remembered that the course 
 of the disease is always very dependent on the early access and the 
 extent of intestinal ulceration, and that this is a morbid state to 
 which the residents in warm climates are particularly prone. On 
 the other hand, however, it may be argued, that inasmuch as the 
 rate of progress of tubercular phthisis may depend on intercurrent 
 pneumonia or bronchitis excited by cold, the resident in warm 
 climates has in this respect an advantage over the inhabitant of 
 colder climates. This may be true of the well-clothed and carecl- 
 for European, but the argument has no application to the hospital- 
 frequenting classes of the native community; they, from consti- 
 tution, from insufficient clothing and habitations, are as much 
 exposed to the injurious effects of cold and wet as the dwellers in 
 more northern latitudes. 
 
 In fifty-two of the clinical cases, at the time of admission, the 
 disease had passed on to the stage of softening; in twenty-four the 
 tubercles were still in their solid state, and in three there was 
 doubt. 
 
 With one exception, both lungs were affected in all ; and of 
 fifty-five of these, we have information as to the side in which 
 the disease had made most progress. It was furthest advanced 
 on the left side in thirty-six ; on the right side in nineteen. 
 The observation universally made by European writers, that the 
 tubercular deposit commences in the upper lobes and travels 
 downwards, is equally true of the disease in India. I would 
 remark, however, that I have witnessed cases of transition, as 
 it were, between tubercular deposit and grey induration, in 
 which there seemed to be a blending of the position-cha- 
 racter of pneumonia and phthisis : the acme of the disease 
 was neither in the upper nor the lower part of the lung, but 
 rather midway between. This observation is not unimportant 
 as regards diagnosis, for we certainly meet in practice with cases 
 in which the signs of excavation are distinct at the inferior angle 
 of the scapula, without signs of consolidation in the upper part of 
 the lung. Such are, probably, of the pathological character just 
 adverted to. 
 
 In twenty-nine cases examined after death, in which the tuber- 
 cles had softened, a single cavity was found only in two ; in all the 
 others the cavities were numerous, and in different stages. 
 
 The deposits of tubercle usually take place at many points ; 
 these increase in size by accretion, and aggregate into nodules. 
 The same order of progress occurs in the process of softening: 
 
558 PHTHISIS PULMONALIS. 
 
 commencing at points, increasing in size, and coalescing into exca- 
 vations of various forms and dimensions. It is important to keep 
 this fact before the mind, because it gives a significance to the 
 early and undoubted signs of tubercular softening — I mean the 
 variously sized but sharply defined moist ronchi. My cases exhibit 
 that constant co-existence of pleuritic adhesion with fatal tubercular 
 pulmonary disease, which has generally been noted by other ob- 
 servers. The adhesions have a distinct relation to the stage of the 
 disease. They are not unfrequently absent in the miliary stage, 
 but are invariably present when excavations have formed. They 
 take place in accordance with that protective law, which has in 
 view the prevention of the effusion of abnormal fluid collections 
 into serous sacs. Pleuritic adhesions were observed in all my in- 
 spections after death. 
 
 The morbid appearances of pneumonia have been less frequently 
 present. There was hepatisation in twelve cases, and sanguineous 
 engorgement in six. The frequent absence of the signs of inflam- 
 mation of the pulmonary tissue, affords conclusive evidence that 
 the deposition of tubercular matter is not necessarily a result of 
 infiammatoiy action. But, on the other hand, the not unfrequent 
 occurrence of intercurrent pneumonia requires to be carefully borne 
 in mind and regarded in treatment. 
 
 Louis found the larynx diseased in one fourth of his cases, and 
 the epiglottis in one sixth. My observations in India show fully 
 an equal proportion of this complication. In eighteen of seventy- 
 nine there was hoarseness of voice. In thirty- one cases inspected 
 after death, the larynx was ulcerated or abraded in nine, the epi- 
 glottis in six, and the trachea in 7.* 
 
 In fifteen cases, a turgid or ulcerated state of Peyer's glands, and 
 in sixteen, circular ulcers in the large intestine, were found after 
 death. In only one case was there reason for attributing the intestinal 
 ulceration to tubercular deposit and softening. My researches, as 
 already previously stated f, have not suggested to me that there is 
 any difference between the morbid process which leads to the for- 
 mation of circular ulcers in the large intestine in phthisis, and that 
 which causes the same form of ulcer in dysentery, consecutive on 
 hepatic abscess, or simple and primary. 
 
 Diarrhoea was absent in only five of the seventy-nine cases. Of 
 these five, only one proved fatal ; the tubercles were in a miliary 
 
 * I need hardly remark, that the morbid state of the different parts of the air tubes 
 was not unfrequently noticed in (lie same case ; and that these numbers (nine, seven, 
 h\x) do not represent twenty-two instances of phthisis. 
 
 t Page 3G9 (foot note.) 
 
TREATMENT. 559 
 
 state, and there was no intestinal ulceration ; death had been 
 caused by co-existing hepatisation of the lung and pleuritic 
 effusion. The mesenteric glands were noted as tubercular in seven 
 cases, but this probably does not represent the full proportion, 
 because in many there is no record of the state of these structures, 
 which gives rise to the impression, that they had occasionally been 
 overlooked. 
 
 In two, miliary tubercles existed in the subperitoneal tissue. 
 Case 195 is an additional instance of this morbid condition. 
 
 In one case perforation of the intestine took place. In two, the 
 liver was found in a state of cirrhosis. 
 
 Fatty liver was observed by Louis in one third of his cases, but 
 much more frequently in females than in males. This morbid 
 state has not been found to co-exist with phthisis in the same pro- 
 portion in England. It was noticed in only one of my thirty-one 
 fatal clinical cases, but they were all males, and probably my 
 attention has not been sufficiently fixed on this question of 
 pathology. I attach no weight, then, to my observations on this 
 point. 
 
 Bright's disease of the kidney has been noted in only one of the 
 cases. " 
 
 Treatment. — On this subject it is needless to enlarge. The 
 principle now generally admitted, — that the indication for the 
 prevention, cure, and stay of this disease, is the application of a 
 well-arranged system of tonic regimen and remedies — must com- 
 mand the assent of every practical physician. Cod-liver oil has of 
 late years been extensively used in phthisis in India as in other 
 countries, and though the cases, which have formed the principal 
 subject of my present remarks, were generally either admitted in 
 a stage too advanced, or were too short a time under observa- 
 vation, to afford evidence of the efficacy of this remedy, still proof 
 has not been wanting to me in other fields of practice. Though 
 I am fully persuaded that the diathetic treatment of phthisis, 
 as now generally pursued, is correct, still it is necessary to be 
 careful, and to guard against its tendency to withdraw the atten- 
 tion from the occasional occurrence of intercurrent pneumonia, 
 and the modification in treatment which this contingency neces- 
 sarily enjoins. 
 
560 
 
 PHTHISIS PULMONALIS. 
 
 Section II. — Statistics of Phthisis Pulmonalis. 
 
 Table XXXVII. — Admissions and Deaths, with Per-centage,from Phthisis 
 Pulmonalis, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six 
 Years from 1848 to 1853. 
 
 
 
 
 1848 to 1853. 
 
 Monthly Average. 
 
 
 
 
 
 Admissions 
 
 De.iths on 
 
 
 Admissions. 
 
 Deaths. 
 
 Admissions. 
 
 Admissions. 
 
 total Deaths. 
 
 January 
 
 34 
 
 23 
 
 677 
 
 1-6 
 
 51 
 
 February 
 
 
 
 34 
 
 18 
 
 52-9 
 
 1-8 
 
 5-6 
 
 March . 
 
 
 
 41 
 
 18 
 
 43-9 
 
 1-9 
 
 4-7 
 
 April . 
 
 
 
 40 
 
 21 
 
 52-5 
 
 1-9 
 
 6-6 
 
 May . 
 
 
 
 36 
 
 23 
 
 63-9 
 
 1-6 
 
 8-0 
 
 June 
 
 
 
 32 
 
 22 
 
 68-7 
 
 1-5 
 
 72 
 
 July 
 
 
 
 39 
 
 26 
 
 666 
 
 1-9 
 
 8-5 
 
 August . 
 
 
 
 29 
 
 29 
 
 100-0 
 
 1-5 
 
 8-8 
 
 September 
 
 
 
 53 
 
 19 
 
 359 
 
 2-5 
 
 6-1 
 
 October 
 
 
 
 33 
 
 31 
 
 93-7 
 
 1-1 
 
 9-1 
 
 November 
 
 
 
 41 
 
 18 
 
 43-9 
 
 1-4 
 
 5'4 
 
 December 
 
 
 
 33 
 
 20 
 
 60-6 
 
 1-4 
 
 5'0 
 
 Total 
 
 
 
 445 
 
 268 
 
 60-1 
 
 17 
 
 65 
 
561 
 
 CHAP. XXIV. 
 
 ON PERICARDITIS AND ENDOCARDITIS. 
 
 Section I. — Introductory Remarks. 
 
 In this and the following chapter I shall describe affections of 
 the heart and aorta, as observed by me in natives of India, and 
 shortly allude to these diseases in Europeans. 
 
 Fifty-six cases have been received into the clinical ward of the 
 Jamsetjee Jejeebhoy Hospital, during the six years from 1848 to 
 1853. I shall consider them under two heads. 1. Twenty-five 
 cases of pericarditis and endocarditis, in the present chapter. 
 2. Thirty-one cases of structural disease of the heart and aorta, 
 in the chapter which follows. 
 
 This inquiry will tend to correct the erroneous impression 
 which has existed, that acute rheumatism in India is rarely asso- 
 ciated with pericarditis or endocarditis. The relation of cardiac 
 disease to previously existing rheumatism is apparent in twenty- 
 nine of the fifty-six cases; and in all probability it would have 
 been evident in a still greater number, had the record of all been 
 equally complete. 
 
 When we compare the admissions under the head " Rheumatism " 
 into our Indian hospitals with those which take place into hospitals 
 in Europe, we may expect to find in the former a smaller propor- 
 tion of affections of the heart. The explanation, however, is 
 sufficiently simple. In the greater number of cases of rheuma- 
 tism treated in hospitals in India, the disease is chronic; it is 
 unattended with swelling of the joints or febrile disturbance, and 
 occurs for the most part in persons cachectic from malaria,, 
 syphilis, scurvy, mercury, imperfect means of subsistence, &c. It 
 is not, I need hardly observe, in association with this form of 
 disease that pericarditis and endocarditis have been so frequently 
 noticed in European countries. 
 
 It may be that acute articular rheumatism is not so common in 
 
 o o 
 
562 PERICARDITIS AMD ENDOCARDITIS. 
 
 India * as in colder climates, yet it is by no means rare ; and a 
 complicating pericarditis or endocarditis is, I believe, as frequent an 
 occurrence in the one country as in the other. 
 
 Of no rule in practice am I more thoroughly convinced than that it 
 is as incumbent on the practitioner in India as in Europe, carefully 
 to watch and search for the physical signs of pericarditis and endo- 
 carditis in every case of acute, rheumatism. If this rule be neg- 
 lected, the co-existence of these diseases in India will necessarily 
 continue to be considered an unusual event. f 
 
 Section II. — Causes, Symptoms, and Treatment. 
 
 The important practical facts deducible from the twenty-five 
 cases of pericarditis and endocarditis are arranged under the fol- 
 lowing heads: — 
 
 * This statement, -written some years since in India, has been fully confirmed by recent 
 opportunities of observing the great frequency of acute articular rheumatism in hospi- 
 tals in London. 
 
 f In No. 11 of the "Indian Annals of Medical Science," for January 1859, 
 there is a Tery interesting communication from Dr. Gordon, Surgeon of the 10th 
 Eegiment, on " Eheumatism and aUied diseases." The author concurs with me in 
 opinion that acute rheumatism is not so common in India as in colder climates, but 
 dissents from my statement that pericarditis and endocarditis are as frequent a com- 
 pbcation of acute rheumatism in the one country as the other. He justly explains the 
 discrepancy between us, by observing, that my residts had reference to the inmates 
 of civil or general hospitals, — his, to regimental hospitals ; for it is a great error to 
 compare the statistics of communities so different as the inmates of civil, and military 
 regimental hospitals. The greater proportion of men invalided for heart disease in 
 the United Kingdom than in India, seems to me to prove, as is explained in the text, 
 the comparative rarity of acute rheumatism in India, rather than the infrequency of 
 pericarditis, as a complication, as Dr. Gordon supposes. 
 
 The subject of cardiac disease in Europeans will come under consideration in the 
 concluding section of the next chapter, and I would only now remark that my oppor- 
 tunities of judging of its frequency in regimental hospitals, at different periods of my 
 service, have not been few, and that many cases have come under my observation. 
 Indeed the only case of acute endocarditis unconnected with rheumatism which I have 
 ever witnessed, was in the hospital of the 12th Lancers, at Kirkee. iu June 1857. 
 The patient was admitted on the 16th with palpitation and uneasiness of the cardiac 
 region, but no abnormal sounds were detected : and it so chanced that the day on 
 which I examined him. towards the end of the month, was the first on which a mitral 
 murmur was discovered. This patient was left behind when the regiment went on 
 service, and I had the opportunity of watching him in the depot hospital. The 
 murmur persisted, and on the 21st August, increased precordial dulness, not present 
 a1 first, indicated commencing hypertrophy and dilatation. There is no apriori reason 
 why acute articular rheumatism should be less accompanied with percarditis in soldiers 
 in India than in Europe. The kind of data necessary to prove the contrary must be 
 limited, and while the question is still sub judicc, I woidd again urge that a careful 
 search fi <r I he physical signs of pericarditis and endocarditis should be the rule of prac- 
 tice in every case of acute rheumatism in India, both in civil and military hospitals. 
 
COMPARATIVE PREVALENCE. 
 
 563 
 
 I. The proportion of cases of peri- 
 carditis and endocarditis, and 
 of both combined. 
 II. The result of the cases. 
 
 III. Relation to difference of sex. 
 
 IV. The proportion of cases in dif- 
 
 ferent castes. 
 V. Classification, 'with reference to 
 
 Age. 
 VI. The different occupations of those 
 
 affected. 
 VII. Relation to habits of life. 
 VIII. The months of the year in which 
 most prevalent. 
 IX. Relation of the disease to rheu- 
 matism, cachexia, and pulmo- 
 nary inflammation. 
 X. The leading symptoms and signs 
 treated of under the following 
 subdivisions : — ■ 
 
 XL 
 
 1. Pain at margin of the left ribs. 
 
 2. Pain at the precordial region. 
 
 3. Increased action of the heart. 
 
 4. The state of the pulse. 
 
 5. The absence or presence of 
 
 fever. 
 
 6. Difficulty of breathing. 
 
 7. Anxiety of countenance. 
 
 8. Occurrence of delirium. 
 
 9. Increased praecordial duhiess. 
 
 10. Purring tremor. 
 
 11. Praecordial fulness. 
 
 12. Friction murmur. 
 
 13. Jogging movement of the 
 
 heart. 
 On the treatment of the disease: — 
 
 1. Blood-letting, general and 
 
 local. 
 
 2. The application of blisters. 
 
 3. Mercurial influence. 
 
 I. The 'proportion of cases of Pericarditis and Endocarditis, 
 and of both combined. — Thirteen would seem to have been of 
 pericarditis alone. But in regard to six, the details are not suf- 
 ficiently stated to justify the exclusion of co-existing endocarditis; 
 thev must, therefore, be regarded as doubtful, though the probability 
 is in favour of pericarditis alone. 
 
 There are four cases of endocarditis alone : of these, the mitral 
 valve was affected in three, and the tricuspid valve was believed to 
 be so in one. 
 
 There are eight of pericarditis and endocarditis combined : in 
 three the aortic valves, in four the mitral valve, and in one both 
 aortic and mitral valves were engaged. In seven, the pericarditis 
 took precedence of the endocarditis, and in the remaining case 
 the endocarditis was first observed. 
 
 II. The result of the cases. — Nine of the twenty-five cases 
 proved fatal. Of these eight are in the list of pericarditis, but five 
 of them are classed with those in which the co-existence of en- 
 docarditis was not disproved. One is in the list of pericarditis and 
 endocarditis combined. Two of the fatal cases occurred in asso- 
 ciation with rheumatism, two were present in individuals of very 
 cachectic habit, and four were instances of pericarditis secondary 
 on pneumonia, pleuritis, or phthisis pulmonalis. 
 
 Of these last four fatal cases, in two death took place from 
 pulmonic disease. In the first the pericardial inflammation had 
 terminated in adhesions, in the second in opaque patches on the 
 surface of the heart, and the endocarditis in valvular disease. 
 
 O O 2 
 
564 rEMCARDITIS AND ENDOCARDITIS. 
 
 It will subsequently appear, that of the twenty-five cases, seven- 
 teen were associated with rheumatism, two with cachexia; four 
 were secondary on pulmonic disease, and two primary or idiopathic. 
 It has just been stated, that of the rheumatic cases two were fatal, 
 of the cachectic all, of the pulmonic two*, and of the primary one. 
 The deduction from these cases is therefore comfirmatory of the 
 usual observation, that in pericarditis associated with rheumatism, 
 the prognosis is much more favourable than under the other cir- 
 cumstances in which the disease arises. 
 
 Of the sixteen discharged cases, in five no signs of cardiac 
 disease were left behind, and recovery was regarded as complete. 
 They were, with one exception, cases of pericarditis ; in the excep- 
 tional case endocarditis was also present. In three the signs of 
 valvular disease were so slight, that it is very probable they also 
 should be included in the list of perfect cures. 
 
 Of the eight cases in which complete restoration did not take 
 place, in one valvular disease was left, in six valvular disease and 
 pericardial adhesions, and in one pericardial adhesions alone. The 
 adhesions were in six inferred to exist from the severity of the 
 symptoms, and the distinctness and duration of the physical signs, 
 but in one there was greater certainty, in consequence of a well- 
 marked and persistent jogging motion of the heart. 
 
 III. Relation to difference of sex. — Of the cases under ex- 
 amination, four were females, but only three of these were hospital 
 patients. Of the four, two were Hindoos and two Parsees. These 
 data are much too limited to justify any attempt at precise com- 
 parison of the frequency of the disease in the two sexes. So far as 
 they go, they show as great a prevalence in females as in males. 
 The proportion of total female admissions into hospital during the 
 period to which these cases refer was about one to seven males, 
 and there is nearly the same proportion in the admissions from 
 pericarditis and endocarditis. Moreover, as the clinical ward was 
 for males only, I am satisfied, that in regard to the female inmates 
 of the hospital, there has not been the same care in looking for the 
 disease. 
 
 IV. The proportion of cases in the different castes. — The caste 
 of twenty-three of the cases only is stated, but from these I shall 
 exclude the females, so as to admit of a more accurate comparison 
 between the affected and the total hospital admissions of the dif- 
 ferent castes. The classification of the females according to caste 
 
 * Two in which death took place from pulmonic disease long after the pericarditis 
 are excluded 
 
CAUSES — RELATION TO CASTE. 
 
 565 
 
 has not been attended to in the hospital returns of disease. There 
 are, therefore, nineteen cases to be considered under this head : of 
 these nine, nearly one half, are Hindoos. The proportion which the 
 Hindoo male hospital* admissions bear to the total male admis- 
 sions is not quite one half. There are four cases of Parsees, nearly 
 one fifth of the affected, but the proportion of the total male 
 Parsee hospital admissions is about one twelfth. There are four 
 cases classed under the head Christians in the hospital returns, 
 viz. three Portuguese and one European. The proportion of total 
 hospital Christian admissions is about one fifth. There are two 
 cases of Mussulmans, being one ninth and a half of the affected, 
 whereas the proportion of Mussulman hospital admissions is rather 
 more than one third. 
 
 From these data, then, it would seem that there is about an equal 
 liability to pericarditis and endocarditis in the Hindoo and native 
 Christian classes, but that compared with them, these affections are 
 more than twice as common among Parsees, and not one fourth so 
 frequent among Mussulmans. It will not fail to be observed that 
 of the four female cases, two were also Parsees, making six Parsees 
 affected out of a total of twenty-three. Under a subsequent head 
 it will appear that all the cases which occurred in Parsees were 
 in association with acute articular rheumatism. These facts con- 
 firm the general impression on my mind, that acute articular 
 rheumatism, with pericarditis and endocarditis, is more com- 
 mon among Parsees than any of the other classes of the native 
 community of Bombay. Of the comparative exemption of the 
 Mussulman population, as shown by these statements, I am unable 
 to suggest any explanation ; and it would be waste of time, and 
 might lead to error, were I to speculate on deductions from data 
 so limited. 
 
 * Total number of Hospital Admissions from 1848 to April 1S52. 
 
 
 
 
 
 
 c 
 
 a 
 
 
 
 
 
 
 u 
 
 
 c 
 
 S 
 
 .- 
 
 V 
 
 <C 
 
 
 
 
 « 
 
 
 
 3 
 
 
 
 rt 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 
 S 
 
 fe 
 
 H 
 
 W 
 
 £ 
 
 o 
 
 d. 
 
 (n 
 
 H 
 
 1848-49. 
 
 3,045 
 
 487 
 
 3,532 
 
 1,154 
 
 1,064 
 
 482 
 
 145 
 
 487 
 
 3,532 
 
 1849-50. 
 
 3,653 
 
 589 
 
 4,242 
 
 1,335 
 
 1,377 
 
 681 
 
 260 
 
 589 
 
 4,242 
 
 1850-51. 
 
 4,133 
 
 713 
 
 4,846 
 
 1,712 
 
 1,347 
 
 715 
 
 359 
 
 713 
 
 4,846 
 
 1851-52. 
 Total. 
 
 3,543 
 
 583 
 
 4,126 
 
 1,486 
 
 1,064 
 
 629 
 
 364 
 
 583 
 
 4,126 
 
 14,374 
 
 2,372 
 
 16,746 
 
 5,687 
 
 4,852 
 
 2,707 
 
 1,128 
 
 2,372 
 
 16,746 
 
 o o 3 
 
566 PERICARDITIS AND ENDOCARDITIS. 
 
 V. Classification with reference to age. — The ages of only 
 twenty-three of the cases are recorded : — 
 
 From 10 to 20 7 
 
 „ 21 „ 30 10 
 
 „ 31 „ 40 4 
 
 „ 41 „ 50 2 
 
 23 
 
 The lowest age is seventeen, and the highest fifty. Seventeen 
 cases were between the ages of seventeen and thirty, four between 
 thirty-one and forty, and two between forty-one and fifty. Of those 
 between seventeen and thirty, fourteen occurred in connection 
 with rheumatism, — a fact which goes to support the common 
 statement that rheumatism, with pericarditis and endocarditis, is a 
 disease rather of the earlier than the advanced periods of life. 
 
 VI. The (liferent occupations of those affected. — Of five cases, 
 including three females, the nature of the occi^ation is not stated. 
 That of the remaining twenty was as follows : — 
 
 2 Sailors 
 
 1 Labourer. 
 
 3 Servants 
 
 1 Carpenter 
 
 3 Fruit, vegetable and fish 
 
 1 Grain seller 
 
 hawkers 
 
 1 Schoolmaster 
 
 2 Eeggars 
 
 1 Oil seller 
 
 2 Sepoys 
 
 1 Dyer. 
 
 1 Baker 
 
 1 Cook. 
 
 On examining this statement, it appears that of the twenty 
 persons, sixteen followed occupations which, more or less, lead to 
 exposure to wet or vicissitudes of temperature : this is the case 
 of sailors, hawkers, beggars, sepoys, bakers, cooks, dyers, and 
 labourers. 
 
 VII. Relation to habits of life. — It is stated of only five of the 
 twenty-five cases, that there was addiction to the use of spirituous 
 liquors ; of these two were Parsees, two Hindoos, and one a Portu- 
 guese; one patient was habituated to opium smoking. 
 
 In regard to the remaining nineteen cases, it may be inferred of 
 the greater number that they were not of intemperate habits. 
 
 VIII. The months of the year in which most prevalent. — The 
 admissions occurred in the following months : — 
 
 3 in January 
 
 2 ,, February 
 
 „ March 
 
 1 „ April 
 
 „ May 
 
 1 ,, June 
 
 3 in July 
 
 3 „ Augusl 
 
 1 ,, September 
 
 4 „ October 
 
 2 „ November 
 2 ,, December 
 
CAUSES — RELATION TO SEASON, RHEUMATISM, ETC. 567 
 
 The relation of the disease to cold and wet is also very well 
 shown in this statement. There are nine cases in the cold months 
 of November, December, January, and February. Those of Fe- 
 bruary were admitted in its first half — one had been ill fifteen 
 days, the other eight days, they are therefore justly classed with 
 the occurrences of the cold season. There are fifteen in the rainy 
 season, in the months of June, July, August, September, and 
 October. Of the four which occurred in June, three were ad- 
 mitted after the 20th, and are consequently correctly classed as 
 admissions of the rainy season ; and of two the relation to wet 
 as a cause is distinctly recorded. Of the four cases in October, 
 three are correctly classed as admissions of the rainy season: 
 they were received into hospital before the 12th of the month, 
 and two of them had been ill fifteen and ten days respectively. 
 The fourth admission in October was of a very susceptible indi- 
 vidual, who had on a former occasion suffered from rheumatism. 
 The single case which occurred in the hot season, in the month of 
 April, was a Parsee female in good circumstances, who on previous 
 occasions had suffered from rheumatism. 
 
 IX. Relation of the disease to Rheumatism, Cachexia, and 
 Pulmonic Inflammation. — In seventeen cases the disease was 
 associated with acute articular rheumatism. In sixteen the rheu- 
 matism was present at the period when the cardiac symptoms 
 appeared, and afterwards co-existed with them. In one case the 
 rheumatic symptoms were not present with the cardiac symptoms, 
 which occurred in an individual who had some years previously 
 suffered from an attack of acute rheumatism, and in whom the 
 diathesis, at the period of the attack of pericarditis, may be assumed 
 to have been still present. Of these seventeen cases, eight were 
 Hindoos, six Parsees, two Christians, and one a Mussulman : six 
 were of pericarditis alone, four of endocarditis, and seven of peri- 
 carditis and endocarditis combined. 
 
 Of the remaining eight cases, in which rheumatism was ab- 
 sent, two occurred in very cachectic states of the system ; in one 
 the cachexia was distinctly sj^philitic, and in both, pericarditis 
 alone was present. Four were extension of inflammation from 
 the lungs or pleura, and were with one exception cases of pericar- 
 ditis: in the exceptional one endocarditis also existed. Two must 
 be looked upon as instances of primary pericarditis. 
 
 Of the total cases of pericarditis and endocarditis there was only 
 one in which, so far as the record shows, Bright's disease of the 
 kidney existed. 
 
 o o 4 
 
568 PERICARDITIS AND ENDOCARDITIS. 
 
 We notice distinctly in these cases the greater relation that 
 subsists between endocarditis and acute articular rheumatism, than 
 between pericarditis alone and rheumatism. All the cases of endo- 
 carditis, single or combined, were, with one exception, associated 
 ■with rheumatism ; whereas of the thirteen cases of pericarditis, 
 seven were unconnected with rheumatism ; and of the six cases in 
 the list of uncombined pericarditis noted as occurring in association 
 with rheumatism, it is not improbable that in two of them endo- 
 carditis was also present. Of the two cases of apparent primary 
 pericarditis, one is peculiar in its nature, and will presently be 
 made the subject of comment. 
 
 X. The leading symptoms and signs observed. — In analysing 
 the symptoms, attention must be confined to twenty-two cases; for 
 of three the record is so incomplete as to render their exclusion 
 necessary. 
 
 Pain at the margin of the left ribs was present in seven cases, 
 in some extending to the precordial region, and in two or three to 
 the epigastrium and abdomen generally. 
 
 Precordial pain, either alone, or associated with pain at the 
 margin of the left ribs, existed in eight. 
 
 To consider this symptom from another point of view, pain 
 (precordial and hypochondriac) was observed in ten cases ; in two 
 it was confined to the margin of the left false ribs, in three 
 to the precordial region, and in five it was common to both 
 situations. Of these ten, six were of pericarditis alone, thus 
 leaving four of this form in which pain was not observed ; two 
 were of endocarditis, leaving two of this form in which pain was 
 not present ; and two were of pericarditis and endocarditis com- 
 bined, leaving six of this form not characterised by pain. 
 
 From these statements, then, it appears that we are justified in 
 referring the symptom pain more to pericarditis than to endocar- 
 ditis ; for of the eighteen cases of pericarditis, simple and combined, 
 pain was present in eight ; but of the twelve of endocarditis, simple 
 or combined, pain was characteristic of only four. These cases also 
 confirm the now generally admitted fact, that in a considerable 
 proportion of instances of pericarditis and endocarditis pain is not 
 complained of. Of the twenty-two cases now under review, pain 
 was present in ten, but absent in twelve. 
 
 Increased action of the heart is noted as having existed in 
 eight cases. In five, pericarditis and endocarditis were com- 
 bined ; in two, endocarditis, and in one pericarditis existed alone: 
 thus there would seem to be a more frequent relation between 
 
SYMFTOMS — TALriTATION, PULSE, FEVER. 569 
 
 increased action of the- heart and endocarditis than between it and 
 pericarditis. Of the twelve cases in which endocarditis, simple 
 and combined, was present, palpitation existed in five ; but of 
 the ten cases in which there was pericarditis alone, palpitation is 
 noted of only one. It is further evident from this statement, 
 that in a large proportion of cases of pericarditis and endocarditis, 
 the action of the heart is not notably increased. Of the twenty- 
 two cases under review, of eight only is increased action recorded 
 as a symptom. 
 
 Impulse remote. — In one case the impulse of the heart is 
 stated to have seemed distant and obscure. 
 
 The state of the pulse. — In sixteen cases the character of the 
 pulse differed markedly from the healthy standard. In four it was 
 jerking ; of these, three were of pericarditis and endocarditis com- 
 bined, and one of pericarditis alone. As the jerking pulse is not 
 noted of any case of simple endocarditis, it may probably be inferred 
 that this character of pulse is more related to pericarditis than 
 endocarditis. It occurred only in simple or combined pericarditis. 
 
 In eleven cases the pulse is described as small, and in some it 
 was also sharpish ; six were of pericarditis, three of endocarditis, 
 and two of pericarditis and endocarditis combined. It may, 
 therefore, be inferred, that smallness of the pulse is as frequently 
 referable to endocarditis as to pericarditis. 
 
 In only one case is the pulse stated to have intermitted, and 
 this feature was not observed till long after the acute symptoms of 
 pericarditis had ceased, and the disease was believed to have 
 terminated in adhesions. 
 
 From a consideration of these cases, then, we may infer that an 
 abnormal pulse is more frequently observed in pericarditis and 
 endocarditis than pain or palpitation ; that its most common 
 quality is smallness associated with occasional sharpness, then a 
 jerking character ; but that an intermitting pulse, formerly looked 
 upon as symptomatic of pericarditis, is of infrequent occurrence, 
 and that we shall err, if we allow it weight in determining the 
 diagnosis. 
 
 Febrile symptoms were observed in fifteen cases : of these five 
 were of pericarditis alone, three of endocarditis, and seven of pericar- 
 ditis and endocarditis combined. Fever, then, would seem to be as 
 frequently related to endocarditis as to pericarditis. A reference 
 to the remaining eight cases, of which febrile disturbance is not 
 recorded, will show that in some of them fever had been present in 
 the earlier stages of the illness, though it was not noticed when the 
 
570 PERICARDITIS AND ENDOCARDITIS. 
 
 patients were under observation in the hospital. In others, in 
 which the disease was consecutive on pulmonary inflammation, it 
 was impossible to relate the febrile symptoms to the pericarditis, 
 rather than to the previously existing pulmonary disease. 
 
 The review of these cases, in reference to the presence or 
 absence of fever, goes to show that pericarditis and endocarditis 
 rarely exist without some degree of pyrexia. This was par- 
 ticularly true of those associated with acute articular rheumatism, 
 and in them, no doubt, the fever was as much due to the 
 affection of the joints as to pericarditis and endocarditis. But 
 there is more than this ; for I am satisfied that a close observa- 
 tion of cases of acute articular rheumatism will very generally 
 show, that coincident with the commencement of pericarditis 
 or endocarditis, there is a marked exacerbation of the febrile 
 disturbance. The increase of fever in more than one case of 
 acute rheumatism (for some days under treatment, and in which 
 the state of the heart had been regularly inquired into), has led 
 me to suspect the occurrence of pericarditis or endocarditis ; and 
 on careful examination the physical signs have, in each instance, 
 confirmed the suspicion. 
 
 It is not improbable, that in acute rheumatism, in the sthenic 
 constitutions of the inhabitants of European countries, with fever 
 greater in degree and more continued, febrile exacerbations may 
 not be so significant as I believe them to be in acute rheumatism 
 in the asthenic constitutions of the natives of India, with fever, 
 less in degree, and remittent in type. It is when the exacerbation 
 becomes longer in duration, occurs at irregular periods, or is of 
 increased severity, that it becomes indicative of the access of 
 cardiac inflammation. 
 
 Some degree of hurry and shortness of breath were present 
 in eight of nineteen cases; for under this head I have also ex- 
 cluded those instances of pericarditis associated with pulmonic 
 disease. Of the eight cases, four were of pericarditis alone, 
 two of endocarditis, and two of pericarditis and endocarditis 
 combined. In none did the difficulty of breathing amount to 
 orthopncea. 
 
 The expression of cov ntenance was observed to be anxious in five 
 cases; two were of pericarditis, one of endocarditis, and two of 
 pericarditis and endocarditis combined. 
 
 The occurrence of delirium was noted only in one case. The 
 occasional presence of nervous symptoms in acute rheumatism 
 and pericarditis, independent of direct affection of the brain, first 
 
PHYSICAL SIGNS. 571 
 
 pointed out by Dr. Watson, though not illustrated by these cases, 
 is practically very important. I can call to mind more than one 
 case of head symptoms misunderstood at the time, but which 
 were afterwards suspected to be of this nature. 
 
 The review which has just been made of the general and local 
 symptoms of pericarditis and endocarditis, goes to confirm the 
 now well-established fact that it is to physical signs we must trust 
 for the means of forming a precise diagnosis of these diseases ; 
 that without these signs many cases will escape detection, and 
 very few will be recognised with certainty. 
 
 Physical Signs. — Increased ^>rcecordicd dulness was present in 
 nine cases : of these four were pericarditis alone, and five pericar- 
 ditis and endocarditis combined — in all, the dulness probably de- 
 pended on effusion into the pericardium. In two, the pyramidal 
 form of the dull region Avas well marked; in two, effusion was 
 found after death, and in a third, also fatal, no post mortem ex- 
 amination was made. In three of the six in which recovery took 
 place, the dulness disappeared by absorption of the effusion : this 
 was verified some time afterwards in one case by dissection. In 
 the three remaining recovered cases, there was persistence of 
 some degree of dulness, dependent, it was believed, on hypertrophy 
 and dilatation of the left ventricle of the heart : these were instances 
 in which considerable valvular disease existed. 
 
 Purring tremor was present in only three, and was accom- 
 panied with friction sound. The tremor, then, in these cases, was 
 probably consequent on pericarditis, and not on mitral valvular 
 disease. 
 
 Precordial fulness was observed in only two, and was, appa- 
 rently, caused by effusion into the pericardium. 
 
 Friction murmur, — The number of cases of pericarditis alone, 
 and combined with endocarditis, amount to twenty-one ; but from 
 these, four must be excluded, in which no examination of the 
 region of the heart had been made. Of the seventeen cases which 
 remain, friction sound was heard in fifteen : it was absent in two — 
 in one, consequent on the considerable effusion as indicated by the 
 extent of the dulness, but in the other it is not noted, because 
 I could not satisfy myself of its presence, though others at the 
 time thought that it existed. 
 
 The duration of the friction sound is stated in nine cases: in 
 two it was present upwards of thirty days, and the result was in all 
 probability adhesion of the surfaces ; in two the friction murmur 
 was heard for twenty and twenty-one days — in one adhesion was 
 
572 PERICARDITIS AND ENDOCARDITIS. 
 
 suspected, in the other* it was proved to exist by subsequent dis- 
 section; in two the sound was present for fourteen days with 
 in one probably opaque patches, and in the other adhesions ; in 
 one case the murmur existed for seven days, and adhesions in all 
 likelihood resulted; in one the sound was heard for four days, 
 and probably some degree of opacity of the surface was left 
 behind ; in one the murmur was audible for three days only, and 
 in this case, on dissection many months after complete recovery, 
 opaque patches were found here and there on the surface of the 
 heart, but no adhesion. 
 
 In five of the cases in which friction murmur had been present, 
 there was the opportunity of examining the body after death. In 
 three a considerable time had elapsed between the period at which 
 the sound had been audible, and death'; in two f patches of organised 
 lymph existed on the surface of the heart, but there was no adhe- 
 sion of the surfaces ; in one firm adhesions united the heart to 
 the pericardium. In two cases death occurred at the time when 
 the friction sound existed ; in one $ there were eight ounces of 
 reddish serum in the sac of the pericardium, and flakes and shreds 
 of lymph were deposited on the surfaces ; in the other § twelve 
 ounces of clear fluid were found in the sac of the pericardium, three 
 hours after death, — this fluid spontaneously coagulated into a gela- 
 tinous mass when removed from the body, but there were no flakes 
 of lymph deposited on the surfaces, and no vascularity of the serous 
 covering of the heart, or lining of the pericardium. 
 
 Four of the fatal cases confirm the generally received, and no 
 doubt correct, opinion, that the friction murmur is for the most 
 part dependent on the roughening of the surfaces from lymph-de- 
 posits ; but case 235, if correctly observed, would seem to show that 
 effusion of the liquor sanguinis (the fibrine being as yet undeposited 
 in the solid form) is adequate to cause a friction sound. The case 
 was for a very short time under observation, and that immediately 
 before death. Moreover, the abnormal sound may possibly have 
 proceeded from the great vessels compressed at their origin by the 
 fluid — a cause which has been suggested || as adequate to pro- 
 duce abnormal sound in pericardial effusion. For these reasons, I 
 am unwilling to attach undue importance to this case; yet it 
 seems to me to justify inquiry on the following points : — 
 
 1. Is it not probable that in exudations of liquor sanguinis 
 from the inflamed capillaries of seroug linings of closed sacs, the 
 
 * Case 232. t Cases 231, 233. J Case 234. § Case 235. 
 
 || " Walshe on Diseases of the Lungs and Heart," p. 216, 1st edition. 
 
PHYSICAL SIGNS — FRICTION MURMUR. 573 
 
 deposition of the fibrine, in the solid form, does not take place so 
 soon as is generally supposed ? 
 
 2. Whether the movement of the liquor sanguinis (the fibrine 
 as yet in the liquid form) between the serous surfaces is inadequate 
 to produce a friction murmur ; and whether, in considering this 
 question, we ought not to bear in mind those cases of pericarditis 
 in which this sound is present from the commencement, and to 
 account for which has always been a difficulty, — explained by 
 some on the supposition that the surfaces are roughened from the 
 turgid state of the capillaries which precedes effusion, by others, 
 as Dr. Hope *, on the improbable idea that lymph may be effused 
 in the dry state, as first suggested by Laennec ? 
 
 In fcwof of the fatal cases in which the friction sound was distinct, 
 death took place several months afterwards — in one from cholera, 
 in the other from pulmonary disease. In both, opaque patches 
 were found on the surface of the heart, but no adhesion between it 
 and the pericardium. In case 233 there was also valvular disease, 
 and it may be argued that an endocardial murmur may have been 
 mistaken for a friction sound. But this objection cannot be urged 
 against case 231 : in this, the friction murmur had been undoubted, 
 and the valves and heart were quite healthy, with the exception 
 of a few opaque patches on the surface of the right ventricle. 
 This case establishes the fact, that there may be friction sound, 
 then disappearance of it, and no greater structural change 
 than a few opaque patches on the surface of the heart. 
 Though this fact may now be admitted, still the statement made 
 relative to the duration of the friction murmur, as observed in 
 these cases, leaves little room for doubt, that when this sign 
 ceases, after having been present for fourteen days and upwards, 
 adhesion between the heart and pericardium has probably taken 
 place. 
 
 The following are the five fatal cases in which friction murmur 
 was observed : — 
 
 231. Pericarditis. — Friction murmur distinct, and then altogether disappearing. — 
 He teas cured. — Eight months afterwards, death from cholera. — Opaque patches on the 
 surface of the heart. — No pericardial adhesions. — Tayjah Dongur Sing, a Hindoo 
 fruit-seller, twenty-eight years of age, in tolerable condition, for six years addicted to 
 opium-smoking, was admitted into the clinical ward on the 28th June, 1850, having 
 been ill only since the day preceding. The countenance was somewhat anxious, the 
 respiration short and hurried (sixty-eight in a minute), and almost entirely abdo- 
 minal ; the skin was of natural temperature ; the pulse seventy-six, rather small, but 
 
 * Hope's Treatise on Disease of the Heart, 4th edit., p. 144. 
 f Cases 231, 233. 
 
574 PERICARDITIS AND ENDOCARDITIS. 
 
 sharpish ; and the tongue was a good deal furred. On percussion of the anterior part 
 of the chest no defective resonance was detected, and vesicular respiration was dis- 
 tinct and unmixed. In the prsecordial region, over a spot about an inch and a half in 
 diameter, just internal to the nipple, there was heard a murmur, partly of a rubbing, 
 partly of a creaking character. In this situation there was tenderness on pressure. 
 The sounds of the heart were distinctly audible, and the impulse was not much in- 
 creased. He pointed to the precordial region, and to the margin of the left false ribs, 
 as the seats of pain, felt since the day preceding his admission. The pain did not 
 extend to the back or left shoulder. He was quite free of all pain of the limbs ; but 
 he stated that he had suffered eight years previously from a severe attack of swelling 
 and pain of the joints, chiefly the knees and ankles ; and the marks of scarifications 
 were still visible on the knees. For this affection of the joints, he had also undergone 
 two long courses of mercury, and continued ill for seven months. Subsequently, how- 
 ever, he had enjoyed good health. The only circumstance to which he coidd attribute 
 his present illness was exposure to wet, to which he had been subjected ten days pre- 
 viously. Forty-eight leeches were applied to the prsecordial region, followed by a 
 blister ; three grain and then two-grain doses of calomel with one eighth of a grain of 
 tartar emetic, and one fourth of a grain of opium, were given every fourth hour. On 
 the 30th June the gums were tender, and the calomel was omitted ; on the 1st July the 
 mercurial influence was still more developed. On the 29th June the friction murmur 
 was still distinct ; on the 30th it had disappeared, and was not again heard. He was 
 discharged well from the ward on the 10th July. This patient again presented him- 
 self at the hospital on the 21st August, having experienced some uneasy sensations in 
 the prsecordial region, but the sounds and impulse of the heart were natural ; and after 
 the action of some aperient medicine he was quite relieved, and left the hospital on the 
 22nd August. He was not again seen till the 7th of March, 1851, when he was ad- 
 mitted in the collapsed state of cholera, that disease being at the time prevalent : 
 re-aetion did not take place, and he died on the evening of the 10th. 
 
 Inspection. — Chest. — There was no increased quantity of fluid found in the pericar- 
 dium, and there were no adhesions between the pericardium and the heart. The inner 
 surface of the pericardium was pale, and without deposit of any kind. The heart was 
 rather small; there was no dilatation of any of its cavities. Over the centre of the 
 anterior wall of the right ventricle there was an opaque patch, about half an inch long and 
 quarter of an inch in breadth, which, with moderate traction with the forceps, could be 
 separated from the pericardial covering of the heart in the form of a thin firm layer of 
 areolar tissue. The free surface of the patch was quite smooth. At the upper part of 
 the left ventricle there was a smaller and a thinner patch. Elsewhere, here and there 
 on the surface of the heart, other opaque spots were noticed. The endocardium was 
 healthy, and so were also the valves. There were two or three small spots of com- 
 mencing deposit on the inner surface of the ascending aorta. 
 
 'Remarks. — This case has been already published by me in the London Medical 
 Gazette, of the 16th May, 1851. It was so because at the time Dr. W. S. Kirkes had 
 called in question the commonly received opinion, which maintains that when there 
 has been acute pericarditis, with friction murmur, followed by disappearance of the 
 
 mur r and restoration lo tolerable health, this result has been effected by pericardial 
 
 adhesion. This case confirms Dr. Kirkes' opinion; and, I think, definitely proves 
 that we may have friction murmur and recovery, without any other structural change 
 than the opaque white patches so frequently observed on parts of the surface of the 
 heart. 
 
 232. Phthisis pulmonalis. Secondary pericarditis. — Friction murmur, distinct 
 
 for in-cut a days. Death eighteen months afterwards. Firm pericardial adhesions 
 
 Brighfs disease of the kidney. Kannyah, a Hindoo baker, thirty-two years of age, 
 
 a native of Bangalore, and lately arrived in Bombay from Poona, was admitted, after 
 
PHYSICAL SIGNS — FRICTION MURMUR. 575 
 
 eleven days' illness, into the clinical ward, on the 27th September, 1849. He was 
 reduced in flesh, and the respiration was short and hurried. The whole of the right 
 side of the chest was dull on percussion, the dulness increasing from above down- 
 wards. In places there was crepitus rale, in others bronchial respiration. He con- 
 tinued under treatment till the 11th December. There were febrile symptoms, with 
 evening exacerbations. The sputa, at first in part rusty and adhesive, frothy and 
 clear, subsequently became opaque, and were expectorated in detached masses. The 
 dulness on the right side and bronchial respiration continued for some time unehano-ed, 
 but at the period of his discharge had considerably lessened. During his stay crepitus 
 was heard in the left dorsal region. 
 
 He was re-admitted on the 1-ith June, 1850. He had improved in health after 
 leaving the hospital, till five days before his re-admission, when, consequent on ex- 
 posure to cold, he had a return of febrile symptoms, cough, and dyspneea. There was 
 didness, with large crepitus, and bronchial respiration in the left mammary, lateral, 
 dorsal, and scapular regions. On the right side crepitus was also audible ; but nothing 
 is noted regarding the resonance on percussion. The sounds and rhythm of the heart 
 were natural. He continued suffering from febrile and pulmonic symptoms till the 
 23rd June, when a distinct friction murmur, synchronous with the heart's action, and 
 obscuring the soimds, was heard between the left nipple and the sternum. The pulse 
 was frequent and jerking. The murmur continued distinct till the 13th July, when it 
 ceased ; and there was left some degree of roughness and shortness of the first sound. 
 On the 3rd August, and for some time afterwards, the impidse of the heart was dis- 
 tinct between the third and fourth left costal cartilages, but it was not perceptible 
 below the nipple. The febrile and pulmonic symptoms continued, but became less in 
 severity ; the dulness and bronchial respiration of the left side lessened in deoree 
 and he was discharged in improved health on the 20th September. He continued in 
 tolerable health for about a year, when he began again to suffer from cough and febrile 
 symptoms, and was re-admitted into the clinical ward on the 6th January, 1852. He 
 was a good deal emaciated. The respiration was short and hurried ; there was did- 
 ness on percussion of the right scapular and dorsal regions, but undue resonance of the 
 subclavian region. In all these regions there was blowing respiration and increased 
 resonance of voice. The left subclavian and axillary regions were somewhat dull on 
 percussion, and there was bronchial respiration mixing with occasional subcrepitous rale. 
 There was no increased precordial dulness, and nothing abnormal was detected in the 
 sounds and impidse of the heart. There was dulness on percussion for an inch and a 
 half below the margin of the right false ribs, and some uneasiness on pressure there. 
 He complained of frequent cough. The sputa were copious, puriforru.and in detached 
 masses. The pulse was small and frequent. There Mas no diarrhoea. He died on 
 the 10th January. During his second admission the urine gave no trace of albumen 
 on the one occasion on which it was examined. During his last admission if was 
 examined on the 9th January, when it was stated to be twenty ounces in quantity, of 
 brown colour, specific gravity 1-035, giving a deposit under heat and nitric acid, which 
 became of a brown colour. 
 
 Inspection fourteen hours after death, — Head, — The vessels of the pia mater were 
 congested, and about two ounces of serous fluid were found at the base of the skull. 
 Chest. — The mucous membrane of the trachea presented here and there a blush of 
 redness : there were also small red points on that of the larynx. The lobes of the 
 right lung were firmly adherent to each other. The two upper ones were completely 
 sobdified by aggregation of crude tubercles. About an inch and a half below the apex 
 of the upper lobe, and near to its posterior surface, there was a cavity the size of a 
 pigeon's egg, lined by a smooth membrane. The inferior lobe, also, had scattered 
 crude tubercles, with intercurrent sanguineous engorgement. Both lobes of the 
 left lung were more or less solidified, but the upper one more so, from tubercular 
 deposit ; there was no cavity. The internal surface of the pericardium was firmly, 
 
576 PERICARDITIS AND ENDOCARDITIS. 
 
 closely, and generally adherent to the outer surface of the heart. The left ventricle of 
 the heart was slightly dilated, but there was no hypertrophy of its walls. The valves 
 of both sides were healthy. Abdomen. — The external appearance and size of the liver 
 were natural. "When incised, it was found to be congested in the second degree. The 
 spleen was healthy. Both kidneys were slightly enlarged, somewhat lobulated, mot- 
 tled red and pale yellow, and finely granular externally ; their incised surfaces were in 
 general pale : the cortical portion of both was somewhat enlarged and encroached upon 
 the tubular. These changes were most marked in the left kidney. The stomach and 
 intestines were not examined. 
 
 233. Asthenic pneumonia, leading to red induration of the upper lobes. — In its 
 course, pericarditis and endocarditis of the left ventricle and auricle, causing structural 
 disease of the mitral valve. — Not traced to rheumatism. — Dilatation of all the cavities 
 of the heart. — Sebastian Fernandez, a native of Groa, thirty-one years of age, following 
 the occupation of a servant, and using spirituous liquors, was admitted into the clinical 
 ward on the loth July, 1850. He was a good deal reduced, had been under treatment 
 in the hospital a month before for cough, from which on previous occasions he had 
 also suffered. Subsequent to his discharge from hospital, and about fifteen days 
 before his second admission, the cough had become more troublesome, and for the last 
 eight days had been attended with febrile symptoms, coming on with chills at irregular 
 times, and terminating with sweating ; and the sputa had been tinged with blood. 
 The respiration on admission was observed to be slightly hurried ; there was some de- 
 gree of dulness on percussion of the left subclavian region, and the general character 
 of the respiration there, as well as in the left scapular region, was more bronchial 
 than normal. The sounds and impulse of the heart were natural. He continued 
 suffering from cough — the physical signs unchanged — occasional accessions of 
 fever, and slight dysenteric symptoms, with a pulse decreasing in strength, till 
 the 31st July, when, for the first time, some degree of preternatural precordial 
 dulness was observed. The dulness extended from the third to the fifth rib, and from 
 the left margin of the sternum to the nipple. At the fourth costal cartilage, internal 
 to the nipple, both sounds of the heart were distinct, and continued so in a direction 
 upwards. About an inch below and external to the nipple there was a rough murmur, 
 ol scuring the first sound, but the second was tolerably clear. On moving the stetho- 
 scope downwards and outwards, about an inch and a half below and external to the 
 nipple, the murmur became louder, and obscured both sounds of the heart. The 
 features were contracted, and the pulse was scarcely perceptible. The bowels were 
 relaxed, and he had vomited frequently. He continued under treatment till the 29th 
 September, when he was transferred to another ward. During this period occasional 
 febrile symptoms were present. The pulse was in general small, sometimes irritable. 
 The action of the heart was increased ; the precordial dulness somewhat extended. 
 The cardiac murmur continued as described, but latterly it was less rough, and some- 
 what fainter, and did not obscure both sounds. The pulmonic symptoms and signs 
 continued, and there was more or less gastro-enteric irritation present. The urine 
 showed no trace of albumen. He was treated with stimulants, tonics, and anodynes, 
 and small blisters were applied to the precordial region. Shortly afterwards he left 
 the hospital, and was not again heard of till the 24th February. 1851, when he applied 
 for re-admission, and was received into the clinical ward. He complained chiefly of 
 ibrt and distention of the abdomen after eating, and the breathing was hurried. 
 Dulness on percussion of the right subclavian and axillary regions was noted, with a 
 bronchial character of the respiration there, as well as in the left subclavian and 
 scapular regions. The precordial dulness extended from the third rib to the margin 
 of the left false ribs, and transversely from the right margin of the sternum to half 
 an inch external to the nipple. The action of the heart was increased. A little internal 
 to the nipple there was a blowing systolic murmur, which became more audible iu a 
 direct ion downwards, but gradually disappeared in a direction upwards ; the second 
 
PHYSICAL SIGNS — FRICTION MURMUR. 577 
 
 sound of the heart was distinct. The pulse was email and feeble, the dyspnoea in- 
 creased, and he died on the 5 th March. 
 
 Inspection twelve hours after death. — Chest. — The lungs did not collapse. The 
 left lung adhered firmly to the costal pleura throughout its entire extent ; the 
 greater part of the upper lobe was in a state of red induration, the lower lobe was 
 somewhat condensed, and a good deal of frothy serum oozed out when it was cut ; 
 there was no pleuritic effusion. The right lutig was unconnected by abnormal adhe- 
 sion to the costal pleura ; the upper lobe was in a state of red induration similar to 
 that of the left side, but rather less in degree ; the posterior part of the third lobe 
 was also condensed, and the anterior crepitated feebly ; the bronchial tubes were 
 filled with frothy serum, and the mucous membrane was red ; there was no pleuritic 
 effusion. The heart extended from the third to the seventh left rib. There was 
 no fluid in the sac of the pericardium. Opaque thickened patches existed on 
 the surface of the heart, chiefly that of the right ventricle. The cavity of the left 
 ventricle was dilated, but the walls were of natural thickness; the mitral valve was 
 considerably thickened, and the aurieulo-ventricular opening was so contracted as 
 not to allow the point of the little finger to pass through. The free margins of the 
 aortic semi-lunar valves were thickened. The left auricle was also dilated, and its 
 lining membrane presented an opaque thickened appearance throughout, with gramdar 
 effusion here and there, in patches. There was considerable dilatation of the right 
 auricle and ventricle, and both contained firm fibrinous coagula. Abdomen. — The liver 
 was rather smaller than natural, but healthy in structure. The kidneys were healthy. 
 
 234. Empyema of the right side of the chest. — Secondary pericarditis. — Friction 
 Murmur. — Lymph effusions found after death. — Miguel Eozario, aged thirty-five, a 
 
 native of Goa, a cook by occupation, had been in bad health for some time before 
 his admission into the Jamsetjee Jejeebhoy ^Hospital, on the 23rd July, 1852. He was 
 affected with cough, and with dyspnoea, and the indurated edge of the liver projected 
 for two or three inches below the margin of the right ribs. The dyspnoea increased 
 and there were occasional febrile symptoms, and on the 13th August a distinct friction 
 murmur was perceived in the precordial region, best heard at the apex. There was 
 slight increase of precordial dulness. The face became puffed, the feet and hands 
 cedematous, and he died on the 19th. 
 
 Inspection thirteen hours after death. — Chest. — The right sac of the pleura con- 
 tained several pints of purulent fluid ; the lung was compressed, and the liver was 
 displaced downwards. The surfaces of the pleura were covered with flaky lymph. 
 The left lung was healthy. The pericardium contained about eight ounces of blood- 
 tinged serum, and flakes and shreds of lymph adhered generally to its inner surface. 
 The heart was of natural size, and there was no disease of the valves. 
 
 Remarks. — For this case I am indebted to Dr. Haines, under whose care the patient 
 was. I had not an opportunity of seeing the patient during life, nor the morbid 
 appearances after death. 
 
 235. Acute arachnitis and pericarditis, leading to considerable effusions, coagulating 
 into a jelly-like masswhen removed from thebody. — Friction murmur. — In a pregnant 
 female.— Joomkee, a Hindoo female, a beggar, thirty years of age, was brought to the 
 Jamsetjee Jejeebhoy Hospital on the evening of the 9th August, 1852. She had 
 been found alone in a house by[the police, and was believed to have been ill for several 
 days. She was quite comatose, and the pupils were dilated ; the skin was somewhat 
 above the natural temperature : the breathing was hurried : the pidse was small and 
 frequent. The upper limit of the precordial dulness was the lower border of the 
 second left rib, the lower limit was the upper border of the sixth rib ; the inner the 
 middle of the sternum, and the outer a vertical line drawn along the external margin 
 of the nipple. The impulse of the heart was increased, and a thrilling sensation was 
 communicated to the hand when placed on the precordial region. The action of the 
 
 P P 
 
578 PERICARDITIS AND ENDOCARDITIS. 
 
 heart was tumultuous, and the sounds confused. There was distinct induration below 
 the left false ribs. She was in about the sixth month of pregnancy, and the foetal 
 pulsations were audible to the left of the fundus of the uterus. During the 10th the 
 coma continued ; the pulse became feebler ; the breathing more hurried, and at the 
 evening visit a friction murmur was heard at the second left costal cartilage, but not 
 at the apex — here the sounds were still confused. She died early on the morning 
 of the 11th. 
 
 Inspection three hours after death. — Head. — About eight* ounces of fluid flowed 
 from the cavity of the arachnoid and base of the skull, and speedily coagulated 
 into a jelly-like mass. It was of red colour, but this was probably due to some ad- 
 mixture of blood which had escaped from the sinuses, wounded in removing the dura 
 mater. There was no increased vascidarity of the membranes, or redness of the sub- 
 stance of the brain. The ventricles were empty. Chest. — The diaphragm rose high 
 in the chest. The lungs showed no traces of disease. The pericardium was distended, 
 and occupied a space extending from the first to the fifth left rib, reached to the right 
 border of the sternum, and on the left side half an inch beyond the nipple. It con- 
 tained about twelve ounces of clear greenish fluid, which speedily coagulated into a 
 tremulous jelly-like mass. There was no vascularity of any part of the inner surface 
 of the pericardium or outer surface of the heart, and no trace of lymph deposit. The 
 endocardium, the valves, and muscular tissue of the heart, presented no appearance of 
 disease, unless a greater degree than usual of redness of the muscular structure may 
 be so considered. There was no dilatation of any of the cavities, and they con- 
 tained little blood, and no fibrinous coagula. The spleen was considerably enlarged. 
 The liver was of natural size, and healthy. Both kidneys were somewhat larger than 
 natural, but their structure was healthy. The gravid uterus extended as high as the 
 umbilicus, and contained twins between the fifth and sixth month. 
 
 Jogging movement of the heart was noticed only in one case, and 
 in this the history pointed to pericardial adhesions as the probable 
 result : it may, therefore, be looked upon as tending to confirm 
 the opinion entertained by Dr. Hope relative to the import of this 
 sign. 
 
 XI. On the treatment of the disease. — The following obser- 
 vations have reference to seventeen cases : — 
 
 In none was general blood-letting required ; the constitutions of 
 the patients admitted into the Jamsetjee Hospital are for the most 
 part too asthenic to justify the use of this antiphlogistic means. 
 
 In eleven, local blood-letting by leeches was had recourse to. 
 The stage of the disease, and the state of the pulse and skin, were 
 the guides to the adoption and degree of this measure. Of its 
 efficacy, when the circumstances are appropriate, there can be no 
 doubt. 
 
 In fourteen cases, one or more blisters, from three to four inches 
 square, were applied to tbe precordial region. The liquor lyttss 
 was the preparation generally selected, and it was usually applied 
 after suitable local depletion, or in cases for which the latter mea- 
 
 * The character of the cerebral effusion is the only fact in this case not witnessed 
 by myself. I am indebted to Mr. Sebastian Carvalho for the statement. The heart 
 and pericardial effusion were seen by me. 
 
TREATMENT. 579 
 
 sure was considered inappropriate. Blisters were not used more 
 frequently, when liquid effusions were believed to be present, 
 tlian when they were supposed to be absent. Looking upon 
 the derivant action of a counter-irritant as a means which tends 
 to favour the restoration of normal circulation in the inflamed 
 capillaries, and believing that this is necessary to ensure the 
 absorption of liquid effusions, or the organisation of lymph-deposits, 
 it seems to me, as regards the application of blisters, an immaterial 
 question which of these processes must be brought into action 
 before recovery can take place : in both, a more or less complete 
 return to normal capillary circulation in the structures adjoining 
 the deposits, is essential. 
 
 Mercurial influence was induced in ten cases. In all, with 
 one exception, local blood-letting had also been used, and in all 
 blisters applied. Of these ten cases, three were of pericarditis 
 alone, one of endocarditis, and six of pericarditis and endocarditis 
 combined. Five of the ten cases in which mercury was used, re- 
 covered; but in the other five, though life was saved, structural change 
 remained behind. Of the eight cases classed under a former head as 
 recoveries (p. 564), mercurial influence was induced in five ; but in 
 three it formed no part of the treatment, which in one consisted 
 of local blood-letting and blisters, in another of blisters, in a third 
 of Dover's powder and nitre alone. The mercury was given every 
 third, fourth, or sixth hour, in the form of calomel, in two or three- 
 grain doses, combined with a quarter or half a grain of opium ; 
 and in cases in which there was much febrile disturbance, from a 
 quarter to a third of a grain of tartar emetic was added. The 
 calomel was used with caution, so as not to cause a greater effect 
 than slight swelling of the gums, and gentle ptyalism ; and this 
 state was maintained for several days. The mercurial treatment 
 was never had recourse to without a strict inquiry into the state of 
 the patient's constitution, with the view of ascertaining the like- 
 lihood of a scorbutic or other cachexia. This care is essential in 
 the treatment of the class of patients who resort to this hospital, 
 and indeed, I might add, of natives of India generally. 
 
 We find, then, that of ten cases brought under the influence 
 of mercury, five recovered, — but in these local blood-letting and 
 blisters had also been used ; and that of eight cases in which re- 
 covery took place, mercurial action, preceded by blisters and 
 leeches, had been induced in five, but in three mercury had not 
 been given. In this statement, then, we have no striking proof of 
 the efficacy of the mercurial treatment of pericarditis and endo- 
 
 P P 2 
 
580 PERICARDITIS AND ENDOCARDITIS. 
 
 carditis : yet my impression is in favour of its cautious adoption in 
 suitable states of the constitution, and stages of the disease. 
 
 The present state of therapeutic science teaches us that mercury, 
 under some circumstances, favours the absorption of lymph-de- 
 posits; and so long as this doctrine remains unrefuted, it is the 
 course of prudence to yield to it some measure of our faith, and to 
 act in some degree under its guidance. At the same time, how- 
 ever, we must never forget, that if mercury may influence for 
 useful ends states of the blood well constituted as regards fibrine 
 and red corpuscles, it can hardly fail to cause harm in opposite 
 conditions. But these principles have been already fully explained 
 and enforced in various parts of this work. 
 
 In one case in which the use of mercury was contra-indicated, 
 liquor potassce was substituted, because in similar asthenic states 
 many good recoveries of pneumonia in the second stage seemed to 
 have been brought about by this remedy. 
 
581 
 
 CHAP. XXV. 
 
 ON ORGANIC DISEASE OF TIIE HEART AND AORTA. 
 
 Section I. — In Natives of India. 
 
 This section records the clinical history of twenty-eight cases of 
 structural disease of the heart, and three of aneurism of the aorta. 
 The important facts may be arranged under the following heads: — 
 
 I. The nature and situation of the 
 
 structural change. 
 II. Relation to difference of sex. 
 
 III. The proportion of cases in the 
 
 different castes. 
 
 IV. Classification with reference to 
 
 age, 
 V. The different occupations of those 
 
 affected. 
 VI. Relation to habits of life. 
 VII. Relation to the months of the 
 year. 
 VIII. Relation of the structural changes 
 to pericarditis, endocarditis, 
 and rheumatism. 
 IX. Relation to Bright's disease of the 
 kidney. 
 X. The leading symptoms and signs, 
 
 XI. 
 
 treated of under the following 
 heads : — 
 
 1. Dyspnoea. 
 
 2. Dropsy. 
 
 3. Precordial pain. 
 
 4. Pain below the margin of 
 
 the right ribs. 
 
 5. Scapular pain. 
 
 6. Character of the pulse. 
 
 7. Precordial fidness. 
 
 8. Increased impulse of the 
 
 heart. 
 
 9. Precordial didness. 
 
 10. Dulness below the margin 
 
 of the right ribs. 
 
 1 1 . Character of the murmurs. 
 
 12. Precordial thrill. 
 On medical treatment. 
 
 I. The nature and situation of the structural changes. — Of 
 the thirty-one cases, eighteen proved fatal in hospital, and two in 
 all probability, shortly after discharge. Of the eighteen fatal cases 
 an examination of the body after death was made in seventeen. 
 Let us first notice the structural changes which existed in them. 
 
 In eleven there was dilatation of both ventricles of the heart ; 
 in six, associated with disease of both aortic and mitral valves ; in 
 four with disease of the mitral valve, and in one with disease of 
 the aortic valves alone. 
 
 In ten there was dilatation and hypertrophy of the left ven- 
 tricle. In these, with two exceptions, there was dilatation of the 
 
 p p 3 
 
582 0RQASIC DISEASE OF THE HEART. 
 
 rio-ht ventricle also : in five there was disease of both the aortic and 
 mitral valves, in three of the mitral valve, and in two of the 
 aortic valves only. 
 
 In one case there was hypertrophy of the right ventricle, asso- 
 ciated with obstructive disease of the pulmonary semi-lunar valves. 
 It is here narrated : — 
 
 236. Contraction of the orifice of the pulmonary artery, probably congenital. — Much 
 hypertrophy, without dilatation of the right ventricle of the heart. — No disease of the 
 left side. — Mahadoo Babajee, a Hindoo beggar, fifteen years of age, of short stature, 
 and disproportionately large head, a native of Alibag, in Angria's Colaba, and resident 
 in Bombay from his childhood, was admitted into the clinical ward on the 22nd Sep- 
 tember, 1850. He stated that from childhood he had suffered from dyspnoea, occasional 
 cough, and pain of the praecordial region; that he was liable to febrile attacks; that 
 on one occasion his abdomen had become very tumid ; that for four months before ad- 
 mission he had experienced pain, without swelling, of the large joints, and to these 
 symptoms occasional headache had been added. On admission, the respiration was 
 observed to be slightly hurried ; the skin was cool ; the pulse small and easily com- 
 pressed ; the abdomen somewhat full, but supple ; the tongue coated with a white fur ; 
 the bowels regular, and the urine free. The chest sounded well on percussion, with 
 exception of slight increase of the precordial dulness, which extended vertically from 
 the fourth to the sixth rib, and transversely from the middle of the sternum to the 
 left nipple. The respiratory murmur was somewhat puerile in character, and without 
 rales. The action of the heart was somewhat increased, and its apex beat in the in- 
 tercostal space between the fifth and sixth rib, at the left border of the sternum. 
 There was a systolic murmur, best heard a little below and internal to the nipple, 
 continuing distinct upwards and to the right side, and fading in the opposite direction. 
 The second sound was normal. No thrilling sensation was experienced on placing the 
 hand on the prsecordial region. He remained under treatment till the 26th Xovember, 
 when he was discharged, little relieved. During his stay, the physical signs of heart 
 disease continued as on admission. He complained of dyspnoea, of cough, occasional 
 pain of the joints, of headache, and febrile disturbance from time to time, The pulse 
 was always small, and easily compressed; the urine free, specific gravity from 1/012 
 to T020, and without trace of albumen. This patient was re-admitted into the 
 hospital on the 19th March 185 1, affected with febrile symptoms. The systolic murmur 
 was still present; also dry bronchitic rales. He was attacked with symptoms of 
 cholera on the 23rd, and died on the 24th. 
 
 Inspection twenty-four hours after 'death. — Head. — The calvarium, chiefly the 
 occipital and frontal portions, was very thick, being more than quarter of an inch, but 
 without any increase of the density of the diploe. The furrows of the middle menin- 
 geal artery were deeply grooved. The membranes of the brain were very much con- 
 gested. The substance of the brain was firm, showed more bloody points than usual, 
 and the cortical portion was of darker tint than natural. Chest. — The heart weighed 
 seven ounces and a half. With exception of the right auricle there was no dilatation 
 of the cavities. The walls of the left ventricle were of natural thickness ; those of the 
 right ventricle were thicker than those of the left — they were rather more than half 
 an inch thick. The orifice of the pulmonary artery Mas of size only sufficient to permit 
 the passage, of half the length of an ordinary dissecting case blow-pipe, and the surface 
 towards the cavity of the artery, and immediately surrounding the opening, had a 
 rough and papillated appearance, as of firm granular-lymph deposit. The orifice 
 seemed to be constructed by adhesion of the free edges of the semi-lunar valves, with 
 exception of their central part. The valves, however, were very little thickened, and 
 a probe passed readily into the little pouch between them and the internal surface 
 
PATHOLOGY. 583 
 
 of the artery. The trunk of the pulmonary artery was of diminished capacity, and 
 the walls were thinner than natural. The aorta and its valves were healthy. The 
 lungs were not congested with blood ; in parts they were dry and woolly, and the 
 surface somewhat irregular, from slight emphysema. 
 
 Remarks. — Presuming on the rarity of disease of the valves of the right side of the 
 heart, it was supposed that the aortic valves were the seat of disease in this case; but 
 my belief is that a more careful inquiry into the situation at which the murmur was 
 best heard wovdd during life have led to a correct diagnosis. The stunted growth, 
 the absence of dilatation of the cavities of the heart, the freedom from dropsical 
 symptoms or other signs of congestion, and the small pulse, all show that the blood 
 was maintained in very reduced quantity ; indeed, it was only by an adaptation of 
 the quantity to the very contracted pulmonary orifice that the circulation of the blood 
 could have been carried on. The complete absence of congestion of the lungs, so 
 different from what obtains in most forms of heart disease, was interesting, but of easy 
 explanation. 
 
 In the four following cases there was aneurism of the left ven- 
 tricle. In all, the opaque state of the endocardium showed that 
 endocarditis had at a former period been present, and was pro- 
 bably the cause of the atrophy and impaired irritability of the 
 muscular fibre which had led to the formation of the aneurismal 
 pouches. In three of the cases there was disease of the mitral 
 valve, and in one, of the aortic valves. 
 
 237. Dilatation of both ventricles. — Hypertrophy of the left. — Disease of aortic valves 
 anal the well-marked results of pericarditis and endocarditis, consecutive on rheumatism, 
 related to syphilis. — Ahmeenah, a Hindoo female, thirty-nine years of age, had, about 
 a year before she came under observation, been the subject of syphilis, followed by 
 pain and swelling of almost all the joints, and latterly by dyspnoea, and fulness of the 
 epigastrium. She was admitted into the hospital on the 14th December, 1848, affected 
 with general anasarcous swellings, dyspnoea, and cough. There was precordial dulness 
 from the third to the seventh rib, and from the middle of the sternum to an inch ex- 
 ternal to the left nipple. The impulse of the heart was increased, and a sawing murmur 
 took the place of both sounds, and was loudest between the third and fourth rib, about 
 half an inch to the left of the sternum, continuing audible as the stethoscope was 
 moved towards the clavicle, but lessening in the direction of the apex. There was 
 occasional sibilus mixing with the respiration. The pulse was feeble. There was 
 fulness and uneasiness at the epigastrium, and hepatic dulness extended to within an 
 inch of the umbilicus. The urine was not albuminous. The dropsical symptoms and 
 the dyspnoea increased ; and she died on the 25th December. 
 
 Inspection. — On examining the body after death, the pericardium was found to ex- 
 tend from the second to the seventh rib, and its cavity contained about four ounces of 
 serum. It was connected to the surface of the heart, chiefly over the left ventricle, by 
 firm adhesions. The serous covering of the heart was for the most part thickened and 
 opaque. The heart was much enlarged— there was dilatation of both ventricles, with 
 hypertrophy of the left ; the tricuspid and mitral valves were healthy. The lining 
 membrane of the left ventricle, towards the aortic orifice, was for a considerable extent 
 opaque, and much thickened. There existed at the upper part of the septum a thimble- 
 like depression about an inch in diameter, lined by thickened endocardium, roughened 
 by granules of lymph. The ring of the aortic valves felt cartilaginous and firm, but 
 there was no dilatation of the aorta. 
 
 238. Aneurism of the left ventricle of the heart, consequent on endocarditis and 
 pericarditis. — Mahomed Allee, aged forty, a Mussulman, a native of Bengal, resi- 
 
 P P 4 
 
58-4 ORGANIC DISEASE OF THE HEART. 
 
 dent for fourteen years in Bombay, following the occupation of a sailor, and not in- 
 temperate in his habits, was admitted into the clinical ward on the 6th November, 
 1849, and died on the 12th of the same month. He was a good deal reduced; the 
 countenance was anxious; the respiration hurried; the pulse feeble and intermitting. 
 He was easiest when on the right side, or in the sitting posture. Decubitus on the 
 back or the left side led to much aggravation of the dyspnoea, and anxiety ; and in conse- 
 quence of the suffering which they occasioned, minute and repeated examinations of 
 the chest were impracticable. The precordial dulness extended from the fourth costal 
 cartilage to the seventh, and transversely from the middle of the sternum to just ex- 
 ternal to the left nipple. The impulse of the heart was somewhat increased. There was 
 a systolic murmur audible at the fourth costal cartilage, increasing in the direction of 
 the apex, decreasing above the base. The second sound was natural. He complained 
 of constant pain about the left scapula, but none of the prseeordial region. The pain 
 at the left scapular region had existed for about three months, but the dyspnoea came 
 on only nine days before his admission into the hospital. Aboxit two inches below 
 and external to the left nipple there was a depressed cicatrix — the mark, he said, of a 
 gun-shot wound received during the late war in Scinde. Was never affected with 
 rheumatism, or pain of the precordial region. 
 
 Inspection. — Chest. — The lungs collapsed on opening the chest, and there was about 
 a pint of serous effusion in the sacs of the pleura. The upper lobes of both lungs, 
 more especially at their apices, contained many scattered miliary tubercles, with some 
 induration of the intervening pulmonary tissue ; the rest of the lung healthy and 
 crepitating, but somewhat congested. The pericardium contained about two ounces 
 of serum. The heart was much enlarged ; it occupied vertically a space between the 
 lower margin of the second rib and the level of the seventh, and transversely from the 
 sternal junction of the second right rib to the left nipple. There were firm close adhesions 
 between the pericardium and the posterior and upper part of the left ventricle ; also 
 general thickening and opacity of the serous covering of the heart. The left ventricle 
 was very much dilated. At its apex, and posteriorly below the mitral valve, it was 
 filiated into two distinct pouches. The latter pouch was large enough to hold a small 
 orange, its walls were membranous and opaque, and it contained fibrinous coagula. 
 The rest of the walls of the ventricle was of natural thickness. There was slight 
 thickening of the mitral valve ; the orifice of the aorta was dilated. The right ven- 
 tricle was also dilated ; the semi-lunar valves were healthy. There was no morbid 
 appearance found in the interior of the chest corresponding with the cicatrix on its 
 exterior. Abdomen. — There was about a pint of serum in the cavity of the peritoneum. 
 The free lower margin of the liver was about three inches below the ensiform cartilage, 
 and about an inch below the margin of the right ribs, and the organ was somewhat 
 congested. The kidneys were healthy. 
 
 239. Rheumatism, followed by pericarditis and endocarditis. ■ — Disease of tin mitral 
 valve. — Dilatation of the right side of the heart. — Dilatation and hypertrophy, with 
 circumscribed aneurism of the left ventricle. — Death expedited by acuU general perito- 
 nitis. — Abdool Rahman, a Mussulman horsekeeper, fifty years of age, an inhabitant 
 of Hydra bad, in the Deecan, and a resident in Bombay for about six years, was ad- 
 mitted into the Jamsetjee J. jo.-l.h. >y Hospital on the 13th December, 1849. He had 
 been addieted to the use of spirituous liquors for several years, smoked ganja and 
 tobacco, and latterly also took opium. About three years before admission he had 
 suffered for a month from pain of the large joints, unattended with swelling he said ; 
 but that since then there had been no recurrence. For a year and a half he had ex- 
 perienced more or less dyspnoea, easily increased by exertion, but unattended with 
 cough, tiU about eight days before admission, when cough began to be troublesome, 
 and the dyspnoea to be more urgent, followed in two or three days by puffiness of the 
 face and oedema of the feet and legs; and in this state he was admitted into hospital. 
 
PATHOLOGY. 585 
 
 The respirations were twenty-six, and chiefly abdominal. With exception of increased 
 precordial dulness, the chest sounded well on percussion ; but sibilous and subcrepitous 
 rales were present more or less in all parts of the lungs. The precordial dulness 
 extended vertically from the third costal cartilage to the margin of the left false ribs, 
 and tranversely from the middle of the sternum to about three inches external to the 
 nipple. The impulse was forcible, extensive, and heaving, and the apex beat between 
 the sixth and seventh ribs, an inch external to the nipple. There was a systolic 
 bellows murmur very distinct below the nipple, and in the direction of the apex, but 
 becoming faint above the base. The second sound was distinct, but wanting in sharpness. 
 The skin was cool; the pulse 96 to 100, small, easily compressed, and slightly jerking 
 He complained of cough and dyspnoea, — both increased at night, the latter becoming 
 very urgent on slight exertion. The abdomen full and supple, without any sense 
 of fluctuation ; and there was dulness below the right false ribs for about two and a 
 half inches, and extending upwards as high as the level of the sixth right rib. 
 The bowels were slow, and the urine reported free. He continued under treatment till 
 the 4th Match ; the dropsical symptoms disappeared, and the dyspnoea and cough 
 were much alleviated. The general character of the pulse was small, irregular 
 and unequal, and varying in frequency. The rhythm of the heart's action was often 
 observed to be irregular, two pulsations being succeeded by a period of considerable 
 repose, and a distinct thrill was in general perceptible on placing the hand on the 
 precordial region. The didness of the precordial region, and the character 
 of the murmur and of the second sound, continued unchanged. The urine was 
 free, of varying density, and never albuminous. He was treated chiefly with com- 
 binations of camphor mixture, sesquicarbonate of ammonia, spiritus etheris nitrici, 
 tincture of hyosciamus, and preparations of squills. After his discharge from the 
 hospital, he from time to time presented himself at the morning visit, and the physical 
 signs of heart disease were found to continue without change. At length he was 
 re-admitted into the clinical ward on the 21st August, 1850. The abdomen was 
 tense, tender, and fluctuating ; the pulse frequent, and almost imperceptible ; dyspnoea 
 urgent. He died about twelve hours after admission. 
 
 Inspection nine hours after death. — Chest. — On opening the cavity of the chest, 
 the lungs collapsed, and were found crepitating. There were old adhesions of the 
 costal and pulmonary pleure of the right side. The pericardium was in relation with 
 the anterior wall of the chest from the first to the sixth rib, and tranversely beyond the 
 right margin of the sternum to the right, and beyond the nipple to the left. There 
 was no adhesion of the pericardium to the heart, but the surface of the heart, more 
 particularly of the left ventricle, was covered with opaque patches. The right auricle 
 was very much distended. There was also much dilatation of the right as well as of 
 the left ventricle, and in both were found coagula of blood. The walls of the left 
 ventricle were for the most part of natural thickness, with the exception of one place 
 in the internal wall, midway between the apex and the mitral valve, where the coats 
 were much thinned, the muscular tissue being almost removed, so as to form a pouch 
 the size of a walnut. The endocardium surrounding the margin of the pouch for about 
 half an inch was opaque and thick. The mitral valve was thickened, so as to permit 
 regurgitation into the auricle. The aortic valve and the aorta were healthy. Abdomen. 
 — About two pints of turbid serous fluid were found in the cavity of the peritoneum, 
 and an abundant effusion of coagulable lymph over the surface of the intestines formed 
 tender bands of adhesion between them and the parietes, and between the convolutions. 
 In several places the adhesions circumscribed collections of serum. The liver was 
 rather smaller than natural, and its substance felt hard under the knife ; its external 
 surface was granular, but there was no very distinct appearance of cirrhosis of its in- 
 cised surfaces ; the external surface was covered with patches of coagulable lymph ; 
 its anterior margin was firmly adherent to the ascending colon as well as to the 
 diaphragm. In the mucous membrane of the ccecum there was an ulcer about the 
 
586 ORGANIC DISEASE OF THE HEART. 
 
 size of a rupee ; and in that of the ascending colon there were three or four smaller 
 ulcers, with patches of redness here and there. The other parts of the intestinal 
 canal were healthy. Both kidneys were somewhat tabulated externally, and, when 
 incised, the cortical portion presented a slightly granular appearance ; the apices of 
 some of the pyramids seemed somewhat indurated and fibrous. The spleen and 
 stomach were healthy. 
 
 240. The former subject of rheumatism. — Dilatation of the left ventricle. — 
 Disease of the mitral valve. — Much thickening of the endocardium. — An aneur- 
 ismal sac at the apex. — Also the marks of former pericarditis. — Shamoo, a female, 
 forty years of age, a Hindoo milk-seller, a native of Aurungabad, and resident a month 
 in Bombay, was admitted into the Jamsetjee Jejeebhoy Hospital on the 7th August, 
 1852. The face was puffed ; the feet and legs cedematous ; the respiration short and 
 hurried ; the skin coldish ; and the pulse small, and easily compressed. The precor- 
 dial dulness extended vertically from the second intercostal space to the margin of the 
 left false ribs, and transversely from the right border of the sternum to beyond the 
 left nipple. The impulse of the heart was feeble. There was a faint systob'c murmur, 
 most distinct at the apex. At the base the sounds were confused, but the murmur was 
 hardly audible. The abdomen was rather full, and was dull on percussion for about 
 three inches below the right false ribs and the sternum, where there was uneasiness 
 on pressure. She stated that three years before she had suffered from rheumatism, 
 and that fifteen days before admission there had been a severe febrile accession, pre- 
 ceded by chills, which continued for three days, and was followed by oedema of the 
 legs, and uneasiness of the abdomen. She continued with little change in the symp- 
 toms, and died on the morning of the 1 1th August. 
 
 Inspection three hours after death. — Chest. — Eight ounces of reddish serum were 
 foxind in the pericardium. The heart was considerably enlarged. There were opaque 
 patches on the anterior surface of the right ventricle, and at the apex of the heart there 
 was a patch the size of a dollar, of thick organised areolar tissue, somewhat reddened, 
 adherent fn-mly to the surface of the heart, but forming no adhesion with the inner 
 surface of the pericardium. The left ventricle was much dilated, and the walls were 
 in places somewhat thickened. The endocardium of the posterior surface of the left 
 ventricle was converted into an opaque thick membranous layer, with here and there 
 cacoplastic yellow deposit, about two lines in thickness. There were also opaque 
 thickened patches of the endocardium of the anterior surface. At the apex there was 
 a pouch in the thickened endocardium, large enough to hold a walnut, corresponding 
 to the patch of adventitious tissue on the external surface; the muscular covering of 
 the pouch was much thinned. The mitral valve was opaque and thickened, not ossified. 
 The aorta and valves were healthy. There was no dilatation of the right ventricle, 
 and the valves were healthy. The lungs were healthy and crepitating. The body was 
 not further examined. 
 
 In six there was both aortic and mitral valvular disease, in 
 six disease of the mitral valve o-nry, in two of the aortic valves 
 alone, and in one * of the pulmonary semi-lunar valves. 
 
 The co-existence of dilatation of both or one of the ventricles of 
 the heart, with various stages of valvular disease has been shown. 
 
 In nine cases the existence of former pericarditis was proved by 
 the presence of opaque patches on the surface of the heart; and 
 in two of these adhesion between the pericardium and the surface 
 of the heart also existed. 
 
 * Case 23G. 
 
TATHOLOGY. 587 
 
 In six there was in the opaque condition of the endocardium of 
 the left ventricle evidence of previous endocarditis. 
 
 Both the pericardium and endocardium had been affected in five 
 cases. 
 
 In five there was effusion of serum exceeding two ounces, in the 
 sac of the pericardium. 
 
 In the following case rupture of the left ventricle of the heart 
 had taken place : the muscular fibre had probably undergone fatty 
 degeneration. 
 
 241. Rupture of the heart from fatty degeneration. — John Amarago, a sailor, fifty- 
 five years of age, was admitted into the Jamsetjee Jejeebhoy Hospital on the Gth 
 March, 1852, with bronchitic symptoms. The pulse was soft, and rather full, and 
 there was some heat of skin. He died suddenly and unexpectedly the day after ad- 
 mission, no information having been obtained in regard to his previous history. 
 
 Inspection. — The pericardium was distended with bloody serum, mixed with clots. 
 The left ventricle was ruptured longitudinally in two places, about an inch apart from 
 each other, in the upper and outer part of the ventricle. The fissures were one an 
 inch, the other half an inch in length ; one extended through the substance of the wall 
 of the ventricle, and opened into the cavity obliquely ; the other was a rupture of the 
 external fibres only. The walls of the ventricle were somewhat thickened, but 
 there was not any dilatation of the cavity. Over the right ventricle there was more 
 than the usual amount of adipose tissue, and in two situations in the substance of the 
 left ventricle were two distinct, defined, light yellow, granular-looking patches, occupy- 
 ing half the thickness of the wall, The aortic valves were healthy. There were 
 points of deposit on the inner surface of the ascending aorta. 
 
 Remarks. — Though unfortunately a microscopic examination was neglected, there 
 can be no doubt that the heart in this case was affected with fatty degeneration. 
 
 In three cases there was dilatation of the ascending portion of 
 the aorta, and in one the aorta was contracted. In three there 
 were thickened patches of athermatous deposit on the inner sur- 
 face of the aorta. 
 
 In two cases there was aneurism of the thoracic, and in one 
 of the abdominal aorta. One of the former and the latter are here 
 detailed.* 
 
 * I find in my notes the following two additional cases of aneurism of the aorta, 
 observed subsequent to my return to India ; also one of perforation of the aorta and 
 death by htemorrhage. 
 
 1. A Hindoo admitted in November 1856. There was much dyspncea ; considerable 
 tumefaction with dulness at the epigastrium. The dulness extended above the ensi- 
 form cartilage. There was dulness of the right dorsal region ; clearness but absence 
 of breath sounds in the right lateral and mammary regions. Dulness on percussion 
 at the sternal end of the right subclavian region, with pidsation there greater than at 
 the heart, with single murmur at times, but disappearing when the pidse at the wrist 
 was faint. No abnormal cardiac sounds detected, but the heart action was feeble. 
 No difference of pulse. He died thirty-six hours after admission. 
 
 Inspection. — The upper lobe of the right lung was displaced by a large aneurismal 
 dilatation, the size of the fist, involving the whole of the ascending aorta, stopping at 
 the arch and not affecting the vessels given off from it. The aortic orifice was 
 
588 ORGANIC DISEASE OF THE HEART. 
 
 242. Great dilatation of the ascending aorta and the arch. — An aneurismal tumour 
 at the commencement of the descending aorta. — TJiere was no external swelling, but tlie 
 other signs of the disease were well marked. — Sungoor Seeclee, a Mussulman sailor, 
 an inhabitant of Bahrein, and of African extraction, forty-one years of age, was ad- 
 mitted into the clinical -ward on the 9th January, 1849. He was somewhat reduced in 
 strength, and the respiration was rather short and hurried, and easiest in the sitting 
 posture. There was no marked dulness of the chest. He had occasional cough, with 
 scanty muco-puriform expectoration. Sonorous rale was audible in the left scapular 
 region, but elsewhere the vesicular respiration was good. There was no increased 
 impulse of the heart at the precordial region, and the two sounds were distinct, but 
 from the third rib upwards in the line of the sternum, inclining to the right towards 
 the sternal junction of the right clavicle, there was a heaving impulse, very evident 
 under the stethoscope, indistinctly so to the hand, attended with a single sound, but 
 no murmur. When in the recumbent posture, there was occasional wheezing observ- 
 able in the respiration. The pulse at the left wrist was 104 in the sitting posture, 
 and of good strength ; the pulse at the right wrist, and in the right carotid artery, was 
 imperceptible. The abdomen was soft ; the tongue was moist and clean ; no difficulty 
 
 enlarged ; the valves slightly thickened. There was inadequacy of the valves, from 
 increased size of the orifice. Hypertrophy with dilatation of the left ventricle; — dila- 
 tation of the right. Congestion of posterior parts of the lungs. Much congestion of 
 the liver, which explained the epigastric fulness. 
 
 2. Balloo Krishna, a Hindoo labourer, twenty-eight years of age, was under treatment 
 for supposed pleuritis in the early part of November 1856. He was discharged, and 
 some days afterwards when sleeping exposed, he became affected with great dyspnoea, 
 and was again admitted on the 28th November. There was urgent orthopncea, with 
 the face and trunk bent forwards. The dyspnoea, always great in degree, increased in 
 paroxysms, and was attended with muco-puriform expectoration. The voice was feeble, 
 and there was some difficulty of deglutition. The pulse feeble ; the skin coldish. 
 No disease of the heart or aorta detected, though carefully sought for. He experi- 
 enced slight relief from the cautious inhalation of chloroform in small quantities. He 
 died on the 7th December. 
 
 Inspection. — An aneurismal tumour, the size of a hen's egg, communicating by an 
 opening, the size of a rupee, with the posterior wall of the aorta at the commencement 
 of the arch, was found crossed obliquely by the innominate artery, and also by the left 
 carotid and subclavian, both displaced somewhat to the left. The sac was filled with a 
 coagulum, from which a fibrinous band extended down the ascending aorta into the 
 left ventricle. The inner surface of the ascending aorta was roughened and thickened 
 from atheromatous deposit. Some dilatation of the left ventricle. No other cardiac 
 disease. There was congestion of the liver, and the thin edges of the lungs were 
 solidified from collapse. 
 
 A curious case of perforation of the aorta was kindly communicated to me by Dr. 
 Crawford, who also allowed me to examine the morbid structures : — 
 
 3. A soldier of the 18th Eoyal Irish swallowed a piece of chicken bone — came to 
 hospital — pain at lower part of sternum, anol symptoms of gastric irritation ; very 
 little difficulty of swallowing. On the sixth day profuse hsematemesis and death. 
 
 Inspection. — A narrow (two lines broad) piece of bone, one anol a half inch long, very 
 pointed and sharp, lay in a sloughy depression, two inches long, three quarters wide, of 
 the lower and back part of the oesophagus ; it had penetrated the aorta. The sloughy 
 state extended to the tissues between the oesophagus and aorta, but haol not reached 
 to those of the aorta. Under an effort of vomiting, the sharp point impacted 
 vertically in the mucous membrane, had penetrated the aorta, then a process of idcer- 
 ation and sloughing, by which the bone was loosened, and hajinorrhage the conse- 
 quence. 
 
PATHOLOGY. 589 
 
 in deglutition. When sitting he experienced uneasiness at the epigastrium ; when 
 recumbent the uneasiness extended over the chest and shoulders. He had first 
 observed these symptoms two months before he came under observation, and they 
 had gradually increased. He attributed his illness to his having often been obliged 
 to lift heavy weights on board ship. During his stay in hospital, his nights were 
 restless ; he had occasional cough, and uneasiness about the sternum. On the 13th 
 there was a slight murmur audible at the top of the sternum, but it was not again 
 heard. Decubitus was easiest on the right side. He complained of difficulty of 
 swallowing on the 2oth, and there was some degree of febrile excitement. The 
 breathing became disturbed, and the pulse feeble. He gradually sank and died, 
 without any marked change in the symptoms, on the 30th January. 
 
 Inspection twenty-five hours after death. — Chest. — Just above the semi-lunar 
 valves the aorta became dilated to about four times its natural calibre. The dilata- 
 tion involved the ascending aorta, the arch, and commencement of the descending 
 aorta ; it included all the coats of the artery, with probably an exception at the com- 
 mencement of the descending aorta, where there seemed to be a separate pouch, 
 closely adherent to the bodies of the fourth, fifth, and sixth dorsal vertebrae, and filled 
 by firm and fibrinous coagula. In the ascending portion of the aorta there was a loose 
 coao-ulum, and at the commencement of the arteria innominata there was thickening, 
 with irregularity of the surface of the lining membrane. The dilated arch of the aorta 
 pressed upon the trachea just above its bifurcation. The dilated pouch at the com- 
 mencement of the descending aorta made pressure on the oesophagus. The lower lobe 
 of the left lung adhered by recent adhesions to the costal pleura, and hepatised 
 nodules were felt on pressing it. The heart was healthy. 
 
 243. Aneurism of the abdominal aorta. — Death by rupture. — Soorga Chunderbund, a 
 Mahratta washerman, forty years of age, in the habit of smoking tobacco and drinking 
 moderately, was admitted into the clinical ward on the 21st March, 1848. He was 
 considerably reduced in flesh ; the countenance was anxious ; and he moved about 
 with a stooping gait. In the epigastric region, chiefly, but not altogether, to the left 
 of the median line, reaching to the umbilicus, and extending below the arch of the left 
 false ribs, from the ensiform cartilage downwards, there was a round indistinctly 
 circumscribed swelling, becoming more prominent on decubitus on the right side. The 
 swelling was strongly pulsating anteriorly and laterally, but there was no bruit 
 audible under the stethoscope. In the rest of the abdomen, along the margin of the 
 right ribs and the ensiform cartilage, and in the left hypochondrium above the upper 
 margin of the tumour, the sound was tympanitic on percussion. The action and 
 sounds of the heart were natural. He complained of pain of the loins, of impaired 
 appetite, and uneasiness after food. The pidse was somewhat full, and the bowels 
 slow. He stated that about a year previously, whilst engaged in ironing clothes, 
 he felt a slight pain, first at the epigastrium, and that six months after he perceived a 
 small pidsating swelling, which gradually attained the size which it presented on his 
 admission. He died suddenly the day after admission. 
 
 Inspection eight hours after death. — There was a large quantity of blood (several 
 pints) between the layers and at the root of the mesentery. Just below the superior 
 mesenteric artery, and extending below the giving off of the renal arteries, there 
 arose from the anterior surface of the aorta a tumour larger than a goose's egg, filled 
 with coagula, and ruptured at its apex, which extended between the folds of the 
 mesentery. The vena cava was pushed before the tumour, and was apparently com- 
 pressed. 
 
 Of the seventeen cases examined after death, the state of the 
 Langs is not mentioned in the report of two. In six there was 
 congestion of part of the lungs : five of these were cases in which 
 
590 ORGANIC DISEASE OF TIIE IIEAIIT. 
 
 there was dilatation of both ventricles, and one dilatation with hyper- 
 trophy of the left ventricle. In five there was oedema of the lungs, 
 and in all of them dilatation of both ventricles was present. In 
 four there was more or less serous effusion into the sacs of the 
 pleura, and in these there was also dilatation of both ventricles; 
 in three the pleural effusion was associated with oedema of the lungs. 
 In five, old pleural adhesions existed. In two there were hepatised 
 nodules here and there in the substance of the lungs. In one 
 tubercles existed ; in one emphysema. In one the lungs were re- 
 ported to be healthy. In these statements we find the relation between 
 congestion of the lungs, serous effusion into the sacs of the pleura, 
 or into the pulmonary air cells, and heart disease, well illustrated. 
 
 Cases not fatal in hospital. — There were thirteen of this class : 
 two, as already stated, were believed to prove fatal shortly after 
 the patients were discharged. 
 
 Of these thirteen cases, in eight there was hypertrophy and 
 dilatation of the left ventricle. 
 
 In seven there was mitral valvular disease, in one aortic val- 
 vular disease, in one disease of the tricuspid valve, and in one 
 aneurism of the arch of the aorta. 
 
 II. Relation to difference of sex. — Of the twenty-four cases, 
 there are only three females. The observations made under this 
 head, in reference to pericarditis and endocarditis, are equally 
 applicable to the present division of the subject (p. 56-i). 
 
 III. Proportion of cases in the different castes. — Of the 
 thirty-one persons, fifteen were Hindoos, nine Mussulmans, six 
 Christians, and one a Parsee. On comparing this statement with 
 the corresponding one in the preceding chapter* it will be ob- 
 served that the proportions of Hindoos and Christians are very 
 similar, but those of Mussulmans and Parsees are altogether 
 opposed. This result makes it evident that the data have been too 
 limited to justify any general conclusion on this point. 
 
 IV. Classification ivith reference to age. — The ages were as 
 follows : — 
 
 From 10 to 20 3 
 
 „ 21 „ 30 1° 
 
 „ 31 „ 40 11 
 
 „ 41 „ 50 5 
 
 „ 51 „ 60 1 
 
 „ 61 „ 70 1 
 
 31 
 * Page 564. 
 
RELATION TO AGE AND OCCUPATION. 591 
 
 The lowest age was fourteen, and the highest sixty-five. Be- 
 tween the ages of fourteen and thirty there were thirteen cases, 
 and of these, five were in individuals who were reported to have 
 suffered from rheumatism. Between the ages of thirty-one and 
 forty there were eleven cases, and of these, four had been affected 
 with rheumatism. Between the ages of forty-one and fifty there 
 were five cases, and of these, two had suffered from rheumatism. 
 Of the two cases between fifty-one and sixty-five, one had also 
 been affected with rheumatism. 
 
 When we compare this statement with that under the same head 
 relative to pericarditis and endocarditis *, we find that in the pre- 
 sent, the range is considerably more extensive — it is between the 
 ao-es of fourteen and sixty-five instead of seventeen and fifty. 
 We observe, also, that the cases below twenty are considerably 
 f ewer — less than one half ; that between twenty-one and thirty 
 they are also less .numerous, but between thirty-one and forty the 
 proportion is more than double. 
 
 Of the thirty-one cases, twenty-one occurred between the ages 
 of twenty-one and forty, and of these, nine had suffered from 
 rheumatism ; of the remaining ten cases, three had suffered from 
 rheumatism. 
 
 V. The different occupations of the affected. — Excluding the 
 three females, and four whose occupations are not mentioned, the 
 remaining may be classed in the following manner : — 
 
 . 4 
 
 Sailors. . 
 
 . 9 
 
 Servants 
 
 Labourers 
 
 . 4 
 
 Beggar 
 
 Horsekcepers . 
 
 . 2 
 
 Plasterer 
 
 Washermen . 
 
 2 
 
 Tailor 
 
 17 
 
 1 
 1 
 
 1 
 
 7=24 
 
 There may be observed in this statement the same relation be- 
 tween probable exposure to cold and wet and heart affections, as was 
 noted relative to these influences, and pericarditis and endocarditis: 
 the reason is evident. But there is another point of interest in 
 the etiology of heart disease, which is also illustrated — the 
 frequency of the affection in individuals whose occupations 
 require active muscular exertion. Of the twenty-four cases, the 
 seventeen in the first column were thus circumstanced, and it is 
 worthy of note that of the three cases of aortic aneurism, two 
 occurred in washermen f , the third in a sailor. 
 
 * Page 5GG. 
 
 f It is unnecessary to state for the information of the Indian reader, hut it may ho 
 for that of the European, that the method of clothes-washing in India necessitates 
 considerable, violent muscular exertion of the arms and upper parts of the body. 
 
592 ORGANIC DISEASE OF THE HEART. 
 
 VI. Relation to habits of life. — The habits of only" twelve are 
 mentioned : of these four were not addicted to the use of spirits, 
 but eight were ; four of them were Hindoos, two Mussulmans, one 
 Parsee, one native Christian. 
 
 VII. Relation to the montlts of the year. — The admissions 
 occurred in the following months : — 
 
 2 in January 
 
 2 „ February 
 
 3 ,, March 
 
 1 ,, April 
 „ May 
 
 2 ,, June 
 
 4 in July 
 
 4 ,, August 
 
 5 „ September 
 „ October 
 
 4 .. November 
 4 ,, December. 
 
 As regards structural disease of the heart itself, it is not pro- 
 bable that we shall find any connection between admission into 
 hospital and the season of the year. But when we recollect that 
 admission is generally sought for relief from the secondary affec- 
 tions — dropsical effusions, and bronchitic attacks — we may be 
 prepared to find the same relation between cold and wet and 
 admission for heart disease, that we found to obtain between 
 these states of the weather and pericarditis and endocarditis.* 
 This statement confirms such expectation ; eleven cases were 
 admitted in the cold months of Xovember, December, January, 
 and February, and fifteeo in the wet months of July, August, and 
 September ; in the hot months of April, May, and October only 
 one case was admitted. 
 
 VIII. Relation of the structural changes to Pericarditis, Endo- 
 carditis amd Rheumatism. — Excluding the three cases of aortic 
 aneurism, and confining my observations to the twenty-eight cases 
 of heart-disease, it appears that the existence or not of previous 
 rheumatism has been stated of twenty cases ; of these twelve had 
 experienced, but eight never, an attack of this disease. 
 
 IX. Relation to BrigMs disease of the kidney. — There are 
 seventeen cases in which examination of the body after death was 
 made : in seven of them the condition of the kidneys is not 
 mentioned ; of the ten remaining cases, in six the kidneys were 
 healthy ; in four there was some degree of Bright's disease, but 
 in none had it proceeded to any great extent. This statement, so 
 far as it goes, shows a more frequent association of structural 
 disease of the heart and Bright's disease, than the corresponding 
 one in the' preceding chapter f did between this affection of the 
 kidney and pericarditis and endocarditis. In my notice of Bright's 
 disease \, it appeared that cardiac disease had been noted in six 
 
 * Page 566. t Page 567. } Page 482. 
 
SYMrTOMS AND TIIYSICAL SIGNS. 503 
 
 cases. Thus, we have an aggregate of ten cases in which these 
 two affections were combined. But in four, the cardiac disease 
 was fairly traceable to rheumatism ; and in the remaining six, 
 though rheumatism was not mentioned in the history, yet the 
 evidences of pericarditis and endocarditis were found after death, 
 and the kidney-disease was apparently of later date than the heart- 
 disease. Therefore my cases do not tend to confirm the relation 
 of antecedence and sequence between Bright's disease and disease 
 of the heart. 
 
 X. The leading symptoms and signs. — Dyspnoea. — The breath- 
 ing was somewhat short and hurried in twenty cases. Of these, 
 thirteen were fatal : in eleven there was dilatation of both ventri- 
 cles, in one dilatation and hypertrophy of the left ventricle, and in 
 one hypertrophy of the right ventricle. In three of the fatal cases 
 the lungs were found more or less congested after death, in five 
 there was oedema, in one pleural effusion, in one emphysema, in 
 one old pleuritic adhesions, in one the lungs were reported to be 
 healthy, and in one there was no note of the appearances. Thus 
 in eight of the twelve cases the dyspnoea was accounted for 
 by the presence of pulmonary congestion or oedema. 
 
 Of the ten cases not fatal, there was in seven, it was believed, 
 dilatation with hypertrophy of the left ventricle and disease of the 
 mitral valve, in two there was disease of the aortic valves, and in 
 the third of the tricuspid valve. 
 
 From these data, it would appear that dyspnoea has been gene- 
 rally associated with dilatation of the ventricles, and consequent 
 congestion and oedema of the lungs. 
 
 Dropsical symptoms were more or less present in sixteen cases : 
 of these ten were fatal ; in nine of them dilatation of both ventri- 
 cles, in one dilatation and hypertrophy of the left ventricle were 
 found after death. In the six uot fatal there was dilatation and 
 hypertrophy of the left ventricle, and disease of the mitral valve. 
 
 We find, in this statement, a close relation between dropsical 
 symptoms and conditions of the heart which must involve more 
 or less systemic venous obstruction. 
 
 Precordial pain was not noted in any case. 
 
 Pain below the margin of the right ribs was present in six, and 
 was attended with dulness on percussion in the same situation. In 
 four there was dilatation of both ventricles, and in two dilatation 
 and hypertrophy of the left ventricle. The pain and abnormal 
 dulness were undoubtedly due to congestion of the liver. These 
 symptoms are practically important from the risk of mistaking 
 
 Q Q 
 
59-i ORGANIC DISEASE OF THE HEART. 
 
 them for indications of hepatic inflammation. This error was com- 
 mitted in one instance, and I am satisfied that the caution now given 
 is not uncalled for. (See p. 529.) 
 
 Scapular pain was present in one case, in which aneurism of 
 the left ventricle was found after death. 
 
 Character of the pulse. — The state of the pulse is distinctly 
 noted in eighteen cases. In fourteen it was small : of these, 
 there was disease of the mitral valve alone in nine, of both 
 aortic and mitral valves in three, of the aortic valves alone in 
 one, and of the pulmonary semi-lunar valves in one. The 
 pulse was reported to be irritable in two cases : in one there 
 was disease of both mitral and aortic valves — in the other 
 of the mitral valve alone, and in this case the pulse was also 
 sometimes characterised as small. It was jerking in nine cases; 
 of these, four were fatal, and in all there had been diastolic 
 murmur during life, and aortic valvular disease was found after 
 death ; of the five not fatal, there was diastolic murmur in three. 
 In the remaining two the jerking pidse was noted only at the left 
 V( T i s t — it was small at the right ; in one dilatation of the aorta was 
 suspected, in the other this character might have been due to the 
 aneemic condition of the patient, for it had ceased before he left 
 the hospital. The pulse was intermitting in one case, and in this 
 there was disease of the mitral valve, dilated aortic orifice, and 
 ventricular aneurism. In two cases the pulse was irregular: in 
 one there was aortic and mitral valvular disease, and in the other 
 mitral disease alone. 
 
 From this statement it appears that smallness is the cha- 
 racter of pulse generally met with in cardiac valvular lesion, and 
 that it may be held to indicate mitral regurgitation, or obstructive 
 aortic disease. In four of the cases in which the pulse was jerking, 
 the existence of aortic regurgitation was not only made clear, l.\ 
 the discovery of aortic valvular affection after death, but also by the 
 presence of aortic diastolic murmur during life. In three of the 
 cases not fatal, diastolic murmur was present, and hence aortic 
 valvular regurgitation was diagnosed. 
 
 In my observations on the pulse in the preceding chapter*, I have 
 pointed to the rarity of an intermitting pulse in pericarditis and 
 endocarditis; and now in the cases of structural disease, we find 
 this character of pulse present only in one. The pulse, then, has 
 been observed to intermit in only two of fifty-six cases of varied 
 affect i un. of the heart. It is therefore evident, that intermittence 
 
 * Page 509. 
 
SYMPTOMS AND THYSICAL SIGNS. 505 
 
 of the pulse is a symptom of little value in the diagnosis of cardiac 
 disease. 
 
 Precordial fulness was noted in only one case, in which there 
 was dilatation of both ventricles, hypertrophy of the left, and 
 disease of the aortic and mitral valves. 
 
 There was increased impidse of the heart in thirteen cases — of 
 these eight were fatal : in six of them there was dilatation of both 
 ventricles, and hypertrophy of the left, in one dilatation of both 
 ventricles, with aneurism of the left, and in one hypertrophy of 
 the right ventricle. In the five not fatal, there was probably — 
 judging from the precordial dulness — dilatation and hypertrophy 
 of the left ventricle. 
 
 There was abnormal precordial dulness noted in twenty-two 
 cases : of these twelve proved fatal, and in nine of them there 
 was dilatation of both ventricles, in two dilatation and hyper- 
 trophy of the left ventricle, and in one hypertrophy of the right 
 ventricle. 
 
 Of the ten cases not fatal, there was in eight believed to be 
 dilatation and hypertrophy of the left ventricle, in one dilatation 
 of the right ventricle, and in one aortic valvular disease, with, 
 probably, some degree of dilatation of the left ventricle. 
 
 In twelve there was increased dulness beloiv the margin of 
 the right ribs. Of these, seven were fatal : in five there was dila- 
 tation of both ventricles, and in two dilatation and hypertrophy 
 of the left ventricle alone. In three of these cases the condition of 
 the liver after death is not mentioned, in two it was increased in 
 size and the substance mottled red and white from congestion, in 
 one there was mottling but no increase of size, and in one there was 
 no increase of size noted but tendency to cirrhosis. Of the five 
 cases of hepatic dulness, not fatal, in four there was dilatation and 
 hypertrophy of the left ventricle, and in the other dilatation of the 
 right ventricle. Under this head might also have been included a 
 case in which there was dulness below the margin of the right 
 ribs, from displacement of the liver downwards by pleuritic 
 effusion. 
 
 Character of the murmur* — There was a mitred systolic mur- 
 
 * It is very necessary, more particularly in native hospitals, to remember the fact 
 of ansemic cardiac murmurs, so as to avoid errors in diagnosis. The state of constitu- 
 tion, the basic systolic character of the murmur, the absence of precordial dulness, the 
 occasional presence of venous hum, and the disappearance of the sound with improve- 
 ment in the general system, ought in general to suffice. I do not allude to this subject 
 without good reason. About three years ago, cardiac disease was reported to be very 
 common among the native workmen at Aden. Then followed a period of wonder and 
 
 Q Q 2 
 
596 OKGANIC DISEASE OF THE HEAIIT. 
 
 mur alone observed in ten cases, and of these the termination was 
 fatal in five. There was found after death in one slight thickening 
 of the mitral valve and aneurismal dilatation close to it, in one 
 the mitral valve was thickened, and permitted regurgitation and 
 an aneurismal pouch existed between this valve and the apex of 
 the heart, in one there was no thickening of the mitral valve but 
 the auriculo-ventricular opening was of greater than natural dia- 
 meter and must have permitted regurgitation, in one the mitral 
 valve was opaque and thickened with an aneurismal pouch at the 
 apex of the heart, and in one there was general thickening of the 
 mitral valve with ossific deposit chiefly at the free margin. In 
 all these cases the aortic valves were healthy. 
 
 There was in three cases a mitral systolic and a diastolic mur- 
 mur: the result was fatal in one, and much thickening of the 
 mitral valve was found after death. In this case there was also an 
 aortic systolic murmur, and disease of the aortic valves. 
 
 There was a mitral systolic and diastolic murmur, ivith both 
 sounds of the heart audible at the base, observed in three cases : 
 one, narrated below, proved fatal, and much ossific thickening of 
 the mitral valve and some degree of thickening of the aortic 
 valves were found after death. 
 
 244. — Acute rheumatism. — Pericarditis, and endocarditis. — Dilatation of the right 
 side of the heart. — Dilatation and hypertrophy of the left ventricle. — Ossific state of 
 the mitral valve. — Hepatic congestion. — Mahadoo Ruggoo, aged twenty-four, a Hindoo 
 labourer, of originally rolmst frame, a native of Sattara, but resident in Bombay for 
 a period of three years, following the occupation of a boatman, addicted to the use of 
 spirits for a year, was admitted into the clinical ward on the 10th August, 1849. 
 About twelve months before, consequent on exposure to wet and cold, he became 
 affected with febrile symptoms, pain and swelling of the large joints, succeeded by 
 uneasiness of the chest, dyspnoea, and cough. The pectoral symptoms and the af- 
 fection of the joints had continued more or less. On admission, the breathing was 
 short and hurried ; the pulse irregular and feeble ; the skin of natural temperature ; 
 the bowels reported to be regidar. The only abnormal dulness of the chest was of 
 the precordial region — it reached from the third to the seventh rib, vertically, and 
 transversely from the left border of the sternum external to the nipple. The impulse 
 of the heart was feeble ; the sounds were distinct, but distant, and there was no mur- 
 mur. Dry bronchitic rales, with occasional crepitus, were heard here and there 
 tliroughout both lungs. The abdomen was full, but not resistant. There was dulness 
 on percussion two inches below the margin of the right ribs, and midway between the 
 ensiform cartilage and the umbilicus, and uneasiness was complained of on pressure 
 of the dull parts. With little alteration in those symptoms, he continued till the 2nd 
 of September, when the impulse of the heart was observed to be somewhat increased, 
 
 correspondence and the final solution, that aneemic had been mistaken for organic 
 murmur. The mistake was the less excusable, because the tendency to a scorbutic 
 taint had always existed more or less in the Indian native troops and workmen at 
 Aden. 
 
grWOPTQMS AND PHYSICAL SIGNS. 597 
 
 and a distinct rough murmur was audible just below the nipple, external to it, and 
 obseurino- both the sounds of the heart : but the sounds of the heart were both heard at 
 the third costal cartilage and upwards. The cough, the dyspnoea, pain of joints from time 
 to time, the heart signs last noted, the bronchitic rales, and occasional crepitus, the 
 hepatic dulness and tenderness, with occasionally pale intestinal evacuations, continued 
 with little change, and on the 20th September there were added puffiness of the face, 
 cedema of the feet and ankles, and some degree of drowsiness. At this tune cholera was 
 prevalent in Bombay, and this patient became affected for several days with vomiting 
 and watery purging, and considerable collapse, during which the dropsical symptoms 
 much decreased. They recurred on cessation of the purging; the dyspnoea continued; 
 he became delirious and drowsy, and died comatose on the 5th October. The cardiac 
 murmur was last heard on the 1st October. The urine was frequently tested ; at 
 first it was free and of low density ; latterly it was scanty ; it never showed any 
 trace of albumen. Leeches were on one or two occasions applied to the epigastrium, 
 and blisters to the precordial region. An attempt was made to induce the consti- 
 tutional effect of mercury, but it was necessary to desist, in consequence of the 
 irritable state of the bowels. The rest of the treatment consisted of diuretics, or 
 stimidants, or depressants, according to the indications. 
 
 Inspection nine hours after death. — Head. — The inner surface of the scalp was 
 slightly tinged yellow. The brain and the membranes were not congested with blood, 
 and were in every respect healthy. There was about one ounce and a half of serous 
 fluid at the base of the brain. Chest. — The lungs did not collapse very freely. In 
 places there were a few bands of recent adhesion between the costal and pulmonary 
 pleura?, and there was very little serous effusion in the sacs of the pleura. The 
 situation of the heart corresponded to the dull space noted on admission. The peri- 
 cardium contained about five ounces of serum, but there was no perceptible alteration 
 in the appearance of its serous surface. The heart was larger than natural; its 
 serous covering to a considerable extent, particularly over the right ventricle, presented 
 an opaque appearance, but nowhere were there traces of recent lymph; a considerable 
 quantity of dark coloured liquid blood flowed from the divided vessels of the right 
 side; the right ventricle was considerably dilated; the tricuspid and pulmonary 
 valves were healthy ; the left ventricle was dilated, and its walls, perhaps, of little 
 more than natural thickness, the mitral valve was converted into a thick ossific irre- 
 gular mass, and the aortic valves were somewhat thickened but not by earthy deposit. 
 The ascending aorta and the arch were narrower, and their coats somewhat more 
 attenuated than natural. The left auricle was considerably dilated, and yellow opaque 
 patches, somewhat raised above the surface, were seen on its serous covering. The 
 posterior part of the left lung was very much congested, and somewhat indurated, but 
 not distinctly hepatised. There were several red indurated nodules, the largest the 
 size of an egg, in different parts of the right lung, especially in the upper lobe. 
 Abdomen.— About a pint of dark-coloured serous fluid was found in the peritoneal 
 cavity. The liver was almost of natural size ; when incised, it presented a mottled 
 red and buff-coloured appearance, and was somewhat indurated. The kidneys were 
 healthy. 
 
 //, maris.— Tim case is of interest in many points of view. The heart-disease was 
 clearly related to an attack of acute rheumatism. On admission, a faulty diagnosis 
 was formed from the presence, but faintness, of the sounds of the heart, and the 
 absence of all murmur. The dulness of the precordial region, and the feeble pulse, 
 were attributed to pericardial effusion. Increased bulk of the heart and disease of 
 the valves were not suspected. Again, when increased impulse of the heart, with a 
 rough murmur at the nipple, obscuring both sounds of the heart, were noted, a fresh 
 accession of pericarditis, with lymph effusion, was suspected — for I was not then 
 aware of what this case and subsequent ones have since taught me, that a initial 
 murmur may obscure both sounds at the apex, but leave them distinct at the base, 
 
 Q Q 3 
 
598 ORGANIC DISEASE OF THE HEART. 
 
 There was aortic systolic murmur alone in one case ; also dia- 
 stolic murmur in one. Neither were fatal. 
 
 Aortic systolic and diastolic murmur was present in four cases, 
 and in all the result was fatal : in one the aortic valves were dis- 
 eased, and the mitral healthy ; in one the aortic valves were 
 much thickened, the mitral valve also, and in this, as already men- 
 tioned, a mitral systolic and a diastolic murmur were also present ; 
 in one there were warty-like deposits of lymph on the aortic 
 valves, with disease of the mitral valve, but no mitral murmur 
 had been recognised during life; in one the aortic valves were 
 thickened, and the orifice patulous, and there was very slight dis- 
 ease of the mitral valve. In three of these cases the pulse was 
 jerking ; in one it was small. 
 
 The sounds of the heart were confused, without distinct murmur, 
 in three cases, both fatal : in one there was hypertrophy and dilata- 
 tion of the left ventricle, with disease of the mitral and aortic 
 valves, — but the murmurs were not heard, on account of the dis- 
 turbed and laboured action of the heart. In the other there was 
 considerable dilatation of the cavities of both sides, and some 
 thickening of the aortic and mitral valves. 
 
 These statements support the opinions generally entertained 
 in regard to cardiac murmurs. They show the relation between 
 murmurs best heard at the base, and aortic valvular disease, 
 and that of murmurs best heard at the apex, and mitral valvular 
 disease. The fact that a mitral murmur obscuring both sounds 
 at the apex may co-exist with audible first and second sounds at 
 the base was first taught me by case 24-4. I am not acquainted 
 with any writer on the physical signs of heart-disease who states 
 this fact, with the exception of Dr. Walshe.* The case to which I 
 have just referred occurred to me some time before the publication 
 of this excellent work. The fact that a mitral murmur may co-exist 
 with audible first and second sounds at the base is not only of 
 diagnostic value, but seems to me to favour those views of the 
 sources of the sounds of the heart which do not attribute much of 
 the first sound to tension of the mitral valve. The sounds of the 
 heart being confused, and murmur being absent, though valvular 
 disease is present, is practically important as regards the diagnosis 
 of cases first submitted to observation in very advanced stages, 
 when the feebly acting heart is oppressed and transmits imperfectly 
 the blood through the orifices.f 
 
 * Walshe on the Diseases of the Lungs and Heart, pp. 223 — 226. 
 
 t Dr. Stokes, in his Treatise on Diseases of the Heart and Aorta, has some excel- 
 
TREATMENT. 599 
 
 Precordial thrill was observed in only two cases : one proved 
 fatal ; and there was hypertrophy and dilatation of the left ventricle 
 with aneurism, and mitral valvular disease. The other was not 
 fatal, and mitral valvular disease was believed to be present. 
 
 XI. Medical treatment, — Dilatation of the cavities, hypertrophy 
 of the muscular fibre of the heart, associated with structural change 
 of the valves, is an incurable form of disease. All that we can 
 attempt is to regulate the bodily and mental states in such manner 
 as shall maintain the actions of the heart as unembarrassed as 
 possible ; and to remove, by appropriate means, the secondary 
 dropsical and bronchitic affections when they occur. The only 
 practical points to which I shall advert are,— 1. The signal benefit 
 frequently derived, under failing action of the heart in valvular 
 disease, from preparations of iron, and the free assiduous use of 
 ammonia and other stimulants. I have witnessed several cases in 
 which imminent peril was averted, and life prolonged, by these 
 means. On the other hand, I have never met with a case of con- 
 firmed valvular disease in which digitalis or other sedatives were 
 not distinctly contra-indicated ; and I look upon the association 
 which used to exist in the minds of practical men between digitalis 
 and heart-disease as a very serious, and, I believe, now generally 
 admitted, error in therapeutics.* 2. A comparison of the 
 dropsical effusions from cardiac-disease, and those from Bright's dis- 
 ease, shows the greater scope for the exhibition of hydragogue 
 cathartics and diuretics in the former. The following case is a 
 good illustration of the efficacy of elaterium in this form of 
 disease : — 
 
 2i5. Aortic and mitral valvular disease. — Hypertrophy, with dilatation of the left 
 ventricle.— General dropsy.— Bapid relief from elatcriuui.— Discharged.— UooTbavuck 
 Seedee, an African sailor, of twenty-five years of age, and large frame, but reduced by 
 
 lent observations on an error of another kind — that of mistaking the murmur of old- 
 standing valvular disease for that depending on recent endocarditis. Tliis involves a 
 question of diagnosis, which should never be absent from the mind in the investigation 
 of cardiac disease. 
 
 * The contents of this chapter were presented very- much in their present form to 
 the Medical and Physical Society of Bombay in 1852, and published in the first num- 
 ber of the second series of the Society's "Transactions." Since then, Dr. Stokes's work on 
 the Diseases of the Heart has been published. The perusal of this admirable treatise 
 has not suggested to me the expediency of, in any respect, modifying this analysis of 
 my own clinical experience. In regard to the observation to which this note is re- 
 ferred—on the value of stimulants and the danger of depressants of the muscular fibre 
 of the heart— I woidd direct the attention of the clinical student to the valuable prac- 
 tical principle on which Dr. Stokes insists in various passages of his work— that the 
 important question in organic valvular disease is the quality of the action of the mus- 
 cular fibre, not the mere condition of the valves. 
 
 Q Q 4 
 
GOO ORGANIC DISEASE OF THE HEART. 
 
 sickness, was received, on the 3rd September, 1852, into the clinical ward. The face 
 was puffed, and the breathing was short, hurried, and oppressed. There was general 
 anasarca, a swollen and fluctuating abdomen, and shifting dulness on both sides of the 
 chest to above the lower limit of the subclavian regions. The pulse was of moderate 
 volume, of natural frequency, with a peculiar thrill. The precordial dulness could not 
 be distinguished from the general dulness. The impulse of the heart, though extended, 
 was very feeble, and the apex beat two inches directly below the left nipple. Both 
 sounds of the heart were obscured by murmurs ; one, blowing, best heard at the base 
 and in the line of the aorta ; the other, musical, best heard at the apex and to its left. 
 The only history he gave was, that""ten months before, while on the voyage from Muscat 
 to Aden, the dropsical symptoms came on and had persisted. He was treated for 
 three days with elaterium, which acted well, and rapidly reduced the dropsical effu- 
 sions. A diuretic of acetate of potass, spiritus setheris nitrici, and tincture of squills, 
 was then used. The urine increased to upwards of fifty ounces daily, and gave no 
 trace of albumen. The dropsy was altogether removed, and he was discharged on the 
 IStli September. The pulse had lost its thrilling feel, was of moderate volume, and 
 compressible. The breathing was easy. The precordial dulness extended from the 
 lower margin of the third costal cartilage to the seventh rib, and from the median line 
 to one vertical from the nipple. The two murmurs continued distinct, and possessed 
 the same characters as on admission. The hepatic dulness reached upwards to the 
 fifth rib, and interiorly to a line extended from the tenth right to the seventh left 
 rib. 
 
 He was re-admitted on the 16th November. The dropsical symptoms had returned, 
 but not to the same degree. The cardiac signs were unchanged, but the pulse was 
 feebler and again jerking, and bronchitic dry rhonchi were present. A similar course 
 of treatment was followed again, with removal of the dropsy, and he was discharged 
 on the 1st December. The pulse, however, had not resumed its former volume, and 
 continued jerking. The mitral murmur had lost its musical character and become 
 rough. 
 
 Remarks. — An African sailor, sailing along the coast of Arabia, becomes affected 
 with general dropsy and marked symptoms of hydrothorax. This case a few years 
 ago woidd have been called, in the language of Indian nosology, beriberi, and an air 
 of mystery have been thus thrown over one of the simplest events in pathology. 
 
 Section II. — In Europeans in India. 
 
 Disease of the heart and aorta is not uncommon in Europeans in 
 India. Many years ago Dr. E. H. Hunter*, in a series of interest- 
 ing reports, addressed to the Medical and Physical Society of Bom- 
 bay, directed the attention of the profession in India to the fre- 
 quency of cardiac-disease in Her Majesty's 2nd or Queen's Eoyal 
 Eegiinent, and suggested the probability that it was owing to 
 undue parading in the tight thick dress of the European soldier, 
 so unsuitable for the climate of India. At the period now referred 
 to, I enjoyed the privilege of frequent communication with 
 Dr. Hunter, and on many occasions had the opportunity of wit- 
 nessing his cases, and appreciating the accuracy and care with 
 
 * "Transact ions, Medical and Physical Society of Bombay," No. 1, p. 239; No. 2, 
 p. 222 ; No. 5, p. 47. 
 
IN EUROPEANS IN INDIA. G01 
 
 which he diagnosed cardiac and pulmonary disease, at a time when 
 the physical signs of these affections were not so well understood, 
 or so generally studied, as at present. 
 
 In the European General Hospital also many instances of cardiac 
 and aortic disease in sailors and others came under my observation. 
 Seven of the former and two of the latter have been elsewhere 
 detailed by me.* 
 
 The subject, however, requires further careful clinical and 
 statistical investigation, for the following reasons : — 
 
 1 . Dr. Grordon f is of opinion that disease of the heart bears 
 an inconsiderable ratio to the admissions of acute J rheumatism ; 
 but the exact ratio is not stated. He further thinks that the num- 
 ber of men invalided in consequence of disease of the heart in 
 India, is not a tithe so large as in the United Kingdom. No 
 precise data are given, but my own experience, as stated above, as 
 well as subsequently, convinces me that the disease is not very 
 unfrequent. 
 
 2. Facts for determining the ratio of heart-disease to acute rheu- 
 matism, and of invaliding from heart-disease in India, do not, I 
 believe, as yet exist — not only from a want of clinical infor- 
 mation on the disease itself, but also because cases are not 
 unfrequently returned " Carditis," in which the derangement of 
 the heart's action is merely functional. I make this latter state- 
 ment with much confidence ; not only of Europeans in the Indian 
 army, but in the British army also. In respect to the former, I 
 some years since satisfied myself by carefully examining the invalids 
 sent to Bombay with " disease of the heart ; " in several it did not 
 exist: in respect to the latter — in 1857, 1858, and 1859 — ■ when, 
 as superintending surgeon at Poona, I weekly visited all the 
 European hospitals at the station. 
 
 3. Palpitation, increased at night and by mental and physical 
 excitement, without cardiac pain, dulness, or murmur, generally in 
 pale young soldiers, is surely not unusual in hospitals in India, 
 and is not unfrequently erroneously returned " carditis." It may 
 often be traced to drinking or smoking in excess, to exposure to 
 the sun, and to the debilitating effects of elevated temperature and 
 frequent recurrences of fever or other forms of disease augmented 
 by medical treatment unduly depressing. It is also sometimes 
 
 * "Transactions, Medical and Physical Society of Bombay," No. 6. 
 f " Indian Annals of Medical Science," No. 11, p. 7. 
 
 j The word "acute" does not occur in the passage adverted to, hut it is evidently 
 implied by the context; in fact, the question entirely rests upon it. 
 
602 ORGANIC DISEASE OF THE HEART. 
 
 feigned. If these be the causes it necessarily follows, that the 
 affection will vary much in different regiments : I am acquainted 
 with some in which it was hardly known, and others in which it 
 was very common. 
 
 Dr. Gordon remarks*: "As far as my experience goes, there is, as 
 already stated, no want of care among medical officers in making 
 minute examination of the cases under their care." To this state- 
 ment a large part of my experience leads me cordially to assent ; 
 but there remains behind a portion which tells me that it is not 
 invariably applicable. 
 
 It is on these grounds that I conclude, that, cardiac disease 
 in Europeans in India has still to be clinically and statistically 
 investigated. 
 
 * " Indian Annals of Medical Science," No. 11, p. 10. 
 
603 
 
 CHAP. XXVI. 
 
 * 
 
 ON SUN-STROKE. 
 
 The influence of high atmospheric temperature in exciting or 
 modifying febrile and other forms of disease, has been elsewhere 
 explained in this work.f In the present chapter I propose to 
 describe effects of direct or indirect solar heat — more immediate, 
 often very urgent — which have less of the character of unmixed 
 fever, and evince earlier and greater disturbance of the brain, the 
 heart, and the lungs. 
 
 But as in inflammatory remittent, ardent continued fever, and 
 the type compounded of these, there is often disturbance of the 
 brain, heart, and lungs ; and, as in sun-stroke, there is the heat of 
 skin, the frequency of pulse and defective secrections, characteristic 
 of fever, — difficulty has been sometimes experienced in drawing the 
 line between fever and sun-stroke, and in keeping distinct the pa- 
 thology, etiology, and therapeutics of these two forms of disease. 
 In the first edition of this work sun-stroke was treated very briefly^:, 
 
 * Of the many names applied to this affection — insolation, coup de soleil, ictus 
 solis, heat apoplexy, heat asphyxia, sun fever, calenture, erethismus tropicus — I 
 have, after much consideration, selected the simplest, because it involves no patho- 
 logical theory, and expresses merely, what all admit, that the chief exciting cause 
 is great solar heat, direct or indirect, and that the attack is often sudden and 
 dangerous. 
 
 t Pages 8, 57, 61, 81, 162, 164, 363, 437, 642, 650. 
 
 { Not only very briefly, but I fear, also, very unintelligibly, if I may judge from 
 the manner in which my opinions have been misunderstood and misrepresented. 
 
 Mr. Scriven in a paper on "Sun Fever," in the 4th volume of the "Indian 
 Annals of Medical Science," at pages 502 and 503, notices my remarks on the effects 
 of elevated temperature, and misstates my opinions in the following instances: — 
 
 1. By combining statements in the 3rd chapter of the 1st volume on ardent 
 continued fever with others in the 19th chapter of the 2nd volume on sun-stroke, 
 he represents me to say, that, the blood is unduly heated in ardent fever, and that 
 undue heating produces no chemical change of the blood. Whereas there is no 
 allusion to a heated state of the blood in my chapter on ardent fever; and the manner 
 in which " materies " is used, in contrasting the causes of remittent fever, and of 
 ardent fever, must satisfy the most casual reader that a " materies " introduced from 
 
604 SUN-STROKE. 
 
 because, though occasional cases occurring in my hospital practice 
 had made me sufficiently familiar with the general clinical characters 
 
 without was referred to. The words are "iu the former (ardent fever*) there is no 
 'materies' in the blood, as iii the latter (remittent fever), exercising a sedative influence 
 on vital actions and requiring time for elimination " (vol. i. p. 264). The only 
 observation on undue heating of the blood, is in the following words at page 585 of 
 the 2nd volume. " From a review of all the attendant circumstances, it seems to me 
 not an unreasonable suggestion to offer that the temperature of the blood may become 
 much increased, and that to this altered condition of the blood the deranged actions 
 may in part be due." 
 
 2. Mr. Seriven writes: "Dr. Morehead I see still looks upon it (sun-stroke) as an 
 inflammatory disease, and recommends early bleeding, tartar emetic, &c, and this too, 
 under the head of diseases ' to the extreme degree ' of which ' the terms coup de 
 soleii, &c, have been given;' and amongst which he considers encephalitis and phrenitis 
 may be included. On the post-mortem appearances, however, of those extreme cases 
 in which the brain is found healthy, he does not touch, and, seems not to entertain 
 the idea of such patients dying from cerebral syncope." 
 
 Whereas (a) the word "inflammation" is not once used in my remarks on sun-stroke. 
 It was purposely avoided, because I do not consider the disease to be an inflammation. 
 (f>) The early bleeding and tartar emetic are recommended by me in ardent fever. 
 The only allusion made to them in connection with sun-stroke, is in the following 
 words. " In the commencement of the second degree" (that is the stage of eases 
 of sun-stroke iu which the pulse is frequent, full, and firm), " the same means are 
 still indicated." (c) Blood-letting &c, are not recommended by me in the extreme 
 degree of sun-stroke ; on the contrary, my words are " but in the advanced stages of 
 this degree (second), and in the third degree from its commencement when coma co- 
 exists with a rapid feeble pulse, blood-letting, and free purging, if had recourse to, 
 will necessarily expedite the fatal issue;" and again, " cold effusion frequently applied, 
 and the exhibition when practicable of ammoniated stimulants, from time to time, 
 are the means which hold out the fairest prospect of good." (d) The object of my 
 incidental allusion to encephalitis or phrenitis is to express my belief, that, if there is 
 such a disease as the phrenitis of Cullen in tropical climates, it is those occasional 
 cases of sun-stroke in which the delirium is violent. The logical inference from my 
 remarks is, not that sun-stroke is an inflammation but that the phrenitis of Cullen is 
 not an inflammation, (e) The term cerebral syncope is not used by me, because I 
 think it objectionable ; but if it be implied that the depression of the action of the 
 heart, and the tendency to death by syncope in extreme cases, are not recognised by 
 me, I can only remark, that in the description of symptoms and treatment much 
 prominence is given to them ; indeed, in the latter, it is twice emphasised by italics. 
 The words are, "as soon as the impairment of the cerebral functions sets in, the pulse 
 begins to fail in strength, and when coma is fairly established it becomes small and 
 rapid. In the most aggravated form, that in which there is coma at the outset, the 
 pulse is small and rapid from the beginning. It appears then that eo-existent with 
 tin- oppression of the brain, there is always a marked sedative influence operating on 
 the action of the heart." 
 
 To a medical writer, whose sole object ought to be to elicit truth, the free and 
 fair criticism of others must always be very acceptable. But when he finds his 
 opinions on important questions of pathology and treatment perverted by garbled 
 references and inaccurate statements, it is a duty which he owes to himself and to the 
 character of medical literature to enter his protest against the proceeding. 
 
 * This and other parenthetical passages in this note arc not in the original text, but 
 their introduction is necessary, to render the quotations intelligible when separated 
 from the context. 
 
PRELIMINARY REMARKS. 605 
 
 of the disease, still it seemed to me inexpedient to enlarge upon 
 my own limited experience, in a work professing to be chiefly 
 the record of personal research. The late contingencies of 
 public service in India have, however, enhanced the importance 
 of sun-stroke as a disease of our armies ; and my altered official 
 position on my return to that country has afforded me the oppor- 
 tunity of collecting information, and thus in a measure participating 
 in the experience of others. The following clinical history is 
 drawn from these and other sources*, as well as from my own pre- 
 vious practical knowledge of the disease. 
 
 * The papers before me, to which chief attention has been given, are : — - 
 
 1. A short sketch of the medical topography of the fortress of Bnkkur, and the 
 cantonment of Sukkur, &c, in 1839, by I. Don, M.D., staff surgeon. "Transactions, 
 Medical and Physical Society of Bombay," No. 3. 
 
 2. Some remarks upon the climate of Sukkur in Upper Scinde, during the months 
 of April, May, June, and July 1846, with an account of the fever prevailing there 
 during 'these months, by N. Hefferman, M.B., H.M's 60th Bines. " Transactions, 
 Medical and Physical Society," No. 10. 
 
 3. Manuscript notes, by Dr. Crawford, 18th Royal Irish, on coup de soleil, as 
 observed by him in H.M's 51st Eegt., in operations at Rangoon, in April 1852, 
 kindly lent for perusal. 
 
 4. Report of a board of medical officers, assembled by order of Major-General 
 Sir Hugh Rose, K.C.B., commanding Central India Field Force, dated 18th May, 
 1858, to investigate circumstances connected with the death of several men of H.M's. 
 71st Highlanders, before Koonch, on the 7th May, 1858, as well as other points re- 
 ferred to in a letter from the superintending siu-geon of the force No. 65 of 1858, 
 dated 8th May, 1858, to the chief of the Staff. President: Surgeon A. Stewart, 14th 
 Light Dragoons. Members: Surgeon W. Simpson, 7th Regt.; Assist. Surgeon O'Brien, 
 3rd Bombay European Regt. 
 
 5. Reports on coup de soleil in H.M's 71st Regt. (right wing) in Central India, 
 1858, by W. Simpson, M.D., Surgeon, H.M's. 71st Regt, 
 
 6. Cases of coup de soleil, in the 3rd European Regt., Central India Field Force, 
 by T. W. W. Ward, Esq. 
 
 7. Cases of coup de soleil, at Shikarpoor, by Assistant Surgeon, A. K. Simpson, M.D. 
 
 8. Cases of coup de soleil, in the 3rd troop H. A., by Assistant Surgeon J. H. 
 Wilmot, M.D. The last five papers are in the " Transactions, Medical and Physical 
 Society, Bombay," No. 4, new series. 
 
 9. Major-General Sir Hugh Rose's despatch on the operations attending the 
 capture of Calpee, dated Gwalior, 22nd June, 1858. 
 
 10. The summaries of twenty-seven cases fatal in Rajpootana and Central India kindly 
 shown to the author by C.White, Esq., Deputy Inspector-General of hospitals inBombay. 
 
 11. Manuscript report by Assistant Surgeon Lofthouse, 14th Light Dragoons, lent 
 for the author's perusal, by the Deputy Inspector- General. 
 
 12. Queries issued to medical officers of the Central India Field Force, by 
 Superintending Surgeon Arnott, with replies thereto from Assistant Surgeon Naylor, 
 Field Hospital, Jhansi ; Assistant Surgeon Lofthouse, 14th Light Dragoons; Surgeon 
 Ward, B. European Regiment ; Surgeon Ewing, 95th Regiment, and Assistant Surgeon 
 Sylvester, forwarded by Dr. Arnott, for the author's perusal. 
 
 13. Manuscript report of the "25111 Regiment, N.I. for the year 1858-9, while in 
 Central India, by Dr. W. Stuart, Surgeon of the Regiment. 
 
 14. Manuscript case of an engineer at Kotra, in Scinde, by Assistant Surgeon Niven. 
 
606 SUN-STROKE. 
 
 I shall class my remarks under the heads: — 1. Symptoms. 
 2. Pathology. 3. Etiology. 4. Treatment. 
 
 Symptoms. — When the various descriptions of sun-stroke are 
 carefully considered, a want of uniformity in the symptoms is 
 apparent ; and when the investigation is still further pursued, it is 
 evident that the discrepancy depends upon the circumstance that in 
 sun-stroke the tendency to death is by three different ways: (1) 
 by coma; (2) by syncope; (3) by coma and syncope combined. 
 I shall succeed best in rendering the symptoms intelligible by 
 describing those which, though not all present in every instance, 
 may be regarded as typical of these three varieties, and then re- 
 marking more particularly on the phenomena which have chiefly 
 attracted the attention of observers as characteristic of the disease. 
 
 With the view of rendering my own remarks more easily under- 
 stood, and of obviating the necessity of frequent circumlocution, 
 I shall designate the first variety — that in which there is death, or 
 tendency to death, by coma — the cerebrospinal ; the second — that 
 in which there is death, or tendency to death, by syncope — the 
 cardiac; and the third — in which there is death, or tendency to 
 death, by coma and syncope combined — the mixed. 
 
 1. The cerebrospinal variety. — In this the premonitory symp- 
 toms are headache, more or less severe, delirium, tendency to drowsi- 
 
 15. Private notes on this and allied subjects, from Deputy Inspector-General 
 W. M. Muir, M.D. 
 
 16. Remarks on the disease termed insolatio'or heat apoplexy, with observations 
 on its pathology by Marcus G. Hill, Officiating Assistant Garrison Surgeon, Calcutta. 
 "Indian Annals of Medical Science," vol. iii. p. 188. 
 
 17. On Sun Fever, by J. B. Seriven, Esq. "Indian Annals of Medical Science," 
 vol. iv. p. 496. 
 
 18. On erethismus tropicus, by J. R. Taylor, Esq., Deputy Inspector of Hospitals. 
 "Lancet," 21st and 28th August, 1858. 
 
 19. Coup de soleil in India, by R. H. A. Hunter, Esq., 1st Class Staff Surgeon. 
 "Medical Times and Gazette," December 18th, 1858. 
 
 20. On heat apoplexy, coup de soleil, or sun fever, by James Ranald Martin, Esq., 
 F.R.S. "Lancet," 1st, 8th, and 15th January, 1859. 
 
 21. Heat apoplexy, summary of a report of sixteen cases in H.M's. Regiment, 
 Barrackpore, by Thomas Longmore, Esq., Surgeon, 19th Regiment. "Lancet," March 
 26th, 1859. 
 
 22. On insolatio, sun-stroke, or coup de soleil, by W. Pirrie, M.D., Assistant Surgeon, 
 II.M.'s 71st Regiment. "Lancet," May 20, 1859. 
 
 23. Brief notice of a paper on coup de soleil by Dr. Poet, Professor of Medicine, 
 Grant Medical College. " Transactions, Medical and Physical Society of Bombay," 
 No. 4, new series, Appendix, p. xxix. 
 
 21. Manuscript report on sun-stroke, occurring in K Battery, Royal Artillery, 
 at Baroda, in May 1859. 
 
 Numbers 13 and 24 have since been published. "Transactions Medical and Physical 
 Society," No. 5, new series. 
 
SYMPTOMS. 607 
 
 ness, flushing of the face, increased vascularity of the conjunctiva, 
 and a dry hot skin. The pulse is accelerated, full, occasionally 
 jerking, but generally easily compressed ; there is much thirst, and 
 the urine is scanty and high coloured, with sometimes a frequent 
 desire to micturate. More or less of such symptoms as these may 
 continue for some hours, and then, -without further aggravation, 
 may be gradually removed by appropriate treatment, or, after vary- 
 ing periods, sometimes, indeed, so transie'nt as to escape notice, they 
 assume the following characters : — The drowsiness increases, the 
 pupils contract, convulsive twitching of the muscles is observed, 
 the respiration becomes somewhat hurried and oppressed, the action 
 of the heart is tumultuous, the pulse still frequent becomes 
 smaller and more compressible, and the heat of skin increases in 
 pungency. Now succeed coma and dilated pupils, sometimes pre- 
 ceded by convulsion ; the respiration becomes more oppressed and 
 slower, and often stertorous, the countenance swollen and livid, 
 the action of the heart still tumultuous, but feebler, and the pulse 
 rapidly sinks. Death may thus take place in from two to nine 
 hours from the commencement of the attack, and the skin continues 
 pungently hot to the close, and even for some time after death. 
 
 2. Cardiac variety. — Sometimes without premonitory warning, 
 generally consequent on direct exposure to the sun, the individual 
 falls down insensible, makes a few hurried gasping respirations, 
 and instantly expires.* This is death by syncope. Or a sense 
 of faintness and prostration is experienced, with vertigo, dimness 
 of vision, dilated pupils, drowsiness, from which the patient may 
 be roused by pinching, loud speaking, or sprinkling the face with 
 -water. There is constriction of the chest, with sighing respiration, 
 a sense of weight or sinking at the epigastrium, with nausea and 
 sometimes vomiting. The face and lips are pale, the skin is 
 generally cold and clammy, with exception of the head, which is 
 somewhat hot. The pulse is feeble, and generally slow 7 . In a 
 large proportion recovery will take place from these symptoms 
 under judicious management ; on the other hand the pulse may 
 sink, the respiration become more sighing and irregular, and death 
 result, sometimes preceded by convulsion. 
 
 3. The mixed variety. — The premonitory symptoms — of longer or 
 shorter duration — are headache, delirium, drowsiness, vertigo, pro- 
 stration with tendency to weep or to laugh on being questioned f ; 
 a sense of constriction of the chest, nausea, vomiting, palpitation, 
 the pulse frequent, soft, small, and compressible ; the countenance 
 
 * Dr. Pirrie. t Dr. Simpson. 
 
608 SUN-STROKE. 
 
 is pale, the skin sometimes hot, at others rather cold. Such symp- 
 toms may be gradually recovered from, or aggravation may take 
 place, characterised by convulsion, coma, oppressed breathing, 
 lividity of lips and nails, failing pulse, a skin sometimes hot but 
 moist, at others cold and clammy, with death, partly by coma, partly 
 by syncope. 
 
 Remarks on some of the principal symptoms. — Delirium is 
 sometimes present in the premonitory stage of the cerebrospinal 
 and mixed forms. It is occasionally though rarely violent, and 
 when so, is generally of short duration ; for, unless subdued, it 
 speedily terminates in convulsion and coma. 
 
 Convulsion is liable to occur in all the forms, preceding the 
 coma in the first and third, and occurring very shortly before 
 death in the second. 
 
 Coma. — The insensibility of syncope, which attends more or less 
 the cardiac variety, is pathologically distinct from the coma of the 
 other two. It ceases with the reviving action of the heart, and 
 does not return unless on a recurrence of the syncope. Eecovery 
 from incomplete coma, in the first and third forms, is not unfre- 
 quent ; but such cases require to be watched with great care, for 
 the tendency to relapse is great. The patient may have seemed 
 alert in the comparative coolness of the morning, but as the day 
 advances, the drowsiness may recur and pass into complete coma 
 sometimes preceded by convulsion. Dr. Simpson truly observes, — 
 " No patient can be considered out of danger till the skin becomes 
 cool and moist." Eecovery from complete coma would seem to be 
 occasional, but rare. Dr. Taylor expresses himself with more 
 confidence on this point than any other writer. In the cases 
 which he witnessed at (xhazeepore in 1843, recovery from deep 
 coma was rare ; but in his subsequent experience at Eangoon in 
 1852, he found that in cases of insensibility, sometimes lasting 
 from one to three hours, and in some instances attended with one 
 or more epileptic fits or convulsions, cold affusion in the shade was 
 successful — not one case terminated fatally. The difference he 
 attributed to the treatment. At Ghazeepore there was copious 
 abstraction of blood in all the cases; — at Eangoon blood-letting 
 was abstained from, and cold affusion used. 
 
 The pupils are generally contracted when the drowsiness of the 
 first and third forms is passing into coma, or when convulsion im- 
 pends ; but they become dilated when the coma is complete. 
 There is also some degree of dilatation with the insensibility of 
 the second form. 
 
SYMPTOMS. 609 
 
 The respiration in the cardiac and mixed varieties has the 
 irregular, gasping character of syncope, with a sense of constriction 
 of the chest. Coincident with the coma of the first and third forms, 
 the breathing becomes laboured and slow, and in cases in which 
 the access of coma is speedy, and complete, it is a striking symp- 
 tom from the outset of the attack. 
 
 The tumultuous action of the heart — greatest in degree in the 
 cerebro-spinal variety —is also present in the mixed, and is most 
 marked in the stage of coma ; but it is not then regarded merely 
 as a consequence of the impeded pulmonary function, but as due 
 to a more direct influence on the heart itself. This view is pro- 
 bably correct, because cardiac disturbance of this kind is not 
 unfrequently observed as a single derangement, after undue ex- 
 posure to solar heat : it very likely precedes in many cases the 
 attack of the cardiac form. 
 
 The pulse is frequently full, sometimes firm, at the commence- 
 ment of the first form, when the premonitory symptoms have been 
 of considerable duration ; but as the drowsiness advances it becomes 
 compressible, and sinks as the coma increases. In the third variety, 
 the pulse is wanting in volume and power from the very commence- 
 ment ; and in the second it is always small and often slow. 
 
 The peculiar, dry, pungent heat of skin is observed chiefly in the 
 coma and premonitory stage of the cerebro-spinal and mixed forms ; 
 and is always in greatest degree in sthenic Europeans recently 
 arrived from colder latitudes. 
 
 A cold clammy skin, usually, though I believe not invariably, 
 attends the syncope of the cardiac form : it is also noticed some- 
 times in the mixed form, and in this too the skin is occasionally 
 hot and moist. It is not improbable that in this latter form 
 the skin will be hot and dry in Europeans recently arrived, 
 as was the case in the 71st Regiment; but occasionally cold 
 and clammy in natives, and asthenic Europeans long resident, as 
 happened in the 14th Light Dragoons. Both these regiments 
 suffered in Central India in the same field: the first had been 
 only three months in India, having reached it by the overland 
 route ; the second had served about twenty years. 
 
 Colour of the skin. — During the premonitory stage of the first 
 variety, the face is flushed and the general surface redder than 
 natural, but when coma and oppressed breathing supervene, it 
 becomes swollen, more or less purplish and finally livid. In the 
 second variety, the face and general surface are pale. This is also 
 often the case at the commencement of the third form, but in 
 
 It R 
 
G10 SUN-STROKE. 
 
 this, towards the close, when coma and dyspnoea are established, the 
 lips and nails become purplish and livid. 
 
 Nausea and vomiting, preceded by giddiness and dimness of 
 vision, are most common in the cardiac and mixed forms, and are 
 related to the syncopal condition. 
 
 But as is well known, nausea and vomiting are also not unfre- 
 quently indications of cerebral disturbance. It is important to 
 remember that in occasional cases of the cerebro-spinal form, the 
 premonitory symptoms may be uneasiness of head, slight suffusion 
 of the eyes, listlessness and fretfulness of manner, with irritability 
 of .stomach so great as almost exclusively to engage the attention of 
 the observer. These are often perplexing. The vomiting is sympto- 
 matic of cerebral disturbance, and if it be rightly understood, and 
 the appropriate remedies used, the result will be satisfactory ; but 
 a grave error will be committed if the principal derangement is 
 overlooked, and the treatment directed to the secondary and sym- 
 pathetic disorder. 
 
 The bowels are not affected with any characteristic derangement ; 
 they are often natural, sometimes constipated, at others relaxed. 
 This last condition when present will in general, jorobably, be 
 found to have preceded the attack of the second variety. 
 
 The urine is high coloured and scanty, in association with the 
 increased heat and cerebral disturbance of the first and third forms. 
 A frequent desire to micturate is sometimes a premonitory symp- 
 tom, to which Mr. Longmore has specially called attention: in 
 referring to it he very justly observes, "If this symptom should 
 prove to be a general precursor of the attack it might be rendered 
 valuable as an indication of the approaching danger, which, by 
 early and proper care, might then probably be averted ; and its 
 presence at a time when heat apoplexy was prevalent would make 
 the surgeon alert to obviate the more serious symptoms which might 
 be expected to follow." 
 
 Convalescence. — In the milder attacks of the cardiac form, re- 
 covery, when no abiding state of debility is present, is often rapid. 
 During the operations of the Central India Field Force in May and 
 June 1858, it was not unusual for officers and men struck down to 
 be recovered by cold affusion on the field and to return to duty. 
 
 The premonitory symptoms of the other two varieties, when 
 {•light and brought under treatment at the commencement, may 
 lie recovered from by two or three days of careful management. 
 But when these symptoms have been greater in degree, or of 
 longer duration, or have partially merged into those of the more 
 
PATHOLOGY. 6 1 1 
 
 advanced stages, then recovery may be characterised by pros- 
 tration of strength, partial paralysis, blunted sensation, imperfect 
 respiration, and deranged secretions. 
 
 Pathology. — The post-mortem appearances in the cerebro-spinal 
 and mixed forms are varying degrees of congestion of the cerebral 
 vessels and of serous effusion in the sub- arachnoid space and ven- 
 tricles, varying degrees of engorgement of the lungs, of the right side 
 of the heart, and of the general venous system, with more or less 
 congestion of the abdominal viscera. The blood is always fluid. The 
 post-mortem appearances referable to the cardiac form have not 
 yet been carefully studied, but doubtless they are those which fol- 
 low death by syncope, from paralysis of the fibre of the heart, 
 when the cavities of both sides are filled with blood; or from spasm 
 of the heart, when the so-called concentric hypertrophy is found. 
 
 I concur with those who think that the phenomena of sun-stroke 
 are produced by depressed function more or less complete, and vary- 
 ing in degree, of the cerebro-spinal and sympathetic nervous systems. 
 Whilst as yet there are only head symptoms, the derangement is con- 
 fined to the cerebrum ; when the respiration becomes implicated, the 
 medulla oblongata has become involved. In those cases of sudden 
 death by syncope there is an influence, similar to concussion from 
 a blow or a copious cerebral haemorrhage, which not only destroys 
 consciousness and respiration, but at the same time paralyses the 
 fibre of the heart. In the slighter degrees of syncope it is not 
 improbable that the ganglia or periphery of the sympathetic system 
 are primarily affected; and it is further not unlikely that the 
 slighter degrees of deranged respiration may be caused in some 
 cases also through the same nervous channel by an influence un- 
 favourable to circulation exercised on the pulmonary capillaries, as 
 suggested by Dr. Wood*, or by an influence exercised on the 
 bronchial fibres, leading to some amount of spasm. 
 
 In the mixed form there is from the commencement depression 
 to some extent of the nervous influence which regulates the action 
 of the heart ; it is in this fact that resides the difference between it 
 and the first form. The nature of the proximate cause of this dis- 
 turbance of the nervous system will be considered in connection 
 with the etiology. 
 
 It has been conceived by several recent observers, that in a large 
 proportion of cases death is caused by asphyxia — apnoea — induced 
 by insufficiency of oxygen in the atmospheric air consequent on 
 rarefaction by heat. 
 
 * "Practice of Medicine," vol. ii. p. 108. 
 r r 2 
 
612 SUN-STROKE. 
 
 The principal fact adduced in favour of this opinion is the en- 
 gorged state of the lungs, the right side of the heart, and venous 
 system found after death. 
 
 The arguments against it, are: — 1. The fact, that when death 
 takes place speedily by coma, that is, when great depression of the 
 nervous influence of the medulla oblongata is coincident with or 
 follows closely upon that of the cerebrum, the post-mortem ap- 
 pearances are identical with those of death by asphyxia, viz. 
 eno-orgfed lungs, right side of heart, and venous system. The 
 reason is evident. Failure of the medulla oblongata as effectually 
 puts a stop to respiration as irrespirable air or mechanical occlusion 
 of the air passages ; but in correct pathological language this is not 
 death by asphyxia, but by coma*, and it is important that this 
 distinction should be carefully observed. 
 
 2. Atmospheric air is in a more rarefied state by elevation at 
 ordinary Hill Sanitaria than it ever is by the heat of the hofseason 
 in the plains, in any part of India.! Consequently, asphyxia from 
 insufficiency of oxygen resulting from rarefaction of the air by 
 heat is an untenable proposition. 
 
 * I am aware that there may be exceptional cases in which the medulla oblongata 
 suffers first, unpreceded by insensibilty, and that, strictly speaking, in these cases, 
 ■when fatal, death cannot be said to occur by coma ; yet such are few and practically 
 unimportant. It is well to regard the expression "death by coma" as synonymous 
 with death by failure of the nervous influence of the medulla oblongata in respiration. 
 
 f To make this assertion more evident, let me state the physical facts which bear 
 upon it, and then suggest certain probable inferences :— (a) Normal respiration in man 
 may be assumed to consist of sixteen respirations in the minute, with each of which 
 30 cubic inches of air are inhaled, which is equivalent to 400 cubic feet in twenty-four 
 hours, (i) 400 cubic feet of dry air at 32° F. contains 83 -2 cubic feet of oxygen. 
 (c) 400 cubic feet of air at 32° F. will, at 80° F., expand to 441'21 cubic feet; 
 and the proportion of oxygen in 400 cubic feet of this expanded air is 75-428 
 cubic feet, (d) 400 cubic feet of air at 32° F. will, at 100° F., expand to 459 cubic 
 feet ; and the proportion of oxygen in 400 cubic feet of this expanded air is 72-51 
 cubic feet. (<-) In latitudes of temperature 80 c F. at the sea level, there is at a height 
 of 5000 feet a decrease of temperature to 60° F. ; and 400 cubic feet of this air, ren- 
 dered less dense by elevation, contains 74-19 cubic feet of oxygen. At a height of 
 10,000 feet the temperature falls to 40° F., and the proportion of oxygen in 400 cubic 
 feel of this still more rarefied air decreases to 63294. 
 
 From those data it may be inferred : — 
 
 1. Thai as the temperature of the pulmonary air-cells in man is about 100° F., it 
 is improbable, whatever the external atmospheric temperature may be, that air with a 
 larger proportion of oxygen than 72-51 cubic feet in 400 cubic feet ever reaches the air- 
 cell- ; and therefore the conclusion is erroneous, that the air of a climate at 100° F., when 
 in the air-cells oxygenating the blood, contains a less proportion of oxygen than that 
 supplied by a climate at 32° F. 2. In tropical countries, at elevations of 5000 and 
 lo. iiiio feet, with atmospheric temperatures at 60° F. and 40° F.. and proportions of 
 oxygen (in 400 cubic feet) of 74*19 and 63*294 cubicfeet, there must, when the air raised 
 to 100° F. reaches the air-cells, be still more rarefaction, from heat, and consequently 
 
RATE OF MORTALITY. G13 
 
 3. Air so deficient in oxygen as to asphyxiate would operate 
 generally, not partially, on all the warm-blooded animals exposed 
 to its influence; and there could be no recovery from the asphyxia 
 without removal into a more respirable atmosphere. We have an 
 illustration of this in the blast of the simoom, affecting not a few 
 individuals but an entire kafila. 
 
 Rate of mortality. — On this point satisfactory data are wanting, 
 in consequence of the different system of classification, followed by 
 different observers. Some include under the term " sun-stroke" all 
 degrees of the immediate effects of solar heat, others merely the 
 severer forms. 
 
 The following are the results taken from the reports before me: — 
 
 
 Treated. 
 
 Deaths. 
 
 Mr. Hill's collected Cases 
 
 Dr. Taylor's, Ghazeepore ..... 
 Mr. Longmore, Barrackpore, (19th Regiment) 
 Mr. Lofthouse, (14th Lt. Dragoons) 
 Dr. Simpson (71st Regiment) .... 
 Mr. AVard (3rd Bombay European Regiment) 
 Mr. Ewing (95th Regiment) .... 
 Sir Hugh Rose and Dr. Stuart* (25th Regt. B.N.I.) 
 Field Hospital, Jhansi ..... 
 
 
 504 
 115 
 16 
 80 
 89 
 25 
 60 
 200 
 29 
 
 259 
 16 
 
 7 
 10 
 24 
 
 6 
 17 
 
 10 
 
 further decrease in the proportion of oxygen. Hence there is in the air in the air-cells 
 at heights a considerably less proportion of oxygen than in the air in the air-cells in 
 the plains. 3. But in tropical climates there is undoubtedly less oxygenation of the 
 blood, because there is less necessity for, and less generation of, animal heat. At 
 elevations of 10,000 feet the temperature is 40°, and man is found healthy and robust; 
 therefore there must be sufficient oxygenation of the blood — to generate animal heat — 
 to meet the demand of the low external temperature. By what means is respiration 
 so adjusted as to satisfy the different requirements of a tropical climate at the sea 
 level, and of an elevated locality ? certainly not by a different proportion of oxygen in 
 the air respired, for that at the elevation where more oxygenation is necessary con- 
 tains much less oxygen than that at the sea level in the tropics, where the degree of 
 oxygenation is diminished. The adjustment is effected by the varying amount of air 
 received into the lungs at each respiration, and by the varying number of inspirations 
 taken in the minute. In the warm climate at the sea level the respiratory function is 
 reduced by lessened expansion of the lungs. • In the elevated locality the respiratory 
 function is increased, to meet the diminished proportion of oxygen and the greater 
 demand for animal heat, by (a) augmented pulmonary exjmnsion, (b) increased 
 number of respirations : this obtains within certain limits. If there be no longer 
 capacity of air-cells, or increase of respiratory movements to compensate for the 
 diminished proportion of oxygen, then symptoms of asphyxia begin. 
 
 For the calculations on which this note is based, and for the suggestkm that the 
 air in the air-cells must always be at a temperature of about 100° F., whatever that 
 of the external air may be, I am indebted to the kindness of Dr. Forbes Watson. 
 
 * The number 200 is from Sir Hugh Rose's dispatch. Dr. Stuart, in his report, 
 says, " Sixteen cases only admitted into hospital, none fatal; but of course many in 
 the field, none of them fatal." 
 
 u r 3 
 
614 
 
 SUN-STROKE. 
 
 Etiology. — The documents before me supply the following 
 facts in reference to season, age, period of service in India, and 
 duration of attack. The months of prevalence have been almost 
 exclusively April, May, and June, but chiefly May and the first 
 half of June. 
 
 In respect to age, my only data are derived from twenty-seven 
 fatal cases of the Eajpootana and Central India Field Forces, and 
 ten of the K Battery of Eoyal Artillery fatal at Baroda. 
 
 Age. 
 
 Rajpootana, 
 
 and Central 
 
 India Field 
 
 Forces. 
 
 K Battery. 
 
 19 years and under 
 
 20 to 25 
 26 to 30 
 
 31 to 35 
 36 to 40 
 
 12 
 8 
 4 
 2 
 
 2 
 2 
 6 
 
 Total 
 
 26 
 
 10 
 
 The period of service in India of twenty-seven fatal cases was, 
 in ten, six months and under ; in twelve, seven to nine months ; in 
 four, four to sixteen years, and in one it was not noted. 
 
 The 71st Eegiment arrived in India at the end of February 
 1858, and had eighty-nine men attacked with sun-stroke, be- 
 tween the 5th May and 15th August, The K Battery had also 
 been only six months in India, when it suffered at Baroda. These 
 corps then illustrate the relation of sun-stroke to recent arrival 
 from colder latitudes. 
 
 Death occurred at varying periods from the commencement of 
 the attack, thus: — 
 
 
 Rajpootana 
 
 und Central 
 
 India Field 
 
 Forces. 
 
 Day of admission . 
 Following day 
 Upwards of live days 
 Not Noted . • . 
 
 19 
 4 
 3 
 1 
 
 27 
 
 
 K Battery. 
 
 1 to 3 hours .... 
 4 to 6 „ 
 7 to 12 „ 
 13 to 24 „ 
 
 2 
 
 1 
 
 6 
 1 
 
 10 
 
CAUSES — TKEDISrOSING AND EXCITING. (515 
 
 Sun-stroke is not confined to Europeans. In Dr. Don's report on 
 the Medical Topography of Sukkur, there is an interesting account 
 of the sufferings of an escort of Bengal and Bombay Native Infantry, 
 when marching in the latter half of May 1839 from Sukkur to 
 Dadur. The 25th Eegiment Bombay Native Infantry, during the 
 campaign in Central India, in 1858, was, as already stated, tem- 
 porarily crippled by sun-stroke; and I have it from the best authority, 
 that the appearance presented by the corpses of many of the rebel 
 troops opposed to the Central India Field Force showed that death 
 had resulted from sun-stroke and not from wounds. The meteoro- 
 logical observations made during the seasons of prevalence of sun- 
 stroke are very meagre, but the temperature would seem to have 
 ranged from 96° to 120° in the shade. This high atmospheric heat, 
 chiefly observed on the Coromandel coast, Central India, the north- 
 west provinces, Scinde, and the Punjab, may be received as the 
 chief exciting cause. 
 
 But predisposing causes are also very influential. There is a very 
 general concurrence of opinion that the sthenic constitution of the 
 recently arrived European predisposes to the cerebro-spinal form 
 of the disease, and this predisposition may be greatly increased by 
 the intemperate use of alcoholic drinks. Then, as predisposing 
 conditions of the cardiac and mixed forms may be named the asthenic 
 constitution of the natives of India, and of long resident Europeans, 
 increased by fatigue and other exhausting causes, also, a diathesis 
 cachectic from malaria, scurvy, or from degeneration of the fibre 
 of the heart or secreting structure of the liver or kidney. 
 
 The * high atmospheric heat probably excites the cerebro-spinal 
 form of sun-stroke by increasing the temperature of the blood some 
 degrees above its normal standard ; and it produces this effect, not 
 so much by direct conduction to the body, as by impaired evapora- 
 tion from the cutaneous surface, leading to an undue accumulation 
 of animal heat in the following ways : — 
 
 1. A still or moist atmosphere of 94° F. and upwards. Dr. Taylor 
 remarks of sun-stroke at Grhazeepore : — " This epidemic was 
 undoubtedly the direct morbid effect of the high temperature 
 of the season. Instead of the regular hot winds from the N.W. 
 the wind during the month of May had been constantly N.E. 
 and the tatties were consequently of little service. The ther- 
 
 * In restricting my observations to the temperature, moisture, and movement of 
 the atmosphere, I by no means wish to express a belief that there may not be other 
 states, electrical, &c, also influential ; but on these questions it is idle to speculate. 
 Observation, not speculation, is the desideratum. 
 
1 G SUN-STROKE. 
 
 mometer at the end of May averaged 105° in the shade, and 
 from the unfavourable direction of the wind for working the tatties, 
 the heat in the barracks could be but little diminished. On the 
 1st of June the wind was still N.E. and light with the thermometer 
 at 104°. The sensation of heat was intense. On the morning of 
 the 2nd, the day of the outbreak of the epidemic, the wind came 
 round to the N.W. and was strong and scorching. The thermo- 
 meter in a covered passage facing N.E. showed a temperature of 
 108° at two P.M." 
 
 Mr. Naylor observes of the Field Hospital at Jhansi, — in which, 
 during six weeks, the thermometer ranged at noon from 110° to 
 120°, — "but it was observable that it was not in the hottest days 
 that the affection showed itself, the most favourable periods of its 
 occurrence being rather those cloudy days, accompanied with a 
 moist condition of the atmosphere, when even the water in the 
 cooja could not be rendered cool." It is to the stillness and 
 moisture of the heated air, favoured by some degree of vitiation, 
 that are due the attacks in barracks and hospitals. Dr. Taylor 
 alludes to the injurious influence of the crowding of masses of 
 infantry, during the march and on parade, compared to what ob- 
 tains in artillery and cavalry; and Dr. Lofthouse attributes the 
 greater immunity from sun-stroke of the cavalry of the Central 
 India Field Force to the less exhaustion of men on horseback, and 
 to the air currents caused by the rapidity of their movements. 
 
 2. The refrigerating effect of evaporation must be lessened when 
 the due proportion of water in the blood is not kept up by a suf- 
 ficient and regular supply of drinking water. The importance of 
 this consideration is universally admitted. It is stated by Dr. Don 
 that the much greater exemption from mortality in the Bombay 
 than in the Bengal Regiment of the Sukkur escort was attributed 
 by the commanding officer to the men of the former " being sup- 
 plied, as is the custom in the Bombay army, with canteens of 
 water, with which they refreshed themselves on the march, as well 
 as at all times on duty, when water could not otherwise have been 
 readily procured." 
 
 3. If the opinion of physiologists relative to the influence of the 
 vaso-motor nerves on the size of the capillaries, and consequently on 
 the quantity and movement of the blood in them, be correct, then 
 it is very likely that a sequence of the action of direct solar heat 
 on the cutaneous surface may be such diminished secretion by the 
 sudoriferous glands as shall materially lessen refrigeration by 
 evaporation. 
 
CAUSES— PREDISPOSING AND EXCITING. 617 
 
 Tu these three wayS — the first having reference to still moist 
 hot air, the two last equally to hot dry air — the temperature of 
 the blood may become increased by accumulation of animal heat 
 from defective cutaneous evaporation.* On this point Dr. Simpson 
 makes the following valuable practical remark : — " Every man 
 seized with sun-stroke, and who could answer questions, informed 
 me that he had not perspired for a greater or less extent of time, 
 sometimes not for days, previous to being attacked, and that he 
 had enjoyed good health as long as he perspired, but that on the 
 perspiration being checked he felt dull and listless, and unable to 
 take much exertion without making a great effort." 
 
 But there is still another circumstance which favours the increase 
 of heat in the subjects of sun-stroke. 
 
 We have already seen that recent arrival from colder latitudes 
 predisposes to the cerebrospinal form. Dr. Crawford, in his " Notes 
 on Coup de Soleil in the 51st Eegiment at Eangoon," says, that 
 obesity was present in all the fatal cases. Dr. Taylor remarks: 
 " The subjects of the disease were with few exceptions large- 
 chested, muscular, and fat men." These conditions of the system 
 favour undue generation and retention of animal heat. 
 
 It is not, however, only by increasing the heat of the blood, in 
 the manner explained, to a degree incompatible with the mainte- 
 nance of the functions of the nervous system, that elevated tem- 
 perature acts as the exciting cause of sun-stroke. In the cardiac 
 form, we must look for another explanation ; because in these 
 speedily fatal attacks, the sudden violence of the onset, and in the 
 milder attacks, the cold and clammy skin, are inconsistent with the 
 idea of a gradual heating of the blood as the proximate cause. The 
 action must therefore be direct either on the nervous centre near 
 to the origin of the vagus nerve, or on the general periphery of the 
 cutaneous nerves, as supposed by Dr. Alison. His f words are : 
 " The effect of very intense heat applied to a pretty large surface 
 of the body, as in an extensive burn, or to the whole body, as in 
 the case of a coup de soleil, is also quite similar to that of con- 
 cussion." 
 
 To recapitulate. 1. The cerebro-spinal form, commencing with 
 cerebral symptoms, without much depression of the pulse in the 
 first instance, characterised by pungent heat of skin, and proving 
 
 * When evaporation is deficient, and the external air above 100, then there will be 
 increased heat of the body, not only from accumulation of animal heat, but also by 
 conduction from the air. 
 
 f "Outlines of Pathology and Practice of Medicine," p. 13. 
 
G18 SUN-STllOKE. 
 
 fatal by coma, is due to increased heat of the "blood disturbing 
 and depressing the functions of the cerebro-spinal nervous system. 
 2. The cardiac form, with small or imperceptible pulse, cold aud 
 clammy skin — often suddenly coming on and proving speedily 
 fatal — is due to a direct depressing influence, probably on the entire 
 nervous system, irrespective of the condition of the blood. 3. In 
 the mixed form there are varying proportions of both conditions, 
 viz. — overheated blood and direct influence on the nervous system. 
 
 It is at present a favourite doctrine with many pathologists that 
 sun-stroke is in part due to a supposed venous condition of the 
 arterial blood. I am not acquainted with any facts or any sound 
 arguments which go to justify this hypothesis. The explanation of 
 asphyxia given by Kay, and universally assented to by physiolo- 
 gists for the last thirty years, is, that death takes place in conse- 
 quence of the stagnation of blood in the pulmonary capillaries, 
 leading to general congestion of the vascular system behind, and 
 permitting but a scanty stream of blood to pass to the left side of 
 the heart. Little, if any, of the deranged phenomena can be 
 reasonably attributed to the poisonous influence of the small quan- 
 tity of venous blood which for a minute or two before death passes 
 to the left ventricle, and thence through the systemic arteries.* 
 
 Again, it follows from Kay's experiments, that venous blood will 
 not circulate through the pulmonary capillaries, and that therefore 
 the supposed continued circulation of venous blood poisoning the 
 tissues generally is inconsistent with ascertained facts. 
 
 The idea of the assumed pathological import of venous blood 
 would seem to have originated — 1. In forgetfulness that Bichat's 
 opinion that venous blood is poisonous has been long since dis- 
 proved ; and that the phenomena of asphyxia are little, if at all, 
 dependent on the circumstance of the blood in the arteries being 
 
 * It is very remarkable that though there is a universal assent to Kay's theory, 
 and a general dissent from the doctrines of Bichat that the venous blood is poison- 
 ous ; still, this latter erroneous view is freely applied by pathologists at the present 
 day. I would instance Dr. Watson's fifth lecture, in which, speaking of Dr. Kay, he 
 says, " His experiments tend moreover to prove, that venous blood, circulating through 
 the arteries has no direct poisonous operation " (p. 69, vol. i.). But further on, at p. 73, 
 drawing the distinction between death by syncope and apncea, he attaches an im- 
 portance to the venous character of the blood which reaches the left side of the heart, 
 more consistent with the theory of Bichat than that of Kay. If in asphyxia the blood 
 stagnates at the lungs, at first incompletely and shortly afterwards completely, we have 
 in the general congestion from venous obstruction, and in the insufficient quantity of 
 blood in the arteries in the first instance, and shortly afterwards its absence altogether, 
 an adequate explanation of the phenomena without attributing anything to the venous 
 (condition of the slender and transient stream which for a few minutes may circu- 
 late through the arterial system. 
 
PREVENTION AND TREATMENT. 019 
 
 venous. 2. In the erroneous inference that persisting diminished 
 respiration, either from elevated temperature, or slight vitiation of 
 the atmospheric air, from small quantities of carbonic acid, as in 
 cities, crowded rooms, &c. leads to a venous condition of the blood 
 in the arteries : there is no evidence of this in an altered colour of 
 any part of the surface of the body. The effect of the diminished 
 respiration is altogether different. The appetite for food, digestion, 
 assimilation, and the quantity of blood, are brought into harmony 
 with the diminished respiration, and there results not venous blood 
 and purple lips, but anasmia more or less, as shown in the pallid 
 countenance of the tropical resident and of the dweller in the 
 impure air of crowded cities. 
 
 The passage of venous blood from the venous into the arterial sys- 
 tem takes place only when its complete aeration has become impos- 
 sible, either from an insufficiency of oxygen or defect of the lung, or 
 of nervous influence ; and the immediate sequence of this is the com- 
 mencement of stagnation in the pulmonary circulation. There is 
 no fact, so far as I am aware, which can justify the assumption that 
 venous blood can continue to circulate in the arterial system, and 
 in consequence of its venous character excite derangement. A 
 venous condition of the blood in the arteries must, it seems to me, 
 be always consecutive on defective aeration, be preceded by pul- 
 monary stagnation, attended by the symptoms of apnoea, and, 
 if not speedily removed, followed by death. 
 
 The opinion that malaria is an exciting cause of sun-stroke 
 appears to rest on no sufficient grounds. The occurrence of death 
 by coma in a proportion of the severer forms of remittent fever is 
 no reason for concluding that sun-stroke is caused by malaria, the 
 more especially as this latter disease prevails most at seasons which 
 hitherto have not been regarded as those in which malaria is 
 chiefly generated. 
 
 Prevention and Treatment. — The prevention of sun-stroke by 
 avoiding as far as practicable the predisposing and exciting causes, 
 is of essential importance. 
 
 The following influences must be carefully guarded against : — 
 (a) Needless exposure to the sun. (b) Exhaustion from fatiguing 
 duties, defective commissariat arrangements, and other causes, 
 (c) Intemperance from the excessive use of alcoholic drinks. 
 
 A full and well-regulated supply of good drinking water, under 
 all the circumstances of military service in the hot season, is an 
 essential measure for the prevention of sun-stroke. It ministers 
 to the cooling effect of evaporation from the cutaneous surface, and 
 
G20 SUN-STROKE. 
 
 materially assists in warding off that state of exhaustion which 
 leads to syncope. 
 
 Protection of the body from direct, reflected or radiated solar 
 heat by suitable clothing, is a subject to which of late much 
 attention has been justly given.* The object in view is to devise 
 the best practicable means of obstructing the transmission of 
 external heat to the body without interfering with free cuta- 
 neous evaporation. The non-conducting head-dress with ventilat- 
 ing arrangements, and the loose tunics of suitable light wadded 
 material, are constructed on this principle. If the pathological 
 views which attribute much to the implication of the medulla 
 oblongata be correct, the importance of a neck-piece to the 
 head-dress, already established by ample experience, is very intel- 
 ligible ; and a similar observation may be made relative to the 
 spinal cord, the solar plexus and the general nervous periphery, 
 and the necessity of providing for their protection by suitable 
 clothing. The great importance of space, of the interception of 
 external heat, of ventilation, and of means, as wet tatties and pun- 
 kahs, of reducing the temperature, and of agitating and maintain- 
 ing pure the atmosphere in tents, barracks, and hospitals cannot be 
 too strongly insisted upon ; while the injurious effect of crowding 
 men in masses during the march and on parade should receive 
 its just measure of attention.f 
 
 In the medical treatment of sun-stroke there is now great 
 unanimity of opinion ; and the conclusions so generally admitted 
 are in accordance with the views entertained of the pathology and 
 etiology of the disease. General blood-letting has few supporters. 
 
 * I would refer the reader to the following sources among others of much useful 
 information on this and other subjects, relating to the health of the soldier in 
 India : — " The British Army in India," by Julius Jeffreys ; " The British Soldier in 
 India," by Dr. F. Mouat ; " Reports on Coup de Soleil," by a Board of Medical Officers, 
 and by Dr. Simpson ; " Transactions, Medical and Physical Society of Bombay," No. 4. 
 New Series. 
 
 f It may happen that troops are so circumstanced, that a slight change of air may 
 exercise a very beneficial effect. The following is an illustration : — 
 
 In May 1859, K Battery, Royal Artillery, and two companies of the 4th Regiment 
 were stationed at Baroda, in Guzerat. The atmosphere was still, and the ther- 
 mometer rose to 110° in the shade. Both corps were housed in equally good barracks, 
 with punkahs day and night. The stable duties of the battery entailed however 
 greater exposure, and the canteen reports showed a large daily consumption of arrack, 
 which increased after sickness commenced on the 27th May ; between which day and 
 the 2nd June ten men died of sun-stroke, and there was amongst the men a general 
 dread of the disease. The mm weir now moved out in tents to Dubka. on the banks 
 of the Myhee, fourteen miles from Baroda, and within the influence of the sea breeze, 
 and with space fur recreation and amusement. No more deaths occurred. The 
 health of the men improved, and they returned to Baroda with fewer sick than they 
 
TKEYENTION AND TREATMENT. G21 
 
 Though it may be admitted that an occasional case occurs in 
 which cautious venesection might be useful, yet the evidence of 
 the great injury usually resulting from it is so conclusive that 
 there should be no hesitation in altogether interdicting this pro- 
 ceeding in the treatment of sun-stroke. The cause of the ill 
 success of blood-letting is not difficult to understand. The proof, 
 occurring more or less early, but certainly at some period or 
 other in all attacks, of a sedative influence on the heart, distinctly 
 contra-indicates its use. The affusion of cold water over the head, 
 neck, and chest has been proved to be the most efficacious means of 
 treatment; and as its power is greater the earlier it is resorted 
 to, well arranged methods of applying it should be always 
 ready at hand. It acts in two ways. 1. By reducing the heat of 
 the body. 2. By stimulating the nervous system through the 
 impression made on the periphery of the cutaneous nerves. The 
 first is the mode of action which is probably most beneficial in the 
 cerebro-spinal form ; the second in the cardiac form. 
 
 The extent and continuance of the affusion must be regulated by 
 the temperature of the surface of the body and the state of the 
 pulse. While the skin is hot and dry, and the pulse of good 
 volume, water may be freely poured over the head, neck, spine, and 
 chest, and frequently repeated ; but when the cold, clammy skin, the 
 sighing respiration, and the small pulse, indicative of syncope, 
 are present, the water should be merely dashed, or sprinkled from 
 time to time, on the face and chest. It should never be forgotten 
 that after the temperature of the body has been reduced, and the 
 skin become accustomed to the impression, the affusion of cold water 
 soon begins to exercise a sedative influence on the heart. In using 
 this remedy, therefore, the distinction between the cerebro-spinal 
 and the cardiac form of the disease should be borne in mind, and 
 the state of the pulse and skin should be carefully watched and 
 noted. 
 
 These cautions are very necessary, for if they be disregarded, 
 and a routine system be adopted, it may be safely predicted that 
 cold affusion in sun-stroke will share the fate of all powerful 
 remedies used without discrimination and judgment, and soon cease 
 to maintain the high place to which it is justly entitled in the treat- 
 ment of this disease. 
 
 had had for some time. There was only one death from sun-stroke in the detachment 
 of the 4th Regiment, and little sickness of any kind. 
 
 The improvement in the men of the battery was doubtless due to greater tem- 
 perance, relief from stable duties, the cooler locality, and mental interest and occupation. 
 
622 SUN-STROKE. 
 
 When the patient is able to swallow, stimulants and nourishment 
 should be given, with a frequency and in quantities according to 
 the state of the pulse.* 
 
 It is, moreover, of great importance in the treatment of sun- 
 stroke to supply the patient freely with good drinking water. Dr. 
 Crawford, of the 18th Eoyal Irish, in the notes of his experience 
 in Eangoon, attaches more weight to this indication than any 
 other writer with whose works I am acquainted. If the view 
 taken of a deficient supply of good water, as a predisposing 
 cause, be correct, the necessity of diluents in the treatment is 
 self-evident. 
 
 When the tendency to death by coma or syncope has been over- 
 come, and febrile reaction and some degree of local congestion 
 remain, the treatment should be conducted on ordinary prin- 
 ciples. Moderate local blood-letting, mercurial and other purga- 
 tives, and diuretics, may be used with milch advantage. But in 
 applying this principle of treatment it should be remembered that 
 the patient has lately passed from a state of which a sedative 
 influence on the heart was a constituent, and that this condition 
 may easily be reproduced by injudicious evacuation and the neglect 
 of appropriate nourishment. 
 
 Concluding Remarks. — This important subject has been very 
 inadequately explained by me, but this, in fact, is unavoidable, and 
 only to be remedied by further careful clinical observation and 
 description. The following are the points on which information is 
 chiefly to be desired : — 
 
 1. A more careful and precise observation of the symptoms with 
 reference to the different tendency to deatli in different cases. 
 
 2. Carefully conducted post-mortem examinations with the view 
 of determining whether the division into- cases fatal by coma and 
 by syncope is correct. 
 
 3. Meteorological observations on the temperature, moisture, 
 pressure, movement, and electrical states of the atmosphere. 
 
 * In an anonymous letter, dated May 1859, published in the "Lancet," and also in 
 a private letter from a friend whose judgment I respect, it has been suggested that 
 Marshall Hall's ready method might be of use in the treatment of sun-stroke. The 
 idea rests on the belief that death takes place by asphyxia, from defect of the aerating 
 medium. I have already expressed my dissent from this pathology, but nevertheless 
 I think the suggestion ought not to be lost sight of. for, as in some cases of narcotic 
 poisoning, the influence on the medulla oblongata may be so transient in an occa- 
 sional case of sun-stroke, as not to preclude the idea of advantage from artificially 
 assisting respiration. But, irrespective of this, the change from dorsal decubitus, 
 involved in the acts of the " ready method," is likely to retard the pulmonary con- 
 gestion, and thus postpone deatli. 
 
PRETENTION AND TREATMENT. 623 
 
 4. Precise facts, bearing on the state of predisposition, having 
 reference to exposure, clothing, diathesis, habits, exhausting con- 
 ditions, supply of water, accommodation, age, residence in India, 
 and previous disease. 
 
 5. Precise clinical notes on the condition of the patient 
 before the use of remedies, and on the effects produced by the 
 remedies. 
 
624 DELIRIUM TREMENS. 
 
 CHAP. XXVII. 
 
 ON DELIRIUM TREMENS. 
 
 Section I. — On the Symptoms and Treatment of Delirium 
 Tremens in the European General Hospital at Bombay. 
 
 As my clinical knowledge of this important disease has been chiefly 
 acquired in the European General Hospital at Bombay, I shall 
 confine my present observations, in a great measure, to my experi- 
 ence in that institution. 
 
 During the five years, from July 1838 to June 1843, 237 
 patients were under treatment for delirium tremens, being 3-1 per 
 cent, of the total hospital admissions. Forty-one cases terminated 
 fatally, being 17*8 per cent, of the admissions from delirium tremens, 
 and 7 "5 per cent, of the aggregate deaths in the hospital. 
 
 Though 17-8 per cent, was the average annual rate of mortality 
 for the five years, it varied considerably in different years, and very 
 strikingly in different months. In the years 1839 and 1841, the 
 deaths were above 20 per cent, of the admissions, whereas in the 
 year 1842 they were only 7. Throughout the five years, there 
 was not a single fatal case of delirium tremens recorded in the 
 months of January and February, though the admissions from the 
 disease were respectively 3-2 and 5-3 per cent, of the total hospital 
 admissions ; whereas in the months of May and October the rate of 
 mortality from delirium tremens was above 40 per cent,, though 
 the admissions were not above 4'7 and 1*2 per cent, of the aggre- 
 gate hospital admissions. In the month of May the admissions 
 were also numerically considerably above those of any other month 
 of the year. 
 
 The data from which these statements have been made, will be 
 found, with additional statistical details of a similar character, in 
 the tallies which are annexed to this chapter.* 
 
 * When we compare the statistical fads of these live years with those of the ten 
 which succeed, it is found that in the hitter there were 453 admissions of delirium 
 
SYMPTOMS AN]) TREATMENT. 625 
 
 Persons admitted into tlie General Hospital, affected with delirium 
 tremens, have belonged generally to one of the following classes : — 
 1. Engineers and boilermakers connected with the Steam Flotilla, 
 or works in the dockyard — men not long resident in India, and 
 whose ages may range from twenty to thirty-five. 2. Non-com- 
 missioned officers and soldiers attached to the different branches 
 of the military department at the presidency — men of various 
 periods of service in India. 3. Seamen belonging to the public 
 service or to merchant ships, who have been on shore on liberty, 
 and have for a succession of days been dissipating in the bazaar : 
 or seamen and others out of employment who have been lodging 
 in taverns. 
 
 From the class of seamen, however, the admissions have been 
 considerably the most numerous. 
 
 Symptoms and Treatment. — The division of delirium tremens 
 into two species, which has been made by some writers *, is clini- 
 cally correct. The first in general immediately succeeds the 
 excitement of hard drinking without an intermediate period of 
 abstinence from the accustomed stimulus, and is characterised by a 
 flushed countenance, full pulse, slight tremors, a tongue coated in 
 the centre and frequently florid at the tip, with, generally but not 
 invariably, more or less irritability of stomach. In the second 
 the symptoms come on in the habitually dissipated, after the 
 
 tremens into the European General Hospital, equivalent to 3"7 per cent, of the total 
 hospital admissions. Of these thirty-eight died, being a mortality-rate from this 
 disease of 8 - 4 per cent. Though 8 "4 per cent, was the average mortality for the ten 
 years, it has varied considerably in different years, and very strikingly in different 
 months. In the year 1848 the deaths were 20 - 4 per cent, of the admissions, whereas, 
 in the year 1853, they were only 22. Throughout the ten years there is only one 
 death from delirium tremens in the months of January and February, though the ad- 
 missions were respectively 2 - 5 and 2-4 per cent, of the total admissions. The month 
 of greatest mortality has been October, viz., 26-6 per cent., when the admissions per 
 cent, of the total hospital admissions were not more than 3 - 7. Though the great 
 mortality of the month of May does not appear to the same extent in these ten years 
 as in the five which preceded, yet the aggravation in the hot months (April and May) 
 is sufficiently apparent. 
 
 The striking difference between these statements and those in the text is the much 
 lower rate of mortality from 1844 to 1853 than from 1838 to 1843. Particidar 
 reference will be made to this in the sequel. The tabular returns for these ten years 
 are also annexed to this chapter. On this subject I would further refer to Dr. Stovell's 
 " Decennial Eeport of the European General Hospital," published subsequently to the 
 1st edition of this work, in No. 3, new series, "Transactions, Medical and Physical 
 Society of Bombay." 
 
 * ■• Copland's Dictionary- of Practical Medicine, and British and Foreign Medical 
 Review," vol. ix. p. 47-3. 
 
 S S 
 
626 
 
 DELIRIUM TREMENS. 
 
 accustomed stimulus has, from some cause or other, been for a 
 time withheld.* 
 
 * As my remarks on deUrvum tremens have reference to a particular series of cases, 
 and were written at a time (1843) when the diaries were before me, and the clinical im- 
 pressions fresh on my mind, I am unwilling to alter the statements made in the text, 
 though I believe that a fuller explanation respecting the division into species is neces- 
 sary to prevent misapprehension. The first species probably includes cases that now 
 woidd be classed as " ebrietas." The definition of the second species leaves it to be im- 
 plied that it comes on in the habitually dissipated, only after the accustomed stimulus 
 has been withdrawn : but this is an error, and not consistent with the toxsemic theory 
 of the pathology. In the "British and Foreign Medico-Chirurgical Beview" for 
 October 1859, the subject of delirium tremens is fully considered as respects its 
 pathology and causes, and partially as respects its treatment. The principal doctrines 
 inculcated are: — 1. Delirium tremens is a toxaemia from alcohol, and becomes devel- 
 oped when the poisoned condition of the blood and of the nervous matter is sufficient 
 in degree. 2. The idea that the attack comes on in the habitually dissipated, when 
 the use of alcohol has been suddenly discontinued, is an error ; and therefore to with- 
 hold this stimulus cannot be injurious, but, ou the contrary, must be beneficial. («.) 
 The erroneous idea has arisen in consequence of delirium tremens occurring in indi- 
 viduals admitted into hospitals with injuries, and it is maintained that the explanation 
 of this event is not as hitherto supposed — the suspension of the use of alcohol — but the 
 shock of the injury, acting as a determining cause in constitutions in which the toxaemia 
 is considerable, but not of itself sufficient to excite the disease, (b.) It is argued that the 
 withdrawal of alcohol cannot be the cause, because observation shows that in gaols and 
 houses of correction, into which .the dissipated are received in large numbers, delirium 
 tremens rarely occurs in the recently admitted, though, as a matter of course, the use 
 of alcohol has in them been discontinued. 3. Not only is the treatment by free opiates 
 and alcoholic stimulants condemned, but it is maintained that, as the patient is 
 alcohclised when suffering from delirium tremens, to propose the use of more alcohol 
 in the treatment is irrational. 
 
 These doctrines are in part correct, but they do not embrace the whole subject, and 
 are therefore, it seems to me, in part erroneous. The following appear to me to be 
 the defects : — 1. The distinction between the toxa?mic effect on the nervous system 
 of the continued use of alcohol, and the stimulant effect on the heart of regulated 
 quantities occasionally given, is not observed. 2. Though the disease often comes on 
 when the toxaemia is complete, without any suspension of the use of alcohol, yet 
 when the toxaemia is not complete, it may be determined by the sudden withdrawal 
 of alcohol ; and the error has consisted merely in a too general application of tin's 
 occasional fact. («.) The explanation would seem to be, that the removal of the 
 stirrmlAnt effect of the alcohol by depressing the action of the heart determines the 
 attack, just as the shock does in the case of injury, or depletion in a co-existing 
 inflammatory disease. (?>.) The argument that delirium tremens is rare in the 
 inmates of gaols, is not of much force ; for the evident answer is, that though the 
 use of alcohol was suspended on admission, the disease did not hecome developed 
 because the toxsemia was insufficient. Indeed, it might be anticipated that delirium 
 tremens would not frequently attack the recent admissions into gaols, for a person on 
 the verge of delirium tremens cannot be said to be in a state well fitted for the com- 
 mission of general crime. 3. When the toxaemia is great, the withdrawal of alcohol 
 may determine the attack. In this state the general tremor, the small pidse, the 
 damp and coldish surface, indicate the necessity of stimulants, and alcohol, used with 
 this new, will under these circumstances sometimes prevent the attack. But it does 
 not follow that in Less degrees of the toxsemia, where the same necessity for a stimu- 
 lant docs not exist, it may not be withdrawn with perfect safety: this measure is, thin. 
 
FIRST SPECIES — SYMPTOMS AMD TREATMENT. 627 
 
 Of the first species, cases are occasionally admitted into the 
 General Hospital, occurring, usually, in steam-engineers, and not 
 unfrequently terminating by convulsion unexpectedly coming on, 
 passing into complete coma, with rapid pulse, pungent heat of skin, 
 and proving fatal in a few hours after the accession of convulsion. 
 Symptoms of gastric irritation, in this form of the disease, are 
 common, and require to be specially attended to in directing the 
 treatment. Many cases do well under the use of cold affusion fre- 
 quently repeated, attention to rest and quietness, the exhibition of 
 effervescing draughts with a few minims of tincture of opium, and 
 the application of sinapisms to the epigastrium, or a blister, if the 
 symptoms are more urgent. Six or seven grains of calomel, with 
 one grain of muriate of morphia, and one of ipecacuanha, given at 
 bed-time, preceded by cold affusion to the head and a hot foot-bath, 
 are often beneficial. 
 
 It is only in this species that the question of the local detraction 
 of blood, can, with advantage, be entertained ; and probably the best 
 guides to its successful use are the diathesis of the individual, 
 — whether plethoric or not — the knowledge of the length of time 
 to which he has been addicted to habits of dissipation, and the 
 duration of the symptoms. In young men of robust constitution, 
 not long resident in India, and not confirmed drunkards, it is often 
 useful, at the commencement of the attack, to detract blood locally 
 by cupping the nape of the neck, or leeching the temples ; but it is 
 only under these circumstances that this practice holds out any 
 prospect of benefit. In regard to the general abstraction of blood, 
 it is even in these cases very seldom expedient, and, if ever had 
 recourse to, should be carried into effect with very great caution. 
 
 Stimulants (wine, &c.) in this form of delirium tremens are not 
 usually required, — but the state of the pulse and skin sometimes 
 calls for their exhibition. When symptoms of gastric irritation are 
 not present (and such cases occasionally occur), tartar emetic com- 
 bined with more or less opium, according to the character of the 
 
 the only method by which the attack can be prevented. 4. In the treatment of 
 delirium tremens, alcohol shoidd not be used without good reason, because the 
 tendency of its frequent repetition must be to increase the alcoholism ; but when the 
 skin and pulse indicate on general therapeutic principles the necessity of stimulants, 
 then they must be used in this as in other diseases, and wine and brandy are the I iest 
 at our command. Tendency to death by syncope must not be neglected in delirium 
 tremens, because the stimulants used temporarily to avert an immediate and pressing 
 danger are by frequent repetition likely to increase the toxaemia, and lead to a remoter 
 evil. Here as in the practice of medicine generally, the physician's science lies in a 
 correct appreciation of the good and the evil of Ids remedies ; and his art in the skill 
 with which the first quality is sifted from the other, and usefully applied. 
 
628 DELIRIUM TREMENS. 
 
 head symptoms, in the manner to be subsequently more particularly 
 adverted to, is perfectly applicable. 
 
 But the second species of the disease is the one of greatest 
 importance, and most frequent occurrence ; the other being com- 
 paratively rare. 
 
 The division of the second species into three stages, first, I 
 believe, suggested by Dr. Blake *, is in accordance with the cha- 
 racter of the disease as observed in the European General Hos- 
 pital at Bombay, viz. : — 1. A stage of depression, characterised by 
 tremors (in some cases excessive), a feeble pulse, sleepless nights, 
 but no delirium, anorexia, and frequently irritability of stomach. 
 2. The stage of active delirium. 3. The third stage, in cases which 
 have gone on favourably, is one of lengthened sleep, followed by 
 recovery; in cases which have progressed unfavourably, it is a state 
 of low muttering delirium, with contracted pupils, tremulous 
 agitation, feeble and rapid pulse, and generally terminates fatally 
 by convulsion and coma, or by coma unpreceded by convulsion. It 
 is to this train of symptoms, that throughout these remarks I shall 
 apply the designation " third stage.'''' 
 
 First stage. — By treating this stage with stimulants, wine, 
 brandy, ammonia, and occasionally f an opiate at bed-time pre- 
 ceded by cold affusion to the head, — the occurrence of the second 
 stage is sometimes prevented, and recovery takes place ; or, if not 
 prevented, it is much lessened in severity. 
 
 When there is irritability of stomach with slimy and florid 
 tongue, effervescing draughts with a few minims of laudanum, 
 sinapisms or a blister to the epigastrium, with stimulants according 
 to the state of the skin, pulse and tremors; also a grain of muriate 
 of morphia, with two or three grains of calomel, and an effervescing 
 draught at bed-time, preceded by a hot foot-bath, — constitute the 
 best method of treatment. In the management of this stage, 
 stimulants ought never to be abruptly stopped, but always gradu- 
 ally lessened, and an adequate diet should be reverted to as soon 
 as practicable. 
 
 * l; Edinburgh Medical and Surgical Journal for October 1823." I regret that 
 I have not had the opportunity of consulting Dr. Blake's "Practical Treatise on 
 Delirium Tremens," published in 1830; or the second edition of 18-10. 
 
 f I have said occasionally an opiate at bed-time advisedly, because it requires to he 
 given with discrimination; for not unfrequenUy the first symptoms of the second stage 
 come on after an opiate given at bed-time — whether in consequence of the opiate, or 
 because if has chanced to have been given at the period when the commencement of 
 the second stage was to be looked for in the regular course of the disease, is a question 
 which I do not pretend to resolve. Of the fact as now stated I have no doubt. 
 
SECOND SrECIES SECOND STAGE — SYMFTOMS. 629 
 
 The second stage, or that of active mental excitement. — It is 
 unnecessary to enter into any particular description of the delirium 
 of this stage : it is the symptom which most particularly charac- 
 terises the disease, and is fully and accurately delineated in all the 
 best works on practical medicine.* There are, however, certain 
 particulars which, though noted by some observers, have not re- 
 ceived that attention which their importance (as bearing on treat- 
 ment) seems to me to require ; and on these points I shall somewhat 
 extend my remarks. 
 
 It has been observed by Dr. Hoeg Guldberg, physician to the 
 hospital at Frederickstadt, that the critical sleep occurs in the 
 greater number of cases on the fourth day ; but it does not appear 
 whether he dates from the commencement of the first stage, or 
 from that of the second. In all probability from the former ; for, 
 on carefully examining a great many of the diaries of cases treated 
 in the European General Hospital, I find, that of twenty-six cases 
 in which the access of the second stage, and its termination, were 
 distinctly recorded, the average duration of this stage was forty-six 
 hours — the shortest period being twenty-four, and the longest 
 sixty. 
 
 It is stated by Dr. Blake, that the mental irritation requires a 
 given time to subside ; and it is also the opinion of Dr. Ware of 
 Boston, that this disease runs a certain course. From considering 
 the cases which had passed under my own observation, I had 
 arrived at a similar conclusion, when not aware that the same view 
 had been entertained by previous observers. 
 
 The circumstances which suggested this opinion to me, were : — 
 1. The frequently observed fact, that the quantity of opium which 
 on one day failed to induce sleep, succeeded on the following; a 
 circumstance to be explained, either on the supposition, that the 
 natural tendency of the symptoms was to abate, after a certain 
 course, or that the effect of the opium was cumulative — a con- 
 clusion which would be contrary to our experience of the action of 
 this medicine in all other forms of disease. 2. In cases treated 
 with full opiates frequently repeated, I have several times remarked, 
 that sleep was induced for three or four hours, but that the patient 
 afterwards woke up delirious as before ; and some of these cases 
 terminated fatally. 
 
 It is the circumstance of the second stage running a certain 
 
 * Dr. Stovell, at page 68 of his Decennial Report, gives an excellent summary of 
 his observations on the character of the illusions of patients with delirium tremens 
 in the European General Hospital. 
 
630 DELIRIUM TREMENS. 
 
 course, — winch seems to me not to have received its full conside- 
 ration in relation to treatment. For, if acknowledged, it may be 
 safely affirmed, that the indication of cure is not by full doses of 
 narcotics to force a state of sleep, but to conduct the patient 
 through the period of delirium, by withdrawing all sources of 
 irritation, by moderating or sustaining the circulation, and by 
 calming the nervous excitement. Though a similar opinion is 
 expressed by Dr. Elake in the following words : " It does not 
 appear to me to be of any service to attempt to break the chain of 
 morbid concatenation too abruptly, as the stage of mental irrita- 
 tion seems to require a given time to subside, in proportion to the 
 stage of exhaustion, to the mode of treatment adopted, and to its 
 previous causes," I am not aware that any subsequent writer has 
 given to this feature of the disease that prominence which its im- 
 portance demands. 
 
 The indications of cure, as thus stated, are best effected by 
 cold affusion, tartar emetic combined with opium or other narcotic, 
 and stimulants. 
 
 In regard to cold affusion, it may be used with excellent effect 
 three or four times in the course of the twenty -four hours, — the 
 most important, however, being that before bed-time, — in all cases 
 in which the circulation is steady, the skin not covered with per- 
 spiration, or its temperature not reduced below the natural standard ; 
 or, in which there are not present any of the local complications 
 which usually contra-indicate the use of this remedy. In cases 
 in which, from the state of the pulse, there may be doubt of 
 the propriety of the cold affusion, it frequently becomes quite 
 admissible by preceding its application, by a stimulant (as brandy) ; 
 and in the still more doubtful cases, — even in instances in which 
 the measure may be decidedly contra-indicated, — there is good 
 effect from using cold affusion to the head, and at the same time 
 a hot foot-bath. 
 
 There has not been much difficulty experienced in inducing 
 patients to submit to this remedy, and it is hardly necessary to 
 add that the employment of coercive measures to effect it is alto- 
 gether inadmissible. In considering this statement, however, it 
 must be borne in mind, that I write of the disease in a climate 
 whose mean temperature is about 80°, that the water used has 
 never been artificially cooled, and that the practice of frequent 
 bathing is habitual to many of the patients. The first considera- 
 tion is important, as bearing on the question of the temperature 
 of the water; and the second, as, in all probability, explaining 
 
SECOND SPECIES — SECOND STAGE — TREATMENT. 631 
 
 the little difficulty which has been experienced from the opposition 
 of the patients. 
 
 But the exhibition of tartar emetic with opium or other nar- 
 cotic, first introduced into practice by Dr. Law, of Dublin*, 
 and followed by Dr. Graves f, Dr. Clendinning J, and others, 
 constitutes the most successful means of controlling the symp- 
 toms of this stage of the disease. This mode of treatment was, 
 during the five years to which my remarks apply, much followed 
 in delirium tremens, in the European General Hospital at 
 Bombay; and there was also, during the same period, ample 
 opportunity of comparing it with that by free opiates frequently 
 repeated. 
 
 Tartar emetic and opium, in proportions modified according to 
 the s} r mptoms, and associated with the use of cold affusion and 
 stimulants, is, in my judgment, a much more successful and satis- 
 factory method of treating the second stage of delirium tremens than 
 the more common plan of giving free opiates uncombined, or in 
 combination with stimulants alone ; and is moreover devoid of the 
 risk of positive injury, which more or less attends the latter system 
 of treatment. 
 
 Tartar emetic was given in doses from half a grain to a grain 
 in an ounce and a half of camphor mixture, with from twenty 
 to thirty minims of tincture of opium or tincture of hyosci- 
 amus, repeated every hour, second, or third hour § ; the variations 
 in the dose, and the intervals, being dependent on the state of the 
 circulation, the condition of the skin, and the degree of mental ex- 
 citement. Though in determining these variations, there is room 
 for the exercise of discretion in each particular case, still, it will 
 be found, that the greater number are sufficiently controlled 
 by three quarters of a grain of tartar emetic and thirty minims 
 of tincture of opium or tincture of hyosciamus every second 
 hour, continued till sleep is induced, — with intermissions of 
 several hours, at times, if the sinking of the pulse or reduction of 
 
 * "London Medical Gazette for 2nd July and 30th July, 1835." 
 
 t " The Dublin Journal of Medical Science for May, 1836." 
 
 \ "London Medical Gazette," January 14th, 1842. 
 
 § In regarding the proportion of opium here recommended, in reference to nay ob- 
 jections to an exclusive opiate treatment of delirium tremens, the clinical student must 
 bear in mind the well-established therapeutic fact, that the narcotic effect of opium is 
 lessened by antimony. But I would add, that Dr. Stovell, in applying these prin- 
 ciples, has usually reduced the quantity of tincture of opium to ten minims ; and in 
 the expediency of this modification I am disposed to concur. I would therefore re- 
 commend it, as the ride, instead of the larger quantity stated in the text to have bet n 
 given in the series of cases to which these remarks specially refer. 
 
 s s 4 
 
G32 DELIRIUM TREMENS. 
 
 the temperature of the skin, should indicate the expediency of 
 this measure. The tincture of opium is the more useful ; the 
 tincture of hyosciaruus was used in milder cases, and chiefly with 
 the view of avoiding the constipating effect of the opium. Tartar 
 emetic thus combined and repeated every hour, very seldom, even 
 in grain-doses, causes nausea or vomiting. In fact, it has seemed 
 to me that in the second stage of delirium tremens, there is as 
 complete a tolerance of the emetic action of tartar emetic as in 
 pneumonia ; and this I have remarked, even in cases in which there 
 had been irritability of stomach during the first stage, — an observa- 
 tion which accords with Dr. Law's experience.* 
 
 In cases treated in this manner for about twenty-four hours, 
 without tendency to sleep, it is often useful to intermit the 
 medicine for a few horns before bed-time, then to use cold affusion, 
 preceded, if the pulse and skin indicate the expediency, by a 
 stimulant ; and after the affusion to give one dose of the antimo- 
 nial with a drachm of tincture of opium. By this means, sleep 
 is often induced in cases in which, without this fuller opiate, it 
 might have been still postponed for several hours. It is, how- 
 ever, very generally of no avail to adopt this course within the 
 first twenty-four hours of the second stage. 
 
 Stimulants, as wine, brandy, ammonia, are more or less required 
 throughout the treatment of this stage of the disease; and their use 
 is perfectly compatible with that of cold affusion, tartar emetic, and 
 opium. The degree to which these stimulants are required in in- 
 dividual cases, must vary according to what may be known of the 
 previous history of the patient ; and the state of the pulse and skin 
 at different periods ought to be the principal guide. From six to 
 eight ounces of port wine in the twenty-four hours will generally 
 be sufficient, though the necessity of adding brandy to the extent 
 of from four to six ounces, not unfrequently occurs ; and it follows, 
 that the cases in which there is the greatest necessity for stimu- 
 lants, are those in which the utility of tartar emetic is least appa- 
 rent, and in which it is most frequently necessary to intermit its 
 use. But cases of this nature constitute a small proportion of the 
 admissions, and occur for the most part only in those whose career 
 of dissipation has been protracted, and who have suffered from 
 several former attacks of the disease. 
 
 * On this point Dr. Stovell writes :— " I am in the habit of giving antimony with- 
 out reference to the presence or absence of irritability of stomach; for not only is 
 there marked tolerance of this medicine in those eas< a in which there is no irritability 
 of stomach, but its use lias often appeared to allay this irritability in cases where it 
 existed." 
 
SECOND SrECIES — SECOND STAGE — TREATMENT. 633 
 
 It has been well remarked by Dr. Budd*, that in the manage- 
 ment of the second stage of delirium tremens, it is of consequence 
 tc attend to the diet of the patient, with the view of encouraging 
 any desire for solid animal food that he may evince. This sug- 
 gestion is very important ; and it will frequently be found that 
 there is during this stage no great disinclination for food on 
 the part of the patient, — such being rather a feature of the first 
 stage. 
 
 The not unfrequent injurious effects of opium, too often repeated, 
 or given in doses too large, in the treatment of the second stage of 
 delirium tremens did not escape the observation of Dr. Pearson t 
 and Dr. Blake ; and has been brought forward of late years very 
 prominently by Dr. Wright, of Baltimore, and Dr. Ware, of Boston.}: 
 On no point of practice is my conviction more decided, than that 
 opium in full doses requires to be used in delirium tremens with 
 very considerable caution, — much more, indeed, than is generally 
 believed ; — and that it is liable, under some circumstances, to hasten 
 a fatal result by convulsion and coma, or to aggravate and modify 
 the train of symptoms which characterise the third stage. The fol- 
 lowing have seemed to me the leading objections which may be 
 urged against the treatment by opium, as frequently followed. 
 
 1. If there be good grounds for supposing that the tendency 
 of the second stage is to run a certain course and terminate 
 in sleep, then the indication of cure is, surely, not to attempt 
 to cut short this stage abruptly, by large doses of narcotics ; for it 
 would be as sound practice to attempt to obviate the hot stage 
 of an intermittent fever, or the febrile or eruptive stages of the 
 exanthemata. 
 
 2. In support of the opinion that the treatment of the second 
 stage, by free opiates, may tend to interfere with its regular course, 
 I would state that in selecting from the cases treated in the General 
 Hospital those which illustrated the duration of this stage §, I con- 
 fined myself to those in which the change from the first to the 
 second stage was well marked, and in which the occurrence of 
 sleep was critical and followed by recovery; and almost without 
 exception, these cases proved to be instances in which the treat- 
 ment with tartar emetic and opium, or hyosciamus, cold affusion, 
 and stimulants had been used. In those in which the treat- 
 
 * " London Medical Gazette." May 13th, 1843. 
 
 f " Copland's Dictionary of Practical Medicine." 
 
 + "British and Foreign Medical Review," vol. vii. p. 268. 
 
 8 The result of which is stated at page 629. 
 
634 DELIRIUM TREMENS. 
 
 ment by free and frequently repeated opiates had been followed, 
 and in which the issue had also been successful, I experienced a 
 difficulty in determining the commencement and termination of 
 the second stage ; because opium had very generally been given 
 more or less freely during the first stage, and had plainly masked 
 the period of transition; and again, very frequently during the 
 course of the second stage, sleep had been produced for some hours, 
 but been succeeded by a recurrence of delirium, again to be checked, 
 and perhaps again to return. It is not disputed that a full opiate 
 given during the period of excitement is frequently followed by 
 sleep, but if the law as stated be just, the probability of this 
 result depends on the time of the stage at which the remedy has 
 chanced to be given ; and then it acts favourably merely in con- 
 formity with the natural tendency of the disease, and, not because 
 there has been an accurate adaptation of the quantity to the degree 
 of excitement. 
 
 3. It has seemed to me, that in cases treated with free opiates 
 there is a greater tendency to pass into the third stage, and that 
 a greater number terminate by convulsion and coma. I have 
 not attempted, by a scrutiny of the cases, to offer a numerical 
 statement in support of this opinion ; for, in all questions of 
 medical treatment, such data are open to evident sources of 
 fallacy, — the principal of which is, that there are many important 
 circumstances bearing on success which do not admit of expression 
 by numbers. Still, however, the opinion, as stated, is the result 
 of the impression left on my mind by the cases when under obser- 
 vation, strengthened by a careful review of a great many of the 
 diaries. 
 
 4. As has already been remarked, it was the opinion of Dr. 
 Pearson, that after a certain time it is injurious to persist in the 
 use of opium, for the action of the medicine confuses the symp- 
 toms of the disease ; and a similar conviction is still more strongly 
 expressed by Dr. "Wright, of Baltimore. My suspicion on this 
 point was excited — when it was not known to me, that such 
 views had been already entertained — by the following circum- 
 stances: — A man under treatment for delirium tremens in the 
 second stage, took one grain of tartar emetic, and one drachm of 
 tincture of hyosciamus, every hour for ten successive times, after 
 which there succeeded convulsive agitation of the hands, which 
 moved about as if in search of objects; there was a rolling motion 
 of the tongue about the teeth and the cheeks, as if in search of 
 something in the mouth ; the pulse was 108, of moderate strength ; 
 
SECOND .SPECIES — THIRD STAGE — SYMPTOMS. 635 
 
 there was constant incoherent low muttering ; the pupils were very 
 much dilated. Under the use of blisters, tartar emetic in smaller 
 doses, with spiritus aetheris nitrici, this patient recovered. The symp- 
 toms just detailed are those of the commencement of the third stage 
 of the disease, with the exception that the pupils were much dilated 
 instead of being contracted. It is hardly necessary to observe that 
 henbane in poisonous doses dilates the pupils, and opium contracts 
 them. 
 
 The mode of exhibiting opium to which these remarks are 
 intended to apply is, not only the unusually large quantities 
 recommended by some American practitioners, but — 1. The use 
 of tincture of opium in doses of one drachm or one drachm 
 and a half, with stimulants, given every hour or every two hours 
 for many times. 2. The exhibition of from a drachm and a half 
 to three drachms of tincture of opium at bed-time, followed by 
 a half dose every hour or second hour, for two, three, or more 
 times. 3. One and a half-grain doses of muriate of morphia 
 with a few grains of blue pill at bed-time, repeated every second 
 hour in grain doses for two, three, or more times, if required. 
 The first mode I have witnessed, the second and third I have fre- 
 quently practised, using at the same time cold affusion. 
 
 Before proceeding to consider the symptoms characteristic of 
 the third stage of the disease, there are signs which mark as 
 it were, in unfavourable cases, the approaching transition of the 
 second into the third stage ; and which, as bearing on treatment, 
 it has seemed to me of much moment carefully to note. After 
 the second stage has gone on for some time, without sleep, 
 the pulse begins to increase in frequency, rising above 100 and 
 becoming more compressible, the skin is damp, the expres- 
 sion of countenance vacant, and the pupils begin to contract* ; 
 
 * Dr. Barlow, in his "Manual of the Practice of Medicine," p. 541, writes:— 
 " The diagnosis of delirium tremens, in its perfect form, is not difficult ; from 
 phrenitis it may be distinguished by the softer pulse, the moist tongue, perspiring 
 skin, scanty urine, and, by what is perhaps a still more important sign, the dilated 
 pupil." That dilatation of the pupil is characteristic of delirium tremens, is, I appre- 
 hend, not a usual belief. Copland and Wood state that it is contracted in the second 
 stage. My own opinion is that it presents no peculiarity in the second stage, but 
 that its contraction is to be. viewed as a sign of the 'impending dangers of the third 
 stage. 
 
 On my return to India, I requested Dr. Leith, who had succeeded to the surgeoncy 
 of the European General Hospital, to favour me by noticing the state of the pupil in 
 the second stav:>" of delirium tremens. The following is his reply, dated 21sr January, 
 1358 : — "With reference to the question whether or not the pupil is contracted or 
 dilated during delirium tremens, I find I have noted the symptom in eighteen of the 
 cases treated in my wards during last year without any opium, and find that in nine 
 
636 DELIRIUM TREMENS. 
 
 the tremors increase and assume more the character of subsultus 
 tendinum than in the earlier period of the disease, and the patient 
 catches at objects, not so much, apparently, from fancying them 
 present when not so, as from miscalculating the distance when 
 they are really before him. 
 
 On the occurrence of these symptoms, danger impends either 
 from the sudden access of convulsion with succeeding coma and 
 death, or the passing of the disease into the third stage, character- 
 ised by still increased frequency (120), and feebleness of pulse, 
 constant agitation, low muttering delirium, contracted pupils, roll- 
 ing of the tongue within the lips and cheeks as if in search of 
 objects in the mouth, — passing gradually into coma, and termi- 
 nating fatally in a few hours. 
 
 When these symptoms which indicate the transition of the 
 second stage into the third become developed, then all narcotic 
 medicines should be completely intermitted ; the" head should be 
 
 it was dilated, in seven it was of natural or moderate size, and in none was it stated 
 to be contracted. With regard to the statement 'natural' size, or 'moderate' size, 
 it is indefinite ; and, latterly, I have compared the size during the attack with the 
 size after recovery." 
 
 Dr. Leith, in his report of the hospital for the year 1858-59, published in No. 5, 
 new series, " Transactions, Medical and Physical Society of Bombay," thus states his 
 latest conclusions: — "For some time past I have attended to the state of the pupil of 
 the eye in all cases of delirium tremens that have come under my care, and the result 
 of my observations is, that the pupil is dilated in this disease, but that at the same time 
 the iris is sensitive, readily obeying the stimulus of light ; the pupil oscillates about a 
 moan diameter abnormally large." Dr. Leith also explains " a diagram, in which 
 there is a row of disks of uniform size, each having in its centre a smaller black disk 
 which represents the pupil of the eye," by means of which he gave precision to his 
 observations. He further states, — " With the aid of this diagram or scale, I estimate 
 and note the relative size of the pupil on admission and during delirium ; and again, 
 after all signs of delirium have for some time ceased, — the patient being also free 
 from the influence of opium or other medicine. I take care that the circumstances as 
 to light are the same at each observation ; and to secure this, I find it best that the 
 patient's eyes should be directed to the sky and not to the observer, and that the time 
 of day be always the same." 
 
 The inference which I draw from these statements, though it is not distinctly 
 stated, is, that the dilatation of the pupil, observed in the second stage of delirium 
 tremens, was not great in degree. The following circumstance (doubtless not over- 
 looked by Dr. Leith) renders additional caution necessary in conducting an inquiry of 
 lliis nature in this hospital. During my time, the cases of delirium tremens were 
 treated in the ordinary light wards ; they are now treated in darkened cells, badly 
 constructed and situated in the basement floor. I still incline to the opinion, that in 
 patients in the second stage of delirium tremens, undrugged with narcotics, and not 
 
 secluded in small darkened rooms, but pla 1 in ordinary light, the diagnosis is not 
 
 assisted by an abnormal state of the pupil, dilatation or contraction, but that the pupil 
 is usually what may be fairly termed natural. Further inquiry is, I think, still 
 necessary. 
 
SECOND SPECIES — THIRD STAGE — TREATMENT. 637 
 
 shaved, a blister should be placed on the nucha, the hot foot-bath 
 should be used, and if the scalp be hot, cold cloths should be ap- 
 plied to it; camphor mixture should be exhibited every second 
 hour, either with a small portion of tartar emetic or spiritus setheris 
 nitrici, according to the state of the pulse and skin ; wine should 
 also be given, and the importance of mild nourishment, as beef- 
 tea and chicken soup, is very great. These means, if adopted at 
 the proper time, and assiduously pursued, are not unfrequently 
 successful,— the patient falls asleep, and awakes comparatively well. 
 It is under these particular circumstances, and also at times earlier 
 in the disease, while all these conditions are not yet present, 
 that the application of a blister to the nape of the neck is of 
 great utility. This is a point of practice which, so far as I know, 
 has not been estimated according to its just importance; for it is 
 generally stated, that blisters ought to be confined to the first stao-e 
 of the disease, a remark in all probability correct as regards their 
 application to the epigastrium, but not to the nape of the neck or 
 to the head. 
 
 In the course of these observations, I have anticipated the de- 
 scription of the symptoms ; but it remains that a few words be said 
 of the treatment of the third stage. Supposing that the course 
 above recommended has been gone through, a blister should now 
 be applied to the scalp, camphor mixture one ounce and a half 
 with half a drachm of spiritus Eetheris nitrici, should be given every 
 second hour with wine and light nourishment. Under this treat- 
 ment, in instances in which the symptoms of the third stage were 
 fully formed, I have known recovery to take place ; but in them 
 there was frequently room for suspicion that the symptoms had, 
 to a certain extent, been caused by the free exhibition of nar- 
 cotics; — and the fact of recovery from a combination of symp- 
 toms which, resulting in the natural course of the disease, is usually, 
 if not always, followed by death, is an additional argument in sup- 
 port of the opinion that the too free use of narcotics is apt to 
 complicate and modify the symptoms of the third stage. 
 
 It has been stated by Dr. Blake that when the pulse rises 
 above 100, there is room for apprehension. This remark is in 
 accordance with my experience ; care however being taken not to 
 mistake a frequency of pulse caused by muscular exertions which 
 the patient in his excitement may have been just undergoing, — 
 for that frequency which is permanent, and which takes place 
 when the disease is progressing unfavourably. 
 General Remarks on Treatment. Blood-letting, general and local. 
 
638 DELIEITJM TREMENS. 
 
 Purgatives , Emetics, &c. — It is unnecessary to notice particularly 
 the use of general or local blood-letting in the treatment of deli- 
 rium tremens, for with the exception of local depletion, in a few 
 cases of the first species, I believe that all are agreed in consider- 
 ing it inadmissible. It is not often, indeed, (so rarely is it had 
 recourse to), that there exists the occasion of witnessing positive 
 injury from general or local blood-letting in the second species 
 of the disease. The opportunity, however, sometimes occurs, 
 when the application of leeches may have been thought necessary, 
 in consequence of the complication of local inflammatory dis- 
 ease, as dysentery ; and it may be very safely affirmed, that this 
 measure is never adopted without a positive aggravation of the 
 characteristic symptoms of delirium tremens. 
 
 Laxatives or 'purgatives have not been used by me in the second 
 species of delirium tremens, except with the view of removing ex- 
 isting constipation. Given with this object they are of course fre- 
 quently required, but further than this, their exhibition does not 
 constitute any part of the treatment, for free purging in this form 
 of the disease must generally be injurious. I am aware that these 
 opinions are opposed to the statements of several very excellent 
 writers * ; but it must be recollected that I write of the disease as 
 observed in a climate in which affections of the bowels are common, 
 and easily excited ; and in which that free use of purgatives, often 
 safe, and perhaps necessary, in the management of the diseases of 
 extra-tropical countries, is generally injurious. 
 
 Emetics may occasionally be useful in the first stage, when the 
 tongue is coated and white, and symptoms of gastric irritation are 
 not present. Cases of this nature are, however, rare, and there- 
 fore the utility of emetics, in the treatment of delirium tremens, 
 is very limited. 
 
 There are other points of general management on which I have 
 thought it unnecessary to dwell, because it ma}^ be presumed that 
 there is little difference of opinion in regard to them. They are — 
 1. The advantage of secluding the patient in a quiet, and par- 
 tially darkened room, under the care of a trustworthy attendant. 
 "2. The injurious effects of strait-jackets, or bonds of any kind, 
 and the extreme rarity of any necessity for their use, when the 
 management of the patient is conducted with ordinary intelligence 
 and tact. 3. The necessity of guarding against the risk of injury 
 to the patient, either from the suicidal tendenc} r , which is not unfre- 
 
 * "Copland's Dictionary of Practical Medicine," &c. 
 
GENERAL REMARKS ON TREATMENT. 639 
 
 quently present, or from the efforts made by him to escape from 
 some imaginary danger.* 
 
 This account of the symptoms and treatment of delirium tre- 
 mens was presented to the Medical and Physical Society of Bombay, 
 in 1843, and published in the Transactions of the Society f, in the 
 form in which it is now reproduced. I expressed myself then, 
 with confidence, on the superiority of the treatment here recom- 
 mended, over that with opium and stimulants, because my oppor- 
 tunities of forming an opinion had been ample, and because I felt 
 the practical question to be one of very great importance in the 
 treatment of European Hospital sick in India. It has therefore 
 been to me a source of great satisfaction, to find these views fully 
 corroborated, during the last ten years, by the experience of the 
 medical officers who have succeeded me in the European General 
 Hospital, more especially by Dr. Stovell, who has borne repeated | 
 
 * The fulfilment of these indications ought never to be aimed at by the construc- 
 tion of darkened, barred, and secluded cells in the basement or other parts of a 
 building not deemed suitable for other sick. The necessary protection of the patient 
 from self-injury, and of the other inmates of an hospital from disturbance, ought to 
 be effected without adding to the alarm characteristic of the disease — the idea of im- 
 prisonment and forcible restraint. 
 
 t No. vi. p. 139. 
 
 I " Transactions, Medical and Physical Society of Bombay," No. 9, p. 53; No. 10, 
 p. 861 ; Second Series, No. 2, p. 66 ; and No. 3, p. 70. 
 
 Since these remarks were ■written, I have seen two reports, in which a different 
 system of treatment has been advocated. Dr. Lay cock, in the "Edinburgh Medical 
 Journal" for October 1858, recommends an almost exclusive expectant treatment — 
 by food, occasional cold affusion, and the soporific influence on the miud of a placebo, 
 given at bed-time as an anodyne. Dr. Leith, in his report of the European General 
 Hospital, Bombay, for the year 1857-58, published in the fom'th number of the new 
 series of the " Transactions of the Medical and Physical Society," states : — " The 
 treatment of delirium tremens during the year has been chiefly expectant, and in the 
 uncomplicated cases that have been under my own immediate care no medicine what- 
 ever has been given. The patient is secluded, and kept as quiet as the present im- 
 perfect hospital accommodation will allow; and where there is any heat of head, the 
 cold affusion is used, and sometimes along with it the hot pediluvium. In many cases, 
 however, even these remedies are not emj:>loyed. Attention is always paid to alimen- 
 tation, and strong broth is given at regular intervals. I had followed this plan for 
 many years in the cases that from time to time came under my care, and now that I 
 have had trial of it in a more abundant field of observation, I continue to lie satisfied 
 with it." On referring to the return, I find that the mortality was 8 per cent. 
 
 These two reports are of much interest, for they confirm the toxemic view of I lie 
 pathology of the disease, and the correctness of the general principles of treatment 
 recommended in this chapter. But it no more follows that an expectant treatment is 
 the best in delirium tremens because eases very generally l'eeover under it, than thai an 
 expectant treatment is the best in all other forms of toxsemic disease. In treating 
 delirium tremens there is not merely the question of recovery, but— ^1. Can the dura I ion 
 
6-iO DELIRIUM TREMENS. 
 
 testimony to the success of the system here advocated. Though, 
 as I have elsewhere remarked, figured statements, as data from 
 which alone to judge of the success of medical treatment, are open 
 to very evident sources of fallacy, and must be used with much 
 caution, yet I feel satisfied that I run no risk of misleading others, 
 when I point to the statistics of the European General Hospital, in 
 proof of the greater efficacy of the treatment of delirium tremens, 
 by the means, and in accordance with the principles, here incul- 
 cated. From 1838 to 1841 — the years during which I became 
 convinced, from careful clinical observation of the evils of an exclu- 
 sive opiate and stimulant treatment — the mortality from delirium 
 tremens was 24*5 per cent. Whereas, from 1842 to 1853 — a period 
 during which I know that the disease was chiefly treated in the 
 manner recommended by me — the mortality was 9*4 per cent. 
 Why, the year 1848, in which the mortality again rose to 20*4 per 
 cent., is the single exceptional year of these twelve, I am unable, 
 from the data before me, to explain ; but it would be interesting 
 to inquire, by examination of the diaries of the cases of that year, 
 
 of the delirium be shortened ? 2. Can the delirium be moderated and thus the 
 general management be much facilitated and exhaustion in a measure obviated ? 
 The answer to these questions is affirmative. It is these objects which the treat- 
 ment by tartar emetic and small opiates with alimentation effects, and the neglect of 
 which is the objection to an exclusive expectant method. 
 
 It may be gathered from Dr. Laycock's cases, that the average duration of treat- 
 ment was seven days ; and allusions to strait -jackets show that in cases there was 
 much violence, for which restraint was used. Dr. Leith gives no details either in 
 respect to the duration of the attack or the character of the delirium, but seclusion in 
 the small barred rooms of the hospital of necessity supplied restraint. 
 
 The tartar emetic treatment tends to shorten the attack, and so to moderate the 
 delirium as very materially to facilitate the control and management of the patient 
 without strait-jackets, and small, barred, darkened rooms. But the chief advantage 
 of moderating the delirium is not the convenience to the attendants, but the protec- 
 tion of the patient from direct injury, and, above all. from the exhausting effects of 
 the constant muscular exercise which attends the unmitigated delirium of this disease. 
 Of the importance of this, any one who feels the pulse and skin of a patient affected 
 with delirium tremens, after a paroxysm of restless movement and great alarm, may 
 satisfy himself. Alimentation is a very essential part of treatment, but surely much 
 of its value is lost if the patient be allowed to exhaust himself by uncontrolled i 
 ment. Tartar emetic with small opiates, proportioned to the degree of excitement, 
 1 rev< nt much of the exhaustion which residts from muscular waste, and does not in- 
 terfere with the taking of food: hence its utility in the treatment of delirium tremens. 
 
 J have dwelt at length on this question, because, not only is it of great importance 
 in reference to the treatment of delirium tremens, but also to those general principles 
 which are unfortunately gaining ground — that because recovery follows, expectant 
 treatmenl is Q( cessarily the b usion is neither logical nor consonant to 
 
 rational pathology or therapeutics. 
 
REVIEW OF TATIIOLOGT AND PRINCIPLES OF TREATMENT. 641 
 
 whether there had not been a backsliding into the old, and I fear, 
 still too common, system of treatment.* 
 
 Section II. — On the Pathology, the Principles of Treatment, and 
 
 Diagnosis. 
 
 I propose in this section to extend the observations of my origi- 
 nal paper, in the hope of reconciling the discrepancies which exist 
 in the treatment of delirium tremens. The following statements 
 relative to the general pathology of the brain, may be received as 
 probably true. 
 
 1. The functions of the brain may be deranged by toxcemia. 
 It is very likely that the symptoms peculiar to this disease — 
 the busy, apprehensive delirium, the sleeplessness, the muscular 
 tremors — are of this nature. The poison may be " alcohol accu- 
 mulated slowly in the blood, incorporated, if we may so speak, 
 with the nervous matter of the brain," as suggested by me in 
 1848f, or a "compound formed of alcohol, and perhaps some 
 morbid matter generated in the system," as advanced by Dr. 
 Todd, in 18504 
 
 * On my return to Bombay, in August, 1856, I requested Dr. Leith to have the 
 kindness to cause the diaries of the cases of delirium tremens for Ihe year 1848 to be 
 examined, with the view of ascertaining whether the surmise hinted in the text was 
 correct or not. The following is the reply: — "I at last have got the diaries of the 
 delirium tremens cases of 1848 searched out, and I have gone over them, and the fol- 
 lowing is the result : of those entered in the register, the diaries of eight cannot be 
 found — of these two died, six recovered ; of the thirty-six that have been by me ex- 
 amined, thirty were treated with free use of opiates and brandy — of these six died and 
 twenty-six recovered ; six were treated with mist, antimon. c. opio chiefly — of these 
 one died and five recovered." It is evident that the treatment with free opiates and 
 stimulants was the ruling system of the year 1818. 
 
 f " Transactions, Medical and Physical Society of Bombay," No. 9, p. 127. 
 
 j "London Medical Gazette," vol. xiv., new series, p. 1078. 
 
 As bearing upon this subject, I may allude to the cases of poisoning with Datura 
 which are from time to time received into the Jamsetjee Jejeebhoy Hospital. The 
 symptoms are in many respects allied to those of delirium tremens. The delirium is 
 more muttering, not so busy as that of delirium tremens ; but there is the same 
 rambling of the mind on subjects not present to the senses. There is the same power 
 of controlling the thoughts for a few moments, the same desire to appear rational, and, 
 above all, the same picking at small objects, as if they were indistinctly seen, which is 
 often observed in the advanced stages of delirium tremens. 
 
 Where the quantity taken has been largo, there is coma with agitated movements 
 of the hands and lips, and picking movements of the fingers: in fact, the same clas^ of 
 deranged nervous actions which characterise the third stage of delirium tremens. 
 There is, however, this great difference in these latter phenomena when caused by 
 datura ; they are very generally recovered from, not by a return from coma to a state of 
 health, but the coma ceases, and then succeed the delirium and the other phenomena 
 which attend those slighter cases which have never passed into coma. 
 
 What is the indication of cure in these cases of datura poisoning after the time has 
 
 T T 
 
612 DELIRIUM TREMENS. 
 
 2. The functions of the brain may be deranged from excess or 
 defect of blood in the cerebral capillaries, without reference to its 
 quality. 
 
 3. Determination of blood in the capillaries of the brain is of 
 common occurrence in Europeans in India, characterised by sense 
 of fulness or pain in the head, flushed countenance, injected con- 
 junctivae, heat of scalp, confusion of thought, or some degree of 
 delirium, liable in its more aggravated forms to pass into con- 
 vulsion and coma. The appearances found in fatal cases are more 
 or less vascular turgescence of the membranes and substance of 
 the brain, with more or less serous effusion. The more ordinary 
 exciting causes, are elevated temperature, and immediate excesses 
 in drinking. As proof of the influence of these causes, it may be 
 stated, that of twenty-nine cases, with head symptoms, noted by me 
 in the European General Hospital,* in which there was found after 
 death, increased serous effusion in the cavity of the cranium, with 
 or without increased vascularity, twenty-six occurred in the hot 
 months of the year, and twenty-one in individuals addicted to 
 drinking. 
 
 4. The subjects of the toxcemia which induces delirium tremens, 
 are very likely to be exposed to the causes of, and to be affected 
 
 passed for the exhibition of emetics and purgatives, with the view of removing the 
 poison from the alimentary canal ? Certainly not an attempt to destroy the delirium 
 of datura by the sopor of opium, or to remove the coma of datura by the means of 
 treatment applicable to idiopathic apoplexy. 
 
 They are viewed as deranged states of the nervous system, caused by the presence 
 of a poison in the blood, and which will not cease till time has been given for its eli- 
 mination. If the delirium be troublesome and active, and the pidse does not contra- 
 indicate, antimonials and cold affusion are appropriate means for moderating these 
 deranged actions. If the pulse be feeble and the skin cold, which is often the case, 
 then stimulants are used to counteract this tendency to death by syncope. If coma 
 comes on, then it is recollected that the suspended action of the brain, consequent on 
 narcotic poisons, is atteuded by a degree of congestion, and (the state of the pulse and 
 skin permitting) a few leeches, cold douche, and a blister to the nucha are used to 
 lessen this congestion. It is not to be doubted that these means of treatment are often 
 very useful and conducive to the successful issue of many of these cases. 
 
 The similarity of many of the phenomena of poisoning by datura and those charac- 
 teristic of delirium tremens is a circumstance which seems to me to afford a reasonable 
 confirmation of the idea that delirium tremens is nothing but one form of poisoning by 
 alcohol; and to explain the practical fact, that we most successfully treat the disease 
 when we observe the same indications of cure, i. e. moderate the symptoms, oppose the 
 tendency to death, and allow time for the elimination of the poison from the blood, 
 before we hope for perfect recovery. 
 
 A A-ery interesting account of datura poisoning, as observed in the Jamsetjee 
 Jejeebhoy Hospital, lias been published by Dr. Giraud in the Ninth Number of the 
 " Transactions of the Medical and Physical Society of Bombay." 
 
 * " Transactions, Medical and Physical Society," No. ix. pp. 120 and 121. 
 
REVIEW OF PATHOLOGY AND PRINCIPLES OF TREATMENT. 643 
 
 with, cerebral determination. In them we may expect to find 
 symptoms indicative of both deranged states — that is, symptoms 
 of delirium tremens, and of cerebral determination — combined in 
 varying proportions, according as the one or the other predomi- 
 nates. Allusion has been made to this fact, in reference to the 
 pathology of cerebral complication in remittent fever (p. 57), and 
 it is an. important consideration in the pathology and treatment 
 of delirium tremens. It is because there is some amount of this 
 combination of cerebral determination, in by far the larger pro- 
 portion of cases of delirium tremens met with in European 
 hospitals in India, that tartar emetic and cold affusion are so 
 valuable, and the free use of opium and stimulants so dangerous, 
 in the treatment. 
 
 5. In the early stages of the mixed cases, the danger is from the 
 cerebral capillary derangement ; there is seldom risk from failure 
 of the action of the heart : therefore antimony and cold affusion 
 may be freely used, but opium very cautiously. But as the 
 duration increases, the cerebral danger may still continue, and 
 indications of exhaustion begin to appear ; and now we must be 
 still cautious with opium, use antimony and cold affusion with 
 more reserve, and direct our attention to stimulants and nourish- 
 ment. 
 
 G. In pure unmixed delirium tremens, the danger is from 
 exhaustion, therefore stimulants, nourishment, and opium are indi- 
 cated. But they should be used in that moderate expectant 
 manner, which is a therapeutic rule in the treatment of all forms 
 of toxcemic disease. The coma, and serous effusion of unmixed 
 delirium tremens, are probably related to general anaemia with 
 watery bloori, and not to local hypersemia. It is because this form 
 of disease is rare in Europeans in India, that the treatment exclu- 
 sively appropriate to it is generally inapplicable. This remark 
 must be viewed in connection with what has been written at the 
 concluding part of the preceding head — that in the advanced 
 stages of the mixed cases, there is also hazard from exhaustion. It 
 is probably because unmixed delirium tremens occurs more fre- 
 quently in the asthenic inmates of civil hospitals in the large cities 
 of Europe, that the exclusive treatment with opium and stimulants 
 still finds acceptance in these institutions. 
 
 In these statements I have endeavoured to explain the prin- 
 ciples of the treatment which I have advised, and to account for 
 the apparent discrepancy in the results of clinical experience in 
 India and in other countries, in respect to this disease. The same 
 
644 DELIRIUM TREMENS 
 
 doctrines will be found to pervade the more desultory observations 
 of rny original paper. 
 
 Morbid Anatomy. — The appearances found after death are 
 sometimes trifling and insufficient to explain the phenomena of 
 the disease. There is in a proportion of cases, but not in all, some 
 degree of vascular turgescence of the membranes of the brain, with 
 frequently more or less serous effusion between the arachnoid and 
 the pia-mater, into the ventricles, or at the base of the skull, 
 and occasionally slight opacity of the membranes. 2. There is 
 often dotted redness at the cardiac end of the mucous lining 
 of the stomach, frequently without alteration of texture, but some- 
 times with a mammillated state at the pyloric end or body of the 
 organ. Admitting, however, the frequency of this appearance, 
 it does not support the view originating with Broussais, and sub- 
 sequently supported by Dr. Hannay * of Glasgow and others, that 
 delirium tremens is caused by gastritis. On the contrary, this 
 appearance of the mucous coat of a stomach exposed to the 
 habitual action of the strong stimulus of alcohol, is what might be 
 expected, and doubtless exists in individuals with these habits, 
 even when delirium tremens is absent. The circumstances most 
 important to remember as bearing on the prognosis, are the cere- 
 bral determination, the frequency of previous attacks, and the 
 existence of some local complication — dysentery being that which 
 is most common in delirium tremens in India. 
 
 Diagnosis. — The diagnosis between simple delirium tremens 
 and cerebral determination or inflammation is easily stated. The 
 characteristic delirium, the tremors, the pale countenance and the 
 compressible pulse of the one ; the flushed face, hot head, active 
 delirium, headache, and firm pulse of the other, are sufficiently in 
 contrast. But I have already explained that this picture does not 
 represent the realities of practice. At the bedside of the sick we 
 may readily recognise the peculiar delirium and the tremors of 
 delirium tremens, but we shall generally find something more ; 
 and the practical question which ought always to arise is, does any 
 derangement exist in addition to the toxoemia which causes the 
 symptoms peculiar to delirium tremens, if so, what is its nature ? 
 On the frequency of cerebral determination I have already 
 enlarged. The complication of inflammations, — as pneumonia, 
 pleuritis, dysentery — has been often the subject of comment. Dr. 
 Wood | alludes to the complication of meningitis and delirium 
 
 * "London Medical Gazette," March 3, 1838. 
 
 j "Treatise on the Practice of Medicine," by George B. Wood, M.P.. vol. ii. p. 737. 
 
IN NATIVES OF INDIA. 64.3 
 
 tremens ; this is important and very liable to be misunderstood. 
 The following is an illustrative case. 
 
 246. Meningitis. — -Effusion of lymph and scrum in the sub-arachnoid space. — 
 Symptoms of delirium tremens. — John Eechlin, a discharged European soldier, desti- 
 tute, drinking in the bazaar, and exposing himself to the sun, came to the Jamsetjee 
 Jejeebhoy Hospital in a state -of intoxication on the loth April. The stomach was 
 irritable, and he was delirious in the evening. He was bled to twelve ounces; three 
 dozen leeches were applied to the temples, and a purgative given. The delirium con- 
 tinued, and the illusions were of the character of those of delirium tremens. The con- 
 junctiva; were yellow. On the evening of the 17th, the 18th, and 19th he was treated 
 with potassio-tartrate of antimony, and tincture of opium in repeated but moderate 
 doses. After this there was drowsiness and picking at objects without sleep. The 
 yellowness of the conjunctiva continued. He was now treated with moderate mercu- 
 rial purgatives, diuretics, a blister to the nucha, and afterwards to the scalp. The 
 drowsiness continued, with twitching of the arms, and the pidse lost strength. He 
 died on the evening of the 22nd. 
 
 1 ispt ction jiff, < a hours after death. — There were about four ounces of serum in the 
 cavity of the cranium, chiefly at the base. There was also some serous effusion in the 
 sub-arachnoid space at the convex surface of the brain. The vessels of the pia mater 
 were somewhat congested. The pia mater and arachnoid were in parts opaque, and 
 much thickened, chiefly from lymph deposit between them : this was most marked near 
 the longitudinal fissure about its middle. The substance of the brain was healthy. 
 There was no increased effusion in the ventricles. The cerebellum, pons Varolii, and 
 medulla oblongata were healthy. The lungs and heart were normal. The liver was 
 nearly of natural size, of pale yellow colour from biliary congestion; under the 
 microscope the cells were visible here and there, they contained many fat globules, 
 and were surrounded by granular amorphous matter and free fat globules. The 
 structure of both kidnevs was healthv. 
 
 Section III. — Delirium Tremens in the natives of India. 
 
 During the six years from 1848 to 1853, forty-one cases were ad- 
 mitted into the Jamsetjee Jejeebhoy Hospital; of these, two proved 
 fatal, one being a European whose case has just been detailed. 
 The classes chiefly affected were Hindoos and native Christians. 
 Though the lower classes of the Parsee community drink spirits to 
 great excess, and though I have often seen them tremulous, and 
 exhibiting other indications of intemperance, I have never witnessed 
 one in the second stage of delirium tremens: the cause of this 
 fact I am unable to explain. In respect to the treatment of the 
 disease in natives, I have followed the principles which have been 
 so fully set forth in this chapter, and found them as applicable 
 to natives as to Europeans. 
 
 T T 3 
 
646 
 
 DELIRIUM TREMENS. 
 
 Section IV. — Statistics of Delirium Tremens. 
 
 Table XXXVIII. — Admissions and Deaths, with Per-centage, from Delirium 
 Treiw ns, in the European General Hospital at Bombay, for the Five Years 
 from 1838 to 1843. 
 
 
 
 
 1838 to 1843. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total 
 Deaths. 
 
 January 
 February 
 
 March . 
 April . 
 May . 
 June 
 July . 
 August . 
 September 
 October 
 November 
 December 
 
 
 
 18 
 22 
 11 
 26 
 42 
 24 
 17 
 12 
 18 
 9 
 16 
 22 
 
 2 
 
 1 
 18 
 2 
 2 
 1 
 6 
 
 4 . 
 1 
 4 
 
 18-1 
 
 3-8 
 42-8 
 
 83 
 11-7 
 
 8-3 
 33-3 
 44-4 
 
 6-2 
 18-1 
 
 3-2 
 5-3 
 
 21 
 4-4 
 47 
 3-1 
 23 
 1-9 
 3-3 
 1-2 
 2-3 
 3o 
 
 6 
 
 2-4 
 
 22-4 
 
 3-9 
 
 5-4 
 
 2-8 
 
 11-fi 
 
 14-8 
 
 2-1 
 
 •6 
 
 Total 
 
 
 
 237 
 
 41 
 
 17-8 
 
 3-1 
 
 75 
 
 Table XXXIX. — Admissions and Deaths, with Per-centage, from Delirium 
 7V. ;ii< ns, in the European General Hospital at Bombay, for the Five Years 
 from 1844 to 1848. 
 
 
 
 
 1844 to 1848. 
 
 Monthly Averag 
 
 e. 
 
 
 Admissions. ! Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 
 total 
 Deaths. 
 
 January 
 
 17 
 
 1 
 
 5-8 
 
 2-7 
 
 2-2 
 
 February 
 
 
 
 11 
 
 — 
 
 — 
 
 2-7 
 
 — 
 
 March. 
 
 
 
 23 
 
 3 
 
 130 
 
 4-8 
 
 10-0 
 
 April . 
 
 
 
 23 
 
 2 
 
 87 
 
 4-5 
 
 6-4 
 
 May . 
 
 
 
 18 
 
 1 
 
 00 
 
 3-1 
 
 3-3 
 
 June 
 
 
 
 22 
 
 — 
 
 
 3-1 
 
 — 
 
 July . 
 
 
 
 18 
 
 2 
 
 111 
 
 2-7 
 
 5-6 
 
 Aug 
 
 
 
 18 
 
 2 
 
 111 
 
 33 
 
 13-3 
 
 September 
 
 
 
 18 
 
 2 
 
 11-1 
 
 3-9 
 
 91 
 
 >ber 
 
 
 
 15 
 
 5 
 
 333 
 
 2o 
 
 1-3 
 
 November 
 
 
 
 13 
 
 2 
 
 1.5-4 
 
 2-3 
 
 64 
 
 December 
 
 
 
 10 
 
 2 
 
 12-5 
 
 31 
 
 5-0 
 
 Total 
 
 
 
 215 22 
 
 10-2 
 
 3-2 
 
 5-6 
 
STATISTICS. 
 
 647 
 
 Table XL. — Admissions and Deaths, with Per-centage, from Delirium 
 Tremens, in the European General Hosjrital at Bombay, for the Five Years 
 from 1849 to 1853. 
 
 
 
 
 1849 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 
 total 
 
 Deaths. 
 
 January 
 February 
 March . 
 
 
 
 11 
 
 8 
 
 23 
 
 — 
 
 — 
 
 2-4 
 2-2 
 5-2 
 
 — 
 
 April . 
 May . 
 
 
 
 22 
 23 
 
 
 1 
 
 22-S 
 4-3 
 
 4-2 
 4-4 
 
 •o 
 
 4-2 
 
 June 
 
 
 
 29 
 
 1 
 
 3-4 
 
 5-1 
 
 3-4 
 
 July . 
 August 
 
 
 
 17 
 15 
 
 1 
 
 2 
 
 6-8 
 
 13-3 
 
 3-2 
 
 30 
 
 3-0 
 53 
 
 September 
 October 
 
 
 
 14 
 20 
 
 4 
 
 20-0 
 
 39 
 51 
 
 174 
 
 November 
 
 
 
 24 
 
 1 
 
 4-2 
 
 4-6 
 
 3-3 
 
 December 
 
 
 
 32 
 
 1 
 
 3-1 
 
 5-2 
 
 2-5 
 
 Total 
 
 
 
 238 
 
 16 
 
 6-7 
 
 4-1 
 
 4o 
 
648 CEREBRAL DISEASE. 
 
 CHAP. XXVIII. 
 
 OX CEREBRAL DISEASE AND PARALYSIS. 
 
 Section I. — General Preliminary Remarks on the Pathology 
 and Treatment of Cerebral Disease. 
 
 The situation of the brain and spinal cord and the nature of their 
 physiological actions prevent our ascertaining the morbid states of 
 these organs by physical signs. It is therefore on derangement of 
 function that we are mainly dependent for a knowledge of their 
 diseases ; and the investigation is materially assisted by the variety 
 of the actions in which these nervous centres are engaged, and 
 by the distinctness of the phenomena which attend them. In 
 order to facilitate this inquiry it may be well to state in general 
 terms, the kind of symptoms which indicate deranged function, 
 and then attempt to relate them to conditions of the nervous 
 matter. In following this course, I shall, with the view of sim- 
 plifying the subject, confine my observations to the brain. 
 
 It may be sufficient for clinical purposes, to divide the symptoms 
 of cerebral disease into (a) Those which indicate excess of action.- 
 (V) Those which indicate defect of action. Under the first, may 
 be ranged active delirium, convulsion, pain of head, and of peri- 
 phery of nerves, intolerance of light and of sound. Under the 
 second, may be included muttering delirium, drowsiness, coma, 
 irregular spasmodic action, paralysis, anaesthesia, blindness, and 
 deafness. 
 
 When death takes place from cerebral disease, it is usually pre- 
 ceded by the passage of the first class of phenomena into the 
 second. When we investigate the pathological states of the brain 
 — that is, the proximate causes— in these two classes of symptoms, 
 our practical knowledge is advanced, by simply remembering that 
 they are generally related to different conditions of the capillary 
 circulation, as respects the quantity and quality of the blood, and 
 its rate of movement through the vessels. 
 
PRELIMINARY REMARKS. 649 
 
 In the first set of symptoms, there is probably always either that 
 active state of capillary circulation termed determination of blood, 
 present also in the early stage of inflammation ; or the quality of 
 the blood is altered by the introduction of some external agent 
 of which alcohol may be taken as a type. 
 
 In the second set there is probably a state of capillary circula- 
 tion, in which the blood moves imperfectly, in which, therefore, 
 the processes between the blood and the nervous tissue are inade- 
 quately carried on, — as obtains in passive congestion, in the stasis- 
 stage of inflammation, in anosmia, also when the cerebral substance 
 is partially unfit for function from organic lesion, haemorrhage, 
 laceration, exudation and degeneration of lymph, &c. Or the im- 
 perfect action between the blood and nervous tissue may depend 
 on the quality of the former being altered by foreign agents, as 
 narcotic poisons, or the materies of cachexias. This class of sym- 
 ptoms also often co-exists with evident pressure on the cerebral 
 mass, as from depressed fracture, considerable effusion of blood, or 
 other fluids. Without denying that the nervous matter itself may, 
 in some manner or other, be affected by these mechanical influences, 
 still I would suggest that the primary effect of pressure is exer- 
 cised on the capillary vessels, obstructing the passage of the 
 blood through them, and therefore impairing the functions of the 
 brain from deficiency of the processes between the blood and 
 tissue, just as obtains in passive congestion and ansernia, 
 
 This reference to the general pathology of the brain would be 
 incomplete without an allusion to the influence of concussion, as 
 evincing my belief that a condition distinct from that of disordered 
 capillary circulation, or changed states of the blood, may be opera- 
 tive in some of the deranged actions of the brain. But it is not 
 my intention to enter into the discussion of this question. 
 
 Assuming that these general pathological doctrines are correct — 
 what is their bearing on principles of treatment ? 
 
 1. If it be true that the first class of symptoms — those of excess 
 of cerebral action — tend to pass into the second, and then to end 
 in death, it is very evident that the prompt recognition and treat- 
 ment of these symptoms must be very important. Setting aside 
 for the present toxcemic cases, they are caused by active determi- 
 nation, or commencing inflammation, and are to be controlled by 
 the appropriate use of blood-letting, cold to the head, tartar emetic, 
 and purgatives. 
 
 2. In the treatment of the second class of symptoms much dis- 
 crimination is requisite. When they depend on general cerebral 
 
650 CEREBRAL DISEASE. 
 
 congestion — apoplexy — blood-letting, and purgatives are often use- 
 ful. When they depend on destruction of structure from extra- 
 vasated blood or the results of inflammation, on anaemia, or 
 cachexia, remedies which reduce the action of the heart and 
 lessen the quantity of blood are no longer applicable, because these 
 conditions of cerebral disease are always characterised by failing 
 action of the heart, and require the use of tonics and stimulants. 
 
 The treatment of narcotic poisoning is a consideration apart 
 from my present inquiry. 
 
 The remarks in this chapter are classed under the heads : — 
 1. Apoplexy; 2. Meningitis; 3. Acute Hydrocephalus; 4. Chronic 
 Hydrocephalus; 5. Morbid growths within the cranium ; 6. Hemi- 
 plegia; 7. Facial Palsy; 8. Paraplegia; 9. Paralysis from arsenic. 
 
 Section II. — Apoplexy. — Meningitis. — Acute and Chronic 
 Hydrocephalus. - — - Morbid Growths ivithin the Cranium. — 
 Paroxysmal Headache. 
 
 In pathology, the term cerebral apoplexy is only correctly 
 applied to sudden coma, caused by general cerebral congestion, 
 with or without serous effusion or haemorrhage. But in hospital 
 returns, it is sometimes used to designate sudden coma, caused 
 by general cerebral determination, with or without serous effusion, 
 excited by elevated temperature or alcoholic excess. In this looser 
 acceptation, the term must be understood in the following statis- 
 tical remarks. 
 
 The admissions from apoplexy, into the European General Hos- 
 pital during the fifteen years, from 1838 to 1853, amounted to 
 twenty-nine, and of these twenty-five proved fatal. The subjects 
 of these attacks were chiefly seamen, or others who had been 
 leading lives of dissipation and exposure to the sun, and who 
 had been brought to hospital some hours after the access of the 
 attack. These circumstances explain the great mortality. 
 
 Of the 31 1 fatal cases of European officers so frequently alluded 
 to, eighteen deaths took place from sudden coma, viz., seven from 
 true apoplexy ; nine from elevated temperature, and two from 
 alcohol. It has already been shown (p. 76) that of ninety fatal 
 cases of remittent fever, thirty-three took place with coma, preceded 
 by delirium or convulsion. A scrutiny of all these cases, both 
 febrile and idiopathic, would doubtless show a relation between 
 this train of symptoms and imprudence of one kind or other. 
 Thus, it appears that of the European officers who have died in 
 
ArorLExv. 
 
 651 
 
 the Bombay Presidency, from 1830 to 1850, death has been 
 caused in one sixth by forms of cerebral disease, towards the pre- 
 vention of which ordinary prudence and care exercise an undoubted 
 and considerable influence. 
 
 The admissions from apoplexy into the Jamsetjee Jejeebhoy 
 Hospital during the six years from 1848 to 1853 amounted to 
 forty-five, and the deaths to forty-three. 
 
 In the following table the admissions in different months in 
 both hospitals are shown. 
 
 
 Eur< pean General Hospital. 
 
 Jamsetjee Jejeebhoy Hospital. 
 
 Admissions. 
 
 Deaths. 
 
 Admissions. 
 
 Deaths. 
 
 January 
 February . 
 March . . 
 
 1 
 
 3 
 
 2 
 
 4 
 1 
 5 
 
 5 
 1 
 6 
 
 April . . 
 
 May .... 
 
 June . . 
 
 1 
 9 
 5 
 
 1 
 9 
 4 
 
 3 
 
 4 
 4 
 
 3 
 
 4 
 4 
 
 July . . . . 
 August . . 
 September . 
 October 
 
 1 
 1 
 
 2 
 
 1 
 
 1 
 1 
 
 2 
 1 
 
 3 
 2 
 6 
 3 
 
 3 
 2 
 5 
 3 
 
 November . 
 
 3 
 
 3 
 
 4 
 
 4 
 
 December . 
 
 2 
 
 2 
 
 6 
 
 3 
 
 Total . 
 
 29 
 
 26 
 
 45 
 
 43 
 
 Though it is well to abstain from drawing conclusions on 
 the causes of apoplexy from numbers so limited as these, and 
 stated with so little pathological precision, yet we cannot fail to 
 notice the striking contrast in the months of seizure of Europeans 
 and natives. In the former, one-half of the attacks took place 
 in the hot months May and June ; whereas in the latter, the ad- 
 missions are pretty equally distributed throughout the year. The 
 inference from this fact is, that of the admissions into the European 
 General Hospital a proportion was not true congestive apoplexy, 
 but sudden coma, related to elevated temperature, in other words, 
 sun-stroke. 
 
 With respect to the symptoms and pathology of true apoplexy, 
 I would refer the clinical student to Abercombie's classical work for 
 information equally applicable to India as to European countries.* 
 
 * I would venture to counsel the graduates of the Indian colleges who are fixing 
 the foundations of medical science and of rational medical practice in a new and great 
 country, to study well the writings of this eminent physician, not only on account of 
 the numerous valuable facts with which they are enriched, but also on account of the 
 
652 CEREBRAL DISEASE. 
 
 I have nothing to add to the lucid descriptions and philosophic 
 deductions of this distinguished pathologist. 
 
 Meningitis. — Inflammation of the pia mater and arachnoid, 
 marked by opacity and thickening of these membranes, by deposits 
 of lymph, or by serous effusion containing flaky flocculi, existed 
 in cases 10, 11, 29, 30, 31, 133, 246 ; and the notes of others, 
 some caused by injuries of the head, might have been added. 
 On the whole, then, it would appear that this form of disease 
 has not very frequently come under my notice in hospital prac- 
 tice in India. In the present defective state of hospital medical 
 statistics, there are no records calculated to show whether men- 
 ingitis is of more frequent occurrence in hospitals in European 
 countries than it seems to be in India. Of the 311 fatal cases 
 of sick officers, meningitis was the reputed cause of death in 
 six. 
 
 Acute Hydrocephalus. — During the four years that I held 
 medical charge of the Byculla Schools, the number of children was 
 about 235, and with exception of 25, their ages ranged from five 
 to fifteen, yet case 29 is the only one of cerebral inflammation 
 which came under my observation. During the succeeding eight 
 years, when the medical charge of these schools had passed into 
 other hands, and during which there had been a considerable in- 
 crease in the number of children, the only case with symptoms of 
 acute hydrocephalus which has come to my knowledge, was one 
 which occurred to Mr. Carter, who has kindly favoured me with 
 the following statement of the symptoms and the morbid appear- 
 ances found after death. 
 
 simplicity and accuracy of the diction, and the correct application of principles of 
 reasoning to medical science and observation. The " Pathological and Practical 
 Researches on the Diseases of the Abdomen," though meagre on several subjects of 
 great interest to the Indian practitioner, still contain very much that is valuable to 
 the student of medicine in all countries. The work more particularly alluded to here, 
 " Pathological and Practical Researches on the Diseases of the Brain and the Spinal 
 Cord," is not open to the same objection; for, — if we except the microscopic discrimi- 
 nation of inflammatory from degenerative softening, a more precise knowledge of the 
 pathological changes in diseased cerebral arteries, speculations relative to the influ- 
 ence of cardiac and renal disease, and the correction by Dr. Burrows of Dr. Kellie's 
 faulty experiments relative to the cerebral circulation, — I am not aware of any 
 great addition to our knowledge of the pathology of the brain since Abcrcrombie 
 wrote. 
 
 The little allusion to diathetic conditions, and the activity of the treatment, are to 
 be in a great part attributed to the fact that the subjects were not hospital patients. 
 but from classes of the community less influenced by diathetic states, and more likely 
 to be benefited by depletion. The hospital physician, in comparing his own results 
 with Abercrombie's statements, should bear this fact in recollection. 
 
HYDROCEPHALUS. 653 
 
 247. Acute Hydrocephalus. — A boy, twelve years of age, after being under treat- 
 ment with febrile symptoms from the 8th to the 23rd August, 1848, complained 
 of pain increased by pressure at the margin of the right ribs. On the 26th he 
 had headache, became drowsy, and screamed occasionally. On the 27th and 
 28th there was more or less delirium; there was drowsiness, slight strabismus, im- 
 paired vision, and a pulse ranging from 68 to 80, and a remission of febrile heat of 
 skin. During the 29th, 30th, and 31st, the drowsiness increased, the heat of skin 
 was more marked, the pulse became very frequent, and lost strength ; and he died 
 comatose on the 1st of September. 
 
 Inspiction. — The arachnoid membrane over the hemispheres of the brain presented 
 rather an opaque appearance ; it had also, where investing the cerebellum, an opaque, 
 lymphy, almost puriform character, and was much thickened at the base of the brain. 
 The lateral ventricles were much distended with serum, and the cerebral substance in 
 contact with the ventricles was softened. The fourth ventricle was also much dis- 
 tended, and the membranes about it and around the spinal cord were opaque. The 
 peritoneal surface of the liver was opaque, and studded chiefly at its lower edges with 
 granular lymphy deposit. 
 
 Thus it would seem that in Bombay, during twelve years, in 
 a body of children, in number from 255 to 350, partly Indo- 
 British, partly descended from European parents, and the greater 
 number ranging in age from five to fifteen, only one case of un- 
 doubted strumous meningitis has been observed. How far this 
 result accords with, or differs from, that of similar circumstances in 
 other countries I am unable to judge.* 
 
 "VS nen my attention is turned to the other fields of practice, in 
 which I have been engaged, only one case of acute hydrocephalus 
 in a European child of about ten months old, of strumous parents, 
 who died in the Jamsetjee Jejeebhoy Hospital, comes to my recol- 
 lection. There was no examination after death. 
 
 * In regard to the eight years during which I did not hold medical charge of the 
 Byculla Schools, my statement must be looked upon as an accurate approximation to 
 the truth. A reference to the Returns and Registers of Disease in the Schools for 
 this period, does not show any fatal case referable to hydrocephalus. I have referred 
 to two of the medical officers who have been in medical charge during the period 
 adverted to. Dr. Leith, in reply, observes, " I am certain I did not see a case of acute 
 hydrocephalus in the Byculla Schools"; and Dr. Coles states, "I do not recollect 
 any case of any description of hydrocephalus happening whilst I was in attendance 
 in the schools." Dr. Graham, who has also been in charge of the schools during this 
 period, has returned to England, and I have been unable to make a similar reference 
 to him. 
 
 The question of the comparative greater or less degree of prevalence of acute hydro- 
 cephalus in the children of these schools, is probably part of a more general question 
 of the degree of prevalence of the strumous diathesis. I do not know what might be 
 the result of the application of the test suggested by Mr. Phillips in his work on 
 Scrofula — viz., "Enlarged Cervical Glands discoverable by touch"; but I believe that 
 I am correct in saying that scrofulous disease of the joints, suppurating lymjihatic or 
 tubercular mesenteric disease, is of infrequent occurrence. On the other hand, if the 
 history of these children be traced after they have grown up and left the schools, it 
 will be found that phthisis pulmonalis is a cause of death sufficiently common : I can 
 bring to my recollection several cases in proof of this. 
 
654 CEREBRAL DISEASE. 
 
 Chronic Hydrocephalus, I have seen only two cases, both patients 
 of Dr. Peet. In one the head was three times tapped : the parti- 
 culars of the case, which terminated fatally, have been reported by 
 Dr. Peet.* 
 
 Morbid Growths ivithin the Cranium. — The following is the 
 only instance of this pathological state in my notes. 
 
 248. Amaurosis of both eyes, headache, fatuity, convulsions, tumour in the brain, with 
 much softening of the cerebral substance. — Joshua Paterson, aged twenty-five, seaman 
 of the ship Don Pascoa, was admitted into the European General Hospital on the 25th 
 April, 1841, affected with complete amaurosis of both eyes, and complaining of pain 
 of the right side of the head, fixed at the temple and shooting in different directions. 
 He was somewhat reduced in flesh and strength. He stated that about fifteen months 
 before, he became affected with headache, and had continued subject to it ever since. 
 About seven months before admission the pain was confined to the left temple, and 
 was followed by amaurosis of the left eye. Whilst at sea, about two months since, 
 the pain affected the right side of the head, and the amaurosis of the right eye took 
 place about a fortnight before admission. He continued in hospital till the 2nd 
 December, 1842, (a period of nineteen months,) when he died. During the first month 
 or two there was more or less pain of head. Leeches, blisters, &c, were used. During 
 the greater part of his residence in hospital, he was in a fatuous state, and made 
 little complaint. On two occasions he experienced convulsive fits, followed by sopor, 
 and twice extensive sloughing ulcers formed on the sacrum. Some days before his 
 death he lay in a drowsy state, with twitching movements of the fingers, and refused 
 all food. 
 
 Inspection eight hours after death. — Head. — The lower part of the anterior lobes 
 and the anterior part of the middle lobes of the brain adhered to the calvarium, and 
 were separated from it with difficulty. The brain in these sites, but chiefly the an- 
 terior part of the middle lobe of the left side, was in a very pulpy state; in the latter 
 site there was imbedded a tumour, the size of a small walnut, partly schirrous and 
 partly tubercular in its character. The rest of the brain appeared to be normal. 
 
 Paroxysmal Headache. — There is a circumstance relating to 
 the s}anptomatology of cerebral disease, to which my attention 
 was directed at a very early period of my service in India, and to 
 which a brief allusion may be useful. Cases of paroxysmal 
 headache related to malarious influence, mercurial or syphilitic 
 cachexia, came under my observation from time to time;f but 
 others in which organic cerebral disease was apprehended were 
 also of occasional occurrence : of the latter I may instance three, 
 in which this suspicion proved ultimately correct. The first, an 
 officer seen by me on the Mahubuleshwur Hills, whose case is 
 quoted by Mr. Murray, in his first report on the climate of that 
 sanitarium \ : this officer died of hypertrophy of the brain at Shola- 
 pore. The second, a much esteemed officer, who, after suffering 
 
 * "Transactions, Medical and Physical Society of Bombay," No. 7, p. 97. 
 
 f Such cases have certainly been of less frequent occurrence of late years, and this 
 I attribute to the greater caution observed in the use of mercury in the general treat- 
 ment of disease in India. 
 
 J " Transactions, Medical and Physical Society of Bombay," No. 1, p. 143. 
 
PAROXYSMAL HEADACHE. $55 
 
 for a considerable time from attacks of acute periodic headache, 
 became subject to occasional convulsion, and ultimately died, also 
 of hypertrophy of the brain. The third, an officer of the royal 
 army, under my care at Mahubuleshwur, subsequently died in 
 Dublin of cerebral disease, of the precise nature of which I have 
 not been informed. 
 
 In the year 1836, a communication on this question of diagnosis 
 was submitted by me to the Medical and Physical Society of Bom- 
 bay, in which I brought together the doubtful cases which had 
 occurred in my own practice ; and then quoted a series of instances 
 of cerebral disease characterised, with one exception, by paroxysmal 
 pain of head, extracted from the Fifth Volume of Andral's Clinique 
 Medical, and Abercrombie's work on Diseases of the Brain. The 
 diagnosis of functional from organic paroxysmal headache is 
 sometimes difficult, and depends on a careful consideration of the 
 history, and of the associated symptoms. The beneficial effect of 
 treatment directed under a belief in the functional character of the 
 headache is not always to be relied upon as a means of diagnosis : 
 in two of the three cases above adverted to — those of hypertrophy 
 of the brain — the headache was at times alleviated by the use of 
 antiperiodic remedies. 
 
 The cases of fatal cerebral disease characterised by paroxysmal 
 pain of head, reported by Audral and Abercrombie, submitted by 
 me to analysis, amount to thirty-four, and the conclusions which 
 were drawn from them may now be briefly stated. The following 
 were the lesions found after death : — 
 
 1. Softening of some part of the brain or cerebellum , 
 
 2. Tumours, chiefly encephaloid and scirrhous 
 
 3. Hypertrophy and induration of the whole cerebral mass 
 
 4. Tubercles in different parts of the brain and cerebellum 
 
 5. Patch of effused lymph on the arachnoid membrane . 
 
 9 
 
 13 
 
 3 
 
 Total 34 
 
 1. Softening of some parts of the Brain or Cerebellum. — The 
 duration of these cases was generally very much under a year, dating 
 from the commencement of the illness. In one it was only ten 
 days, and in another twenty. 
 
 The pain was usually confined to a particular part of the head, 
 and in eight of the cases it existed on the side in which the lesion 
 was found after death. In all the pain was persistent, in some 
 obtuse, in others severe, but in all acuter paroxysms took place 
 from time to time. In one case there was no pain of head, but 
 pain of the extremities of the side opposite to that in which the 
 
65Q CEREBRAL DISEASE. 
 
 lesion was found after death : the pain was followed by spasmodic 
 twitching and paralysis. In one case there was pain of head at the 
 site of lesion, and also pain of the neck and of the upper extremity 
 of the opposite side, which gradually ended in paralysis. 
 
 After the pain of head had persisted for some days a sense of 
 diminished power of the extremities of the opposite side began to 
 be experienced. This generally commenced in the upper extre- 
 mit}'-, then extended to the lower, and ended in complete paralysis. 
 Sometimes the diminution of power was preceded by spasmodic 
 twitching, or permanent contraction, of some of the joints ; and in 
 these cases the spasms were preceded by paroxysmal pain of the 
 extremities. In none of the cases under notice did spasm precede 
 the paralysis, without itself having been preceded by paroxysmal 
 pain of the affected parts. 
 
 After paralysis had existed for some time, spasmodic contractions 
 again recurred in some cases, but in these there was reason for 
 believing that there had been aggression of fresh inflammatory 
 action. 
 
 It was usually observed in these cases that with the gradual 
 access of the paralysis there was remission of the pain of the head. 
 
 In these nine cases the fatal result took place in the following 
 manner : — 
 
 By sudden apoplexy from cerebral haemorrhage .... 2 
 
 By gradual exhaustion ......... 1 
 
 By pneumonia .......... 1 
 
 By gradual coma ......... 2 
 
 By convulsion .......... 1 
 
 By access of general inflammation of brain and membranes . . 2 
 
 Total 9 
 
 From this statement it would appear that there is not much 
 likelihood of mistaking pain of head symptomatic of inflamma- 
 tory softening of the brain for functional headache. When the 
 pain — obtuse or severe — is confined to a particular part of the 
 head, is permanent but liable to occasional acute paroxysms, there 
 are grounds for apprehension. When, after the persistence of such 
 headache for some days, there is sense of tingling or pain, spas- 
 modic twitching or awkwardness in using the arm of the ojDposite 
 side, the existence of serious cerebral disease becomes almost cer- 
 tain, unless the individual affected is evidently the subject of 
 malarious cachexia. I make this latter reservation, because I have 
 witnessed at least one very striking case, in which recurrences of 
 intermittent fever with occasional periodic headache were followed 
 
PAROXYSMAL HEADACHE. G57 
 
 by spasmodic twitching of one of the arms and of the muscles of 
 the face. In this case, in consequence of the history, the periodic 
 character of the headache, the cachectic state of the patient, and 
 the choreic character of the muscular action, the affection was 
 attributed to malaria and not to cerebral disease. This patient 
 quite regained his health after return to Faigland.* 
 
 In the relation just stated between inflammatory softening of the 
 brain and pain of head, it will be understood that my observa- 
 tions apply to a certain series of cases ; for it must be well known 
 that softening of the brain often runs its course without pain of 
 head, and is then indicated by the kind of symptoms which have 
 been here described as having taken place in succession to 
 headache. 
 
 2. Tumours in the brain. — In the thirteen cases classed under 
 this head the duration of the disease was considerable. In seven 
 it extended to two or three years, in one to ten, and in another 
 to fifteen. The ages of the individuals affected with encephaloid 
 degeneration ranged from thirty to sixty years. The pain in 
 these cases was more decidedly intermittent than in those of soft- 
 ening ; but it generally became permanent towards the close of 
 the affection. When paralysis of the opposite extremities was 
 present, it generally occurred in the advanced stages, and after the 
 headache had existed for a length of time. The manner of termi- 
 nation was, in several, by the aggression of varying degrees of 
 inflammation of the membranes or substance of the brain. 
 
 3. General hypertrophy of the brain. — The three subjects of 
 this lesion were under thirty years of age, and the duration of 
 illness, dating from the commencement of cerebral symptoms to 
 
 * I have, since this passage was written, seen another case in which the diagnosis 
 was still more doubtful, because there was no influence of malaria to explain it. An 
 officer of about twenty-one years of age, of good constitution, with whom I had 
 travelled to India in July and August of 1856, not long after his arrival accompanied 
 the force to the Persian Gulf, whence he returned about May 1857, after suffering 
 from headache and pain of limbs, looked upon as rheumatic. I saw him at Poona in 
 June, when he was affected with irregular spasmodic movements somewhat choreic in 
 character. They commenced in the right side, became less there and passed to the 
 left side, but subsequently became general, and were sometimes to such a degree as to 
 seem to threaten an attack of general convulsion. The articulation was imperfect, and 
 there was slight facial twitching. The pulse was of good strength, the face flushed, 
 and no notable periodicity of the symptoms. I apprehended organic lesion probably 
 of the cerebellum. He was leeched, and an attempt made to affect the system with 
 mercury without success. There was no marked effect from the treatment, but after 
 upwards of a month he began gradually to improve, and the irregular movements ha. I 
 ceased before the middle of September. He subsequently came to England, and has 
 quite recovered his health. I saw him last in July 1860. 
 
 D U 
 
658 PARALYSIS. 
 
 the period of death, was respectively fifteen, twelve, arid ten years. 
 In all, paroxysmal headache had heen present for some years ; it 
 did not, however, present the fixed and limited character of that 
 usually related to other lesions, but extended over the whole head. 
 In one case there was complication of epilepsy from the commence- 
 ment, and in the other two convulsion towards the close. The 
 headache related to hypertrophy of the brain was frequently 
 attended with irritability of stomach. 
 
 4. Tubercles in different parts of the brain and cerebellum. — 
 The eight subjects of this morbid state were under thirty years of 
 age, and tubercles were generally found present in other organs. 
 In one death took place from pulmonary phthisis. The symptoms 
 which attended the development and progress of tubercles in the 
 brain in these cases were very similar to those already stated in 
 regard to the formation of tumours. 
 
 Section III. — Paralysis. — Hemiplegia. — Myelitis. — Para- 
 plegia. — Paralysis from Arsenic. — Facial Palsy. 
 
 The admissions from paralysis into the Jamsetjee Jejeebhoy 
 Hospital, during the six years from 1848 to 1853, amounted to 
 288, and the deaths to forty-two. They exhibit a mortality of 14-6 
 per cent,, and a ratio of 0*01 per cent, of the total hospital ad- 
 missions, and. 1-02 per cent, of the total hospital deaths. The 
 admissions are pretty equally divided throughout the yeax. 
 
 In my brief remarks on this class of disease, I shall allude to — 
 1. Hemiplegia; 2. Paraplegia; 3. Paralysis from arsenic; and 
 4. Facial Palsy. 
 
 Hemiplegia.— Of the 288 cases of paralysis, by far the greater 
 number have been hemiplegia. I regret, however, that my notes 
 do not supply data for determining with precision the proportion 
 of hemiplegia to the other forms of paralysis. The diaries of forty- 
 seven cases of hemiplegia treated in the clinical ward are before 
 me, and the few practical observations about to be offered have 
 reference to these cases, and are arranged under the heads — 
 1. Causes; 2. Pathology; 3. Symptoms; 4. Treatment. 
 
 Causes. — The ages of the forty-seven clinical patients were : — 
 
 20 to 30 years 
 31 „ 40 „ 
 
 . 22 
 . 13 
 
 41 „ 50 „ 
 
 . 6 
 
 51 „ GO „ 
 
 . 5 
 
 Upwards of GO years 
 
 1 
 
 •17 
 
HEMIPLEGIA — CAUSES, 659 
 
 In this statement, we find that three-fourths of the affected with 
 hemiplegia were below the age of forty. Whether a result so dif- 
 ferent from that which is usually asserted of the relation of age to 
 this disease is sufficient^ explained by the fluctuating character of 
 the population of Bombay, and the probable abnormal proportion 
 of individuals in the prime of life ; or whether the influence of 
 advancing years is less operative in causing hemiplegia in the 
 natives of India than of European countries, is a question which, 
 for the present, must be left sub judice. 
 
 The caste of these clinical patients is stated in respect to forty- 
 five ; viz : — 
 
 Hindoos . . . . . . .19 
 
 Mussulmans . . , . . .12 
 
 Parsees . . . . . . .10 
 
 Native Christians . . . . .4 
 
 In the chapter on Pericarditis and Endocarditis it is shown (p. 
 565) that the proportion of Parsees to the total hospital inmates is 
 only about one-twelfth ; but this statement makes the proportion of 
 Parsees affected with hemiplegia only a little less than one-fourth. 
 Though, from arrangements connected with my clinical ward, the 
 proportion of Parsees affected with hemiplegia to the other castes 
 is here represented in excess, still, from hospital experience and 
 from cases seen in consultation with the College Graduates, I 
 entertain the belief that Parsees are more subject to hemiplegia 
 than the other native classes in Bombay. 
 
 The record of the habits of these clinical patients has not been 
 sufficiently attended to. Seven are mentioned as addicted to the 
 use of spirits, opium, or bhang. 
 
 Of late years it has been maintained by pathologists, that struc- 
 tural disease of the heart, and Bright's disease of the kidney, play 
 an important part in the causation of hemiplegia as well as in that 
 of other forms of cerebral disease. The condition of the heart, 
 j udged of by physical signs, is distinctly noticed in thirty-three of 
 these cases, and in thirty of them the organ was considered healthy.* 
 In Chap. XXV., twenty-eight cases of heart-disease are treated 
 of, and cerebral affection was absent in all. In twenty-five of the 
 forty-seven clinical cases of hemiplegia, the condition of the urine 
 was carefully observed, and in none did it present traces of albu- 
 men. It has been already shown in Chap. XIX., p. 481, that 
 
 * The remaining three eases are narrated in this chapter, 251, 254, 255. If my 
 results were arrived at from fatal cases alone they would conform more nearly to those 
 usually stated; but ou a question open to clinical as well as to post mortem observal ion 
 
 is it not an error to generalise exclusively from the records of the dissecting room? 
 
660 rARALYSIS. 
 
 my cases of Bright's disease do not tend to confirm the etiological 
 relation usually supposed to exist between affections of the brain 
 and albuminuria. 
 
 On these results it may be remarked that they at least suffice to 
 justify a suspicion that it will ultimately be proved that patholo- 
 gists have, on these questions, indulged in a premature and hasty 
 generalisation. The investigations of others have doubtless shown 
 that a coincidence of the diseases is not uncommon; but that the 
 relation is one of cause and effect, is, I would submit, as yet 
 problematical. 
 
 Pathology. — As hemiplegia depends upon a deranged condition 
 of a limited portion of the nervous matter of the brain, it may be 
 assumed that the derangement is generally of a kind which involves 
 structural lesion. The destruction of tissue may be caused by 
 laceration, by a blood-clot, by inflammation ending in softening or 
 abscess, or by degeneration from mal-nutrition consequent on 
 deficient blood-supply from mechanical arterial obstruction or from 
 a general cachectic state. Twenty-nine of my clinical cases were 
 considered to be dependent on cerebral haemorrhage, fourteen 
 on structural lesion from inflammation, and one on degenerative 
 softening. The diagnosis of the hemorrhagic cases chiefly rested 
 on the suddenness of the seizure, the absence of headache, febrile 
 disturbance, soreness of the affected side, and contraction of the 
 joints; that of the inflammatory cases, on the presence of more or 
 less of these symptoms, preceded sometimes by pain of head and 
 febrile excitement. The single case of degenerative softening was 
 proved by inspection after death (255).* 
 
 Of the cases about to be narrated, six f illustrate inflammatory 
 softening; and one (255) degenerative softening. Case 256 shows 
 well the obscurity with which abscess in the brain may form, 
 and case 94 also illustrates this truth. Of the nine cases just 
 referred to, the lesion in four was in a corpus striatum, and in the 
 others was situated elsewhere in a hemisphere. In the eight in 
 which hemiplegia had been present, the lesion was, it need hardly 
 be observed, on the side of the brain opposite to the paralysed 
 extremities. In case 257, not examined after death, there was 
 hemiplegia of the right side, caused as was supposed by haemor- 
 rhage; but the occurrence of gangrene of the left leg, from obstruc- 
 tion of the femoral artery, afterwards suggested the suspicion that 
 
 * The reader ■will bear in mind thai Gluge and Bennett hare lately pointed out 
 that the distinction of inflammatory from degenerative . maybe facilitated 
 
 by the detection with the mi i f exudation < orpuscles in tin- former. 
 
 | Cases 249 to •-'•"' i 
 
HEMIPLEGIA — PATHOLOGY. 66 1 
 
 the paralysis might have been produced by obstruction of a 
 cerebral arterial branch by a blood-clot or fibrinous coagulum. In 
 case 258 there had been hemiplegia of the left side for four years, 
 followed by transient palsy of the muscles, ruled by the portio dura, 
 on the right side ; so that the case formed no exception to the 
 almost universal, but not well-explained, fact, that in hemiplegia, 
 the portio dura of the affected side remains intact. 
 
 249. Hemiplegia of the right side. — Softening of the left corpus striatum. — Crushna 
 Govind, a Hindoo cart driver, of thirty years of age, after twelve days' illness, was 
 admitted into the clinical ward, on the 24th September, 1849. There was paralysis 
 of the right side, face included, indistinct articulation, and deviation of the tongue to 
 the affected side. The right elbow and wrist were permanently flexed. There was 
 no anesthesia. The right side of the chest moved less than the left on inspiration. 
 He was leeched on the temples, a small blister applied, and diuretics and laxatives 
 exhibited. He was comatose on the 2nd October, and died on the 3rd. 
 
 Inspection nine hours after death. — Head. — There was some degree of turgeseence 
 of the vessels of the dura mater ; and those of the pia mater were very turgid with 
 blood even to their minute ramifications. The cortical substance of the brain was of 
 darker colour than natural ; and the white substance, when incised, presented 
 numerous bleeding points. There was dark-red softening in the centre of the anterior 
 and the posterior parts of the left corpus striatum. The posterior softened portion 
 was the size of a small bean : the anterior was considerably larger. There was no 
 increased serous effusion in the ventricles, nor at the base of the skull. The cortical 
 substance of the cerebellum was also darker than natural, and the white substance 
 presented numerous bleeding points on incision. No coagulum of effused blood, old or 
 recent, could be detected in any part of the brain. The kidneys were healthy. 
 
 250. Apoplexy.— Hemiplegia of the right side.— Death. — General congestion of the 
 ■membranes of the brain. — Bed softening of the left corpus striatum. — Munchee, a 
 Portuguese sailor, of forty-four years of age, was brought to hospital on the 11th 
 December, 1848. He was in a comatose state. The pupils were contracted. There 
 was paralysis of the right side, with tremors of the left leg and arm. After excesses 
 in drinking, he had been found on board ship in this condition, two days before he 
 was brought to hospital. He died on the 12th. 
 
 Inspection twenty hours after death. — Head. — On separating the skull-cap from 
 the dura mater, dark-coloured blood oozed in small quantity from the vessels. The 
 glandule Pacchioni were more developed in parts, and caused a firmer than natural 
 adhesion between the surfaces of the arachnoid, where it clips between the hemispheres 
 to line the falx. The vessels of the pia mater were congested, and a thin veil of 
 serum was here and there effused between the arachnoid and pia mater on the convex 
 surface of the brain. The anterior part of the left corpus striatum was, compared to 
 that of the other side, considerably softened, pulpy, and of dark-red colour, but there 
 was no trace of distinct extravasation of blood. The substance of the brain and cere- 
 bellum did not present any other appearance worthy of note. The vessels at the base 
 were healthy. There was no increased effusion of serum in the ventricles. Slight 
 dotted vascularity of the mucous membrane of the stomach existed. The liver and 
 the kidneys appeared healthy. 
 
 2ol. Hemiplegia of the right side.— Softening of the left corpus striatum.— Disease 
 of the mitred valve.— Mahomed-Avad, a Mussulman beggar, of thirty years of age. was 
 brought to hospital by a police peon. He was paralytic of the right side, and very 
 drowsy. He died a few hours after admission. 
 
 Inspection. — The upper portion of the left corpus striatum was reduced to a creamy 
 
 u D 3 
 
6 >2 PARALYSIS. 
 
 e, and was of darker colour. The ventricles of the heart were dilated. The 
 mitral valve was thickened, and on its surface near the attachment of the chorda 
 triii lines?, there were two or three indurated granular bodies. 
 
 2J2. Symptoms of inflammation of the brain, followed by hemiplegia of tl 
 side, and death by coma. — Bed softening of th left corpus striatum found after death. 
 — Pandoo-Souza, a washerman, of twenty-five years of age, a native of Goa, was 
 brought to the Jamsetjee Jejeebhoy Hospital, on the 30th September, 1830, in a state 
 of coma. His friends stated that he had been ill fourteen days with fever attended 
 with headache — that eight days before admission the extremities of the right side 
 had become paralysed. The coma had existed for three days. The pulse was small 
 and slow. He died on the 4th October. 
 
 Inspection mode by Mr. Lesboa. — Head. — An ounce of serum oozed out on sepa- 
 rating the calvarium, and an ounce and a half were found at the base of the skull. 
 The vessels of the pia mater were turgid, and a small point of the superior surface of 
 the left hemisphere at its middle part, anel near to the longitudinal fissure, was opaque 
 from slight lymph effusion into the sub-arachnoiel tissue, and a similar spot was ob- 
 served in the left Sylvian fissure at its commencement. Numerous bloody points 
 appeared on incising the brain. The left corpus striatum when cut into was found 
 darker than the right, and broke down readily into a soft pulpy substance on pressure. 
 There was no surrounding redness. The texture of the right corpus striatum and 
 thalamus was healthy. The other cavities of the body were not examined. 
 
 2-53. Hemiplegia of the right side. — Meningitis and softening of the a 
 
 of the left cerebral hemisph re. — The premonitory symptoms well marked. 
 ■ — An officer, of forty-two years of age, of corpulent and plethoric habit, after twenty- 
 five years' residence in India, became, in April 1834, suddenly affected with giddiness, 
 general but not severe pain of head, tingb'ng sensation in the ring and little finger of 
 the right hand, and subsequently slight impairment of articidation. The senses were 
 undisturbed. He was actively treated and resumed his duties, which were frequently 
 of a harassing description. During one or two months subsequent to the above 
 attack, there was occasional numbness anel tingling of the fingers of the right hand, 
 also at times a dragging of the right leg, and a constant and irresistible inclination to 
 ■sleep after dinner. In the course of the following monsoon all these symptoms were 
 removed, with the exception of the strong inclination to sleep. On returning to Bom- 
 bay in the ensuing cold season, from the Deeean, where the events above detailed had 
 occurred, the somnolency was still experienced, and there was frequent pain over the 
 left temple, with giddiness and feeling of numbness of the right arm. The somnolency 
 he attributed to increasing corpulence, the headache and other symptoms to biliousness, 
 aggravated by the harassing duties of his office; and by the action of a smart purga- 
 tive, they were in general temporarily removed. This officer arrived on the Mahubu- 
 leshwux Hills, on the 4th ilay, 1835, to appearance in robust health. After having 
 fell an increase of headache and giddiness for two days, he was seized in the morning 
 of the 12th with hemiplegia of tl ide and loss of speech without suspi 
 
 of consciousness. He continued without any improvement, and died on the 11th, 
 after having been comatose for only two hours. 
 
 Inspection. — Head. — There was much vascularity of the pia mater, with here and 
 there turbid Lymph effused under the arachnoid. The substance of the brain, on being 
 sliced, showed a sxi A targe portion of the central 
 
 part oi the anterior and middle lobes of the lefl hemisphere was very mat 
 softened and reduced to a pultaceous ma>s. There ••■ Lsion into the ventricles. 
 
 - healthy, hut commencing deposit i listed al t ; ., ! eginning of tin 
 I am indebted t'> .Mr. Murray for the notes of this case, and Tli*- oppor- 
 tunity of witnessing the examination after death, 
 
 254. Incomplete par 
 It ' : of part 
 
HEMIPLEGIA — PATHOLOGY. 663 
 
 ••' lr nmph re. — Bhao, a ITincloo liquor-seller, of thirty-five years of age, habit- 
 ually using spirits in moderate quantity, while evacuating the bowels at midnight, 
 suddenly fell down insensible. On becoming conscious he found the left extremities 
 deficient in power, and on the following day his speech was indistinct and he was 
 affected with headache. Four days afterwards he was admitted into the clinical ward, 
 on the 13th October, 1851. There was incomplete paralysis of the extremities and 
 face of the left side and indistinct articulation. He complained of pain of the right 
 temple, and suffered from febrile accessions coming on with chills at midnight. The 
 praecordial dulness extending from the third intercostal space was continuous with the 
 hepatic dulness, and was bounded externally by a vertical line dropped from the left 
 nipple. There was a systolic murmur at base and apex, but of different tones, also 
 a slight diastolic murmur, most distinct at the apex. The systolic murmur was loudest 
 and roughest at the third right costal cartilage and continued so to the top of the 
 sternum. The pulse was of moderate volume and distinctly jerking in character. The 
 urine was frequently tested and gave no trace of albumen. The bowels tended 
 to be relaxed. He was treated with small blisters to the nucha and diuretics, and on 
 the 5th November the paralysis of the limbs was reported to be removed, but that of 
 the face still to continue. The diarrhoea increased, became dysenteric in character ; 
 he lost strength, and on the morning of the 22nd November hs was found comatose 
 with dilated pupils, stertorous breathing, cold and clammy and imperceptible pulse, 
 and died an hour afterwards. 
 
 Inspection seven hours after death. — Brain. — There was increased vascularity of 
 the membranes of the brain, and on the convex surface considerable increased eflusion 
 of serum into the sub-arachnoid space. There was slight opacity here and there of the 
 arachnoid, and firmer adhesion than usual between the surfaces at the dipping down 
 of the falx. There was about an ounce of serum at the base of the skull. At the anterior 
 part of the right anterior lobe of the brain there was a portion near the under siu'- 
 face about the size of a pigeon's egg, soft, pidpy, and yellow, and in parts consisting 
 almost entirely of pus. There was no cyst and no traces of inflammation of the pia 
 mater or of the arachnoid in the neighbourhood of the abscess. Chest. — The heart 
 reached from the second to the seventh rib, and transversely almost to the junction of 
 the right costal cartilages with the ribs. About an ounce and a half of clear serum 
 was found in the pericardium. On the external surface of the heart there were three 
 or four opaque patches of organised lymph. The right auricle and ventricle were 
 distended with blood. The left ventricle contained a considerable quantity of dark 
 coagulated blood, was dilated, and its walls were somewhat thicker than natural. The 
 mitral valve was considerably thickened from firm warty -looking deposit, and there 
 was similar deposit on the chordae tendinese, which were rendered more friable. The 
 aortic valves were also thickened at their edges and the diameter of the aortic opening 
 increased. The right ventricle was also somewhat dilated. The tricuspid valves and 
 those of the pulmonary artery were healthy. The ascending aorta was considerably 
 dilated, and its inner surface and that of the arch was irregular and very rough from 
 firm organised deposit, which had become ossifie just above the aortic orifice. The 
 coats of the aorta much thickened. The lungs were spongy and crepitating. Abdo- 
 men. — There was no morbid appearance of the mucous membrane of the intestines. 
 The liver was healthy. There was a little encroachment on the tubular portion of the 
 left kidney. The right kidney was healthy. 
 
 Remark. — The examination after death confirmed the diagnosis of the heart disease, 
 as noted on admission, viz., " hypertrophy with dilatation of left ventricle, disease of 
 the mitral and aortic valves, the latter permitting regurgitation, dilatation of the aorta, 
 and roughing of its inner surface." 
 
 255. Hemiplegia of the left side. — White softening in the right cerebral hemisphere. 
 — Niekus, aged sixty, a beggar, an infirm old man, paralytic, and frequently in hos- 
 pital, was admitted on the 1st August, 18.52, in a state of debility. On the 25th (here 
 
 U V 4 
 
66-4 PARALYSIS. 
 
 were convulsive movements of the left side, except the face, which was- calm. Both 
 feet were flexed, pupils unaffected, skin above natural temperature ; pidse rather 
 frequent : was perfectly sensible, but spoke with difficulty, and could not protrude the 
 tongue beyond the lips. He said that he felt pain in the head and nape of the neck, 
 chiefly the latter. On the 27th there was continuance of the symptoms, with, how- 
 ever, towards evening, the convulsive movements affecting both sides. On the 28th 
 the convulsive movements were confined to the left side. He continued to sink, and 
 died on the 4th September. 
 
 Inspection by Mr. Lesboa, fifteen hours after death. — Head. — There were about 
 seven ounces of turbid fluid at the base of the skull. In the substance of the posterior 
 lobe of the right hemisphere, immediately behind, and to the outer side of the pos- 
 terior cornu of the right ventricle, there was softening to the extent which would be 
 occupied by a pigeon's egg. The softened substance was very pulpy, and of yellowish 
 white colour. The surrounding parts of the brain were healthy. The right lateral 
 ventricle was considerably enlarged, but there was no unusual quantity of fluid in it 
 or in the left. The arachnoid membrane, covering the cerebellum, was somewhat 
 thickened and opaque in some points, chiefly around and over the vermiform process. 
 No other morbid change in the brain was detected. Chest. — The lungs were healthy. 
 The aortic semi-lunar valves were thickened at their attached margins by some hard 
 deposits. In other respects the heart was healthy. The liver was smaller than natural; 
 the fibrous capsule was thickened, and the surface irregular and lobulated ; the sub- 
 stance was firm and indurated, and when cut into presented a distinct nodulated ap- 
 pearance. The nodules about the size of a small pea, with bands and streaks of white 
 fibrous tissue crossing between. 
 
 256. Abscess in the left hemisphere of the brain ; for some time general febrile 
 symptoms. — Hemiplegia of the right side some clays before death. — Jeremiah Merit, an 
 African, aged twenty-four, after a month's illness was admitted into the European 
 General Hospital, on the 2nd September, 1842. He suffered from a mild attack of 
 dysentery, and was discharged well on the 9th October. Re-admitted on the 19th 
 October ill with quotidian fever, associated with pain of the left hypochondrium : he 
 was discharged well on the 1st November. Re-admitted on the 24th November, suf- 
 fering from irregular febrile accessions, but to no great extent: he made no complaint 
 of local uneasiness, and the suspicion was entertained that he was disposed to make 
 more of his ailments than their apparent importance justified. On the 20th December 
 his bowels were relaxed, and he complained of cramps of the limbs. On the 21st the 
 right arm and leg were weak. On the 22nd there was complete hemiplegia of that 
 Bide, with occasional twitching of the arm. There was heat of skin, and he was 
 manifestly losing flesh and strength ; no headache complained of. He continued in 
 this state, with generally a febrile accession towards evening. He died on the 28th. 
 
 Inspection seven hours after death. — Head. — There was considerable thickening 
 with an opaque state of the arachnoid membrane of the upper surface of the brain, 
 with yellow points here and there. In the left hemisphere of the brain, above the 
 lat rial ventricle, there was an abscess, the size of a large walnut, filled with pus, and 
 surrounded by a pulpy state of the cerebral substance. The right side of the brain 
 was healthy. Chest. — Old adhesions of the lungs and pearly deposit on the surface 
 of the heart. 
 
 257. Apoplexy, followed by hemiplegia of the right side.— Gangrene of the left foot 
 and leg, apparently from obstruction of the femoral artery. — Kasoojee, a Hindoo, of 
 forty years of age, a native of Kattywar, but for many years resident in Bombay, fol- 
 lowing the occupation of sandal-wood seller, and temperate in his habits, was admitted 
 into the clinical ward on the 12 S 1 1 i October, 1853. There was complete hemiplegia of 
 the righl side, face included, attended with anaesthesia and absence of reflex action on 
 tickling the sole of the affected foot. Be was drowsy and unable to speak, but seemed 
 
HEMIPLEGIA — SYMPTOMS. 665 
 
 to apprehend what was said to him ; was unable to protrude his tongue. He was of 
 spare habit, but the pulse was full. The sounds and impulse of the heart were normal. 
 It was reported that, three days before admission, he had been much exposed to the 
 sun, making preparations for an entertainment ; and that subsequently, after having 
 been for some time in a stooping posture serving his guests, he assumed the erect, 
 position, then fell down suddenly in a state of complete coma, with stertorous breath- 
 ing, but without convulsion of any kind. After a time he vomited, recovered his con- 
 sciousness, but remained in the state present on admission. He continued in the hos- 
 pital till the oth November, when he was removed by his Mends. On the 30th there 
 was febrile heat of skin, and he began to complain of pain of the left leg ; and on 
 the 31st the pulse of the paralytic side was somewhat fuller than that of the left side. 
 On the 2nd November the upper part of the left leg was still painful, but the lower 
 part and the foot were cold and livid, somewhat swollen, and without sensation. No 
 signs of cardiac disease. No change in the paralytic symptoms of the right side. On 
 the 4th, absence of pulsation of the femoral artery at the left groin was noted. The 
 gangrene increased in degree, but not in extent. He suffered from epistaxis two or 
 three times, was restless, and at times wandering. The pidse lost strength and in- 
 creased in frequency, and in this state he was removed from hospital by his friends. 
 Treated with leeches to the head, a blister, and purgatives. 
 
 Remarks. — The history and the symptoms seemed clearly to point to general cere- 
 bral congestion, with partial haemorrhage, as the pi'oximate cause of the attack. The 
 gangrene of the unparalysed foot and leg, apparently from obstruction of the femoral 
 artery, suggests the question, — whether the apoplectic and paralytic symptoms might 
 not also have been due to fibrinous coagula obstructing branches of the cerebral 
 arteries. 
 
 258. Hemiplegia of lift side, persistent. — Facial palsy of the right side, consecutive 
 and transient. — Moorarjee, a Hindoo shopkeeper, of fifty years of age, was admitted 
 into the clinical ward on the 8th August, 1852. There was incomplete hemiplegia of 
 the upper and lower extremities of the left side ; but the portio dura of the right side 
 was also affected, as indicated by the open state of the right eye. The sounds and 
 impulse of the heart were normal. His statement was that the hemiplegia of the left 
 side had existed for four years, but that two days before admission, when cooking his 
 food, he suddenly fell, and that since then giddiness and the facial distortion had 
 been present. He remained under observation till the 15th September, using occa- 
 sional laxatives, diuretics, and small blisters to the nucha, and electro-galvanism to 
 the affected limbs. The urine, frequently tested, gave no trace of albumen. On dis- 
 charge he could close the right eye, and the distortion of face was almost gone ; but 
 the hemiplegia of the left side remained unchanged. 
 
 Symptoms. — The hemiplegia in these clinical cases has been 
 nearly equally divided between the two sides : there were twenty- 
 four of the right, and twenty-three of the left side. The face of 
 the same side was affected in thirty-six, articulation impaired in 
 twenty, and deviation of the tongue to the affected side, was usually 
 observed in the cases in which the face shared in the disease. 
 There was anaesthesia of the paralytic side in ten ; and in some it 
 disappeared under treatment, though no alleviation of the paralysis 
 had been effected. 
 
 There was a state of flexion more or less rigid of the elbow joint 
 of the affected side in seventeen cases ; sometimes accompanied with 
 a similar condition of the wrist or linger joints. This event gene- 
 
666 TARALYSIS. 
 
 rally occurred in cases which had been considered inflammatory 
 from the commencement, or in which the after symptoms indicated 
 the probability of inflammation having affected the cerebral tissue 
 around a blood-clot. 
 
 Dr. Todd, in his clinical lectures on paralysis, has adverted to 
 great muscular rigidity, occurring both early and late. The first 
 related to inflammatory action. The second attributed to the 
 contraction of the cicatrices consequent on absorbed blood-clot 
 acting on the neighbouring healthy tissue, and keeping up a slow 
 and lingering irritation. 
 
 The presence or absence of reflex action in the affected limbs 
 was noted in some of the cases, but not with sufficient regularity 
 to merit notice here. 
 
 I have confined my remarks on hemiplegia to the desultory 
 suggestions, which my own observations have prompted, and have 
 made no attempt to enter upon a full consideration of this impor- 
 tant subject. The work of Abercrombie, abounding with interest- 
 ing facts and philosophic deductions, should be in the hands of 
 every clinical student of this branch of pathology. 
 
 Treatment. — It is sufficiently easy to lay down abstract 
 principles of rational treatment for the different forms of hemi- 
 plegia. The difficulty is in the diagnosis, and consequently in 
 the application of the principles to particular instances. For 
 example, if the hemiplegia is due to recent cerebral haemorrhage, 
 and symptoms of general excess of blood in the cerebral capillaries 
 are present, it may be necessary to reduce this by general or toj)ical 
 blood-letting, cold to the head, position, and purgative medicines. 
 If, on the other hand, general cerebral congestion is absent, these 
 means are not required, and the removal of the clot, by absorption, 
 must be a work of time : in the management of such a case we must 
 be careful not to reduce the system too much, for this reparative 
 process is dependent on a certain vigour of the vital actions ; while, 
 at the same time, we must be watchful for the access of inflamma- 
 tion of the surrounding cerebral tissue, in order that the appropriate 
 remedies may be used. 
 
 Should, however, the hemiplegia be attributable, not to haemor- 
 rhage, but to inflammation leading to lymph exudation and soften- 
 ing, (lien the remedies appropriate for this morbid action, in relation 
 to stage and constitutional state, must be had recourse to. It hai 
 been usual — on a therapeutic principle generally acknowledged 
 and elsewhere fully explained to give, in this state of cerebral 
 disease, mevcwry to the induction of its influence on the system : it 
 
HEMIPLEGIA — TREATMENT. 667 
 
 has generally been used in my clinical cases of this nature ; but 
 benefit consecutive on ptyalism has not occurred in a single instance 
 of paralysis under my care. I am unwilling to express with con- 
 fidence a dissuasive opinion on this point of practice, but I may 
 avow my belief that benefit from mercury in inflammatory hemi- 
 plegia is improbable, simply because the paralysis does not in all 
 likelihood occur till after degenerative softening of the lymph, and 
 of the tissue around, has already taken place. Eecovery from this 
 state can only be effected by absorption of the softened substance, 
 with subsequent cicatrisation and contraction : in processes of this 
 kind mercury is not even theoretically indicated ; for, to be use- 
 ful in inflammation of the brain, it should be given in those 
 early stages of the lymph-exudation which precede softening, and 
 in which, unfortunately, the symptoms are often obscure. I make 
 no reference to the use of mercury in the hemorrhagic cases with 
 the view of favouring absorption of the clot, for I am not aware that 
 an idea so irrational has been entertained by any physician.* 
 
 Electro-galvanism, and strychnine have been used in the ad- 
 vanced stages of many of my cases, but without results calculated 
 to inspire confidence in their efficacy. 
 
 It may, in conclusion, be assumed, that suspension of part 
 of the function of the brain consequent on destruction of struc- 
 ture is a state from which complete recovery can seldom be 
 looked for, that we should be satisfied with endeavouring to limit 
 and to stop the lesion, and then to favour its repair ; and should 
 always recollect that time, and judicious regimen — not medicines 
 — conduce most to this end. 
 
 I am very sensible that these observations on hemiplegia add 
 little or nothing to existing knowledge, and that there is much in 
 respect to this disease to which the medical inquirer in India may 
 turn his attention with interest and advantage, — as the relation of 
 hemiplegia to period of life, to heart and kidney-disease, to parti- 
 cular diathesis and habits, to haemorrhage, inflammatory and 
 degenerative softening, disease and obstruction of cerebral arte- 
 rial branches, to the frequency and import of reflex action and of 
 rigidity of the joints of the affected limbs, the existence of anaes- 
 thesia, and the discrimination of the cerebral nerves which are 
 involved in the deranged processes. 
 
 Myelitis. — Idiopathic inflammation of the membranes or sub- 
 
 * I need hardly say that when symptoms indicate that inflammation is commeacing 
 
 in the nervous matter around the clot, that mercury may be indicated; bul od a 
 principle quite distinct from that of absorption of the clot. 
 
668 PARALYSIS. 
 
 stance of the spinal cord is a rare form of disease. I have notes 
 only of two cases. One a Hindoo, of thirty-five years of age, ad- 
 mitted on the 19th February, 1857, under Dr. Ballingall's care, — 
 with pain in the dorsal and lower cervical regions of the spine, 
 paralysis and anaesthesia of the lower extremities, heat of skin, 
 hurried and oppressed breathing, bronchitic rales and cough. 
 He had been ill four days, and attributed the attack to exposure 
 to cold at night in a boat. The paralysis had commenced in the 
 feet, and the evening after admission it had extended partially to 
 the right arm, with sense of formication in the left. There was 
 retention of urine. He continued with failing pulse, occasional 
 fever, no convulsion, till the 26th, when he died. 
 
 The upper part of the spinal cord, as far down as one fourth of 
 the dorsal portion, was healthy ; but from this to its termination it 
 was diffluent, mottled pink and yellowish in parts, and exhibited 
 under the microscope the exudation corpuscles of inflammation. 
 No trace of spinal meningitis. 
 
 The other case was under my own care. It occurred in a Persian 
 Parsee, who was admitted into hospital on the 14th December, 
 1856, ill, as it seemed, with gastric remittent fever. After six or 
 seven days he complained of pain about the sixth dorsal vertebra, 
 also of the chest and abdomen. The breathing was hurried ; then 
 succeeded paralysis of the upper and lower extremities, with im- 
 paired sensation, and a flexed state of the fingers. No retention 
 of urine. He continued thus till the 1st January, when an attack 
 of general convulsion, followed by coma, supervened. After re- 
 covery, there was more or less incoherence. On the 5th the con- 
 vulsion returned, and he died on the 6th. The catheter had not 
 been required. No inspection permitted. 
 
 Paraplegia. — Cases of paraplegia, consequent on injury of the 
 spine and caries of some of the vertebras, have from time to time 
 come under my observation ; as well as paraplegia in females, 
 without cognizable spinal disease, and referable, in all probability, 
 to hysteria. I cite only the following case, in which there was 
 division of the left half of the spinal cord by a stabbed wound, 
 followed by paralysis and anaesthesia of the lower extremity of the 
 same side. This case is of interest in reference to the functions 
 of the cord, and to the opinions of M. Brown-Sequard, that divi- 
 sion of one segment of the cord causes paralysis of the side of sec- 
 tion, but Loss of sensation on the opposite side not on that of the 
 section. 
 
TAIUPLEGIA. GG9 
 
 259. Division of th left half of the spinal cord hj a wound. — Paralysis and 
 anesthesia of the left lower extremity. — Joseph Gomez, aged forty-five, a painter, 
 was on the evening of the 2nd December, 1851, when sitting quietly in his house at 
 Mazagong, stabbed and wounded in three places by a Malay seaman. The wounds 
 were about the level of the fifth and sixth dorsal vertebras ; one was a foot in length, 
 and extended transversely across the middle of the back, reached to the muscles, and 
 partly divided some of them. A little above this and to the left of the backbone 
 there was a deep stabbed wound, about an inch in length, directed inwards towards 
 the spine ; its depth was not ascertained. There was a third small wound on the 
 back of the arm. When brought to the hospital shortly after the injury, there was 
 paralysis and amesthesia of the left lower extremity. The anaesthesia extended down- 
 wards from the angle of the scapula. There was retention of urine, much diarrhoea 
 and involuntary discharge of faeces. He lingered in this state till the 12th December 
 when he died. 
 
 Inspection. — The punctured wound had sliced off the left transverse process of the 
 fourth dorsal vertebra, and the point of the knife had penetrated the spinal canal and 
 divided transversely the left half of the cord, reaching almost to its median line. 
 Here there was no softening or lymph effusion. About two inches lower down, for 
 about the length of an inch, the cord seemed shrivelled, and to consist of little 
 else than the pia mater and vessels; and below this it again became of natural 
 appearance. 
 
 Re mar 7c. — This case was the subject of inquiry before the coroner, and the above 
 are the notes from which my evidence was given. I am unable to understand the 
 shrivelled appearance of the cord below the injury. The difficulty occurred to me at 
 the time. There was therefore no apparent explanation, such as laceration of the 
 parts, in making the examination. 
 
 But paraplegia is of still further interest iu India and other 
 tropical countries. Bontius, Lind, Clark, and Marshall have 
 described a form of it under the name " Barbiers." It is thus 
 defined by Copland : " Tremor with pricking, formicating pain ; 
 numbness of the extremities, principally of the lower, followed by 
 contractions and paralysis of the limbs ; inarticulation and hoarse- 
 ness of voice, emaciation, and sinking of all the vital powers." 
 This disease has been viewed as related to cachectic states, and ex- 
 posure to wet or cold, as predisposing and exciting causes. Bontius 
 confounded barbiers with beri-beri, and Marshall has accurately 
 pointed out the distinction of the two affections. But the affection 
 described under the former title, and answering to Copland's defi- 
 nition, has of late years been lost sight of. That paralysis, chiefly 
 paraplegic, related to cachectic diathesis and exposure to cold, and 
 independent of spinal structural disease, does occur in the natives 
 of India, is true : it is not common, but I have met with occasional 
 instances. The subject requires investigation; but no advantage 
 can result to science by retaining the name barbiers. It is suffi- 
 cient for the clinical inquirer in India to be aware that paraplegia, 
 related to cachexia, cold, and wet as causes, and independent of 
 
670 rARALYSIS. 
 
 structural lesion of a nervous centre, is an occasional occurrence, 
 and that its pathology and etiology are imperfectly understood.* 
 
 Paralysis from Arsenic. — Paralysis caused by arsenic is not 
 merely a subject of interest, as a toxicological fact, but also from 
 its bearing on the general pathological question of the toxcemic 
 causation of some forms of disease of the nervous system. 
 
 The case which I now quote is a good illustration of this effect 
 from arsenic. 
 
 260. Paralysis from arsenical 'poisoning : — Pneumonia also present. — Cazee Ahmud, 
 a Mussulman, of seventeen years of age, was brought to the Jamsetjee Jejeebhoy 
 Hospital, on the 20th April, about noon. It was stated that having eaten of curds at 
 nine o'clock the previous night, he became affected two hours afterwards with vomit- 
 ing, which recurred several times during the night ; also with purging. On admission 
 into hospital, the pulse was seventy-two, feeble ; the skin of natural temperature, the 
 respiration hurried, and rather thoracic, and the tongue somewhat florid at the tip. 
 There was no recurrence of vomiting after admission. The bowels, however, were 
 relaxed, but to no great extent, and on one occasion the evacuations consisted in 
 part of mucus. The tongue continued florid, and there was uneasiness at the epi- 
 gastrium. He was treated with leeches; and sinapisms to the epigastrium, and 
 effervescing draughts. He was discharged on the 30th April. He was re-admitted on 
 the 7th May. He had become considerably emaciated, and there was partial paralysis 
 of both upper and lower extremities. The hands dropped from the wrists, and the 
 fingers were bent somewhat backwards, and the hands were closed feebly and with 
 difficulty. He was able to bend the knee joints but imperfectly, and he lay stretched 
 with the feet extended, and the toes pointing downward. He was also affected with 
 cough, the breathing was somewhat short and hurried, and the left side of the chest, 
 both anteriorly and posteriorly, was dull on percussion, and the respiratory murmur 
 was inaudible. The pidse was 100, and feeble, the skin cool, the tongue whitish 
 in the centre, not florid at the edges, but there was tendency to diarrhoea, and the 
 evacuations were passed in bed. He stated that after his discharge from hospital on 
 the 30th April he attended several successive days at the police office. On the third 
 
 * In No. 12, of the " Indian Annals of Medical Science," published at Calcutta, July 
 1859, and received while these sheets are passing through the press, there is a very 
 interesting notice of this form of paralysis by Dr. J. Irving. It is stated that in 
 Pergunnah Barra, in the district of Allahabad, situated on the right bank of the 
 Jumna, 319 per cent, of the population are affected with this form of disease, and 
 that it is attributed by the people to habitual use of the kessaree dal (Lathyrus 
 saliva) as an article of food, and to exposure to wet chiefly in the monsoon season 
 between July and October. The Pergunnah is described as swampy, and intersected 
 by numerous jheels and tanks. Males suffer more than females, and different villages 
 are affected in different proportions. 
 
 Dr. Irving further rails attention to notices of this form of paralysis, attributed 
 fco kessaree by other observers, viz., by Dr. K. W. Kirk, in Upper Scinde, in his 
 "Topography of Upper Scinde;" by Col. Sleeman, in the Saugor territories, in 
 '• Rambles and Recollections of an Indian Official;" and by Dr. Thomas Thompson in 
 Thibet, in his "Travels in the Himalayas." The subject is of great interest and 
 calls for further careful investigation. The native opinion on the influence of the 
 Lathyrus sativa is worthy of every attention, but it must be' regarded as still sub 
 judice till submitted to logical and systematic inouiry. 
 
STATISTIC* 
 
 G71 
 
 day lie bad a febrile accession, attributed to haying lain on the ground at the police 
 office. The accession came on in the evening, ceased the following morning, recurred 
 the subsequent night, continued three days without distinct intermission, and left 
 his legs in the state in which they were on re-admission. During his residence in 
 hospital he complained, at times, of pain of the arms and legs, and there was a good 
 deal of desquamation of the cuticle of the hands, and about the shoulders. The 
 pneumonia was treated successfully, with Dover's powder and quinine, and a blister 
 to the affected side. He was discharged on the 4th September. The paralysis, though 
 less, still existed in considerable degree. He was unable to walk. The emaciation 
 was less, but still considerable. There had been no return of diarrhoea. 
 
 It appeared in evidence that the milkman had purchased arsenic, he said, at the 
 boy's request, for killing rats. The opinion of the judge was that the milkman's 
 story was true, and that the boy had taken the poison with suicidal intent. The 
 milkman was acquitted. 
 
 Facial Palsy. — Paralysis of the portio dura, first discriminated 
 by Sir Charles Bell and now well understood, occurs in India as in 
 other countries, presenting its usual characteristic phenomena, and 
 frequently traceable to exposure to cold. The cases which have 
 passed through the clinical ward during the six years do not, how- 
 ever, exceed three in number, and do not suggest anything worthy 
 of notice. 
 
 Section IV. — Statistics of Paralysis. 
 
 Table XLI. — Admissions and Deaths, with Per-centage, from Paralysis, 
 in the Jamsetjee Jejeebhoy Hospital, at Bombay, for the Six Years from 
 1848 to 1853. 
 
 
 1848 to 1853. 
 
 Monthly Average. 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 
 
 25 
 
 3 
 
 12-0 
 
 1-2 
 
 0-7 
 
 February 
 
 
 
 22 
 
 2 
 
 91 
 
 1-1 
 
 0-7 
 
 March . 
 
 
 
 26 
 
 4 
 
 15-4 
 
 1-2 
 
 1-04 
 
 April . 
 
 
 
 20 
 
 2 
 
 10-0 
 
 09 
 
 0-6 
 
 May 
 
 
 
 28 
 
 2 
 
 7-1 
 
 1-3 
 
 07 
 
 June 
 
 
 
 23 
 
 6 
 
 2G-1 
 
 11 
 
 1-9 
 
 July . 
 
 Augitst . 
 
 
 
 24 
 
 6 
 
 25-0 
 
 1-18 
 
 1-9 
 
 
 
 19 
 
 1 
 
 5-2 
 
 0-9 
 
 0-3 
 
 September 
 
 
 
 19 
 
 3 
 
 15-8 
 
 09 
 
 0-9 
 
 October 
 
 
 
 24 
 
 5 
 
 207 
 
 1-1 
 
 15 
 
 November 
 
 
 
 29 
 
 G 
 
 20-7 
 
 1-3 
 
 1-2 
 
 December 
 
 
 
 29 
 
 2 
 
 6-9 
 
 1-2 
 
 0-5 
 
 Total 
 
 
 
 288 42 
 
 146 
 
 111 
 
 1-02 
 
672 tetanus. 
 
 CHAP. XXIX. 
 
 ON TETANUS 
 
 Section I. — The prevalence of Tetanus in certain classes of the 
 community in India. 
 
 That tetanus is a disease of frequent occurrence in certain classes 
 of the community in India, is sufficiently apparent from Dr. Leith's 
 Eegister of Deaths in Bombay, and from the records of the Jamset- 
 jee Jejeebhoy Hospital, 
 
 During the five years from 1848 to 1852 there took place in 
 Bombay 1716 deaths from tetanus, which is in the ratio of 2*5 per 
 cent, of the total deaths during the period. 
 
 Dining the nine years from 1845 to 1853 the admissions from 
 tetanus into the Jamsetjee Jejeebhoy Hospital amounted to 289, 
 and the deaths to 186, or 64-3 per cent. The ratios of admissions 
 and deaths from tetanus to the total hospital admissions and deaths 
 may be learned in respect to six of the nine years, by reference to 
 the tabular statement at the end of the chapter : they are respec- 
 tively - 8 and 3*9 per cent. 
 
 But it would be an error to conclude from the statements which 
 have just been made, that tetanus is a disease which will neces- 
 sarily come frequently under the observation of every practitioner 
 in India. 
 
 Between the years 1829 and 1838, while doing duty with Euro- 
 pean and native troops, and at the sanatory station on the Mahu- 
 buleshwur Hills, and habitually putting myself in the way of 
 observing disease, wherever it was to be witnessed, I did not meet 
 with a single case of tetanus. 
 
 Between the years 1838 and 1845, while attached to the Euro- 
 pean General Hospital at Bombay, and in medical charge of the 
 Jail, House of Correction, and Byculla Schools, only three cases of 
 tetanus came under my notice. Two of them were idiopathic : one 
 
PATHOLOGY. 073 
 
 the son of the marshal of the House of Correction, a European boy 
 of ahout twelve years of age ; the other a sailor in the European 
 General Hospital. The third case occurred in a young English 
 merchant, consequent on a lacerated wound over the tihia, caused 
 by a carriage wheel. 
 
 Thus during the first sixteen years of my service in India, 
 though actively engaged in varied fields of practice, I met with only 
 three cases of tetanus; but during the last nine years 289 have 
 come under my observation in one institution, and a considerable 
 number of them have been under my immediate care. 
 
 I have no data before me to show the proportion of tetanus in 
 the European and native armies of India, but it is probably small. 
 On referring to my notes of fatal cases of European officers, I find 
 two instances in a total of 311 : both were traumatic, consequent 
 on lacerated wounds of the leg, by carriage wheels. The death 
 of a young English merchant in Bombay, from traumatic tetanus, 
 has already been alluded to ; another instance occurred a year 
 or two afterwards in the same class of the community from a 
 wound close to the tibia, caused by the shaft of a buggy. Thus 
 all the instances of tetanus in the higher classes of Europeans, 
 of which I have notes, were consequent on injuries to the leg by 
 carriages. The only other case which I can bring to recollection 
 is that of a medical officer at Vingorla, after a compound fracture 
 of the leg from a fall. 
 
 The brief practical remarks which I have to make on this impor- 
 tant disease will have reference to my experience in the Jamsetjee 
 Jejeebhoy Hospital. In addition to notes of my general impres- 
 sions, the diaries of thirty -three cases, of which about one half was 
 treated in the clinical ward, are before me ; also a very valuable 
 report* on tetanus, as observed in the same hospital by my able and 
 experienced colleague, Dr. Peet. 
 
 I shall arrange my remarks under the heads: — 1. Pathology. 
 2. Causes. 3. Symptoms. 4. Treatment. 
 
 Section II. — Pathology. — Nature of the deranged action with 
 reference to the Physiology of the Spinal Cord. — Division 
 into Idiopathic and Traumatic, Acute and Chronic— Morbid 
 Anatomy. 
 
 In the preliminary observations on the pathology of the brain, I 
 stated that it was sufficient for clinical purposes to divide the symp- 
 
 * "Transactions, Medical and Physical Society of Bombay," No. 1, Hew series, 
 
 . X X 
 
674 TETANUS. 
 
 toms of cerebral disease into, 1st, those which indicate excess in the 
 actions of the brain ; 2nd, those which indicate defect. 
 
 A similar classification may be made of the symptoms of disease 
 of the spinal cord. But when we confine our attention to the spinal 
 cord as a nervous centre, it is necessary to limit the inquiry to 
 the symptoms which indicate excess of action; because those 
 which imply defect may be caused by change in the medullary 
 portion which conducts, as well as in the vesicular portion which 
 originates, nervous influence. In other words, we cannot separate- 
 the defect of action of that part of the cord, which exercises the 
 function of a nervous centre, from that which exercises merely 
 the function of a nervous conductor. 
 
 Defect of action of the spinal cord has been already noticed 
 in that section of the preceding chapter which treats of Paralysis. 
 
 I would therefore now advert to the spinal cord as a nervous 
 centre, and confine my remarks to the symptoms which indicate 
 excess of action, and to the conditions on which this depends. 
 
 It is assumed that the clinical student is familiar with the 
 functions of the grey nervous matter of the spinal cord, as at 
 present taught by physiologists — that it receives impressions— ex- 
 cito-motor — made upon the peripheral extremities of afferent fibres, 
 and in responden.ee generates motor impulses — reflex — which are 
 conveyed by efferent fibres to muscular tissue ; and that the result- 
 ing action may be altogether irrespective of sensation and volition. 
 That in addition to the contraction of muscular fibre induced by 
 volition and reflex action, there is a permanent slight degree, to 
 which the terms antagonistic, muscular tension, tonicity have been 
 applied : it probably depends upon a continuous supply of nervous 
 influence, proceeding from the spinal cord as its centre of gene- 
 ration. 
 
 Excess of action of the spinal cord will then necessarily be indi- 
 cated, — 1. By forcible involuntary muscular contractions, often 
 originating without evident excito-motor impression, but always 
 readily excited by the slightest peripheral irritation. 2. By 
 excess of muscular tension, that is, by permanent rigidity of more 
 or less of muscular structure. 
 
 It is to phenomena of this kind that the term Tetanus has 
 been applied: they bear the same relation to the spinal cord as 
 a nervous centre that active delirium and excessive sensation do to 
 the brain as a nervous centre. 
 
 The subordinate phrases, trismus, opisthotonos, emprosthotonos, 
 pl€Ur08thotono8 t merely express the fact that the phenomena are 
 
tatiiology. G75 
 
 prominently displayed in certain sets of muscles: they are unim- 
 portant in reference to pathology, and may be altogether set aside. 
 
 When inquiring into the proximate cause of excess of action of 
 the brain, I remarked that it probably always consisted either of 
 that active state of the capillary circulation termed determination 
 of blood, or of an altered quality of the blood from some external 
 agent, of which alcohol might be taken as a type. 
 
 It is reasonable and consistent to entertain the same views of 
 the pathology of the spinal cord and to relate tetanus to deter- 
 mination of blood, or to toxaemia. Strychnia may be named as 
 a typical agent of the latter. 
 
 But we experience a difficulty which was not felt in the 
 instance of the brain. Tetanus has been divided into idiopathic 
 and traumatic, centric, and eccentric. The conditions of the 
 nervous centre just stated are sufficient for the explanation of the 
 idiopathic or centric ; but the traumatic or eccentric would seem 
 to imply that altered states of the periphery of afferent fibres may 
 so affect the quality of excito-motor impressions, as to lead to 
 excessive reflex action, irrespective of actual derangement of the 
 centre itself. 
 
 Without pretending to assert that injured periphery of nerves 
 may not be adequate, in some circumstances, to cause the pheno- 
 mena of tetanus, I would express my belief that derangement of 
 the spinal cord, similar to that in idiopathic tetanus, always plays 
 an important, often the principal, part in the pathology of trau- 
 matic tetanus also ; and for the following reasons : — 
 
 1. The rarity of tetanus after, compared with the frequency of, 
 injuries. 2. Tetanus after wounds is most frequent in countries 
 in which the idiopathic disease is not unusual. This fact seems to 
 imply that there exists something common in the causation of the 
 two forms. 3. Tetanus has been frequently observed after trifling 
 injuries ; but this has been chiefly, if not exclusively, in countries, 
 and in classes, in which the idiopathic form is of frequent occur- 
 rence. 4. Tetanus after wounds has not been usually noticed as 
 an early sequence of their infliction, but as an event coming on 
 after an interval of several, sometimes many, days, and in associa- 
 tion with quiescent as well as irritated conditions of the wound.* 
 
 * Dr. Peet mentions a circumstance which bears on this question. The only four 
 cases in which tetanus followed the operation of amputation, were, in persons affected 
 with traumatic gangrene; in one, tetanus came on in ten hours after the operation ; 
 in the second, in twenty hours; in the third, in forty-eight hours ; in the fourth, in 
 between three and four days. 
 
 Dr. Feet, referring to the first three cases, very justly remarks : '-Are they not 
 
 X X 2 
 
676 TETANUS. 
 
 These facts are more accordant with the idea of a diathetic influ- 
 ence extending to the spinal cord than of a mere respondence 
 to excito-motor impressions. 5. Permanent rigidity of muscular 
 structure is a symptom of traumatic as well as of idiopathic 
 tetanus ; and though we might admit that the paroxysms of spas- 
 modic action may be due to peripheral derangement alone, there 
 is no reason for believing that the action of the spinal cord in 
 respect to muscular tension is dependent on the reception of peri- 
 pheral impressions, or likely to be increased by alterations of their 
 quality. 
 
 The statement very generally made by writers on tetanus, that 
 the idiopathic form is not so severe and fatal as the traumatic, 
 is not supported by experience in Bombay. My belief is that 
 on these points there is no difference in the two forms.* If 
 there be little, if any, difference in the pathology of idiopathic 
 and traumatic tetanus, and none in the severity of the symp- 
 toms or in the principles of general treatment, then there is 
 little to be practically gained by dwelling on the distinction : it 
 is perhaps sufficient to say, that when a wound or other injury 
 co-exists with tetanus, it should be treated on ordinary surgical 
 principles. 
 
 Tetanus has also been divided into acute and chronic. 
 
 By the first is understood severity of form, and a fatal result 
 generally within nine days. By the second, less severity of symp- 
 toms, a protracted course, and often a successful termination. 
 
 These terms, which have been objected to by some writers, may 
 be viewed as synonymous with severe and mild, and as indicating 
 the influence of different degrees of the predisposing and exciting 
 conditions. In cases which terminate favourably, — whether they 
 have been mild from the commencement, or severe at first and 
 subsequently mild, — the course is always protracted, arid recovery 
 slow and gradual: this fact seems to imply the influence of a 
 diathetic state. 
 
 In regard to the morbid anatomy of tetanus, the appearances 
 
 calculated to favour the idea that there is in this disease, as in most others, a period 
 of incubation ; a stage during which the efficient cause, or more correctly, perhaps, the 
 disease itself, is actually in existence, without its presence being manifested by any 
 appreciable signs or symptoms?" He further relates the tetanus to the original 
 injury, not to the surgical operation. 
 
 * Dr. Peet, in his interesting report, has already pointed out the discrepancy 
 between tin 1 result of observation in Bombay and recorded statements, and has nar- 
 rated c;ises illustrative of the severity of the idiopathic form of the disease. His 
 opinion is that the idiopathic form is more severe than the traumatic. My im- 
 pression, as just stated is. thai there is no difference in this respect. 
 
PATHOLOGY. 677 
 
 found iii the spinal canal after death are analogous to those found 
 in the cranium, when death has followed close upon symptoms of 
 excessive action of the cerebral functions, viz., more or less 
 increased capillary turgescence, with or without increased serous 
 effusion. These are in fact the only anatomical changes which 
 may be looked for after death in organs which have been the 
 seats merely of active determination. 
 
 The question — whether inflammation of the membranes or sub- 
 stance of the cord is the proximate cause of tetanus, has been 
 discussed. 
 
 In cases which have terminated fatally after a few days' illness, 
 — and of such the records of morbid anatomy may be held exclu- 
 sively to consist, — the presence of only increased vascularity is not 
 conclusive against the idea of recent inflammation during life, for 
 in encephalitis, quickly fatal, no other appearance may be found. 
 But the improbability of tetanus being dependent on inflamma- 
 tion seems to me to rest on facts of another kind. 
 
 1. When inflammation of the cranial contents becomes pro- 
 tracted to those stages when blood-stasis or lesions of structure 
 take place, then excess of action of the brain ceases to be indi- 
 cated; but muttering delirium, drowsiness, coma, irregular mus- 
 cular contraction, and paralysis — the symptoms of defective action 
 — come on. 
 
 2. In chronic tetanus, though protracted for weeks, the symp- 
 toms of excess of action continue to the close. There is never 
 muscular relaxation or paralysis. 
 
 For these reasons, I believe that inflammation is not the proxi- 
 mate cause of tetanus. 
 
 In death from cerebral disease, the suspended function of the 
 sensorium — coma — extends to the medulla oblongata, and death by 
 apnoea takes place. But in many forms of cerebral disease, de- 
 pressed action of the heart is also very evident, and a tendency to 
 death by syncope is thereby created. 
 
 In fatal cases of tetanus, -death takes place partly by apncea, not 
 caused by paralysis of the muscles of respiration, as in cerebral 
 disease, but by their excessive contraction. I have said partly by 
 apncea, because in tetanus a depressed action of the heart, with 
 tendency to death by syncope, is also a prominent symptom, and 
 one which it is most important to regard in treatment. 
 
 The syncope maybe due to paralysis of the muscular fibre of the 
 heart, but in all probability is most generally caused by spasm. On 
 this question my data are limited ; but I have before me the notes of 
 
 x x 3 
 
678 TETANUS. 
 
 three cases observed by me subsequent to my return to India, in which 
 the heart was firmly contracted — in a state of the so-called concentric 
 hypertrophy. In all these cases there was general rigidity of the 
 muscles, and a flexed condition of the fingers at the time of exami- 
 nation, made, in one three hours after death, in another twelve, 
 and in the third nineteen. 
 
 There is still an observation to make relative to the pathology 
 of tetanus. It would seem that the reflex actions of the spinal 
 cord, which affect muscular fibres concerned in organic functions, 
 and little controlled by volition, are usually exempt from derange- 
 ment in tetanus. In this respect the contrast with hydrophobia is 
 very striking ; for in this latter disease the nervous circle of the 
 eighth pair is remarkably involved. Or this feature in tetanus 
 may be described by saying, that the muscular structures on 
 which the excess of action of the spinal cord is expended, are, in 
 the normal state of the system, also subject to contraction from 
 volition. 
 
 Section III. — Etiology. — Diathesis, Cold, Entozoa ? — External 
 
 Injuries. 
 
 The etiology of tetanus is beset with difficulty and obscurity. 
 
 1. It is most probable that there are diatheses influential in 
 the production of both idiopathic and traumatic tetanus. But the 
 nature of the agencies which induce these diatheses, whether akin 
 to malaria, or other climatic conditions, or related to habits and 
 regimen, has yet to be determined. 
 
 Though the disease shows itself most frequently in the native 
 classes who seek relief in civil hospitals, yet it has not been ob- 
 served by me to be particularly related to asthenic and cachectic 
 states, for many of the affected have been in good condition. Again, 
 when we reflect on the possible relation of tetanus to toxcemia, we 
 naturally turn to the pathology of hydrophobia, a kindred affection 
 of a limited section of the spinal cord ; and also to the fact, that 
 tetanus is never recovered from by a sudden cessation of the symp- 
 toms, but always by gradual and slow restoration. 
 
 2. Is cold a common exciting cause of idiopathic tetanus ? My 
 general impression is, that in a considerable proportion of the cases 
 the attack has been attributed to such causes as sleeping on the 
 damp ground or exposure to the night air. But when we inquire 
 into the seasons of admission and death from tetanus generally, 
 the influence of cold is not very evident. 
 
CAUSES. 
 
 679 
 
 The following is a statement of the monthly deaths from tetanus 
 of all kinds recorded by Dr. Leith : — 
 
 
 
 
 
 
 
 1848. 
 
 1849. 
 
 1850. 
 
 1851. 
 
 1852. 
 
 
 
 
 
 
 
 . 
 
 
 
 j: 
 
 JS 
 
 J3 
 
 JS 
 
 
 ~i= 
 
 
 
 
 
 
 
 
 
 a 
 
 a 
 
 s 
 
 rt 
 
 c« 
 
 C «3 
 
 a 
 
 0) 
 
 a 
 
 a 
 
 Q 
 
 a 
 
 a 
 
 
 January ..... 
 
 34 
 
 24 
 
 31 
 
 18 
 
 21 
 
 128 
 
 February 
 
 
 
 
 
 
 27 
 
 17 
 
 25 
 
 28 
 
 32 
 
 129 
 
 M arch . 
 
 
 
 
 
 
 29 
 
 28 
 
 45 
 
 26 
 
 35 
 
 163 
 
 April . 
 
 
 
 
 
 
 18 
 
 24 
 
 52 
 
 26 
 
 36 
 
 156 
 
 May . 
 
 
 
 
 
 
 24 
 
 31 
 
 44 
 
 28 
 
 22 
 
 149 
 
 June 
 
 
 
 
 
 
 25 
 
 28 
 
 50 
 
 21 
 
 34 
 
 15S 
 
 July . 
 
 
 
 
 
 
 27 
 
 24 
 
 37 
 
 27 
 
 21 
 
 136 
 
 August . 
 
 
 
 
 
 
 17 
 
 27 
 
 30 
 
 29 
 
 24 
 
 127 
 
 September 
 
 
 
 
 
 
 16 
 
 24 
 
 27 
 
 31 
 
 28 
 
 126 
 
 October 
 
 
 
 
 
 
 17 
 
 24 
 
 35 
 
 30 
 
 24 
 
 130 
 
 November 
 
 
 
 
 
 
 27 
 
 27 
 
 34 
 
 29 
 
 35 
 
 152 
 
 December. 
 
 
 
 
 
 
 22 
 
 35 
 
 37 
 
 39 
 
 29 
 
 162 
 
 T 
 
 otal 
 
 
 
 
 
 283 
 
 313 
 
 447 
 
 332 
 
 341 
 
 1716 
 
 From this we find that the deaths from December to May 
 amounted to 887, and those from June to November to 829, giving 
 an excess of 58 in favour of the first half-year, which includes the 
 cold months. 
 
 Of the 289 admissions into the Jamsetjee Jejeebhoy Hospital, in 
 nine years — 164 took place from December to May, and 125 from 
 June to November, which gives an excess of 39 in favour of the 
 half year which includes the cold months. Though it may be rea- 
 sonable to attribute part of the excess of tetanus in both these 
 instances to the influence of season, yet it must be borne in mind, 
 that the period referred to is that during which the fluctuating 
 population of Bombay is at its maximum, and during which there 
 is consequently the greatest absolute amount of sickness and death. 
 
 We saw reason to relate excess of action of the nervous matter 
 of the brain to elevated temperature as an exciting cause, and the 
 question naturally arises, may not tetanus — excess of action of the 
 spinal cord — be related to the same exciting cause ? There is no 
 good reason for entertaining this opinion ; for it must be remem- 
 bered that heat as an exciting cause of cerebral disease was most 
 frequently exhibited in the European constitution ; but tetanus is 
 far more common in the native. 
 
 3. Entozoa in the intestinal canal have been suggested as an 
 occasional exciting cause of tetanus. The lumbricus teres is very 
 
680 TETANUS. 
 
 common in natives of Bombay, and doubtless may be found fre- 
 quently present in patients affected with tetanus. But to infer 
 from this fact that there has been relation of cause and effect, would 
 be illogical, just as it would be to regard entozoa as the cause of 
 pneumonia, cholera, or the many other diseases with which in the 
 same classes they co-exist with equal frequency. 
 
 4. In traumatic tetanus* what part does the wound or injury 
 play in the causation of the disease ? I have already (p. 676) stated 
 my belief, that in the pathology of the two forms there is pro- 
 bably little difference. In all likelihood, the degree of a wound's 
 influence as a determining cause varies in different circumstances — 
 considerable when the wound is severe, trifling, if existing at all, 
 when the injury is slight. Indeed, it is sufficiently common to find 
 that the history of cases of tetanus with slight external injury, 
 points as distinctly to cold as an exciting cause, as that of many in 
 which injury does not co-exist. In a word, when the wound is 
 trifling, its influence in the causation of tetanus is, I apprehend, 
 very problematical. If this opinion be correct, then the inference 
 may be drawn, that of the cases registered by Dr. Leith, or admit- 
 ted into the Jamsetjee Jejeebhoy Hospital, the proportion of cases 
 truly traumatic was very limited.f 
 
 5. Tetanus, excited by strychnia or other poisons, if such there 
 be, is related to toxicology, and does not come within the scope of 
 this work. I have witnessed one case of the effect of an over-dose 
 of strychnia taken by mistake by a medical apprentice, and reco- 
 vered from. 
 
 Section IV. — Symptoms. — Muscular Rigidity and Spasms. — 
 Respiration. — Pulse. — Febrile Disturbance, &c. 
 
 Here, as in respect to most of the diseases which have been 
 treated of in this work, it will be taken for granted that the 
 clinical student is acquainted with the descriptions of systematic 
 writers. 
 
 * I make no special reference to the term puerperal, •which has been applied to 
 tetanus occurring in puerperal women. It is sufficient to be aware of the fact that 
 the adverse conditions in which puerperal women, natives of India, are placed, are 
 prcdisponent of tetanus. I would class the disease arising under these'eireumstanecs 
 with idiopathic not traumatic tetanus. A similar remark may be applied to trismus 
 nascent i i '.a, as tin- history of the Dublin Lying-in Hospital amply proves. 
 
 t The train of reasoning which I have followed in this section, will explain why I 
 have not dwelt apon an inference drawn by Dr. Peet, from an analysis of a portion of his 
 cases; viz. that idiopathic tetanus was most common in October, November, December, 
 and traumatic in April, May. and June. 
 
SYMPTOMS. G81 
 
 I shall, therefore, merely notice those symptoms which seem to 
 me the most important. Tetanus commences with excess of 
 muscular tension, which leads to that permanent rigidity which 
 is one of the characters of the disease. This state comes on more 
 or less quickly in different cases, and involves more or less of the 
 muscular structures. The muscles of the neck, the jaws, and 
 abdomen are those which are earliest and most universally affected. 
 This excess of tension is accompanied with sense of stiffness and 
 pain, and leads to more or less permanent closure of the mouth, 
 and rigidity of the anterior abdominal walls.* 
 
 Dr. Peet has called attention to a peculiarity in the expression 
 of the countenance which he correctly thinks is often the earliest 
 indication of tetanus. He says : — 
 
 "But, even before pain is complained of, there is often something very peculiar in 
 the expression of the face : it is not easy, perhaps, to describe exactly in what this 
 change consists, — it has seemed to me to depend upon an apparent increase in 
 breadth, the angles of the mouth being, in some degree, drawn outwards, the lips com- 
 pressed, and the eyelids slightly corrugated. This expression is very different from 
 that present at a later period, in which the skin is wrinkled, the furrows of the face 
 highly developed, the angles of the mouth depressed, and the whole appearance that 
 which has been so well designated by the term 'risv.s sardonicus.' The length of time 
 over which the change in the expression of face first noticed may extend I am unable 
 to state : I have witnessed and pointed it oiit ten hours before any other symptom of 
 tetanus was present." f 
 
 The greater or less permanent rigidity is followed, sooner or 
 later, and sometimes very speedily, by spasmodic contractions, 
 which vary in force, frequency, duration, extent, and preference for 
 particular muscles. In these variations consists the difference in 
 severity in different cases. The extent and force of the permanent 
 rigidity are always in proportion to the force, frequency, duration, 
 and extent of the spasms. The spasms may recur at intervals, 
 ranging from two or three minutes to half an hour or more, and 
 may endure from a second or two to half a minute or a minute. 
 The preference given to one set of muscles over another occasions 
 the varieties which have been previously alluded to (p. 674). 
 
 The spasms may recur without any appreciable excito-motor im- 
 pression, but they are generally very readily excited by trifling 
 
 * The fact that the permanent muscular rigidity — the excess of tension, and the 
 subsequent spasmodic contractions — excess of reflex actions — are distinct, seems to 
 me to complete the proof, that normal muscular tension is maintained by nervous in- 
 fluence generated in the spinal cord. This is a point on which physiologists have not 
 always agreed. 
 
 t " Transactions, Medical and Physical Society at Bombay," 2nd Series, No. 1, 
 p. 13. 
 
682 TETANUS. 
 
 causes, as the sound of the voice, the motion of the observer's hand, 
 the slightest touch, &c, 
 
 I concur with Dr. Peet in believing that it is not always possible 
 to say from the symptoms at the commencement whether the course 
 of the disease will be rapid and fatal, or prolonged and recovered 
 from. I have seen cases that gave every promise of being mild, 
 become suddenly and unexpectedly aggravated, and others which 
 threatened to be severe become unexpectedly moderated. 
 
 The statement usually made that the fatal result from tetanus 
 occurs for the most part within nine days from the commencement 
 of the attack, is on the whole correct. Yet exceptional cases are 
 by no means uncommon. I have seen several in which death took 
 place as late as the twentieth day, under recurrence of an aggrava- 
 tion of the symptoms, or in consequence of increasing asthenia. 
 And I entertain the opinion that more frequent recoveries, and a 
 more protracted course in fatal cases would result, if depressing 
 remedies and full narcotism were abandoned, and moderate ano- 
 dynes, with tonics, stimulants, and support, substituted. 
 
 The abnormal muscular contraction and spasm interfere with 
 the right performance of the function of respiration : hurried re- 
 spiration is always an unfavourable symptom. The marked de- 
 pressed action of the heart is practically a very important feature 
 of the disease, and one which becomes apparent at a very early 
 period in severe cases ; the pulse becomes small and very compres- 
 sible. Dr. Peet dissents from Dr. Parry's remark that, "if the 
 pulse by the fourth or fifth day does not reach 100 or 110 beats in 
 the minute, the patient almost always recovers." It is true that 
 fatal cases, with a pulse considerably below 100, for a longer 
 period than five days, and recovered cases, with a pulse of 100 
 from the commencement, may be observed. Such cases I have 
 witnessed, but still the general clinical fact remains that a frequent 
 pulse is a bad symptom in tetanus, and that when the pulse be- 
 comes small it is generally also rapid. 
 
 On the co-existence of febrile symptoms with tetanus, Dr. Peet 
 remarks : — 
 
 " The mode of commencement of the disease has presented a good deal of variety. 
 In a certain number of cases the manifestation of muscular derangement has been pre- 
 ceded by distinct febrile symptoms, not attributable to the state of the wound. These 
 have reached over a period varying from a few hours to two days. I was at one time 
 under the impression that such cases were invariably acute ; but further experience 
 lias thrown a doubt upon the accuracy of this opinion. Within the last two years I 
 have witnessed at least three cases of recovery where the premonitory febrile dis- 
 turbance was distinctly marked. 
 
TREATMENT. 683 
 
 " Febrile symptoms at or previous to the accession of the tetanic symptoms have, 
 however, been by no means general. In the larger number of cases they were alto- 
 gether absent." 
 
 In these opinions I concur ; and from having witnessed one 
 case of cured remittent fever succeeded by fatal tetanus, and one 
 case of improved tetanus followed by fatal fever, it has seemed 
 to me not improbable that the co -existence of febrile symptoms 
 with tetanus may be sometimes best explained on the supposi- 
 tion of a co-existing malarious influence acting on the affected 
 individual. 
 
 The bowels are usually constipated. The condition of the ex- 
 pellent abdominal muscles, and the small quantity of food taken, 
 are sufficient to explain this symptom. I am not acquainted with 
 any fact which countenances the idea that the muscular fibre of 
 the intestinal canal is in a state of spasm : indeed, it is very doubt- 
 ful whether there is much abnormal contraction of the sphincter 
 ani. Eetention of urine very rarely takes place in tetanus, from 
 which it may be inferred that undue contraction of the sphincter of 
 the bladder is not common. It has been already remarked that the 
 phenomena of the disease point chiefly to implication of muscular 
 fibres normally under the control of volition as well as excito-motor 
 impression. 
 
 Section V. — Treatment of Tetanus. 
 
 The most important clinical facts relative to the treatment of 
 tetanus are : — 1. The evident failing action of the heart. 2. That 
 recovery never takes place except through a protracted course and 
 a gradual subsidence of the deranged actions. 
 
 From the first fact it may be inferred that remedies sedative, as 
 blood-letting, tobacco, digitalis, tartar emetic, purgatives, mer- 
 cury, are contra-indicated. This inference is sustained by clinical 
 experience. Such means have been freely and often used, and, it 
 may be added, are now universally condemned. 
 
 From the second fact, two inferences may be drawn: — 1. That 
 as recovery is always gradual and slow, it cannot be a safe system 
 of treatment to use remedies which, while they make a decided 
 impression on the tetanic symptoms, tend to derange and materially 
 injure other actions important to life. Such remedies are narcotics 
 given to the degree of frequently inducing or maintaining a state of 
 marked narcotism. With this view opium, extract of hemp, bella- 
 donna, inhalation of ether and chloroform, have been used. The 
 tendency of this treatment is, while it relieves the spasm, to cause 
 
684 TETANUS. 
 
 death by coma. Nay, more, associated with narcotism, there is 
 always a failing action of the heart ; therefore, under narcotics used 
 to this degree, the tendency to death by syncope, already distinct 
 in tetanus, becomes seriously increased. Further, if in cases thus 
 treated, the narcotics be intermitted, it will be found that the 
 spasms will recur with greater frequency and severity than before 
 the exhibition of these remedies had commenced. The explana- 
 tion is this : the general powers of resistance of the system will 
 have been lowered, and the influence, whatever it may be, 
 which causes the tetanus will, being less resisted, be more free 
 to act. 
 
 These statements are not grounded on the observation of the 
 bad effects of the excessive use of opium or hemp, for I have 
 always felt that the injurious action of the first especially had 
 already been proved ; but they rest on my own experience of the 
 inhalation of sulphuric ether or of chloroform to the extent of 
 frequently inducing or maintaining a full narcotic influence. The 
 effect of the inhalation of chloroform in relaxing the spasms and 
 relieving the suffering of tetanus is most striking, and the tempta- 
 tion to use it freely is consequently great. But it is treacherous 
 and unsafe. The influence passes off in two or three minutes, and 
 the spasms recur. If the chloroform be frequently repeated, 
 increasing failure of the pulse becomes very evident ; if the remedy 
 be intermitted, it will be found that the frequency of the spasms 
 has been augmented by its use ; if it be continued to the close, it 
 will be found that death is preceded by some degree of muttering 
 delirium and coma, which are not symptoms of the termination of 
 tetanus when unmodified by narcotics. 
 
 A system which leads to results such as these cannot with pro- 
 priety be designated the curative treatment of tetanus. It is 
 euthanasia through chloroform, and if tetanus were an invariably 
 fatal disease, the question of its adoption might perhaps be enter- 
 tained. Such, however, is not the character of this disease, and 
 this would become still more evident if the second inference were 
 more generally acknowledged, and practically applied, viz., that as 
 recovery is always gradual and slow, the indication is to sustain the 
 strength. This we effect by such moderate use of narcotics as shall 
 somewhat relieve pain and lessen spasm, and thus ward off part of 
 that exhaustion which follows the continuance of great suffering; and 
 by tonic remedies, nourishment, and stimulants. A combination of 
 quinine with extract of hemp may be used : the former in doses of 
 from three to six grains, the latter from one to two grains, given at 
 
TREATMENT. G85 
 
 intervals of from two to six hours, with animal broths, and other 
 nourishment in small quantities frequently repeated, and from ten 
 to twenty ounces of wine in the twenty-four hours. By this system 
 of treatment not only are the protraction of the disease and the 
 chances of recovery increased, but the suffering is alleviated — 
 a fact which the protraction of the disease necessarily implies. I 
 have also used chloroform, on the principle of merely allaying 
 the pain and lessening the spasm, every third or fourth hour. For 
 this purpose the inhalation of thirty or forty minims will generally 
 be sufficient. The practical objection to chloroform is the risk of 
 over dose and the temptation to push it beyond the limits of safety. 
 But the relief of pain is not the only practical advantage gained 
 by the moderate and safe use of narcotic remedies as now re- 
 commended: the relaxation of spasm is useful by materially 
 facilitating the ingestion of food, wine, and medicines. Re- 
 covery in one case, in which the trismus was complete, seemed 
 to me to be clue to the use of thirty minims of chloroform inhaled 
 before each time of administering food : this was sufficient to 
 unlock the jaws to the necessary extent without causing injurious 
 narcotism. 
 
 In February 1853 I had the opportunity of witnessing several 
 cases of tetanus in the native hospital at Calcutta through the 
 kindness of Dr. J. Jackson ; and it was satisfactory to me to 
 find that observation in that institution had led to conclusions 
 on the principles of treating tetanus very similar to those which 
 have just been detailed, and which had for some time been enter- 
 tained by me. Dr. Jackson has since published the results of his 
 experience in the first number of the " Indian Annals of Medical 
 Science." There is, I apprehend, very little difference in the prin- 
 ciples of treatment respectively advocated by us. Dr. Jackson, 
 perhaps, attaches more value to chloroform than I am disposed to 
 accord to it. 
 
 Blisters, cold affusion, &c. — have been used : of these I have 
 not any experience ; but when we consider the readiness with which 
 the spinal cord responds to the most trifling peripheral impressions, 
 it seems to me unreasonable to expect any result but harm from 
 remedies of this class. 
 
 To remove constipation, occasional recourse may be had to com- 
 binations of castor oil and turpentine, sometimes with addition of 
 croton oil, or the latter alone given with mucilage. Dr. Jackson 
 has used aloes in small doses from time to time, with the hemp 
 and quinine. 
 
686 TETANUS. 
 
 The five following cases will serve to illustrate some of my state- 
 ments. The first three show the good effect of the treatment 
 recommended ; the fourth proves the striking influence of chloro- 
 form in relaxing the spasms, but as the urgency of the symptoms 
 was great, and the course rapid, the injurious effects of the agent 
 are not apparent; the short continuance of the relief from the 
 chloroform is, however, shown. The last case is an instance of the 
 difficulty which not unfrequently arises in determining the idio- 
 pathic or traumatic character of the disease. 
 
 261. Tetanus. — Treated with quinine, extract of hemp, wine, and nourishment. — 
 Recovered. — Mahomed Azim Khan, a Belooehee horse-dealer, of stout frame, was ad- 
 mitted into hospital on the 26th April, 1853. He had been the subject of guinea- 
 worm for fifteen days. Symptoms of tetanus had come on the day before admission, 
 subsequent to sleeping, exposed to the open air, on the ground. The spasms were 
 frequent, the trismus incomplete, the breathing hurried, and the pulse, not above 100, 
 tended to become weak. He was treated freely with quinine and extract of hemp, 
 and twenty-four ounces of wine were given daily. After this treatment was commenced, 
 the improvement was striking. The spasms lessened, the pulse improved in strength, 
 and the breathing became calm. He was removed on the 7th May by his friends, 
 who wished to take him to Kurrachee. When discharged, there was still some stiff- 
 ness and pain of the legs, with occasional spasms ; but he was otherwise well, and the 
 pulse good. This case was treated by Dr. Forbes Wat -on. 
 
 262. Idiopathic tetanus. — Treated with quinine, hemp, wine, and nourishment. — 
 Recovery . — Eunnee Ram, a Marwaree labourer, of twenty-six years of age, was ad- 
 mitted into the Jamsetjee Jejeehoy Hospital on the 29th March, 1853. He had 
 suffered from tetanic symptoms for ten days unpreceded by injury. Four clays before 
 admission the actual cautery had been applied to the spine and calves of the legs, 
 There was opisthotonos, incomplete trismus, frequent spasms, much sweating, and the 
 surface of the body was covered with sudamina. He remained in hospital till the 7th 
 May, slowly improving ; but on his discharge he was considerably reduced in flesh, 
 and there was still a good deal of rigidity of the muscles of the legs and abdomen. 
 He was treated with quinine, forty grains in the twenty -four hours, given with extract 
 of hemp ; wine sixteen ounces daily, and soup frequently. While under treatment, 
 the pulse was never above 100, and he took the wine and nourishment well. 
 
 263. Tetanus in a child. — Though fated, the good effects of treatment with quinine, 
 hemp, and attention to nourishment were very apparent. — Chund Bux, a Mussulman 
 1 toy, three years of age, residing with his parents at the Lighthouse, Colaba, in a cold 
 exposed situation, was admitted into the Jamsetjee Jejeebhoy Hospital on the 5th 
 December, 1851, on the fifth day of illness, with tetanus. He had a superficial, small, 
 suppurating, but healthy-looking wound on the forehead, caused by a fall ten days 
 before admission. The spasms were frequent, the trismus complete, the pulse feeble, 
 and the child was constantly moaning. Ten minims of the tincture of hemp were 
 given every second hour, and soup, wine, and milk, in small quantities frequently. 
 The spasms were lessened in severity, and then two grains of quinine were added to 
 (lie dose of hemp, and the medicine continued every third hour with the same atten- 
 tion to nourishment. The child seemed to be slowly improving. The spasms were 
 not so frequent, and the permanent rigidity of the abdomen was less. The trismus, 
 however, continued. Nourishment was taken frequently' in small quantities, and the 
 pulse improved in strength. This was the state of the patient on the 14th and the 
 morning of the 15th. But on the evening of the latter day there was again increase 
 
ILLUSTRATIVE CASES. 687 
 
 of the spasms, and he died in the course of the night. The treatment had been un- 
 changed till the evening of the 14th, when the intervals were lengthened to four 
 hours ; but three hours were reverted to on the evening of the loth. 
 
 264. Tetanus treated with chloroform. — Fatal. — Suttoo, a Hindoo labourer, was 
 admitted into the Jamsetjee Jejeebhoy Hospital on the 3rd November, at 4| p.m., 
 after three days' illness with tetanus. There was opisthotonos, with constant short 
 spasms of the abdominal and other muscles, causing general agitation of the body. 
 The pulse was barely perceptible. There was a superficial abraded wound at the 
 lower part of the calf of the left leg, caused by a box falling on it. A drachm of 
 chloroform was inhaled with relaxation of the spasms and development of the pulse, 
 which continued for about three minutes. The spasms and rigidity then recurred. 
 The chloroform was then repeated with similar effect ; it was again used at o\ p.m., 
 at 6^ and at 8 p.m. : in all five times. In each instance the spasms ceased, continued 
 absent about four minutes, then recurred. The pulse lost strength. He refused sa»o 
 and wine, and died at 9£ p.m. 
 
 Remark. — The utmost that can be said in favour of the chloroform is, that twenty 
 minutes' relief from suffering resulted from its use. But whether the fatal result was 
 postponed or hastened, or not influenced by it, is an open question. 
 
 265. Tetanus fatal on the twenty-first day. — Whether traumatic or idiopathic, 
 doubtful. — Treated with quinine, hemp, nourishment, and stimulants. — Fatal. — Spinal 
 veins co7igested. — Deen Mahomed, aged thirteen, a Mussulman buggy driver, was admit- 
 ted into the clinical ward on the 25th November, 1853. There was tetanic expression 
 of countenance. The mouth coidd be opened only to the extent of a quarter of an 
 inch, and the tongue protruded about half an inch. The corners of the mouth were 
 drawn outwards. There was rigidity of the muscles of the back, abdomen, and neck. 
 There were also general tetanic spasms, which lasted about half a minute, and re- 
 turned after an interval of about three minutes. The skin of natural temperature. 
 The puke, small and compressible, was about 80 during the intervals, and rose to a 
 100 during the spasms. There was a small wound covered with a scab on the inner 
 side of the left heel, and a pustule on the anterior surface of the lower third of the 
 right leg. He had been received into the hospital with trismus four days previously, 
 
 .but had deserted, and was now brought back by his friends. His statement was, that 
 the wound on the heel was caused by a stroke from a horse-shoe twelve days before, 
 but of the pustule he could give no account. The night before his first admission he 
 slept in the open air in his buggy. Was temperate in his habits. From the 27th 
 November to 4th December the spasms were not quite so severe, the intervals were 
 somewhat longer, the mouth was not quite so closed, and the pulse had improved in 
 volume. The bowels were generally slow, and the urine passed freely. He became, 
 however, notably thinner, and increased heat of skin was at times observed. Thus he 
 continued, still losing flesh, but with the pidse of pretty good volume, till the 
 morning of the 13th, when he was found bathed in perspiration, with the pulse just 
 perceptible. There had been increase of spasms during the night, and he had been 
 unable to swallow the medicine regularly. He died during the visit at which this re- 
 port was taken. The wound on the heel was nearly well on the 8th. The treatment 
 consisted of quinine four grains, extract of hemp one grain, or one grain and a half, 
 every third hour, chicken soup two ounces every fourth houi', sago two ounces, and 
 arrack half an ounce every fourth hour ; and after the 5th forty minims of chloroform 
 were inhaled every sixth hour, and the bowels were opened by an occasional dose of 
 castor oil and turpentine oil. The wound was poulticed. There was no drowsiness 
 from the hemp. The effect of the chloroform continued for about twenty minutes. 
 
 Inspection three hours and a half after death. — The body was much emaciated 
 and rigid. On examining the wound on the left heel nothing abnormal was detected 
 in the neighbouring blood-vessels and nerves. Head. — On removing the calvarium, 
 
688 
 
 TETANUS. 
 
 the vessels of the membranes of the brain were seen congested. About three ounces 
 of clear serum were found at the base of the skull, but none in the ventricles. The 
 substance of the brain was in a healthy condition. Spinal Cord. — Spinal veins were 
 turgid. The structure of the cord was healthy. Chest. — On opening the chest, the 
 lungs were found collapsed. The structure was healthy, with exception of emphy- 
 sematous patches here and there, chiefly on the anterior thin edges of both lungs. 
 The cavities of the right side of the heart were filled with dark fluid blood. The 
 left ventricle was contracted and contained no blood. Abdomen. — The liver was normal. 
 The spleen was about three inches long, and an inch and a quarter in breadth, and 
 was somewhat firmer than usual ; but the structure was healthy. The kidneys were 
 normal, the distinction between cortical and medullar portions being well marked. 
 
 Section VI. — Statistics of Tetanus. 
 
 Table XLII. — Admissions and Deaths, with Per-centage, from Tetanus, 
 in the J amsetj ee Jejeebhoy Hospital at Bombay, for the Six Years from 
 1848 to 1853. 
 
 
 
 
 1848 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 
 12 
 
 9 
 
 75-0 
 
 1-6 
 
 2-0 
 
 February 
 
 
 
 17 
 
 9 
 
 52-9 
 
 0-9 
 
 2 
 
 8 
 
 March . 
 
 
 
 25 
 
 14 
 
 56-0 
 
 1-2 
 
 3 
 
 7 
 
 April . 
 
 
 
 21 
 
 14 
 
 66-6 
 
 0-9 
 
 4 
 
 1 
 
 May 
 
 
 
 23 
 
 14 
 
 609 
 
 l'l 
 
 4 
 
 8 
 
 June 
 
 
 
 15 
 
 12 
 
 80-0 
 
 0-7 
 
 3 
 
 9 
 
 July . 
 
 
 
 13 
 
 5 
 
 38-5 
 
 0-8 
 
 1 
 
 6 
 
 August . 
 
 
 
 8 
 
 6 
 
 75-0 
 
 0-4 
 
 1 
 
 8 
 
 September 
 
 
 
 12 
 
 11 
 
 91-7 
 
 0-6 
 
 3 
 
 5 
 
 October 
 
 
 
 17 
 
 9 
 
 529 
 
 0-8 
 
 2 
 
 G 
 
 November 
 
 
 
 18 
 
 10 
 
 55-6 
 
 0-8 
 
 3 
 
 
 
 December 
 
 
 
 23 
 
 14 
 
 60-9 
 
 1-0 
 
 35 
 
 Total 
 
 
 
 204 
 
 127 
 
 62-3 
 
 0-8 
 
 3-9 
 
689 
 
 CHAP. XXX. 
 
 ON HYDROPHOBIA. 
 
 Section I. — Short allusion to Symptoms and Pathology. — 
 Illustrative Cases detailed. 
 
 I have witnessed ten cases of this fearful disease, — one in a little 
 girl of the Byculla Schools, and the other nine in the Jamsetjee 
 Jejeebhoy Hospital. 
 
 I have not any notes of the first case, but the child was bitten so 
 severely in the palm of the hand that the excision of the parts was 
 impracticable : nitrate of silver was freely applied. Symptoms of 
 hydrophobia came on in about six weeks, and proved rapidly fatal. 
 Of the other nine cases four occurred from September, 1848, to 
 September 1849, one in 1850, and three in 1851. Of one the 
 year is not given. Among the European officers in the Bombay 
 Presidency I recollect the occurrence of three cases in twenty- 
 five years. There is so little in common in the symptoms of 
 tetanus and hydrophobia that an error in the diagnosis ought 
 to be very rare. In the latter disease there is none of the 
 permanent muscular rigidity, increased by paroxysms of tonic 
 spasm, so characteristic of the former. The deranged muscular 
 action in hydrophobia is confined chiefly to the neck, pharynx, and 
 larynx, and is more clonic in character. An accumulation of viscid 
 mucus about the pharynx, larynx, and mouth, and a consequent 
 hawking and spitting, would seem to be invariably present. I 
 have observed these phenomena only once in tetanus, in slight 
 degree, but with the other symptoms of the disease so well marked 
 as to leave no room for doubt. The sensorial derangement and 
 the agitated actions consequent on excitement and alarm are 
 always, more or less, present in hydrophobia. Symptoms of this 
 kind do not occur in tetanus. 
 
 On the pathology of hydroj^hobia it is sufficient to remark 
 that the morbid poison, the cause of the disease, chiefly expends 
 
690 HYDROPHOBIA. 
 
 its force on the nervous circle of the eighth pair, and extends its 
 influence to the sensorium. 
 
 I shall best describe the phenomena of hydrophobia by narrating 
 the four* cases treated by me in the Jamsetjee Jejeebhoy Hospital. 
 
 266. Hydrophobia : three months after the lite. — Camillo Pereira, a native Chris- 
 tian, from Goa, following the occupation of cook, of fourteen years of age, was ad- 
 mitted into the clinical ward on the 24th December, 1850. It was said that he had 
 been bitten by a strange dog at Karlee on the 26th September. At about the middle 
 of the outer side of the right leg, there were three cicatrices resembling those caused 
 by a bite. He stated that on the night of the 21st December he awoke feeling chilly 
 and uncomfortable, but he fell asleep again, and was able next day to attend to his 
 avocations. On the following night he was again restless, and alarmed with dreams ; 
 and at noon of the 23rd, he was found by a friend in a state of agitation and excite- 
 ment, increased by the sight of water. He passed the night in an excited state, and 
 was with difficulty controlled by his friends. On admission into hospital the following 
 day, he was agitated, and constantly talking to himself. He made no complaint of pain, 
 but when approached or touched he shrieked as if from fear. There was no marked* 
 spasm of muscles observed. The tongue was protruded with effort and with a jerk. 
 He did not seem to be affected by currents of air, but when water was brought, lie 
 became more excited, and was unwilling to drink or even to touch it. Noises dis- 
 tressed him, and he seemed anxious to be left alone. The skin was of natural tem- 
 perature, the pulse frequent, small, and easily compressed. The bowels had not been 
 opened for two days. He died at half-past 10 p.m., about six hours after admission. 
 The excitement and alarm had continued ; the latter was chiefly indicated by an out- 
 stretching of the hands, as if to protect himself. The mouth became filled with ad- 
 hesive saliva, which excited coughing, and was constantly trickling down from the 
 right angle of the mouth. The lower extremities became cold, the pulse scarcely per- 
 ceptible, and the breathing laborious. Pills of extract of hemp and muriate of mor- 
 phia were prescribed, but he had been able to take only two. 
 
 267. Hydrophobia, treated tvitk chloroform. — Mussoojee Govinda, a Maratha, aged 
 fifty, was admitted into the Jamsetjee Jejeebhoy Hospital on the 28th August, 18-19, 
 at 5 A.M. He had been bitten on the calf of the left leg, two months before, by a 
 dog believed to be rabid. The wound healed, and he remained well till two days 
 before admission, when he suffered from fever; and the day before admission, at noon, 
 he became excited and anxious. On admission, there was constant hawking and spiit- 
 ting of frothy mucus, with a frequent ringing scream ; and these symptoms were 
 increased in paroxysms from time to time. He seemed anxious and distressed, 
 somewhat delirious, and maintained a sitting posture, grasping the tapes of the cot. 
 The pulse was very feeble. One drachm of chloroform was placed on a sponge, and 
 slowly brought near to the face: it was inhaled with apparently partial relief. It was 
 repeated every half hour, and in all ten drachms were used. He died at 2 p.m., 
 nine hours after admission. 
 
 268. Hydrophobia. — Chloroform used, but obliged to be discontinued. — Succaram 
 Bappoo, aged twenty-eight, a Bundari, was admitted into the Jamsetjee Jejeebhoy 
 Hospital on the 2nd September, 1849, at half-past 4 p.m. Two months before, he 
 had been bitten on the right leg by a dog supposed to be rabid. Some native reme- 
 dies had been used. The wound had no! completely cicatrised, but it was granulating 
 
 * The other five cases, though seen by me, were treated by Dr. Peet, and have 
 
 1 n fully reported by him in the ninth and tenth numbers of the "Transactions of 
 
 the Medical and Physical Society of Bombay." 
 
ILLUSTRATIVE CASES. 691 
 
 and healthy. The occurrence took place at Girgaum, and the dog was the property of 
 a Parsee. The patient had continued at his occupation as a day labourer till four 
 days before admission. He was brought to the hospital exposed to the rain, and all 
 his sufferings had become aggravated. He was agitated and alarmed, and constantly 
 talking incoherently, and in a supplicating manner. He lay on the abdomen, hawk- 
 ing, and at times making a barking sound ; but there was no great spitting of frothy 
 mucus. The attempt to swallow fluid, or a current of cold air from opening the win- 
 dow, or the approach of the sponge with chloroform to the face, all excited violent 
 general spasms, of short duration, but which seemed to cause much distress. The 
 attempts to give the chloroform were discontinued. The pulse was very feeble on ad- 
 mission, and by degrees became more so ; and shortly before his death, at eight p.m., 
 four hours after admission, was imperceptible. 
 
 269. Hydrophobia in a Parsee boy. — Gorabjee Dhunjebhoy, a Parsee boy, of nine 
 years of age, was admitted into the Jamsetjee Jejeebhoy Hospital about midnight of 
 the 4th.* About a month before he had been bitten on the calf of the right leg by a 
 dog on the road. The bite bled freely : it was dressed with plaster, and got well in 
 three or four days. He continued well till four days before admission into hospital, 
 when he became affected with febrile symptoms, but without spasms. On the after- 
 noon of the 4th, he first showed signs of alarm when water was brought to him, and 
 since then he has continued in an agitated state, talking much and incoherently, and 
 in a supplicating manner. He complained of thirst, but when water was offered to 
 him he became violently agitated, and said that he was unable to swallow. He 
 pointed to the throat, the head, and the thigh, and the bitten limb as the seat of pain, 
 but there was no pain experienced in the cicatrix. There was sense of chilliness and 
 annoyance from the presence of people around him. The pulse was thready and 
 barely perceptible. An attempt was made to give him some of a native remedy in the 
 form of a pulp, which had been sent from Kutnagherry by Captain Haselwood ; but 
 he was able to swallow only a small part of it, and that with great effort. He shortly 
 afterwards began to hawk and spit, and to make attempts to reteh, and some of the 
 medicine was vomited. He continued with increasing anxiety till 11 a.m. of the oth, 
 when he was removed by his friends and died half an hour afterwards. 
 
 * The month and year are not mentioned in my note, but it must have been in 
 1849 or 1850. 
 
G92 BLOOD DISEASES. 
 
 CHAP. XXXI. 
 
 ON BLOOD DISEASES. 
 
 Section I. — Object of the Chapter explained. 
 
 An altered state of the Llood has been regarded as forming part of 
 the pathology of several of the diseases which have already been 
 considered. To discuss the important subject of the pathology of 
 the blood, is not my present object. The title prefixed to this 
 chapter, has been adopted simply as a convenient one for enabling 
 me briefly to notice several blood diseases, which the time, space, 
 or data at my command, do not admit of my treating in a manner 
 commensurate with their importance. They are : — 1. Pyiemia. 
 2. Leprosy. 3. Elephantiasis. 4. Scurvy. 5. General Dropsy, 
 including Beriberi. 6. Eheumatism. 7. Snake Bite. 
 
 Section II. — Pyoemia. — Short notice of SympAoms and 
 Pathology. — Illustrative Cases. 
 
 I use the term Pyoemia, to signify the concurrence of several 
 collections of pus in the subcutaneous and intermuscular areolar 
 tissue, frequently associated with puriform cysts in the substance 
 of internal viscera, and generally attended with more or less febrile 
 disturbance always adynamic and often remittent in type. The 
 term, however, is objectionable, for it implies a relation between 
 the development of the abscesses and the pre-existence and cir- 
 culation of pus in the blood. The previous presence of pus in the 
 blood is however hypothetical. 
 
 Ten cases of this affection are before me: for eight of them I am 
 indebted to Air. S. Carvalho, who, at my request, directed his 
 attention to this subject, during the period that he officiated as one 
 «if the medical officers of the Jamsetjee Jejeebhoy Hospital. Mr. 
 
PYEMIA. 693 
 
 Carvalho submitted his notes to Grant College Medical Society, 
 and subsequently kindly placed them at my disposal. 
 
 Five cases proved fatal, and five recovered. Of the former, an 
 examination after death was made in four. Small puriform cysts 
 were found in the lungs in three, associated in two with similar 
 collections in the kidneys. In none were abscesses found in 
 the liver. In the fourth case no pus was discovered in any of 
 the internal viscera. In none were there traces of phlebitis. 
 In all, the small abscesses had evidently formed consecutive on 
 inflammation. 
 
 In each of the five recovered cases, there were several large sub- 
 cutaneous collections of pus, in such situations as the thigh, the 
 chest, over the scapula, the leg, the neck, &c. In all, two or three 
 abscesses were opened; but in some there was, in addition, the 
 formation of swelling and hardness, which threatened to pass on to 
 suppuration, but which nevertheless subsided : this latter event, 
 however, only took place towards the close of the disease, after the 
 general health had manifestly begun to improve. These abscesses 
 were all preceded by the ordinary signs of inflammation — some 
 degree of pain, heat, swelling, and hardness. 
 
 The cause of the affection was not apparent in any of the cases. 
 A suppurating wound was noticed in only one instance: it was 
 situated on the heel, and after death the veins leading from it were 
 carefully examined, but showed no trace of inflammation. In 
 all the cases there was some degree of febrile disturbance. In 
 the worst, the type was adynamic, with brown dry tongue, failing 
 pulse, and delirium ; and remissions and exacerbations were gene- 
 rally well marked. Irregularity in the period of remission, and 
 the early access of adynamic phenomena, served to raise the sus- 
 picion that the febrile symptoms were not those of malarious 
 remittent fever, and to direct attention to the early detection of 
 suppuration. 
 
 The character of the fever, and the nature of the local phe- 
 nomena, are sufficient to indicate that the disease is one of the 
 blood. In the milder instances, important internal viscera escape, 
 in the severer they are involved. The existence of pus corpus- 
 cles in the blood, entangled in and obstructing capillaries, is un- 
 proved. But even if these bodies had been detected in the blood 
 there is surely so little in common between the constitution of a 
 pus corpuscle and a globule of mercury, as to destroy the force of 
 the asserted analogy between pyaemia and Cruveilhier's frequently 
 quoted experiments. 
 
 Y Y 3 
 
694 BLOOD DISEASES. 
 
 I shall conclude these brief and desultory remarks with a short 
 summary statement of five of Mr. Carvalho's cases : viz. four fatal, 
 and one recovered. 
 
 270. Fever. — Several abscesses. — Small puriform cysts in lungs. — No trace of 
 phlebitis. — A Hindoo, of forty years of age, after eight days' illness, was admitted 
 into hospital with febrile symptoms, enlarged glands of the left side of the neck, and 
 an abscess in the left dorsal region, succeeded by dyspncea, with subcrepitous rhonehus. 
 He died five days after admission. There was purulent infiltration about the pectoral 
 muscles and neck of the left side. The lungs were of dark-red colour and cedematous, 
 and contained numerous puriform cysts, from the size of a hemp-seed to a small bean, 
 and many of them immediately beneath the pleura. No puriform cysts in the liver ; 
 no trace of phlebitis in the axillary and brachial veins of either side. 
 
 271. Adynamic fever. — Several abscesses. — Puriform cysts in the lungs. — One in 
 the kidney. — Small suppurating wound of heel. — No trace of phlebitis. — A Hindoo 
 labourei', of twenty-five years of age, was admitted into hospital with a small wound 
 in the sole of the left heel discharging pus, caused by a thorn twelve days before. An 
 abscess formed above the left knee, and further purulent collections took place, pre- 
 ceded by pain, in both axillne, and about the pectoral muscles, accompanied with 
 adynamic febrile symptoms, and hurried breathing. He died five days after admission. 
 There was no trace of phlebitis in the left saphenous and femoral veins, or in the 
 axillary and brachial veins of the right side. There was purulent infiltration in the 
 anterior and lateral parts of the chest, and extending up the neck, situated in the sub- 
 cutaneous and intermuscular areolar tissue. There had been recent pleuritis on both 
 sides. There were numerotis hepatised nodules in both lungs, from the size of a pin's 
 head to that of a pea, chiefly situated immediately under the plevu'a, with a small 
 deposit of pus in the centre of each. No trace of purulent deposit in the liver or spleen ; 
 but a small one immediately under the capsule of the right kidney. 
 
 272. — Adynamic remittent fever. — Small abscess on the forehead. — Carbuncle on 
 the back. — Numerous puriform cysts in the lungs and. kidneys. — A Brahmin, of 
 twenty-three years of age, was admitted into hospital, after fifteen days' illness with 
 fever. The type, as observed after admission, was distinctly remittent, and of adynamic 
 character. On the twelfth day after admission, a small abscess was noted on the 
 forehead ; and two days afterwards a carbuncle on the back. He died the following 
 day witli hurried breathing. There was recent pleuritis of both sides. The posterior 
 parts of both lungs were iu a state of red engorgement, with many collections of pus, 
 
 i ;: !' about the size of a small pea, and situated immediately under the pleura. No 
 deposits in the liver. After removing the capsule of the kidneys, dark-red spots were 
 observed, which, when incised, snowed pas deposit in the centre ; there were also two 
 or three similar collections of pus deep in the cortical substance. 
 
 273. Many abscesses. — Fever. — Death by exhaustion. — No puriform deposits in 
 !],■ iuli rnal viscera. — A Hindoo sepoy, of thirty years of age, was admitted into hos- 
 pital with a small abscess over the left olecranon, which was attributed to a fall sus- 
 tained eight days before. Other abscesses formed: one over the left trochanter, 
 another a1 the posterior fold of the right axilla, a (bird in (he left lumbar region, and 
 a fourth nil (lie left natis. The febrile disturbance, slight at the commencement, in- 
 creased with the progress of the affection. Diarrhoea came on and he died, exhausted, 
 seventy days after admission. No deposits of pus found in the internal viscera. 
 
 274. Adynamic fever. Several abscesses. Recovery.— A horsekeeper, of thirty 
 years of age, was admitted into the Jamsetjee Jejeebhoy Hospital with febrile symptoms 
 of adynamic type attended with delirium. On the sixth day an abscess over the left 
 pectoral muscle was detected, which lie attributed to a kick from a horse. Sub- 
 sequently, three other abscesses formed: one in the left lumbar region, a second in 
 
LEPEOSY. 695 
 
 the left thigh, and the third in the posterior part of the left leg. The abscesses were 
 all opened, and discharged red-tinged pus. There was at one time some hurry of 
 breathing and bronchitic rales. He also became affected with cholera; yet he re- 
 covered, and was discharged twenty days after residence in hospital. 
 
 Section III. — Leprosy — Tubercular and Aneesthebic. — Short 
 
 Account of the Symptoms and Pathology. 
 
 The disease, which forms the subject of the present section, is 
 the Elephantiasis Grsecorum, the Lepra Arabum — but the term 
 Leprosy is preferred by me, as sufficient and not likely to mislead. 
 Elephantiasis I shall restrict to Bucnemia — the Barbadoes or 
 Cochin leg, the Elephantiasis Arabum — as an appellation more 
 appropriate to this affection than to leprosy. This application of 
 the words leprosy and elephantiasis to these two diseases is in 
 accordance with usage in India. It is unnecessary to add that 
 leprosy is altogether distinct from the genus Lepra, of the order 
 Squamae of cutaneous diseases. 
 
 On the historical interest of leprosy in Europe throughout a 
 series of centuries, I shall not enlarge. It still prevails in Norway ; 
 and the Report of a Eoyal Commission appointed some years since 
 by the Norwegian Crovernment, and drawn up by Drs. Danielssen 
 and Boek, is, I believe, the best practical account of the disease 
 as yet published. * 
 
 Leprosy is common in India. The numbers received into the 
 Leper establishment at Calcutta are unknown to me, but I visited 
 this institution in 1853, and found the accommodation and arrange- 
 ments altogether inadequate for the comfort and well-being of those 
 afflicted with this sad disease. Through the kindness of Dr. A. 
 Hunter, the reports of the Madras Leper Hospital for the years 
 1851 and 1852 are before me. The admissions in these years 
 amounted to 212, and the deaths to thirty- two. The system fol- 
 lowed in this institution, at the time of my visit, when under the 
 judicious management of Dr. Hunter, formed a pleasing contrast to 
 that of Calcutta. The patients were classified according to their 
 previous habits and position in life. Books were provided for the 
 educated ; and gardening and other light occupations conducive to 
 health and cheerfulness were encouraged. The arrangements for 
 
 * I have not had the opportunity of consulting the original work of the Norwegian 
 Physicians, " Traite de la Spedalskhed, ou Elephantiasis des Grecs," &c. It is fully 
 referred to by Mr. Erasmus Wilson in a series of interesting papers in the " Lancet, ' 
 April 1856, and was noticed some years since in the "British and Foreign Medico- 
 Chirurgical Review." 
 
 V Y 4 
 
6 ( jG 
 
 BLOOD DISEASES. 
 
 lepers in Bombay, inferior to those of Madras, are superior to those 
 of Calcutta. There is accommodation allotted for them in the 
 Jamsetjee Jejeebhoy Dhurmsala, and under exacerbations of the 
 disease they are received into a ward of the Jamsetjee Jejeebhoy 
 Hospital appropriated for the purpose. * 
 
 During the six years from 1848 to 1853, 391 cases of leprosy 
 were admitted into the hospital, and of these ninety-nine died. 
 Under the system which obtains of transferring the patients from 
 the dhurmsala to the hospital on exacerbations of the symptoms, 
 and retransferring them to the dhurmsala on remissions, there must 
 necessarily be a considerable number of re-admissions included in 
 the 391 cases above adverted to. 
 
 Though visiting the leprous patients in the hospital almost 
 daily, the various other subjects which pressed upon my attention 
 prevented me from entering upon the careful clinical study of this 
 disease. I, however, requested Mr. Lisboa, an intelligent graduate 
 of Grant Medical College, during the period of his service in the 
 hospital, to investigate the subject, and supply my deficiencies. 
 His researches formed the subject of an interesting communication 
 to Grant College Medical Society.f 
 
 Leprosy in Bombay occurs both in the tubercular and anaesthetic 
 form, and occasional cases are observed in which the characters of 
 both varieties are combined ; but in this brief and imperfect notice I 
 must confine my remarks to a summary statement of the charac- 
 teristic symptoms of the two forms, and to a passing allusion to the 
 pathology and treatment. I trust, however, that at no remote 
 period, the clinical history and pathology of leprosy may be inves- 
 tigated in a manner commensurate with the opportunities enjoyed 
 by many practitioners in India, and worthy of comparison with the 
 careful inquiry of the Norwegian Commission. 
 
 Tubercular Leprosy. — The characteristic phenomena of this form 
 of leprosy are sometimes preceded by a sense of languor and de- 
 pression, and occasionally by distinct febrile accessions. More 
 general^, however, the symptoms come on gradually and slowly, 
 without premonitory indications. Irregularly disseminated patches 
 of the skin become discoloured, and present a dark reddish or livid 
 
 * Before Leaying India in September 1859, I placed the reports of the Madras 
 Leper Hospital in the hands of Dr. Bhao Dhajee, and proposed to him as an object 
 worthy "of his well-known zeal and philantrophy the establishment and endowment, 
 with the aid of his fellow-eountiymen, of an institution in the proximity of Bombay, 
 arranged in such manner as to minister to the comfort and the cheerfulness of this un- 
 fortunate chis^ of sufferers. 
 
 f Extracts have been published in the "Transactions of the Medical and Physical 
 Society of Bombay," No. 2, New Series, p. 290. 
 
LEPROSY. GU7 
 
 appearance, Avith a surface shining as if oil Lad been applied to it. 
 The skin in these situations has, for the most part, its sensibility 
 blunted ; but this state is sometimes preceded by a stage of tender- 
 ness and pain. Then the vivid colour fades, the skin is left brown 
 and tawny, and becomes thickened and tubercular. The morbid 
 deposit is in some cases confined to the cutis, in others it extends 
 to the subjacent areolar tissue. The cutaneous tubercles thus 
 formed are small, soft, reddish or livid, and vary in size from a 
 pea to an olive. They appear on every part of the face, but par- 
 ticularly on the ' nose and ears, and on the legs. In some rare 
 instances they are confined to the legs. The disease may remain 
 stationary in this state for some time; then the tubercles become 
 affected with inflammation, and either suppurate or pass into states 
 of foul ulceration, and those about the toes and fingers may lead to 
 sphacelus and sloughing of the phalanges. The mucous mem- 
 brane of the mouth, the fauces, the uvula, the tonsils, the pharynx 
 and the nasal fossa?, become also studded with tubercular eleva- 
 tions, and these may degenerate and ulcerate, and give rise to sero- 
 puriform and sanious discharges. The disease may now extend to 
 the cartilages, and bones of the nose, and affect internal organs, as 
 the lungs. 
 
 Anaesthetic Leprosy. — Large bullae are often the first sign of 
 this form of the disease. They lead to the formation of spots or 
 patches of lighter shade than the surrounding skin in the darker 
 races, and of a tawny brown colour in the white races. They 
 appear first on the feet, hands, legs, and arms, seldom on the face 
 and trunk till an advanced period. They are sometimes slightly 
 prominent, and the hair on affected parts falls off. These patches 
 are insensible, and extend slowly over the legs and arms to the 
 trunk, and are unattended with swelling. As the disease advances 
 the toes and fingers become shining and slightly swollen and stiff. 
 The soles of the feet and palms of the hands present deep ragg< d 
 furrows; ulcers form on the metacarpal and metatarsal articulations 
 in the lines of flexion, enlarge by sphacelation, and the fingers and 
 toes drop off, and the parts that are left cicatrise. At this stage 
 the lobes of the ears and alas of the nose become thickened and 
 enlarged, and ultimately ulcerate. The voice now becomes hoarse, 
 ulceration attacks the throat ; and after a period of years, more or 
 less prolonged, during which these morbid processes have been going 
 on, diarrhoea or dysentery supervenes, and hastens the fatal result 
 
 General Pathology of bulk forms. — Leprosy is a striking in- 
 stance of a cachexia causing structural change of organs, by exuda- 
 
608 BLOOD DISEASES. 
 
 tion-deposit from the blood, with subsequent degeneration of the 
 deposit, and more or less of the adjacent structures. Drs. Daniels- 
 sen and Boek have stated, that in the anaesthetic form, much of the 
 deposit takes place about the spinal cord, as between the arachnoid 
 and pia mater, and that the cord becomes hard, tough, and reduced 
 in size. 
 
 The morbid anatomy of leprosy has been altogether neglected 
 in India. Mr. Lesboa reports only one case in which an examina- 
 tion after death was made, and in this, though of the anaesthetic 
 form, the appearances described by the Norwegian physicians were 
 not present. 
 
 On the nature of the altered condition of the blood, and of the 
 causes which induce it, I am unable to offer any useful practical 
 suggestion ; and the same remark may be made on the treat- 
 ment. I am not acquainted with any medicines capable of 
 controlling this disease, beyond what obtains in all cachectic 
 diseases from a well-adjusted tonic regimen and suitable tonic 
 remedies. 
 
 Section IV. — Elephantiasis. — Symptoms. — Pathology. — 
 Causes. — Treatment. 
 
 As explained in the last section, I apply the term Elephantiasis 
 to that disease which has been described under the names Elephan- 
 tiasis Arabum, Bucnemia, Barbadoes leg, Cochin leg, Egyptian 
 Sarcocele. It is not uncommon in Bombay, but occurs still more 
 frequently in other parts of India, as in Bengal and on the coast 
 of Malabar. 
 
 Symptoms. — The parts of the body most generally attacked are 
 the extremities — the lower more frequently than the upper — the 
 scrotum, the labia pudendi, and the mamma?. The affection is very 
 often ushered in with rigors, nausea, headache, and febrile excite- 
 ment; then the part which is to suffer becomes red, swollen, with 
 a sense of smarting heat, and sometimes tenderness and hardness 
 in the course of the lymphatics leading to the nearest glands: 
 similar phenomena also occasionally occur in the course of the 
 veins. These general and local symptoms, with exception of a cer- 
 tain degree of tumefaction of the part, disappear in a few days. 
 Then, after irregular intervals, the same train of symptoms recurs 
 from time to time; and after each attack, the affected part is left 
 more tumefied and indurated, till finally it attains that great in- 
 crease of bulk, to which it owes the designation elephantiasis. 
 The cutaneous surface is left of a pale yellowish or livid colour ; it 
 
ELEPHANTIASIS. 699 
 
 is often scaly, rough or fissured, and covered with soft vegetations 
 or horny excrescences, and more rarely is ulcerated. In other cases 
 the surface is traversed by enlarged veins. In the advanced stages, 
 deep-seated suppuration, with offensive discharge and sphacelus, 
 may take place in different parts of the diseased mass, or in the 
 enlarged lymphatic glands in its proximity : sometimes a milky-like 
 fluid oozes in considerable quantity from the hypertrophied papilke 
 of the skin, and generally coagulates spontaneously into a gelatinous 
 mass. 
 
 Pathology. — From the circumstance of the local affection being 
 preceded by febrile excitement *, being liable to frequent recurrences, 
 
 * Since these remarks appeared in the first edition of this work, a report on 
 " Elephantiasis as it exists in Travancore," has been published in the ninth number 
 of the " Indian Annals of Medicine/' by Mr. Waring, in which the primary character 
 of the fever and the secondary character of the deposits is advocated. Dr. Ballingall, 
 in the fourth number of the new series of the "Transactions of the Medical and Phy- 
 sical Society of Bombay," dissents from Mr. Waring's views, and regards the local 
 affection as the primary morbid state, and the fever as symptomatic, and he thinks that 
 the solution of this question has an important bearing on the surgical treatment of 
 elephantiasis. Dr. Ballingall justly does not attach much importance to conclusions 
 drawn from the mere statement of native patients, and he states that his own 
 experience, which he admits to have been limited, does not support the view of 
 periodicity of the attacks of fever and deposit. The fact that fever has ceased to 
 appear in his cases of elephantiasis of the scrotum, after removal of the tumour, seems 
 to him also a valid reason for concluding that the affection is local. 
 
 I still retain the opinion indicated in the text, that the disease is endemic, the fever 
 primary, and the deposit secondary — -just as the albuminous dejiosits in the liver and 
 spleen are secondaiy on recurring intermittent fever. Further, that by preventing 
 the fever in its early stages by suitable treatment and change of air, the deposits 
 may be prevented in a great many cases. The argument in favour of a local origin 
 from the circumstance of fever not returning after removal of the tumour, must, it 
 seems to me, be received with much reservation. First, there should be a complete 
 history as to the duration of the local affection, the locality of its origin and progress, 
 as bearing on the likelihood of the return of fever at the locality of operation. 
 Second. The existence of a large scrotal tumour is sufficient in a malaria-tainted 
 constitution to determine recurrences of fever, with a frequency that may admit of 
 being materially lessened by removal of the tumour, irrespective of considerations 
 relating to changes in the locality of origin, progress, and surgical operation. 
 
 3Ir. Waring also, it seems to me, attaches too much importance to the likelihood of 
 return as an argument against surgical interference ; for though the treatment of the 
 constitutional state cannot receive too much attention after the operation, still it 
 must be remembered that, in the instance of the scrotum, the deposit has probably 
 selected that part in consequence of the favouring influence of anatomical conditions of 
 structure and position, and that, when the tumour is removed, the conditions which 
 favoured its origin have also ceased to exist, and therefore the return of the tumour 
 becomes improbable. Why elephantiasis of the leg is common in some places, and that of 
 the scrotum in others, I do not know. But the fact is so. and is practically important 
 in forming an estimate of the chances of return of elephantiasis in other parts after the 
 removal of a scrotal tumour. 
 
 There is still room for further accurate clinical research in this disease. 
 
700 BLOOD DISEASES. 
 
 consisting of inflammatory action in particular tissues, and leading 
 to peculiar results, elephantiasis may be regarded as a blood disease. 
 An exudation of liquor sanguinis takes place into the interstices of 
 the affected structure, and the lymph becomes formed into fibrous 
 tissue of low organisation. On examining the diseased parts after 
 death, the epidermis and the cutis are found thickened, sometimes 
 to the extent of half an inch and more. The subcutaneous areolar 
 tissue is either hypertrophied in a less degree than the cutis, or it 
 has a semi-liquid gelatinous matter deposited in its areolae. The 
 microscopic appearances of this abnormal fibrous and elastic tissue 
 are described and figured in an interesting account of this disease 
 published by Professor Allan Webb.* The muscles are in general 
 pale, thin, or softened. 
 
 By some pathologists, as Dr. T. A. Wise f , elephantiasis is sup- 
 posed to originate in inflammation of the veins, preventing the free 
 return of blood from the affected part ; but this opinion is not 
 generally concurred in. The more probable view is, that the 
 thickening of the coats of the veins, the state sometimes of dilata- 
 tion, at others of contraction of these vessels, are due to the influ- 
 ence of the lymph exudation and organisation, and the varying 
 necessity, hence arising, for freer channels for the return of an 
 abnormal quantity of blood. A marked difference between the 
 pathology of Leprosy and Elephantiasis is, that in the former 
 there is a more general and extensive exudation dej^osit, and a 
 greater deviation in it from the blood plasma, as is shown by its 
 readiness to undergo softening, ulceration, and gangrene. 
 
 Causes. — Elephantiasis would seem to be related to particular 
 localities ; to be most common in damp, low situations, near to the 
 sea, in warm climates. It has also been supposed that the use of 
 fermented toddy is favourable to its production, just as wine and 
 beer are to that of gout. 
 
 Treatment. — It is of great consequence to note the earliest 
 indications of this disease ; to treat the febrile symptoms on ordi- 
 nary principles with emetics, purgatives, diaphoretics, and rest, 
 and the local inflammation by evaporating lotions and position. 
 After the febrile attack and the coincident local phenomena have 
 been removed, then the indication of cure is to elevate the general 
 health, to prevent recurrences of fever by the use of quinine, and, 
 
 * " Indian Annals of MedlcaJ Science," No. 4. 
 
 t The very instructive observations on Elephantiasis by Dr. Wise, will be found at 
 p. 156, of the seventh volume of the " Transactions of the Medical and Physical 
 .Society of Calcutta." 
 
SCURVY. 701 
 
 when practicable, to have recourse to change of locality. It is 
 very important to follow this course of treatment, for when con- 
 siderable hypertrophy of these fibrous tissues has taken place, their 
 restoration to a normal state is beyond the resources of medical 
 art. By compression with bandages, friction, and iodine applica- 
 tions, the bulk of the affected part may become diminished to 
 some extent; but this result is consequent on the absorption of 
 the liquid inter-areolar effusions, not the removal of any part of 
 the abnormal fibrous tissue. 
 
 The question of the removal by surgical operation of parts 
 affected with elephantiasis, is the only remaining practical con- 
 sideration. Elephantiasis of the scrotum has of late years been 
 very frequently the subject of surgical operation, and much suc- 
 cess has attended the proceeding. It is to Brett, Esdaile, Allan 
 Webb, Shircore, and Baboo Permanand Sett, that we are chiefly 
 indebted for the elucidation of this department of surgery in 
 Bengal *, and to Dr. Ballingall in Bombay. 
 
 Section V. — Scurvy. — Prevalence in India. — Short practical 
 
 Remarks. 
 
 The admissions from scurvy into the European General Hospital 
 at Bombay, during the fifteen years from 1838 to 1853, amounted 
 to 618, and the deaths to nine. Those of the first five years of 
 this term, the period of my service in the hospital, were 182 in 
 number, being 2*4 of the total hospital admissions: of these, none 
 proved fatal. These cases were almost exclusively of seamen from 
 merchant ships, generally small class vessels, badly found, having 
 made long voyages, and belonging to English or Scotch provincial 
 ports. But, in all probability, it will be found that of all ships 
 which trade to our Indian ports, scurvy appears most frequently in 
 coal ships • — of these many arrive yearly at Bombay as well as 
 Aden — and this result might have been anticipated, for their 
 voyages are generally long, and cleanliness is out of the question. 
 
 * It was in the removal of these scrotal tumours that mesmerism was practically 
 applied by Dr. Esdaile, and afterwards by Professor Allan Webb, and a small hos- 
 pital was established for the purpose in Calcutta. The Mesmeric Hospital still 
 existed at the time of my visit in 1853, but chloroform as an anaesthetic had displact d 
 mesmerism ; and, though endeavours were made, with much courtesy and kindness, 
 to show me the mesmeric effects, they proved unsuccessful. I witnessed the dexterous 
 removal of these tumours by Mr. Shircore and Baboo Permanand Sett, and several suc- 
 cessful cases in various stages, after the operation. For details relative to the 
 operation, I would refer to Mr. Webb's and Dr. BaUingall's paper.? already ad- 
 verted to. 
 
702 BLOOD DISEASES. 
 
 In the report of the European General Hospital for the year 
 1851*, Dr. Stovell makes somewhat similar observations on the 
 cases of scurvy for that year. 
 
 Durino- the six years from 1848 to 1853, 364 admissions of 
 scurvy took place into the Jamsetjee Jejeebhoy Hospital: of these, 
 sixty- four died. A considerable proportion of this class of patients 
 had been labourers on the public works at Aden ; and among these 
 many deaths occurred from extensive scorbutic, sloughy ulceration, 
 chiefly of the lower extremities. Consequent on improvement in 
 the re«imen of these public servants at Aden, there was, during 
 the last three years of the term, a considerable diminution in this 
 great but remediable evil. 
 
 In the years 1853 and 1854 admissions of scurvy began to take 
 place from a quarter altogether different. 
 
 In consequence of the desertion of European crews from ships 
 at Melbourne, for the Australian gold diggings, Lascars were 
 shipped in numbers from Calcutta to supply the deficiency. 
 Arriving at Melbourne, after a voyage of two or three months, 
 they were transferred to the deserted ships, and again soon 
 sent to sea. Ships with these Lascar crews, in a very scorbutic 
 state, have arrived at Bombay, and doubtless at other ports also. 
 I am not aware whether these events continue to occur, but if so, 
 it is clearly the province of the magistrate to enforce the regula- 
 tions relative to the shipment of Indian Lascars to other countries, 
 or, should these be insufficient, to bring about their revision and 
 change. 
 
 The general historical details of scurvy are of great interest, 
 but they need not be repeated here ; nor is it necessary to detail 
 the symptoms. 
 
 In regard to the pathology, I would only observe, that scurvy 
 escaped the solidism of Cullen, and has always been regarded 
 as a blood disease. The particular nature of the changes in 
 the blood are now very little better understood than in the days 
 of Huxham and Lind. The water and fibrine are in excess, the 
 red corpuscles defective, and the other constituents within the 
 normal range. These, I apprehend, are all the positive facts which 
 chemists, at the present time, can advance in respect to the blood 
 in scurvy. 
 
 I shall conclude my notice of this disease with the following 
 practical observations : — 
 
 * "Transactions Medical and Physical Society of Bombay," November 10. 
 
SCURVY. TO.') 
 
 1. Scurvy is caused by defects in diet, which involve deficiency 
 in the quantity and variety of the alimentary principles, essential 
 to the healthy constitution of the blood. 
 
 2. The defect is by some attributed to absence of organic vege- 
 table acids ; by others, to insufficient proportion of sulphur, phos- 
 phorus, potash, or vegetable albumen. 
 
 3. Whatever the explanation may be, the practical fact remains, 
 that a diet with a just proportion of azotised nutritive principles 
 and succulent vegetables, is that which prevents scurvy, and effects 
 its cure. The curative effect of a suitable diet is increased by the 
 use of acid fruits or vegetable acids, of which the citric is the best. 
 The bad effects of an unsuitable diet are lessened by the use of 
 vegetable acids or fruits. 
 
 4. Dr. Christison attributed the occurrence of scurvy in the jails 
 of Scotland, in 1845 and 1846, to a reduction in the proportion of 
 milk in the dietaries. That milk is a necessary part of an anti- 
 scorbutic diet for the adult, is sufficiently disproved by the fact, 
 that it does not form a part of the dietary of the British navy. On 
 the other hand, that milk is an efficient anti-scorbutic under certain 
 circumstances, is evident : were it otherwise, scurvy would be very 
 common in children under two years of age. 
 
 5. A review of all these facts seems to justify the practical state- 
 ment, but nothing more, that a diet adequate to prevent and to cure 
 scurvy, should consist of a suitable and varied combination of the 
 albuminous, saccharine and oleaginous principles, with the salts 
 usually associated with them. Milk, as was first observed by Prout, 
 is a typical combination of these principles appropriate for the 
 early periods of life; therefore it is not improbable that Christison's 
 statement is correct, that the reduction of the proportion of 
 milk in a particular dietary is likely to affect its anti-scorbutic 
 properties. 
 
 6. The phenomena of scurvy are well marked, but it is reason- 
 able to infer that the changes in the blood take place gradually, 
 and that they are present in some degree, before they attain to 
 that which occasions the well-known scorbutic symptoms. This 
 consideration is practically important, from the wide range 
 which it justifies us in giving to a scorbutic taint as a condition 
 predisposing to various forms of disease. 
 
 7. I have frequently adverted to certain debilitating influences 
 as predisposing causes of disease generally. The influences alluded 
 to are exposure to cold or wet, elevated temperature, malaria, 
 vitiated atmosphere, inattention to cleanliness, over fatigue of body, 
 
704 BLOOD DISEASES. 
 
 anxiety and depression of mind, previous diseases, &c. These are 
 also predisposing causes of scurvy, and as such are often influential 
 in favouring the development of the disease ; but it will not occur 
 under their influence without the exciting cause of unsuitable diet. 
 
 8. If the conditions just enumerated predispose the system, to 
 attacks of scurvy, it may readily be understood that the opposite 
 conditions — viz. absence of cold, wet, heat, malaria, and defective 
 ventilation, with attention to cleanliness, cheerful occupation of 
 mind, and avoidance of bodily fatigue, must fortify the system 
 against the influence of the exciting cause when operative, must 
 tend to keep off the disease for a time, and to lessen its severity 
 and hasten its cure.* 
 
 9. It is very useful, with reference to a right understanding of 
 the etiology and prevention of scurvy, to ajopreciate justly this 
 distinction between predisposing conditions and the exciting cause 
 of scurvy, and to estimate truly their relative importance. 
 
 Section VI. — General Dropsy. — Beriberi. — Symptoms. — 
 Pathology. — Treatment. — Illustrative Cases. 
 
 The occurrence of general dropsy in connection with renal and 
 cardiac disease, has been already considered, but the affection is 
 not confined to these circumstances. Cases of dropsy related to a 
 very asthenic state, as that proceeding from frequently-recurring 
 malarious fever, are not unfrequent in Iudia. But my principal 
 object, in this section, is to describe a train of dropsical symptoms 
 to which writers on tropical disease have for a long time apj^lied 
 the term " Beriberi." 
 
 Beriberi. — The unnecessary introduction of this word into 
 Indian nosology has served to retard and obscure our know- 
 ledge of the pathology and treatment of general dropsy, as it 
 presents itself to our notice in the natives of India. In the 
 mouth of February 1851 I called the attention of the Medical 
 and Physical Society of Bombay to this subject, and explained 
 the opinions on beriberi which I had been in the habit of stat- 
 ing to the students of Grant Medical College. In June 1853 
 several cases of beriberi were admitted into the Jamsetjee Jejeebhoy 
 Hospital, and were carefully observed by me. They confirmed 
 
 * A large proportion of the men of the German Legion, sent from the Cape of Good 
 Hope to India, were on arrival at Poona in November and December 1858, fainted with 
 scurvy, from unsuitable food at the Cape. Some of them improved during the voyage, 
 and all did .so very rapidly at Poona, under the influences adverted to in the text. 
 
BERIBERI. 705 
 
 the opinions which I had previously expressed on the pathology 
 of this affection.* 
 
 I shall first describe the symptoms of beriberi, then explain the 
 views on its pathology which I have long entertained, and finally 
 narrate the circumstances connected with the hospital cases above 
 adverted to. 
 
 The symptoms sometimes advance gradually, but at other 
 times suddenly appear. When they have been gradual in their 
 approach, the individual experiences for several days a sense of 
 weakness, and inability, or unwillingness to exert himself, and 
 shortly afterwards pain, numbness, stiffness, with more or less 
 oedema of the lower extremities. There is also some degree of 
 dyspnoea present, with a sense of oppression and weight at the 
 epigastrium. The oedema is not confined to the extremities, but 
 extends to the trunk and face, and occasions a puffed and bloated 
 appearance. The weakness of the limbs and the dyspnoea are 
 particularly complained of on motion. As the disease advances, 
 the difficulty of breathing increases, the face becomes more swollen, 
 and the lips livid. The limbs become almost paralytic, the oppres- 
 sion at the epigastrium is aggravated, frequent vomiting takes 
 place, and the ejected matters are sometimes mixed with blood. 
 The urine is scanty and high-coloured, sometimes almost sup- 
 pressed, the thirst is great ; the pulse, at first quick and small, 
 or unaffected, becomes irregular, intermittent, and fluttering. 
 Palpitations are experienced, attended with a sense of suffocation, 
 a sinking pulse, and death. These symptoms may run their course 
 in from two to three weeks ; or the progress may be much more 
 rapid, and when so, the numbness, the stiffness, and oedema of the 
 lower extremities become quickly followed by the dyspnoea, the 
 palpitation, and the sinking pulse. 
 
 These are merely the usual phenomena which attend on serous 
 effusion into the connecting areolar tissue of the extremities, the 
 cavity of the abdomen, the pleura, the pericardium, or into the air 
 cells of the lungs, and their connecting areolar tissue — in other 
 words, the symptoms of general dropsy more or less extensive, more 
 or less quickly forming. Dr. Watson, in his excellent lectures, 
 thus writes of dropsy : — " Now from whatever cause this watery 
 condition of the whole body may arise, the effects resulting from 
 
 * In August 1853, "Remarks on the Pathology and Treatment of Beriberi," were 
 presented by me to the Medical and Physical Society, and published in the 2nd Number 
 of the "Transactions," New Series. 
 
 Z Z 
 
706 BLOOD DISEASES. 
 
 the presence of the water are the same : and of what do patients in 
 this state usually complain ? Why, of shortness of breath and pal- 
 pitation of the heart ; of a sense of impending suffocation if they 
 attempt to lie down or actively to bestir themselves ; of tightness 
 and distress across the epigastrium, relieved somewhat by eructa- 
 tion, augmented by food and drink ; of weight and stiffness of the 
 limbs, and sometimes of drowsiness." 
 
 The morbid appearances found after death in fatal cases of 
 beriberi are anasarca, oedema of the lungs, hydrothorax, hydro- 
 pericardium, ascites, and cranial effusion. In some cases, traces 
 of old or recent inflammation of internal viscera exist ; but these 
 constitute no essential part of the disease. It was the opinion 
 of Dr. Malcolmson, entertained chiefly on account of the supposed 
 paralytic symptoms, that the chief part of the disease was in the 
 spinal cord or its membranes. This idea, however, cannot be sus- 
 tained. Beriberi is a general dropsy ; and in order to understand 
 its pathology, let us call to mind the circumstances in which 
 general dropsy usually occurs. 
 
 There is one form to which the name active has been given : it 
 arises when the surface of the skin, after free exhalation, has 
 become suddenly exposed to cold. The excretion of water by the 
 skin is checked, the blood is driven inwards, and the kidneys from 
 some cause or other do not take on their compensating action — 
 they become congested, and general dropsy with scanty urine is the 
 result, Active dropsy, under these circumstances, implies a certain 
 amount of fulness of the vessels. There are several varieties of 
 passive general dropsy, depending on different deranged conditions 
 
 on congestion of blood, local or general, on disease of the heart 
 
 or of the lungs, or perhaps merely on feeble action of the heart, 
 and also on disease of the kidneys. Passive dropsy, more parti- 
 cularly when related to diseased kidney, more surely occurs when 
 cold or wet is applied to the surface of the body, and the excretion 
 of water by the skin thereby impeded. Again, dropsy may arise, 
 not from disease of the heart or lungs or kidney favouring conges- 
 tion, but from blood deteriorated and abounding in watery consti- 
 tuent ; and here, too, the onset of the dropsy will be favoured by 
 the action of external cold upon the cutaneous surface. If diseased 
 heart, or lungs, or kidneys, or blood too dilute, or vessels too full 
 of blood, in their separate influences, lead to dropsical effusion, 
 
 how much more surely will this result take place if two, 
 
 three, or more of these conditions are associated together — if, 
 for example, we have disease of the kidney and of the heart com- 
 
BERIBERI. 707 
 
 Lined ; or if we have the vessels tolerably full of blood, with excess 
 of watery constituent, circulated by a feeble heart, and the 
 sufferer in both instances be exposed to the influence of external 
 cold. 
 
 Beriberi is, in my opinion, a general dropsy of this complicated 
 character. A state of the system in which the blood is sufficient in 
 quantity, and its water in undue proportion, is the predisposing 
 condition ; and cold or wet is the exciting cause : no doubt in some 
 instances the effusion is further favoured bv co-existing 1 heart, lung, 
 or kidney disease. But how does this state of the blood arise ? It 
 is present in the scorbutic diathesis, and this constitutional con- 
 dition may exist to some extent before the phenomena characteristic 
 of scurvy appear. Let it further be remembered, that impaired 
 irritability of muscular fibre, that of the heart included, is among 
 the early derangements of the scorbutic state. We have thus as 
 predisposing conditions of dropsy, not only watery blood, sufficient 
 in quantity, but also propelled by a feebly acting heart. Let us 
 suppose an individual in this state to have the surface of the body 
 exposed to an atmosphere cold and damp, or to the chilling influence 
 of piercing winds, and we have a combination of circumstances 
 surely adequate to predispose to and excite general dropsy ■ — the 
 more certainly if the skin has been previously actively perspiring, 
 and the kidneys, from congestion or structural defect, do not 
 readily assume-a compensating action. 
 
 The circumstances in which beriberi has usually appeared justify 
 this view of its pathology. The disease always attacks many of a 
 community, and has been chiefly observed in Ceylon, on the Malabar 
 Coast, in the Circars, and among Lascars in ships on the adjacent 
 seas. There has been much written on it by army surgeons in 
 Ceylon, and by medical officers of the Indian army — Dr. Malcolm- 
 son and others, and more lately Mr. Carter ; — but, on the whole, 
 there is a want of fulness in the descriptions on the points on which 
 accuracy is chiefly desirable. There is too much dwelling on 
 symptoms, not difficult to understand, and too little of precise 
 statement on important etiological conditions. I would except, 
 however, Mr. Carter's excellent paper*, which contains much 
 useful information. Notwithstanding these general defects there 
 is still sufficient in the narratives to countenance the opinion 
 that beriberi, more particularly in its acute form, occurs usually 
 in persons favourably circumstanced for the development of a 
 
 * "Transactions, Medical ami Physical Society of Bombay," No. 8. 
 
 Z 7. 2 
 
708 BLOOD DISEASES. 
 
 scorbutic taint, and subsequently exposed to cold dry or moist 
 winds, or to lying on the ground wet with rain or dew, while 
 the body has been inadequately protected with clothing. The 
 practical view to take of each separate case of beriberi is to 
 regard it as a general dropsy, and to investigate it in the method 
 observed in other cases of general dropsy. We should inquire into 
 the state of the heart, the lungs, the kidneys, the condition of the 
 blood ; and carefully review the circumstances in which the indi- 
 vidual has been placed, with the object of ascertaining whether he 
 has been exposed to predisposing and exciting causes of dropsy. It 
 is by keeping distinctly in view the general pathological principles 
 involved in this inquiry that we may hope to reconcile the seeming 
 contradictions of the confused details of which the accounts of this 
 disease are for the most part composed. To me then it seems that 
 beriberi is a general dropsy, and that in regard to each instance, the 
 question ought to be, what is the pathology of this case of general 
 dropsy? Generally it will be found that a scorbutic diathesis and 
 external cold or wet are the determining conditions. 
 
 The symptoms, the pathology, the causes of beriberi have been 
 discussed. The treatment need not detain us long. It resolves 
 itself into prevention and cure. If it be true that a scorbutic 
 diathesis is the predisposing condition, then attention to the means 
 which are preventive of scurvy will also prove preventive of beri- 
 beri; and if external cold be the ordinary exciting cause, then 
 attention to clothing and avoidance of exposure are most important 
 sanitary measures. 
 
 The treatment of the disease when fairly formed should accord 
 with the principles observed in general dropsy. In the acute 
 forms of dropsy in a sthenic habit, with excited vascular action, 
 there may be scope for general blood-letting, but it can be only 
 under such conditions of the general system and of the circulation 
 that this measure can be admissible, and these will not, I appre- 
 hend, be often found present in beriberi. In other cases of dropsy 
 in which vascular action is not depressed, in which there is no irri- 
 tation of the gastro-intestinal mucous lining, we may endeavour to 
 reduce the effusions — by active purgatives, as elaterium, or other 
 members of this class. Then there are other instances in which 
 cathartics are unsafe, and diuretics are the chief remedies to be 
 trusted to. Cases also occur in which the action of the heart is 
 depressed, and in these stimulants must be given at the same 
 time with diuretics. Nor may we forget that the skin is some- 
 times an appropriate channel by which to lessen the Avater of 
 
BERIBERI. 709 
 
 the blood, and favour the absorption of dropsical effusions. The 
 vapour bath, or the hot air bath may be used with this view. In 
 the treatment of beriberi general blood-letting, purgatives, diuretics, 
 and stimulants have been recommended. But if the pathology and 
 therapeutics of dropsy have been rightly explained, then there is 
 no special method of treating beriberi. The means which are the 
 best in one case may be the worst in another. 
 
 Beriberi as observed in the Jamsetjee Jejeebhoy Hospital in 
 Jane 1853. — In the month of June 1853, four cases of beriberi 
 were received into the Jamsetjee Jejeebhoy Hospital. The suf- 
 ferers were Lascars, belonging to a ship which had just arrived 
 from sea. Many others of the crew had also suffered. One indi- 
 vidual died on his way from the ship to the hospital, and an 
 inquest was held on the body. The expediency of elicitino- 
 information relative to the length of the voyage, and the manage- 
 ment of the crew, was suggested by me to the coroner. I shall 
 first quote the deposition of the captain of the ship ; then state the 
 important facts of the cases admitted into hospital ; and finally 
 inquire whether they confirm or not the view which has already 
 been taken by me of the pathology of the disease : — 
 
 "William Eaines, on being duly sworn, says : — I am master of the ship Fai~e 
 Allwm, of the port of Bombay, and have been constantly commanding, or been 
 chief officer of vessels trading out of Bombay, with a Lascar crew, since the year 
 1838. I last left Bombay on the 3rd day of June, 1852, with a Lascar crew of 
 sixty-five men and boys ; and the deceased, Bhana Moorar, aged about forty years, 
 and deceased Jadow Dewa, aged about twenty-five years, both Hindoos, formed 
 part of the crew. We proceeded from Bombay to Singapore, and from thence to 
 Siam, and returned from thence to Singapore, and so back again to Siam ; and from 
 thence to Singapore, which place I quitted for Bombay on the 3rd March this year, 
 expecting to make the Toyage in seven weeks, the average passage being about two 
 months. I had on board curry-staff, rice-water, dall, ghee, salt, &c, as prescribed by 
 the regulations, with a good supply of water; and during such time as the ship was in 
 harbour always supplied the crew with greens, fresh fish, and fresh provisions. The 
 crew all remained healthy till about the 21st day of May last, in latitude 10° N., 
 longitude 64° W. We had then been two months and eighteen days at sea. On the 
 15th day of April I was within about seventy miles or thereabouts of the island of 
 Ceylon; but being unable to stand the strong current and west winds then blowing, 
 after consulting with my Serang and chief officer and passengers, I determined on re- 
 linquishing the attempt to get round Ceylon, and bore away for the line, to come up to 
 Bombay by the southern passage, round the Laccadives and Chagos, and ran to the 
 south of the line as far as 8° 49', and then to the westward as far as 63° W., and 
 crossed the line again, running north, about the 6th or 7th May. and during most of 
 the time had rain and squalls. Most of the water having been consumed, we filled 
 up the water casks with rain water, collected <_>u the surface of a clean awning. After 
 making the Line on the 6th of May, we had light weather, with occasional squalls and 
 constant rain, and came on with the S.W. moonson up to 16° N. latitude on or about 
 the 2nd June, and arrived in the harbour of Bombay on the 6th June, I consider that 
 I first fell in with the S.W. monsoon about three degrees north of the line. The crew 
 
 Z Z 3 
 
710 BLOOD DISEASES. 
 
 were all healthy up to the 21st of May. When in latitude 10° N., longitude 64° W., 
 symptoms of disease first showed themselves. The deceased Jadow Dewa complained 
 of pains in his feet, and loss of strength down the legs, and pain in the chest, with 
 difficulty of breathing, and constipated bowels. I gave him jalap and cream of tartar, 
 and to rub on the chest hartshorn, laudanum, and sweet oil. The crew since the 15th 
 of April had been on reduced allowance of about ten pounds in ninety pounds of rice, 
 fish and water full allowance, the latter being rain water. Between the 21st day of 
 May and 6th June, eight other men were seized in the same manner, and all died ; the 
 average suffering about four or five days ; a Portuguese sepoy died in three days. The 
 deceased Jadow Dewa appeared to be recovering fast, and left the ship on the evening 
 of the 6th of June. Bhana Moorar also appeared convalescent, and left the ship in 
 my dingy. All the survivors of the crew are landed, the voyage being completed. 
 The passengers, twelve in number, natives, and myself and officer, and the majority 
 of the crew, are well. We drank the rain water very freely, and I believe the deceased 
 died of a disease called the beriberi of Ceylon. I had a good medicine chest on board, 
 and treated those taken ill according to the instructions laid down in Dr. Thomas' 
 book of medicine. We had no liquor on board the ship. I offered the crew pickles 
 and vinegar, and also sugur, but they refused to eat it. The passengers and myself 
 used pickles, sugar, and vinegar freely, but the crew declined till latterly. The whole 
 number who were attacked were about thirty-five, of whom ten have died. We were 
 in the latitude of Cochin when the disease first appeared, and were about 10° to the 
 westward of the coast of India, with light N.W. and N.E. winds. The crew were pro- 
 tected from wet as far as possible. The disease attacked persons of all ages, but 
 principally the old and more infirm of the crew. Further I know not. The cargo 
 consisted principally of sugar in bags, of Mailing ivory, teak wood, plant and sapan 
 wood, and raw silk. The hatches were kept constantly open when the weather would 
 permit, the forecastle well cleansed and fumigated with powder burnt and benjamin." 
 The jury returned the following verdict: — "Deceased died of beriberi." 
 
 275. Beriberi. — Recovery, — Purshotum Zeena, a Hindoo kalasee, of the ship Faize 
 Allum, twenty-five years of age, a man of stout frame, was admitted into the Jamsetjee 
 Jejeebhoy Hospital on the 7th of June, 1853. He had been ill sixteen days. The 
 feet, legs, and thighs were (Edematous, and, in consequence of the stiffness of the thighs 
 and groins from the swelling, he walked with a waddling gait. The pulse was easily 
 compressed. There was no abnormal dulness of the prsecordial region, and the sounds 
 of the heart were normal. The bowels were rather confined, and the urine scanty. 
 He complained of uneasiness at the epigastrium and the hypogastrium. There was no 
 vomiting ; the tongue was not coaled, but was rather florid. There was no sponginess 
 or discoloration of the gums. He continued in hospital till the 27th June, when he 
 wis discharged well. For some days after admission he complained of uneasiness and 
 sense of weight at- the epigastrium, and there was abnormal dulness on percussion, to 
 within two inches of the umbilicus. The urine showed no trace of albumen. He was 
 treated with occasional doses of compound powder of jalap, the anti-scorbutic mixture 
 of the hospital, a diet with fresh vegetables, and lemonade, and a small allowance of 
 arrack. Under this treatment the dropsical symptoms and the fulness at the epigas- 
 trium disappeared, and he left the hospital quite well. 
 
 276. Beriberi. —Sli<jht tUxcoluratinnof the gums. — Recovery. — BhowanRama, a Hindoo 
 kalasee, of the ship Faize Allum, thirty-live years of age, and of stout frame; ill for 
 fifteen days. The legs, thighs, and feet were very anaaarcous, and his gait waddling 
 from the sliltiii'ss of the legs and groins. The pulse was very Feeble, and the urine 
 scanty. Ee had uneasiness at the epigastrium, but no dyspncea, except after walking. 
 The sounds of the heart were normal, and there was no dulness of the prsecordial or 
 other regions of the chest, and the respiratory murmur was distinct ; the tongue moist 
 and without fur; the gums discoloured, but not swollen; the teeth felt tender on 
 
BERIBERI. 7 1 1 
 
 eating; urine not albuminous. Hie treatment followed was the same as in the first 
 case, with the addition of the occasional use of the warm bath. He was discharged 
 well on the 27th June. 
 
 277. Beriberi. — Anasarca. — Death. — No kidney disease. — Liver congested. — Cavities 
 of the heart full of thin blood, — Visram Narrayen, a Hindoo kalasee, of the ship 
 Faize Allum, twenty years of age, ill fourteen days, was admitted into the Jamsetjee 
 Jejeebhoy Hospital on the 7th June, 1853. There was general anasarca. The pulse 
 Mas feeble. There was no abnormal precordial dulness; the sounds of the heart were 
 normal ; there was slight fulness of the abdomen ; no swelling of the gums. On the 
 8th and 9th the pulse became feebler, and the breathing oppressed ; the urine was 
 very scanty, but showed no trace of albumen. He died on the afternoon of the 9th. 
 He was treated with stimulants — ammonia and arrack. The body was examined two 
 hours after death, and Mr. Lisboa has favoured me with the account of the appearances. 
 
 Head. — On opening the cranium, about five ounces of serous fluid oozed out. The 
 structure of the brain, cerebellum, pons Varolii, and medulla oblongata was healthy. 
 The ventricles of the cerebrum contained the normal quantity of fluid. Ch< si '. — 
 The cavity of the chest contained only two ounces of thin transparent fluid. Both 
 lungs collapsed freely, and their structure was healthy ; they showed no appearance 
 of cedema. The heart appeared slightly enlarged. On opening both the right and 
 left cavities, they were found to contain a thin red fluid and a few soft red coagula of 
 blood; the fluid in the right ventricle was frothy. Abdomen. — The abdominal cavity 
 did not contain more than two ounces of thin transparent serous fluid. The peritoneal 
 surface of the intestines was of reddish colour from congestion ; all the abdominal 
 viscera were more or less congested, but their structure was healthy. The liver pre- 
 sented appearances of congestion more than any other organ ; from its incised surface 
 fluid blood flowed freely. 
 
 278. Beriberi. — Anasarca. — Gums discoloured. — Hydrothorax. — Fatal. — Cavities of 
 the heart full of fluid blood. — Jadow Dewa, a Hindoo kalasee, of the ship Faize 
 Allum, twenty-five years of age, ill sixteen days, was admitted into the Jamsetjee 
 Jejeebhoy Hospital on the 7th June, 1853. There was general anasarca, the abdomen 
 was rather full, and distinctly fluctuating ; the breathing was oppressed ; there was no 
 abnormal precordial dulness ; the sounds and action of the heart were irregular. He 
 complained of pain at the epigastrium ; the pulse was very small, and the skin 
 coldish ; the gums were discoloured, but not swollen. He died on the morning of the 
 8th. The body was examined five hours after death; and I am indebted to Mr. 
 Lisboa for the account of the appearances. 
 
 Head. — On removing the calvarium, about five ounces of thin serous fluid oozed 
 out. The structure of the brain, and of the other contents of the cranium, was 
 healthy. The ventricles of the cerebrum contained a little more than the normal 
 quantity of thin transparent serum, -with a few bubbles of air. Chest. — Both cavities 
 contained about twelve ounces of serous fluid. The right costal pleura adhered to 
 the visceral, by means of old bands of areolar tissue, which was also infiltrated with 
 seroiis fluid, except at the lower part of the chest, where there was a sort oi 
 holding about four ounces of serum. The left lung collapsed freely. The structure 
 of both was healthy, except that it appeared to be slightly compressed. On pressing 
 the incised surface, a small quantity of frothy serous fluid oozed out. The hearl was 
 apparently enlarged (dilated); both auricles and both ventricles were distended with 
 fluid blood, and some few soft red coagida. The fluid in the right ventricle contained 
 a few bubbles of air. The structure of the heart was healthy. All the abdominal 
 viscera were more or less congested, but otherwise they were healthy. The peritoneal 
 lining of the abdominal cavity, and that covering the intestines, presented a reddish 
 appearance. The blood, examined under the microscope, showed a normal stale 
 of the corpuscles. 
 
712 BLOOD DISEASES. 
 
 The circumstances in which beriberi made its appearance in 
 the ship Faize Allurn were certainly confirmatory of the view 
 which I had taken of the pathology of this disease. The ship had 
 been two months and eighteen days at sea. The crew were for the 
 last month on somewhat diminished rations, and at no period did 
 anti-scorbutics form part of the dietary. The weather was bad, and 
 there was exposure to fatigue. The disease appeared on the 21st 
 May. The weather during the fifteen days preceding had been 
 wet and squally. Of a crew of sixty-five, thirty-five were attacked, 
 and ten died. The officers and passengers of the ship did not 
 .suffer from the disease : they used antiscorbutics freely, and we 
 may assume, at least as regards the passengers, that they were not 
 exposed to the inclemencies of the weather ; and as regards the 
 officers, that they were by clothing better protected than the 
 Lascars. 
 
 It is true that in the four cases which came under my observa- 
 tion in hospital, the external phenomena of scurvy were not 
 present : in two the gums were discoloured, but not swollen and 
 spongy. But in order to explain the pathology of the disease the 
 actual presence of scorbutic phenomena is not necessary. The 
 diathesis is doubtless of gradual formation, and requires, in all 
 probability, the influence, for a considerable time, of the conditions 
 which induce it, before the characteristic symptoms of scurvy 
 appear. Nor can it be questioned that the changes which the 
 blood is slowly undergoing in the gradual development of the 
 scorbutic state must predispose to derangements of various kinds, 
 — must, for example, be favourable, on the surface of the body 
 becoming chilled, to the occurrence of internal congestions with 
 dropsy and occasional haemorrhage. It is, indeed, only when 
 the diathesis is partially formed, that We are likely to meet with 
 beriberi, for it is not probable that sailors really scorbutic will be 
 fit for duty, and exposed to wet and squally weather. 
 
 Though the acknowledged characters of scurvy were absent in 
 these cases, still there were facts which showed that the diathesis 
 existed in some degree. In both the fatal cases the blood was 
 found more or less fluid after death. In all the cases the feeble 
 action of the heart was very remarkable : in three — the two suc- 
 cessful cases, and one fatal — this could not be attributed to thoracic- 
 dropsical effusions, for in none of them was there oedema of 
 the lungs, or effusion into the pleura or pericardium. Again, in 
 the two fatal cases, all the cavities of the heart were dilated and 
 filled with blood, showing that the circulation had ceased from 
 
BERIBERI. 7 13 
 
 failure of irritability of the muscular fibre — that death had beeu 
 by syncope. This defective irritability of the heart points to 
 something in the pathology of the disease, in addition to the drop- 
 sical effusions ; and, perhaps, there is no condition of the system 
 more generally characterised by impaired irritability of muscular 
 fibre than the scorbutic. There is no fact more familiar in the 
 history of disease than occasional sudden death by syncope in 
 patients affected with scurvy. 
 
 There are other considerations of interest in these cases. A sense 
 of weight and uneasiness at the epigastrium is a common symptom 
 of beriberi : in one of the successful cases enlargement of the 
 liver was evident on percussion, and in both the fatal cases a 
 congested state of this organ was well marked. This symptom, then, 
 is probably due to congestion of the liver. This congestion, with 
 the altered state of the blood, also explains the occasional occurrence 
 of hsematemesis in beriberi. In these cases there was no disease 
 of the heart or kidney. 
 
 The principles of prevention and treatment are sufficiently 
 clear. By suitable dietaries, to prevent the formation of the 
 scorbutic diathesis ; by suitable clothing, as far as practicable, 
 to protect the crew from inclement weather. In regard to treat- 
 ment : (a.) the use of antiscorbutic regimen and remedies ; 
 (6.) to regard the feeble pulse as a condition independent of the 
 dropsical effusions, and to give stimulants more or less freely ; (c.) to 
 remove the dropsy by purgatives or diuretics, being guided 
 to the use of the one or the other by the state of the pulse; 
 (d.) to increase the cutaneous capillary circulation by friction and 
 warm clothing. The hot air bath or warm water bath requires 
 caution, in consequence of the increased depression of the heart's 
 action which follows transient excitement from these means. 
 They had better not be regarded as part of the regular treatment 
 of the disease. I attach great importance to the fact, which 
 these cases clearly establish, that the feeble pulse is not con- 
 sequent on the functions of the heart or lungs being interfered 
 with by serous effusions, but is dependent on impaired irri- 
 tability of the fibre — one of the phenomena of the scorbutic 
 diathesis. We shall therefore be disappointed if we expect the 
 power of the heart to improve by the mere removal of the 
 dropsy by purgatives or diuretics. The use of stimulants must 
 go hand in hand with that of these evacuants ; indeed must 
 in many cases, in advanced stages, be the only safe measure. 
 While we keep up the action of the heart, and remove the effu- 
 
714 BLOOD DISEASES. 
 
 sions, it is, if these pathological doctrines be correct, also a very 
 important indication to improve the diathesis by antiscorbutic 
 means. 
 
 In the statistical report of the health of the royal navy for the 
 year 1856, ordered to be printed by the House of Commons, on the 
 26th July, 1858, mention is made of an epidemic dropsy which 
 prevailed in the ship Juno in the Australian seas, and the cause of 
 which appeared to be wrapped in mystery. There is no clinical 
 description of the dropsical symptoms — but from the terms " epi- 
 demic ascites" and " peritoneal dropsy" being used — it may be in- 
 ferred that the effusions were chiefly abdominal. The only account 
 of symptoms is the following : — 
 
 " In general the patients, amongst whom were a large proportion of the strongest men 
 in the ship, exhibited little or no constitutional disturbance, and, with the exception 
 of a sallow complexion or paleness of the whole surface, they presented no unusual 
 appearance. They, however, complained of mental depression, a feeling of uneasiness, 
 and a troublesome barking cough, which generally existed for some days or even weeks 
 previously to the attack." 
 
 The prominent facts were these : — The ship's company had been 
 victualled for a considerable time on salt provisions during the last 
 quarter of 1855. The ship returned to Sydney about the begin- 
 ning of January 1856, from a lengthened cruise amongst the 
 islands in the Pacific ; left Sydney on the 8th of March, reached 
 Hobart Town on the 13th ; sailed again for Sydney on the 28th, 
 and arrived on the 6th April. 
 
 During the stay of the Juno at Sydney, from January to 8th 
 
 March, three cases occurred. From the 16th to the 28th March, 
 
 at Hobart Town, eighteen cases. From the 6th April to 2nd June, 
 
 at Sydney, eight cases. There is a slight discrepancy between the 
 
 total of these figures, extracted from the report, and the following 
 
 summary: — 
 
 " The total number of cases of this singular malady put on the sick list between the 
 3rd January and the 2nd June, amounted to thirty : of these eleven were invalided 
 and nineteen returned to duty. Though no case terminated in death, they were all 
 exceedingly protracted, and the recovery in most instances imperfect." 
 
 The holds were free from offensive effluvia, and to the eye ap- 
 peared to be thoroughly clean ; but in cleansing the lower deck, the 
 wooden shot racks, placed close to the sail lockers, were found 
 to be in a rotten state, and a quantity of dark, slimy matter was 
 discovered beneath. Notwithstanding the occurrence of case?, 
 long after the removal of these offensive matters, the surgeon con- 
 tinued of opinion that the disease originated from " a malarious 
 poison arising from the putrefaction of the vegeto-animal accumu- 
 
RHEUMATISM. 715 
 
 lation on the lower deck, which had been imperfectly going on, and 
 injuriously affecting the health of the ship's company." The re- 
 porter objects to this view, that the persons most constantly en- 
 gaged in cleaning the holds were not attacked in greater number 
 than the rest of the ship's company; and that offensive effluvia, 
 or malaria, arising from similar collections of matter, have existed in 
 innumerable instances, both in houses and in ships, without pro- 
 ducing any disease of the same nature. 
 
 The two following further extracts from the report are, it seems 
 to me, conclusive as to the etiology and pathology of this disease : — 
 
 " The assistant surgeon, in a well written report, observes, ' That although the bad 
 effluvia arising from the dirt and moisture under the shot racks might have had a 
 predisposing influence, he considered that the disease depended on causes producing a 
 morbid state of the fluids, which most resembled their condition in scorbutus.' " 
 
 The surgeon remarks : — 
 
 "A certain reduction of temperature appeared to be necessary for the development 
 of the disease ; for while the men in warm weather continued in the enjoyment of 
 tolerable health, on getting into cooler weather at Sydney and Hobart Town, the dis- 
 ease broke out in consequence of the cold rendering the poison more active, or the 
 people more susceptible, or probably from both causes." 
 
 The disease was clearly dropsy, excited by external cold in a 
 scorbutic diathesis — in other words Beriberi. 
 
 Section VII. — Rheumatism. — Prevalence in India. 
 
 The admissions under this head into the European General 
 Hospital at Bombay, during fifteen years, from 1838 to 1853, 
 amounted to 1457, and the deaths to six. 
 
 Of these 528, with four deaths, took place during the five years 
 of my service in this hospital, being 6*8 per cent, of the total 
 hospital admissions. The admissions were pretty equally divided 
 throughout the year : the greatest proportion, in the month of 
 February, 12*1 per cent., and the least, in the month of October, 
 3-6. By far the largest number were of chronic rheumatism, 
 traceable, in many cases, to a scorbutic taint or previous venereal 
 affection. In the treatment of rheumatism in India, as well as in 
 temperate climates, it is necessary to recollect the great tendency 
 to pericarditis and endocarditis. 
 
 Metastasis to the testicle was observed in several cases of chronic 
 rheumatism, — swelling and hardness of the organ coming on, fol- 
 lowed by cessation of the pain and swelling of the joints, which, 
 however, recurred on the alleviation of the orchitis. 
 
16 
 
 BLOOD DISEASES. 
 
 In my remarks on pericarditis and affections of the heart, it 
 was explained, that though acute rheumatism is not of such 
 frequent occurrence in India as in European countries, yet 
 that it is sufficiently so to command our careful attention, more 
 especially as its relation to cardiac disease is quite as important in 
 the one country as in the other ; chronic rheumatism, however, 
 is much more common in India, particularly in natives. The 
 term is applied to pain in the muscles and joints, often without 
 much or any swelling of the latter, frequently attended with 
 irregular febricular disturbance, and very generally related to 
 scorbutic, malarious, syphilitic, or mercurial cachexia. 
 
 The admissions from rheumatism into the Jamsetjee Jejeebhoy 
 Hospital for four years, from 1848 to 1852, amounted to 1384 : of 
 these 574 were registered as acute, and 810 as chronic. The 
 following tabular statement shows the prevalence in different years 
 and castes : — 
 
 Admissions and Deaths, from Rheumatism, in the Jamsetjee Jejeebhoy 
 Hospital at Bombay, from 1818 to 1852, arranged according to Caste 
 and Sex. 
 
 
 Hindoos. 
 
 Mussulmans. 
 
 Christians. 
 
 Parsees. 
 
 Females. 
 
 Total. 
 
 •a 
 
 S 
 
 ■a 
 < 
 
 ■a 
 
 5 
 
 ■6 
 
 a 
 
 ■a 
 < 
 
 T3 
 
 03 
 
 *6 
 
 a 
 
 -a 
 < 
 
 
 
 a 
 
 < 
 
 T3 
 
 5 
 
 •a 
 
 a 
 
 ■o 
 
 < 
 
 T3 
 
 a 
 
 Q 
 
 1 
 1 
 
 •d 
 
 •5 
 < 
 
 ■6 
 
 5 
 
 1848-49 
 1849-50 
 1850-51 
 1851-52 
 
 83 
 
 72 
 
 120 
 
 114 
 
 4 
 1 
 2 
 1 
 
 95 
 112 
 151 
 129 
 
 3 
 3 
 
 1 
 
 58 
 53 
 64 
 71 
 
 i 
 
 13 
 17 
 43 
 35 
 
 l 
 
 39 
 32 
 57 
 26 
 
 288 
 286 
 435 
 375 
 
 6 
 5 
 6 
 2 
 
 Total 
 
 389 
 
 8 
 
 487 
 
 7 
 
 246 
 
 l 
 
 108 
 
 l 
 
 154 
 
 2 
 
 1384 
 
 19 
 
 Section VIII. — On Snake-Bite. 
 
 My experience in snake-bite is exclusively confined to one 
 species, and to one period of my service in India. The observa- 
 tions which follow were published nearly in their present form, 
 in the year 1850.* 
 
 * " Transactions, Medical and Physical Society of Bombay/' No. 10. 
 
SNAKE-BITE. 717 
 
 Iii the years 1834 and 1835, while in medical charge of the 
 Convalescent Station on the Mahabuleshwur Hills, I made some 
 observations on the effects resulting from the bite of the phoorsa, a 
 small snake common on the hills, and known to the natives by that 
 name. The phoorsa snake is about a foot in length, the tail tapers 
 suddenly from about an inch from the end; the colour is olive 
 brown, of different shades, variegated with white : on the back and 
 sides there are olive brown lozenge-shaped patches ; the belly is 
 white, with brown spots, and the transverse plates under the belly 
 and tail are single ; a small isolated fang is distinct in the upper 
 jaw. 
 
 279. A small dog bitten by the phoorsa snake : fatal. — About the month of January 
 1834, a small puppy dog was brought to me, said to have been bitten on the upper lip 
 by a phoorsa snake, — but, as the animal seemed lively and well, I thought that there 
 might be some mistake: the snake, however, was shown to me, and the dog had been 
 found playing with it. In a short time the lip swelled slightly, and was painful on 
 being touched ; it was rubbed with ammonia, and some was also given internally. 
 During the course of the day the animal appeared sufficiently lively, took food and 
 ran about ; but the swelling continued to increase, and caused much pain. On the 
 following day the face and neck were very much swollen, especially under the lower 
 jaw. The dog died in the course of the day, about thirty hours from the time it had 
 been bitten. 
 
 On dissection, the swollen face and neck were found much infiltrated with bloody 
 serum ; and in some places, especially in the neighbourhood of the bitten part, there 
 was extravasation of blood. The larynx, trachea, and lungs were healthy ; no con- 
 gestion of the mucous lining. The other organs seemed healthy. 
 
 280. A horsekeeper bitten by the phoorsa snake : fatal. — At 11 a.m., on the 20th 
 March, 1834, a horsekeeper, in the service of Colonel Lodwick, was brought to me. 
 On the middle ringer of his left hand there was a small punctured wound, caused by 
 the bite of a snake. The occurrence took place aboiit half an hour before I saw him. 
 He made no complaint of pain ; there was no swelling around the wound ; the pulse 
 was natural : the bitten part was excised, caxistic applied, and a ligature tied round 
 the wrist. At 3 p.m., appearance unchanged ; no complaint but of pain in the hand, 
 which was somewhat swollen. This I attributed chiefly to the ligature, and removed 
 it. On the morning of the 21st, he was reported to have slept well. The hand was 
 considerably swollen — the swelling was tense, painful, and extended above the wrist ; 
 the tongue natural. He made no complaint but of the hand. Cold lotion was 
 directed to be applied. At 1 p.m. it was observed, that over the right tibia, here and 
 there, on the right foot, and also between the fingers of the right hand, the skin had 
 cracked, or rather had assumed an abraded appearance ; and from these points fluid and 
 florid blood oozed and trickled slowly. One of these points had existed on the pre- 
 vious day, but the others had only been noticed within an hour or two. The skin was 
 natural in temperature ; the hand was more swollen ; pulse 64, full and firm ; and he 
 had a sense of weight in the forehead. The saliva was tinged slightly with blood, the 
 tongue expanded, but not furred ; breathing slow. About ten ounces of blood were 
 abstracted from a vein in the right arm, by which the uneasy sensation in the head 
 was rebeved and the pulse reduced ; the blood did not flow very freely, the orifice in 
 the vein being small. At 4 p.m. I found that there was haemorrhage from the arm in 
 which he had been bled; it had been necessary to renew the compress twice, ami three 
 or four ounces of blood had been lost. About the right elbow joint, principally ant.- 
 
718 BLOOD DISEASES. 
 
 riorly, extending down the fore-arm and up the arm, there was tense, elastic, painfid 
 swelling, very similar to that of the bitten hand ; the blood, dark and thin, trickled 
 down the arm from the orifice made in the vein. It was impossible, from the swelling 
 and hemorrhagic tendency, to stop the bleeding in the ordinary way ; it was in part 
 effected by pressure with the finger, afterwards by means of a cork compress and ad- 
 hesive plaster. The pulse had become small, the skin cold ; he was restless and dis- 
 tressed looking, but answered questions freely when spoken to. The tongue was ex- 
 panded, and its edges deeply marked with indentations from the teeth. The blood 
 taken from the arm had not coagulated in the slightest degree ; it was a dark red- 
 brown liquid. Stimulants of brandy and ammonia were given in full doses, and 
 frequently; he continued restless and drowsy, but was always roused when spoken to. 
 The pulse continued barely perceptible ; he complained chiefly of the pain of the swel- 
 ling of the arm in which he had been bled. At 10 p.m. the swelling of the bitten hand 
 had become much reduced, and softer; that of the opposite arm, in which he had 
 been bled, had increased. He continued pulseless, restless, and drowsy, but answering 
 questions when roused, till 5 a.m. of the 22nd, when the breathing became difficult, 
 and he died at 7 a.m. There was nothing peculiar in the appearance of the body ; 
 the bitten hand was much less swallen than it had been. No examination of the body 
 permitted after death. 
 
 281. Parsee woman bitten by a phoorsa snake. — Recovery. — On the 20th April, 1835, 
 at 10 a.m., a Parsee woman, resident in the bazaar at Malcolm Peth, was bitten by a 
 phoorsa on the dorsum of the last phalanx of the ring finger of the right hand. I saw 
 her half an hour afterwards ; a ligature had been applied to the finger ; I excised the 
 bitten part, and applied caustic, and continued the ligature till the afternoon, when it 
 was removed, in consequence of the pain which it occasioned. She complained once or 
 twice of her head, and took some doses of eau de luce. There was swelling of the fin- 
 ger, and the hand, but to no great extent. There was constant oozing of blood from 
 the excised part, which on the 22nd increased to a constant dropping of blood, and 
 continued so during the night. On the 24th the bleeding continued, and the pulse 
 was feeble ; the actual cautery was used, and stopped the bleeding, which was absent 
 on the 25th, but recurred on the 26th, and was stopped by pressure. On the 1st of 
 May she was quite well. Ammonia was the only internal remedy used. 
 
 282. Bog bitten by ei phoorsa snake.— Fated. — Post mortem examination. — A full sized 
 dog, on the morning of the 24th May, 1834, at 10 a.m., was bitten over the right false 
 ribs by a large phoorsa snake. He continued well all day, took food and water freely. 
 In the evening slight diffused swelling about the bitten part, but the animal did not 
 cry on pressure of the part. On the morning of the 25th the dog seemed dull, and did 
 not take his food, the swelling was slight and diffuse, and did not seem to cause pain 
 on pressure. At 2 p.m. the sluggishness was found to have increased, aud near to the 
 animal there was some dark foetid pitch-looking fluid, which must have been either 
 vomited or passed by stool. About eleven o'clock at night he was heard to howl, and 
 probably died at midnignt ; he was found dead early in the morning of the 26th 
 having lived about forty hours ; and more of the dark pitchy fluid was found on the 
 ground, and as it covered the legs and tail of the animal, it seemed to have been passed 
 by stool. The body was not at all swollen. 
 
 Inspection. — The body was carefully examined after death. Around the bitten 
 part there was infiltration of the subcutaneous cellular tissue, for an extent of eighteen 
 inches in a longitunal direction, and six in a vertical. The fibres of the tissue seemed 
 thickened and condensed, so that the fluid did not run freely nor in quantity from the 
 cut surfaces. Where the infiltration was greatest the thickness was about a quarter of 
 an inch, and formed a dark red fleshy-looking substance. Towards the periphery 
 of the infiltrated portion the colouring matter of the fluid was much less in quantity. 
 In no situation did the infiltration pass the mesial line to the left side of the thorax. 
 
SNAKE-BITE. 7 1 ( J 
 
 It was not an ordinary infiltrated cellular tissue, such as is seen in anasarca; the 
 organisation of the tissue seemed to have undergone a change, so that a portion 
 macerated in water lost its dark red colour, but retained the other physical properties 
 — its thickness and firmness. Thorax. — The heart was empty and pale. The ar- 
 terial system empty and contracted. The jugular veins contained some thin fluid 
 blood. The lungs were much collapsed, and perfectly pale, with the exception of a 
 few superficial red patches ; when incised they were perfectly dry. I never saw lungs 
 so devoid of anything like congestion of blood, or so absolutely without serous infiltra- 
 tion, or the natural secretion of the mucous lining. The mucous membrane of the 
 trachea and bronchial tubes was perfectly pale. Head. — The brain firm, healthy, 
 pale, ex-sanguine. Abdomen. — The liver healthy, but with some red serous conges- 
 tion. The stomach and intestines were externally natural ; there was no discoloration 
 nor vascular congestion ; they were laid open from the pharynx to the rectum. The 
 cesophagus was natural ; the stomach contained yellow fluid, mixed with food ; its 
 coats were natural. About two feet of the upper part of the small intestine contained 
 mucus, deeply tinged with bile ; descending the bowels the mucus became tinged 
 with blood, like red currant jelly. Descending still further, this state of the secretioii 
 increased in quantity, and deepened in colour ; in the large intestine, extending to 
 the anus, there was a thick coating of it, very foetid, and in colour and consistency 
 resembling pitch. Wherever this secretion was scraped from the lining tunic the 
 appearance of the latter was natural, no discoloration, no vascularity, no alteration 
 of condition; in every point it was a pale healthy mucous tissue. The bowels 
 were not distended, and, take away their contents, they could not have been more 
 healthy or natural, in colour, structure, and relations. The kidneys were healthy. 
 The bladder was filled with healthy urine ; its lining membrane presented one faint 
 discoloured patch. 
 
720 DRACUNCULUS. 
 
 CHAP. XXXII. 
 
 ON DRACUNCULUS. 
 
 Section I. — Prevalence of, in Bombay Presidency. — Relation 
 to Season. — Allusion to Theories respecting its mode of ori- 
 gin. — Short notice of Symptoms and Treatment. 
 
 Dracunculus, or guinea-worm, from its great prevalence in many- 
 parts of the Bombay Presidency, has, during the last thirty years, 
 engaged the attention of several medical officers* of that establish- 
 ment. 
 
 The inquirers have generally assumed that there probably exists 
 some connection between guinea-worm and an external existing 
 species. Therefore a leading object of their research has been to 
 determine whether any relation subsists between the prevalence of 
 this affection, and particular seasons, soils, and sources of water 
 supply ; and to discover whether the soil or water of affected 
 localities constitutes the habitat of any species of worm zoologically 
 allied to this entozoon. These investigations, as well as those 
 relating to the manner of entrance into the human body of the ova 
 of the assumed external related species, have not led to positive 
 or satisfactory results. In fact, the obscurity in the natural history 
 of entozoa generally, is well illustrated in the instance of dracun- 
 
 * 1. Dracunculus, as prevailing in the Artillery while stationed at Matoongha in 
 the Island of Bombay, has been described by Mr. Smyttau and Dr. Bird, in the early 
 volumes of the " Transactions of the Medical and Physical Society of Calcutta." 
 
 2. There are two papers by myself in the 6th and 8th volumes of the " Calcutta 
 Transactions," on Dracunculus in the 4th Light Dragoons, at Kirkee, published in 
 1833 and 1835. 
 
 3. A communication by Mr. Duncan, on Dracunculus at Bhewndy, in the 7th 
 volume of the "Calcutta Transactions," in 1834. 
 
 4. A Report, by Mr. D. Forbes, on Dracunculus at Dharwar, in 1836 and 1837, in 
 the 1st Number of the " Transactions of the Medical and Physical Society of 
 Bombay." 
 
 5. Note on Dracunculus in the Island of Bombay, by Mr. H. J. Carter, in the 2nd 
 Number of the 2nd Series of the "Transactions of the Medical and Physical Society 
 of Bombay," in 1853. 
 
PBEVAU5NCE. — LOCALITIES. 721 
 
 cuius. I shall briefly notice some of the statements which have 
 been recorded, and allude to the principal inferences which have 
 been drawn from them. 
 
 Annexed to this chapter are tabular returns of dracunculus, as 
 observed by me in Her Majesty's 4th Light Dragoons, in the 
 Jamsetjee Jejeebhoy Hospital, and as prevailing generally in the 
 Bombay army in 1832 and 1833. The total number recorded in 
 these tables amounts to 2926. The ratio of admissions from 
 dracunculus to the total strength of the Bombay army was, for 
 these two years, 3-055 per cent.* During the six years from 1848 
 to 1853 the ratio to total admissions into the Jamsetjee Jejeebhoy 
 Hospital was 2-2 per cent. In considering these tables with the 
 view of determining whether this affection is more prevalent in 
 some months than in others, I have arranged the months in three 
 groups of four each, with the following result : — 
 
 May . . .448 
 
 June . . .480 
 
 July . . . 42S 
 
 August . . . 337 
 
 1693 
 
 ADMISSIONS IN — 
 
 
 
 March . 
 
 165 
 
 November 
 
 April 
 
 273 
 
 December 
 
 September 
 
 246 
 
 January . 
 
 October 
 
 224 
 908 
 
 February 
 
 123 
 
 93 
 46 
 64 
 
 326 
 
 It was in the hospital of the 4th Light Dragoons at Kirkee, in 
 1832, that I first had an opportunity of studying this disease. 
 The secondary trap formation of the part of the Deccan in which 
 Kirkee is situated, suggested to me the idea of following out the 
 opinion formed by Chisholm, from observation in Grenada, that 
 there was a relation between dracunculus and the use of water 
 taken from wells sunk in rocks of igneous origin. This inquiry 
 forms the subject of my communication in the eighth volume of 
 the Calcutta Transactions. 
 
 Through the courtesy of the Zillah collectors I obtained a series 
 of official reports, made by the village or district native function- 
 aries, relative to the absence or presence of Guinea-worm in the 
 villages of the Northern and Southern Concan, and the sub- 
 collectorate of Bagulcotta. The results have been published in 
 the paper just adverted to, but they lead to no satisfactory con- 
 clusion, and need not be reproduced. The following extract of the 
 general summary will suffice: — 
 
 * In 1S57, there were admitted into the Hospitals of the several Police Corps in 
 the Deccan, viz., at Poona, Sattara, and Ahmudnuggur, 1260 cases of Guinea-worm, 
 being a ratio to the strength of 3'4 per cent, Poona was the highest,— 67 per cent 
 
 3 A 
 
722 DRACUNCULUS. 
 
 "1. In four talookas * Guinea- worm does not occur, and in all the upper crust is of 
 laterite rock. The water used is not specified, but, from the physical features of the 
 districts, it must be chiefly that of wells. 
 
 " 2. There are reports from 494 villages in which Guinea-worm does not occur. Of 
 these 364 are in a district the upper crust of which is of laterite rock : the natm-e of 
 the water is not mentioned ; but, from the physical features of the district, it must be. 
 chiefly that of wells. Of the remaining villages, in 109 the water of rivers of con- 
 siderable size is used (of these 102 being situated in districts where primitive rocks, 
 chiefly marble and clay-slate, constitute the geological features, and seven in secon- 
 dary trap districts), and twenty-one villages use the water of nullahs, wells, and tanks. 
 
 "3. Of 991 villages in which Guinea-worm prevails, 309 are in districts of secon- 
 dary trap formation; 451 in districts in which there is a probable alternation of 
 geological structure, but in which the secondary trap formation prevails to a consider- 
 able extent; 215 are in districts in which primitive rocks prevail: in 120 limestone 
 and clay-slate are the principal members of the series. 
 
 " 4. Of the 991 villages in which Guinea-worm occurs, in 479 the nature of the 
 water is not stated ; but, from the physical features of the districts, it must be chiefly 
 of wells. Of the remaining villages, 276 use the water of wells ; 131 the water of 
 nullahs or tanks, and 58 the water of rivers; but in a great proportion of these 
 villages, in which nullah water or river water is used, the disease is stated to occxir 
 every second, third, or fourth year, and not annually." 
 
 The anatomy of dracunculus has been adverted to by Mr. Dun- 
 can and Mr. Forbes, but only minutely and carefully investigated 
 and described by Mr. Carter. Mr. Duncan first called attention to 
 the fact that the greater part of the interior of the mature Guinea- 
 worm is occupied by an ovisac filled with myriads of minute vermi- 
 form young. This observation has been confirmed by Mr. Forbes 
 and Mr. Carter, and all three observers describe minutely the 
 appearance of the young Gruinea-worm and the nature of its active 
 movements. 
 
 When the period for the extrusion of the Guinea-worm from the 
 human body has arrived, the young are emitted in large numbers 
 from the orifice of the protruding end of the worm. Both 
 Duncan and Forbes found that the young died in about six 
 days when placed in water; but the latter observer noticed that 
 when placed in moist red clay they survived for about twenty days, 
 but did not increase in size. Mr. Duncan states, that the soil and 
 pools about Bhewndy abound, in the rainy season, with a worm 
 smaller and more slender, but otherwise exceedingly like the 
 Guinea-worm : it does not, however, appear whether this resem- 
 blance refers to the mature or young dracunculus. Mr. Forbes 
 found that in the months of August and September the tanks in 
 the neighbourhood of Dharwar were abundantly supplied with 
 animalcules, some of which very much resembled the young 
 Guinea- worm, and others were eight times the size: they inhabited 
 * A talooka is a subdivision of a district. 
 
symptoms. 723 
 
 the half-dry beds of the tanks, and appeared to live longest when 
 partially covered with water. 
 
 Mr. Carter discovered that minute worms, having a great resem- 
 blance to . the young dracunculus existed in great abundance in 
 confervae of some tanks in Bombay. He describes the size of the 
 young Guinea- worni to be, length ^ inch, breadth -^-3 ; that of the 
 tank-worm to be length -^ inch, breadth f J . He believes in the 
 identity of these animalcules, notwithstanding the fact, that the 
 specimens taken from the ovisac were double the size of those 
 which were born and leading an independent existence; and the 
 additional fact, recorded by Duncan and Forbes, that the young of 
 the Guinea-worm invariably die in the course of five or six days 
 when placed in water. The further opinions of this able micro- 
 scopic inquirer are also very improbable, viz., that Gruinea-worm is 
 produced by the small tank-worm working its way into the human 
 body through the tubules of the sudoriferous glands, and that the 
 spread of the affection may be best obviated by preventing those 
 affected with it from bathing in tanks and contaminating the water 
 with the young issuing from tbe protruding end of the parent en- 
 tozoon ; — an idea conceived in forgetfulness of the fact, that the 
 young of the Gruinea-worm die in water. 
 
 Dr. Helenus Scott remarks, " It is well known that the men who 
 in India are employed in camps or elsewhere to carry water in 
 leathern bags on their backs, are infested by this animal over all 
 that part of the skin that has often been wetted."* And this state- 
 ment has generally been used as an argument for the entrance of 
 the ovum through the skin. I am ignorant of the nature of the 
 facts on which this observation, with which I have long beeD fami- 
 liar, is grounded ; but I can affirm, after ample opportunity, and on 
 little attention bestowed on the study of dracunculus, that lam unable 
 to bring to my recollection a single instance of a water-carrier affected 
 with it at that part on which the water-bag rests, nor have I any 
 reason for supposing that they suffer more than other classes. 
 
 The manner of propagation of the Guinea-worm, its mode of 
 entrance into the human body, and the question of its relation to 
 an external species, are at the present moment, I believe, no more 
 positively determined than the same propositions in respect to 
 other entozoa. They are all, with one exception— taenia — involved 
 in equal obscurity. 
 
 Symptoms. — The presence of Guinea-worm is often discovered 
 by a corded substance being felt beneath the skin before any indi- 
 
 * Johnson and 3Iartin, on Tropical Climates, 1841, p. 370. 
 3 A 2 
 
724 DRACUNCULUS. 
 
 cation from sense of itching, swelling, or the formation of a bulla 
 has been given. 
 
 The extraction of the worm is sometimes attended with much 
 inflammation and suppuration ; at others it gives rise to little dis- 
 turbance. The first result is influenced by the state of constitution 
 of the individual affected, the situation of the worm — whether en- 
 twined round tendons or not — and the care with which the pro- 
 ceeding is conducted. ■ 
 
 Both Duncan and Forbes are of opinion that the diffusion 
 of the young of the Guinea-worm, consequent on rupture of 
 the parent, among the human tissues, is the cause of the inflamma- 
 tion. It is true that this result is often consecutive on the worm 
 being broken ; but whether the explanation just adverted to is 
 correct or not, I am unable to decide. 
 
 The presence of dracunculus, however, does not necessarily en- 
 tail its extrusion : the worm may shrivel, become cretified and 
 enveloped in areolar tissue. It is not very uncommon to find them 
 thus changed in the dissecting-room of Grant College ; and I have al- 
 ready detailed a case (2 1 5 ) in which a cretified Guinea-worm was found 
 between the pericardium and the inner aspect of the right lung. 
 
 Treatment. — There has been a good deal written on the treat- 
 ment of this affection. It has been a favourite subject for nostrums 
 and special applications. It is best managed on simple surgical 
 principles. The question of extraction when the worm is qui- 
 escent and felt only under the skin first arises. This practice I saw 
 followed extensively in the 4th Dragoons. The worm was cut 
 down upon with a lancet, and a probe passed underneath, and 
 extraction cautiously made. The method followed by native 
 barbers, of digging a small hole down to the worm with a needle 
 and razor, I have also frequently witnessed. By these means ex- 
 traction is often successfully and speedily effected. At other times 
 it is followed by all the evils of inflammation and suppuration. If 
 the worm be over a fleshy part, the operation will generally succeed. 
 If, on the other hand, the worm be situated near tendons — as in 
 the foot, near the ankle, or the popliteal space — the risk of injury 
 from inflammation will be great. On the whole, as a rule of 
 practice, I incline to non-interference. 
 
 Winn, after the formation of the usual bulla, the end of the 
 worm protrudes, the extraction should be very gently and gradually 
 effected, care being taken, by means of rest of the part and ordinary 
 simple surgical appliances, to prevent or moderate inflammatory 
 action. The only caution accessary in respect to water applica- 
 
STATISTICS. 
 
 725 
 
 tions, is not to allow them to come in contact with the worm, lest, 
 by softening its structures, they lead to its rupture. Should, 
 unfortunately, much inflammation with suppuration take place, 
 then the only safe course is to be guided by sound principles of 
 surgery, and not to be led away by an unwise credulity in the 
 asserted efficacy of special plasters and cataplasms, many of which 
 are irritatiug and injurious. 
 
 Section II. — Statistics of Guinea-Worm. 
 
 Table XLIII. — Admissions of Guinea-Worm in the 4th Light Dragoons 
 
 at Ivirkee. 
 
 
 1827. 
 
 1828.. 
 
 1829. 
 
 1830. 
 
 1831. 
 
 1832. 
 
 1833. 
 
 1834. 
 
 Total. 
 
 January 
 Februai 
 
 March 
 
 April 
 
 May 
 
 June 
 
 July 
 
 August 
 
 Septem' 
 
 October 
 
 Novenil 
 
 Decemb 
 
 y 
 
 )er 
 
 er 
 
 er 
 
 
 — 
 
 3 
 3 
 2 
 
 1 
 2 
 
 3 
 
 1 
 
 5 
 
 5 
 2 
 1 
 3 
 
 1 
 
 1 
 2 
 
 1 
 
 1 
 
 5 
 
 7 
 
 57 
 
 64 
 
 48 
 
 26 
 
 3 
 
 1 
 3 
 
 1 
 2 
 3 
 7 
 3 
 1 
 3 
 1 
 1 
 3 
 
 3 
 
 1 
 
 2 
 
 6 
 
 31 
 
 29 
 
 20 
 
 13 
 
 7 
 
 3 
 
 1 
 
 2 
 5 
 
 17 
 
 26 
 
 101 
 
 98 
 
 77 
 
 41 
 
 11 
 
 6 
 
 2 
 
 4 
 
 Tot; 
 
 1 
 
 
 — 
 
 8 
 
 6 
 
 18 4 
 
 215 
 
 26 
 
 104 
 
 390 
 
 Table XLIV. — Guinea-Worm in Jamsetjee Jejcehhoy Hospital. 
 
 
 
 
 
 1848 to 1853. 
 
 Monthly Average. 
 
 
 Admissions. 
 
 Deaths. 
 
 Deaths on 
 Admissions. 
 
 Admissions 
 
 on total 
 Admissions. 
 
 Deaths on 
 total Deaths. 
 
 January 
 
 18 
 
 1 
 
 5-5 
 
 0-9 
 
 0-2 
 
 February 
 
 
 
 13 
 
 — 
 
 — 
 
 0-7 
 
 — 
 
 March . 
 
 
 
 22 
 
 — 
 
 — 
 
 1-02 
 
 — 
 
 April 
 
 
 
 
 49 
 
 — 
 
 — 
 
 2-3 
 
 — 
 
 May 
 
 
 
 
 71 
 
 — 
 
 — 
 
 3-2 
 
 — 
 
 June 
 
 
 
 
 66 
 
 1 
 
 1-5 
 
 31 
 
 0-3 
 
 July 
 
 
 
 
 82 
 
 — 
 
 — 
 
 4-06 
 
 
 August 
 
 
 
 
 70 
 
 — 
 
 — 
 
 35 
 
 — 
 
 September 
 
 
 
 48 
 
 1 
 
 2-1 
 
 2-3 
 
 0-3 
 
 October 
 
 
 
 43 
 
 — 
 
 — . 
 
 2-01 
 
 — 
 
 November 
 
 
 
 39 
 
 1 
 
 2-6 
 
 1-8 
 
 0-3 
 
 December 
 
 
 
 31 
 
 1 
 
 3-2 
 
 1-3 
 
 0-3 
 
 Tot 
 
 al 
 
 
 
 552 
 
 5 
 
 0-9 
 
 2*2 
 
 1-2 
 
 3 A 3 
 
726 
 
 DRACUNCULUS. 
 
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728 HILL SANATARIA OF THE DECCAN. 
 
 CHAP. XXXIII. 
 
 ON THE HILL SANITARIA * OF THE DECCAN. 
 
 It will save unnecessary repetition and the risk of misapprehension 
 if the sense in which certain terms are used is first explained : — 
 
 1. By "Deccan Hill climate or station " is meant an altitude 
 
 of from 4000 to 4500 feet on the Western Ghaut range 
 or its easterly projecting spurs, between about 20° and 
 15° N. latitude. 
 
 2. The term " Deccan table land " is restricted to that por- 
 
 tion of it between 20° and 15° N. latitude which is 
 within about sixty miles of the eastern side of the 
 Western Ghauts, and has a general elevation of from 
 2300 to 1700 feet. It is necessary to be thus precise 
 in indicating the sense in which the term Deccan is used 
 in this report, because at localities more remote from the 
 Ghauts the extremes and the range of temperature are 
 greater at all seasons, and the atmosphere during the 
 rainy season is drier. 
 
 3. The " cold season " is understood to extend from the 
 
 middle of November to the end of February. 
 
 4. The " hot season " from the beginning of March to the 
 
 middle of June. 
 
 5. The " rainy season " from the middle of June to the end 
 
 of September. 
 
 6. October, which has been excluded from this division of 
 
 the seasons, presents much of the character of the hot 
 season months. 
 There are two recognised Sanitaria in the Deccan, Malcolm Pait 
 on the Mahabuleshwur Hills, established in 1828, and the Hill 
 Fort of Poorundhur in 1852. 
 
 Mahabuleslavur II Ills. — On the medical topography and 
 
 * Written early in 1859, and communicated to the Bombay Government. 
 
HILL SANITARIA OF TIIE DECCAN. 
 
 729 
 
 meteorology of these hills there are full and excellent reports* 
 by Mr. Murray, published in the first, second, and seventh num- 
 bers of the Transactions of the Medical and Physical Society of 
 Bombay, from which the following summary statement of some of 
 the leading qualities of the climate has been compiled : — 
 
 
 
 
 Mean 
 
 
 
 Malcolm Pait. 
 
 Mean 
 Temperature. 
 
 Mean Range. 
 
 depression of 
 
 Wet Bulb 
 Thermometer 
 
 Rain- fall, 
 
 Inches. 
 
 Direction ot 
 the Wind. 
 
 Cold Season ■ 
 
 Gi-5 
 
 13- 
 
 10-2 
 
 o-ii 
 
 Easterly. 
 
 Hot Season . 
 
 72-8 
 
 13-6 
 
 13o 
 
 1-09 
 
 NE..NNW.! 
 
 Rainy Season 
 
 64-4 
 
 3-6 
 
 2-2 
 
 243-28 
 
 WSW. 
 
 Month of October . 
 
 666 
 
 9-8 
 
 6-4 
 
 4-58 
 
 Variable. 
 
 t Annual Means . 
 
 66-6 
 
 97 
 
 7-8 
 
 254-05 
 
 
 The station Malcolm Pait is situated on the western slope of the 
 table-land in 17° oQ" N. latitude and 73° 30" E. longitude, and 
 has a general elevation of about 4,500 feet. The accommodation 
 
 * Mr. Murray is unquestionably still the best authority on the hill climates of 
 India, though it is now sixteen years since he last wrote on the subject ; and he will 
 undoubtedly continue to be so, so long as the present ride of changing the niedica 
 officers in charge of hill stations every two years continues in force. 
 
 Mr. Murray was resident at Mahabuleshwur about twelve years, and thus ample 
 opportunities were afforded for the exercise of his intelligent and enquiring mind, and 
 for arriving at useful and safe results. 
 
 The biennial tour of duty came into operation when Mr. Murray left Mahabuleshwur 
 in 1844, and since then at least six different medical officers have been in charge 
 of the station, but without contributing the most fragmentary addition to our know- 
 ledge. Indeed, it is impossible to conceive a system better calculated to cramp and 
 check inquiry than that now in force, not only at Mahabuleshwur, but, I believe, in 
 all the hill stations in India, and this, too, with reference to sanitary questions ill 
 understood and of great moment to the State. 
 
 On this point I write with confidence and from experience. About twenty-five years 
 ago I was for two years in medical charge of Mahabuleshwur during Mr. Murray's 
 absence at the Cape of Good Hope, and I left the station just as I had acquired that 
 preliminary knowledge which further experience of the hill climate might have enabled 
 me to mature and usefully apply. Such, I apprehend, is the process through which 
 every medical officer in charge of a hill station on the biennial system must pass, and 
 such the reason for the backward state of our knowledge of the meteorology and the 
 action on the human body of the hill climates of India. 
 
 Officers should be selected with reference to their qualifications and tastes for the 
 kind of investigation required, and should be left in charge so long as their efficiency 
 and zeal remain unimpaired. The principle, that it is just to extend the benefit of 
 the hill climates to a number of officers, and to effect this by biennial removal, is 
 very considerate ; but it is not one by which scientific objects are likely to be advanced, 
 and this is the paramount end which shoidd be kept in view in medical appointments at 
 hill stations in India. 
 
 f As the month of November has been excluded from the summary, the annual 
 means here given, taken from the original tables, will be found to differ slightly from 
 the means calculated from the sums of the columns of the summary. 
 
730 HILL SANITARIA OF THE DECCAN. 
 
 at present consists of Government quarters for sixteen sick officers, 
 and seventy-seven private bungalows. In the year 1829 a party 
 of invalid soldiers was sent to this Sanitarium, but the selection of 
 cases and of the season was unsuitable. The result was unfavour- 
 able, and the experiment has not been repeated. Since that period, 
 however, the annual resort of an average of about 300 visitors — 
 civilians, military officers, and others, with their families — has afforded 
 ample opportunity of determining the qualities of this hill climate 
 and its influence on the European constitution in health and disease. 
 Poorundhur. — The hill on which the Fort of Poorundhur is 
 placed is an offshoot from the easterly side of the Western Ghaut 
 range. It is situated in 1 8° 22" N. latitude and 73° 54" E. longitude, 
 and is distant nineteen miles from Poona. It is a saddle-backed 
 mountain. The altitude of the highest part of the ridge is 4570 
 feet, but that of the lower fort, in which the Sanitarium is located, 
 is 4200 feet. The lower fort occupies a narrow table about a 
 mile in length, projecting from the northern slope of the mountain. 
 There are two barrack rooms, which afford accommodation for one 
 hundred men, and a very good hospital, adapted for forty sick. 
 There are ten private bungalows, generally occupied in the hot 
 season by officers and their families. A patchery for ten fami- 
 lies and a small female hospital are in course of erection. The 
 Sanitarium may, therefore, at present, be considered sufficient 
 for 130 soldiers and ten families. A good foot-road has been 
 carried round the hill on the level of the Sanitarium, as well 
 as round Wuzurghur, an adjoining hill connected at the same 
 level by a narrow ridge to Poorundhur. This foot-road is about 
 seven miles in extent, and in consequence of its circular character, 
 its position 230 feet below the highest ridge, and the genei-al form 
 and direction of the mountain, there is space for exercise shaded 
 from the sun till nine or ten in the morning. The climate of 
 Poorundhur compared with that of Malcolm Pait has a temperature 
 about three degrees higher, and, in consequence of its more inland 
 position, there is greater atmosjiheric dryness in the months of 
 March, April, and May. The great difference, however, is in the 
 rainy season : at Poorundhur the rain-fall is seventy-two inches ; 
 at Malcolm Pait it is 254. The rain and fog are so incessant at 
 Malcolm Pait that the station is uninhabitable during the rainy 
 season. The Hill of Poorundhur is also frequently enveloped in 
 mist, and though the convalescents remaining there at this season 
 have in general benefited, yet the climate is gloomy, and out-door 
 exercise is often prevented by rain and dense fog. About 650 sick 
 
HILL SANITARIA OF THE DECCAN. 731 
 
 and convalescents have been received into the Poorundhur Sani- 
 tarium since its establishment. The greater number have belonged 
 to regiments stationed in the Deccan. A proportion, however, has 
 been sent from Bombay, Guzerat, and Scind. The selection of 
 cases and of season has been sometimes suitable, at other times the 
 reverse. It is this mixed experience, both at Poorundhur and 
 Mahabuleshwur, not again we may hope likely to occur, which has 
 created data from which the medical inquirer is enabled to ascertain 
 with confidence the right sanitary use of these hill climates. 
 
 Panchgunnee. — Malcolm Pait is rendered uninhabitable from 
 the middle of June to the end of September by incessant rain and 
 fog, consequent on its position on the western side of the mountain ; 
 but it is to this position also that are due a greater coolness and 
 softness of the climate in March, April, and May. There are 
 localities on the eastern side of Mahabuleshwur which possess a 
 climate nearly resembling that of Poorundhur, in which the tem- 
 perature is about three degrees higher than that of Malcolm Pait, 
 the fog less constant during the rainy season, and the rain-fall 
 about fifty inches. Panchgunnee, distant ten miles from Malcolm 
 Pait, overlooking the valley of Wye, at an elevation of 4000 feet, 
 is the locality on the eastern side of which the character of the 
 climate is best known. Notes on the monsoon climate of Panch- 
 gunnee were published by me in the year 1840.* 
 
 Singhur, &c. — The Hill Fort of Singhur, distant fourteen miles 
 from Poona, is placed on a table about 4200 feet above the sea. 
 It has an irregular surface, with a circuit of about a mile and a 
 quarter. There are fifteen private bungalows, usually rented 
 during the hot season by officers and their families from the Poona 
 and Kirkee Brigade. The climate of Singhur cannot differ much 
 from that of Poorundhur. 
 
 Between the river Taptee on the north and the fifteenth degree 
 of north latitude on the south, there are probably many situations 
 more or less spacious on the easterly side of the Western Ghaut 
 range, or on the spurs projecting inland from it, with an elevation 
 from 4000 to 4500 feet, which present the same characteristics of 
 climate in the dry and rainy seasons as Panchgunnee, Poorundhur, 
 and Singhur. But it must be borne in mind, for reasons which 
 Avill presently appear, that the hot-season climates of such localities 
 are two or three degrees warmer and are drier than Malcolm Pait 
 and other similar positions on the western or seaward side of the 
 Ghauts. 
 
 * "Transactions, Medical and Physical Society <>f Bombay," No. 3. 
 
732 niLL SANITARIA OF THE DECCAN. 
 
 The conclusion to which these several statements lead is, that 
 the soldier in this Presidency has not as yet derived much benefit 
 from the Deccan Hill climates ; and the practical question which 
 has now to be determined is, by what system this benefit, if real 
 and important, may be extended. 
 
 The practice hitherto has been to select from among the sick 
 and convalescents in Hospital those men who are not regaining 
 health, or are progressing slowly to recovery. But the climate of 
 these Hills is by no means suited at any season for all cases which 
 come under this description, and at some seasons is unsuitable for 
 them all. It is therefore of the utmost importance that medical 
 officers on arrival in India should early familiarise themselves with 
 the principles relative to the sanitary application of the Deccan 
 Hill climates which past experience has enabled us to advance with 
 tolerable certainty. With the view of facilitating this necessary 
 preliminary object, a memorandum * was prepared by me in May, 
 1858, when Superintending Surgeon of the Poona Division, relative 
 to the Poorundhur Sanitarium, and the doctrines inculcated in it 
 may be regarded as equally applicable to other Hill stations of 
 similar altitude and climate. It will be sufficient to state here as 
 the general result of past experience, that the debilitated soldier, 
 who in the plains of the Deccan, the Concan, Bombay, and Gfujerat 
 regains his strength and efficiency slowly, will after the removal of 
 positive disease be much benefited by a Deccan Hill climate in 
 the month of October and in the hot season ; and at those Hill 
 stations (as Poorundhur) in which the rain-fall is not more than 
 seventy inches, and the mists, though frequent, by no means con- 
 tinuous, there will be still further advantage to many of this class 
 of convalescents by — -after a hot-season residence — their stay being 
 prolonged throughout the rainy season and the month of October. 
 The benefit which may be looked for is this : — The soldier will have 
 become fitted for duty, he will be less liable to fresh attacks of 
 disease, and when attacked the disease will be of milder type. 
 Whereas had he continued exposed to the exhausting hot season 
 of the Deccan or of the coast, he would have remained inefficient, 
 and have become very predisposed to attacks of the severer forms 
 of tropical disease — those forms which swell the mortality and in- 
 validing rates of European troops in India. The ultimate effect of 
 these Hill Sanitaria applied as now explained must be, in propor- 
 tion to the degree in which they are used, to reduce mortality and 
 invaliding. 
 
 * Sec Appendix. 
 
HILL SANITARIA OF THE DECCAN. 733 
 
 But a large proportion of the class of convalescents just adverted 
 to, if sent to the Hills in the cold or rainy seasons, would run the 
 risk of being injured by the return of their former diseases or by 
 the access of others of similar character. It is therefore necessary 
 that caution and judgment should be exercised, not only in the 
 selection of the cases, but also in determining the season. There 
 are cases of imperfect recovery from some forms of organic disease 
 which, if the opportunity of a sea voyage and change to colder 
 latitudes is not available, may be sent to the hills in the hot season, 
 if the facilities of carriage are good, with temporary advantage 
 from avoiding the heat of the plains. But for all cases of imperfect 
 recovery from all forms of organic visceral disease the cold and 
 rainy seasons of the Hills are altogether unsuited, and are generally 
 positively and markedly injurious. The evils which result from 
 the neglect of this now well-ascertained truth were apparent at 
 Mahabuleshwur in the experiment of 1829. They have occurred 
 also from time to time at Poorundhur, and have been very fre- 
 quently observed at the Neilgherry and Himalayan Hill Sanitaria. 
 
 The superiority of the Deccan Hill climate is in the month of 
 October, and from March to early in June. 
 
 The Deccan table-land has, during the cold season, a mean tem- 
 perature of 70°, and a range of 25°. Its climate at this season 
 exercises no injurious influence on the European constitution, and 
 is less likely to be prejudicial in the conditions described above 
 than the climate of the Hills at the same period of the year. 
 
 The Deccan table-land has, in the rainy season, a mean tempera- 
 ture of 73*70°, a range of 14*6°, and a rain-fall from about 30 to 20 
 inches. The climate is genial and refreshing. Though the lower 
 temperature of Poorundhur (67*3°) at the same season is an ad- 
 vantage to some convalescents, still in others it is counterbalanced 
 by the gloom and confinement to quarters consequent on the fre- 
 quent fog and rain. It may therefore, under existing data, be con- 
 cluded that the Hill climate in the rainy season has no advantage 
 over that of the table-land in the neighbourhood of the Ghaut range. 
 
 In the hot season the mean temperature of the Deccan table- 
 land is about 80°, the range 25°, the dryness 22-5°, and a hot wind 
 blows throughout a considerable part of the day. At this season the 
 European constitution is apt to suffer from the influence of elevated 
 temperature, and to become more or less debilitated ; and con- 
 valescence from all forms of disease is tardy and unsatisfactory. 
 
 In the 9th Number of the Transactions of the Medical and Phy- 
 sical Society of Bombay there is a paper by Mr. Murray on the 
 
734 HILL SANITARIA OF THE DBGCAN. 
 
 climate and diseases of Sattara. It contains much valuable infor- 
 mation on the meteorology and general characters of the different 
 seasons in the Deccan, and may be consulted with much advantage 
 with reference to the subject under consideration. 
 
 In Bombay the mean temperature of the hot season is 82°, and 
 the range 11°. The mean temperature of the rainy season is 80-8°, 
 and the range 6'2° ; the rain-fall is 75 inches; and the atmosphere 
 from the middle of June to the end of September is humid, and 
 often not far from the point of saturation. The hot and the rainy 
 seasons in Bombay are exhausting to the European, and a similar 
 remark may be applied to the same seasons on the Western Coast 
 generally, and the low southern portion of the province of Gnzerat. 
 
 It appears, then, that the hot season of the Deccan table-land and 
 the hot and rainy seasons of Bombay, the Coast, and Gruzerat are 
 inimical to Europeans, the degree being in proportion to the pre- 
 vious state of debility of those who are exposed to their influence. 
 
 The value of the Deccan Hill Sanitaria is restricted to the hot 
 season. The weakly soldier of the Deccan stations with the cold 
 and rainy season on the table-land, and the month of October and the 
 hot season at a Hill station, has every advantage which the climate 
 of this part of India is capable of affording. The weakly soldier of 
 the Coast and Gruzerat stations with the cold season of his own 
 locality and the rainy season of the Deccan table-land and the 
 month of October and the hot season at a Hill station, has also 
 every benefit from climate which his circumstances admit of. 
 
 Hitherto the improvement to health which results from a judi- 
 cious use of the climates at our command has, in the instance of 
 the soldier, been confined to the small number of hospital cases for 
 which a change to Poorundhur has been considered suitable. In 
 order to extend the advantage, a modification of system would seem 
 to be all that is necessaiy. In addition to the hospital cases a per- 
 centage of the men in barracks and of their families, say of the 
 former from 10 to 25 per cent, (varying according to the necessities 
 of service), should be selected at Deccan, Coast, and Guzerat 
 stations. The selection should be made by the medical officer with 
 reference to constitution, medical history, and service in India. 
 The men thus selected should leave their stations towards the end 
 of February, so as to reach the Hills at the beginning of March. 
 The Deccan soldiers should return to their stations in the first week 
 of June, if within the salubrious limit, but if belonging to more 
 inland stations, they with those of the Coast and Guzerat should 
 be sent to a well-selected Deccan table-land Sanitarium ; and 
 
HILL SANITA1UA OF THE DECCAX. 735 
 
 all should return to the Hills in the first week of October, remain 
 there till the middle of November, and then proceed to rejoin their 
 respective stations for duty, so as to reach them early in December. 
 
 In this view the Hill stations are regarded merely as hot season 
 Sanitaria, and the establishments and arrangements should be 
 organised with reference to this limited object. For the Sanitarium 
 of the rainy season a suitable locality on the Deccan table-land 
 would require to be selected. 
 
 By this system the Deccan soldier, whether in hospital or at duty, 
 would have the advantage every fourth or fifth year of a hot season 
 on the Hills ; and the Coast and Guzerat soldier of a hot season on 
 the Hills and a rainy season on the table-land. It may be confidently 
 anticipated that a sanitary measure of this scope and nature, in 
 connection with a never-failing attention, under all circumstances, 
 to barrack accommodation and the various other matters of detail 
 which relate to the health and welfare of the soldier, would in a 
 few years have a marked effect in reducing the proportion of sick, 
 of mortality, and of invaliding. It cannot be too often repeated 
 that, by maintaining the general health of troops at as high a .stan- 
 dard as the conditions of service in a tropical climate permit, not 
 only is present efficiency increased, but the predisposition to dis- 
 ease, and particularly to disease of bad type, may be so diminished 
 as most materially to reduce mortality and invaliding. To what 
 degree this advantage may ultimately be foimd to reach, future 
 experience must determine ; but there can be no doubt that the 
 principles are true, and that a sanitary system founded on their 
 strict observance, and faithfully and judiciously followed for a series 
 of years, must prove of very great advantage to the European 
 soldier in India, and consequently to the State. 
 
 The method now proposed of applying the Hill and Deccan 
 climates for the preservation and improvement of the health of 
 the soldier rests on no new or untried doctrines. The proposition 
 merely aims at extending to the soldier, and to the families of 
 soldiers, a system which has for the last thirty years been success- 
 fully followed by civilians and officers and their families ; and which 
 by them has been found to include all the benefit which these cli- 
 mates are capable of conferring. 
 
 It now remains to state briefly the means by which these views 
 may be, under existing circumstances, most readily reduced to 
 practice. The Sanitarium at Poorundhur should be continued on 
 its present scale and plan for the reception of convalescents on sick 
 certificate from regiments in the Deccan. It should be continued 
 
736 HILL SANITABIA OF THE DECCAN. 
 
 as now during the rainy season, so as to admit of further 1 observa- 
 tion of the effects of this season, and of careful comparison of the 
 results with those of the hospital cases from the Coast and Chizerat, 
 whom, as will presently appear, it is proposed to locate on the 
 Deccan table-land during the rains. Though there can be little 
 doubt that the monsoon climate of the Deccan table-land is on the 
 whole preferable to that of Poorundhur, still it is very expedient to 
 take advantage of the already organised establishment at this Sanita- 
 rium for prosecuting the enquiry further, and finally settling the 
 question to the satisfaction of those who may still entertain doubts 
 on the subject. Poorundhur does not admit of extension as a 
 Sanitarium for all seasons, but a hot season site may be found on 
 Fitzclarence Point. Considering, however, the limited space on the 
 mountain, even this extension is inexpedient as a permanent 
 arrangement. 
 
 For the men selected from barracks from all stations, whether in 
 the Deccan or elsewhere, and for the hospital cases from Bombay, 
 the Coast, Gruzerat, and Scinde, a hot season Sanitarium should be 
 established on the Mahabuleshwur Hills in the proximity of Mal- 
 colm Pait. The Deccan soldiers should return to their stations at 
 the beoinnincr f June, and those from elsewhere should be moved 
 to Sattara for the rains, return to Mahabuleshwur in October, and 
 thence proceed to their respective stations in the latter half of 
 November. 
 
 Should it on further experience at Poorundhur, and on com- 
 parison with the results at Sattara, appear that there is greater 
 advantage from the monsoon residence on the Hills than existing 
 data seem to suggest, then instead of moving the Coast and Gruzerat 
 and Scinde soldiers to Sattara for the rains, let monsoon barracks 
 and a suitable hospital be built at Panchgunnee, which would thus 
 become the rainy season position of the military Sanitarium on the 
 Mahabuleshwur Hills. There would in this arrangement be merely 
 the cost of original erection. The establishment of the hot season 
 would be available for the rains, whether passed at Sattara or at 
 Panchgunnee. As the barracks at Panchsrunnee would not be 
 required for men belonging to Deccan stations, they would neces- 
 sarily be on a smaller scale than those at Malcolm Pait. Consider- 
 ing the proximity of Bomba} 7 , Poona, and Sattara to Malcolm Pait 
 the many advantages possessed by the western side of the mountain, 
 and the fact that a well-proved Sanitarium has long existed there, 
 and assuming that the views expressed in this report on the true 
 use of these Hill stations are accepted as just, then there need be 
 
IITLL SANITARIA OF THE DECCAN. 737 
 
 no delay in erecting barracks at Malcolm Pait. For should it 
 afterwards be proved that there are advantages in a residence during 
 the rains at such positions as Panchgunnee, which it is desirable to 
 secure, no unnecessary outlay will have been incurred in erecting 
 barracks at Malcolm Pait, for it must be always remembered that 
 the western side of the mountain has advantages in the hot season 
 over the eastern side, which it would be unwise to throw away ; 
 and as respects the cost incurred at Sattara in carrying out the 
 measures suggested for immediate adoption, it cannot under any 
 circumstances be lost, for there is little risk of barrack accommo- 
 dation proving excessive at a station healthy like Sattara, and 
 otherwise not unimportant. 
 
 Should, however, the distance to Mahabuleshwur be found incon- 
 venient to regiments in the southern Mahratta country or in 
 Kandeish, or, after the railway lines are completed, to those in 
 Central India, then other Hill stations may be sought for, north 
 and south of Mahabuleshwur, in the Grhaut range itself, or on the 
 spurs that project inland from its easterly side; it being borne 
 in mind that if the Sanitarium is for the hot season alone, a 
 westerly position is very important, but that if the rainy season 
 is to be included, then a station on the eastern side of the 
 Ghauts, or more inland on the projecting spurs, must be selected, 
 and the full advantages of the Deccan Hills in the hot season be in 
 some measure sacrificed. 
 
 Though the sanitary advantages to be derived from the Deccan 
 Hill climates, and the means by which they may be effected, have 
 now been considered, there yet remains an important question to 
 discuss with reference to the full benefit attainable from change of 
 climate within the limits of the Bombay Presidency. 
 
 It has been argued in this report that the chief use of these Hill 
 Sanitaria is confined to the hot season, and to the acceleration of 
 convalescence from disease that has been removed, or of recovery 
 from disease which is merely functional ; but that for individuals 
 affected with chronic organic disease benefit from the hot season 
 at a Hill station is only occasional, and at other seasons in 
 such cases the climate is generally positively injurious. It is from 
 organic visceral disease, primary, or complicating or consecutive 
 on the various types of fever, that the greater part of ordinary 
 mortality in India results. It is from these same forms of disease, 
 after they have passed into a chronic state, and also from chronic 
 rheumatic affections, that the great proportion of invaliding in 
 India proceeds. The climate of the Hills in the cold and rainy 
 
 3 B 
 
738 HILL SANITARIA OF THE DECCAN. 
 
 seasons is injurious in all these forms of disease, and the climate 
 of the Deccan table-land in the cold season is also often unsuit- 
 able. It is therefore important to inquire whether in such cases, 
 stationary or retrograding in the cold season in the Deccan, there 
 is any prospect of advantage from change of climate, short of a 
 voyage to sea and return to colder latitudes. It may be with con- 
 fidence replied that the climate of the coast, about the latitude of 
 Bombay, from the middle of November to the end of February, 
 with a temperature of 74'8°, and range of 14°, and without the 
 atmospheric dryness of the inland upland stations, affords this 
 advantage. 
 
 A cold season Sanitarium suitably placed on the coast, and 
 accessible with little fatigue, would be frequently of much utility 
 in the management of cases of organic disease which are retrograd- 
 ing or stationary or slowly convalescing in Deccan hospitals in the 
 cold season. They would recover more rapidly, and become more 
 surely fitted for transference to a Hill station in the hot season, 
 and, in some cases, life might be saved, and invaliding prevented. 
 A sea-coast Sanitarium, then, on a small scale, may be regarded as 
 an important part of the sanitary system of this Presidency. But 
 in order to the safe application of the principle on which its utility 
 rests, it will be very necessary that medical officers, on arrival in 
 India, should early become well acquainted with the state and 
 stages of disease for which it is appropriate, and that the locality 
 be selected with reference to accessibility, facility, and comfort 
 of transport. 
 
 On the subject of a coast Sanitarium it may be useful to remark 
 that, under the improved state of general health which will accrue 
 to the soldier in India from an improved sanitary system, including 
 the avoidance in the hot season of the heat of the plains by resort 
 to Hill stations, the proportion and severity of visceral organic 
 disease and of rheumatic affections will, after a time, become so 
 diminished that gradually the necessity for change to the sea-coast 
 will be lessened. This result may be expected for the same reasons 
 that it is anticipated that mortality and invaliding will, by these 
 same means, become very materially reduced. 
 
 Though this report has reference to the Deccan, and to troops 
 for which the Deccan Hill Sanitaria are available, still it may not 
 be altogether inappropriate briefly to allude to other Hill climates 
 and troops in other parts of India.* 
 
 * For information on the Hill stations of the sub-Himalayan range, the reader is 
 referred to the first, second, and fourth rolumes of the "Indian Annals of Medieal 
 
HILL SANITARIA OF THE DECCAN. 739 
 
 The general principles which have been advanced are applicable 
 to all localities and to all European troops in India, for they tend 
 to one leading practical object, viz. the maintenance of the greatest 
 degree of health and efficiency for the ordinary contingencies of 
 service in a tropical country. This end is to be attained by avoid- 
 ing, as much as possible, unhealthy localities and seasons, such as 
 localities with malarious characteristics, the hot season all over 
 India, and the rainy season in many parts of it. 
 
 The advantages which are, in some measure, peculiar to the 
 Bombay Presidency are : — 
 
 1. Hill stations which, from elevation (4000 to 4700 feet), 
 
 proximity to the sea, and safe approach at all seasons, 
 afford a cool retreat from the heat of the plains in the 
 hot season, without the risk of inj ury from cold and wet. 
 
 2. A considerable extent of country on the Deccan table-land 
 
 possessing in the rainy season a climate salubrious and 
 refreshing. 
 
 3. Facilities for the establishment of Sanitaria on the sea- 
 
 coast in suitable latitudes. 
 Whereas the sub-Himalayan Hill stations, with elevations from 
 4200 to 7400 feet, are of unsafe approach at some seasons, and 
 present, in greater degree than Mahabuleshwur and Poorundhur, 
 the disadvantages of the cold and rainy seasons ; while during the 
 hot season, owing to distance from the sea and other causes, their 
 climates are not so temperate, equable, and dry. Thus the un- 
 favourable hot and rainy seasons of the adjoining plains are ill 
 provided against by these Sanitaria. There is no healthy monsoon 
 climate, and no facility of access to a suitable sea-coast. 
 
 The approach to the Neilgherries is, at some seasons, unsafe, but 
 there are stations at different elevations and on different sides of 
 the mountain, which, with the Mysore table-land and a sea-coast, 
 though of low latitude, give to the Madras Presidency in consider- 
 able degree the advantages stated to appertain chiefly to that of 
 Bomba} 7 . 
 
 The problem which has been kept in view in preparing these 
 observations has been, how to fit the European soldier for the 
 
 Science," also to the eleventh number of the same work, in which the subject is treated 
 fully in Mr. Chever's elaborate paper, li On the means of preserving the health of the 
 European soldier in India." 
 
 Mr. M'Clenand's -Medical Topography of Bengal " contains very useful information 
 on Hill climates and allied subjects. 
 
 The climate of Mount Aboo on the Aravalli range is described in the third number, 
 new series, " Transactions, Medical Society of Bombay," by Dr. Lownds. 
 
 3 B 2 
 
740 HILL SANITARIA OF THE DECCAN. 
 
 maximum of efficient service in India with the minimum sacrifice 
 of health and of life. The attempt has not been made to inquire 
 by what means he may attain to the full physical constitutional 
 vigour of his native land and of the other countries of the colder 
 latitudes of the globe — simply because this condition is incompatible 
 with the circumstances in which he is placed. The question has 
 at different times been proposed, whether a regiment fresh from 
 Europe located at an elevation of 7300 feet, and in a climate such 
 as that of Ootacamund on the Neilgherry Hills, would not retain 
 much of its European vigour. Doubtless it would, a deduction, 
 however, being made on account of the rarefied atmosphere. But 
 this regiment would not be efficient for the contingencies of service 
 in India. If suddenly called to the plains for service in the hot 
 season, it would soon show a heavy sick list, and a rapid loss of 
 vigour and stamina would ensue. Let us suppose the service to be 
 concluded, and the regiment, exhausted by heat and fatigue and 
 sickness, moved back to Ootacamund, and the result would be 
 much mortality and invaliding from congestive, inflammatory, and 
 organic visceral disease. The proof that this is no fancied picture 
 will be readily found in what takes place under the ordinary cir- 
 cumstances of troops fresh from Europe arriving at the commence- 
 ment of the hot season ; and in what has taken place between the 
 years 1840 and 1850 on the transference to the Himalayan Hill 
 stations of several European regiments weakened by service, cli- 
 mate, and disease. 
 
 There is no antagonism between the Hill climates of India and 
 a voyage to sea, followed by a residence in the higher latitudes. 
 The states of disease for which the latter is required are usually 
 unsuited for the former. The Hill climates can never be regarded 
 as a substitute for a voyage to Europe or to Tasmania, but their 
 judicious use will render the greater change less frequently neces- 
 sary, will improve the general health, minister to the comfort and 
 happiness, and increase the efficiency of the European soldier in 
 India, 
 
741 
 
 APPENDIX. 
 
 A. 
 
 Notes and Tables on the Meteorology of Bombay. 
 (Prepared by T. M. Lownds, Esq., M.D., Assistant Surgeon, Bombay Establishment.) 
 
 These tables * of the meteorology of Bombay, for the six years from 1847 
 to 1852, have been compiled from the Colaba pbservatory Eeports, from 
 the published reports for four years; and for 1851-52, I am indebted to 
 Dr. Leith, to whom the daily observations are furnished from Colaba. 
 
 Temperature. — The monthly mean is calculated from the daily obser- 
 vations taken each hour in the twenty-four. A very cursory examination 
 will show how slight are the differences in one year from the mean of six 
 as recorded. The greatest differences from the mean of six years are only 
 as follows, the greatest difference in any of six months being taken : — 
 
 Thus, of six months of January, greatest difference from mean is + 2'1° 
 
 ,, ,, ,, February ,, ,, —1*4 
 
 „ „ ., March „ „ + 07 
 
 ,. ,. „ April „ „ + 07 
 
 „ „ May „ „ +1-5 
 
 „ „ June „ „ +1-6 
 
 ,. „ July „ „ +1-1 
 
 „ !, „ August ,, „ + 0-8 
 
 „ „ ,, September „ ,, — 1-3 
 
 ,, „ „ October „ „ +1'2 
 
 ,, „ ,, November „ „ + 3-3 
 
 ,, „ ,, December ,, „ + o - 9 
 
 January is the coldest month of the year, December and February 
 almost the same, as also November and March ; October forms a' mean 
 between March and April. April and May are the hottest months. The 
 monsoon months vary little in mean temperature, and, as might be expected, 
 the range in them is very small. The great difference between hot and 
 cold months is not so much in greater temperature during day, but in cool 
 nights, and hence the range forms a distinguishing character between the 
 
 * These tables and memorandum, kindly prepared, at my request, with much care, 
 are published in the form in which they were communicated by then- zealous and able 
 author. 
 
 3 B 3 
 
742 METEOROLOGY OF BOMBAY. 
 
 hot and cold season ; of course the range being much greater during the 
 cold than in the hot months. A considerable degree of correspondence 
 will be found relatively between the mean daily and monthly range, and 
 the range of the "Wet-bulb Thermometer. The extremes call for no 
 remark. 
 
 The daily temperature is at its minimum at sunrise, almost without 
 exception. It then rises rapidly for the first two or three hours, until 
 9 a.m., when it rises slowly, and attains its maximum at noon ; occasionally 
 at 11, or even 10 a.m., but this is rare ; still more rarely it is delayed till 
 1, or even 2 p.m., declines slowly till 5 p.m., or sunset, when it again takes 
 a stride or two rapidly downwards till about 7 p.m., when it continues 
 slowly declining till sunrise. The mean daily monthly variation is well 
 represented in the table. The daily variation is sometimes very great, 
 as much as from 20° to 23°, but this is comparatively rare, and only 
 occurs in cold months. In the monsoon, on the contrary, the range is 
 very slight. 
 
 Wet-bulb Thermometer. — I have preferred giving the temperature of 
 wet-bulb, to the calculated dew-point, as some difference of opinion exists 
 about the proper calculation. It will be seen that the temperature of wet- 
 bulb does not differ much froin year to year, and that the range in each 
 month corresponds pretty closely. The mean temperature of humidity 
 represents the point of saturation. Full saturation is supposed to be unit}'. 
 This enables us to compare the atmospheric moisture pretty exactly. It 
 does not vary much. 
 
 Barometer. — Of the barometer I have only given the mean height for 
 each month, and this may be said to be almost without variation in the 
 series of years. It descends with great regularity from its highest in 
 January to its lowest in June, and the height varies little during the monsoon. 
 The average range of the barometer during the whole year is very slight, 
 01 10 inch, or 0112 inch, representing it. The extreme range is highest 
 in the cold months, occasionally the daily variation is as much as 0'2 inch, 
 or a little more. The variation is least in the monsoon months. 
 
 Rain Fall. — The rain table is given so fully, that it seems unnecessary 
 to add anything to it. 
 
 The evaporation in Bombay is excessive, and by the accounts pub- 
 lished, almost equals the average fall of ram. (Vide tables for 1819 = 72 
 inches. 
 
 Direction AMD Force of Winds. — The wind usually sweeps round the 
 horizon every day, blowing, as the tables quoted show, chiefly from the sea, 
 and with a force usually of about half a pound, for an hoirr or two daily, 
 generally less. In the monsoon, the force is greatly increased, and reaches 
 as high as 8 or 10 lbs. The account of the wind must only be taken as 
 approximative, as often there is not wind enough to move a feather. 
 
 I have not said anything of particular variations, as I conceive the pur- 
 pose of the table to be, to give a correct idea of the general climate of 
 Bombay, and such as may easily be referred to for practical purposes. For 
 minute investigation, the Observatory Reports are most admirable. 
 
METEOROLOGY OF BOMBAY. 
 
 743 
 
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SANITARIUM AT POORUNDHUE. 
 
 747 
 
 B. 
 
 Memorandum on the Sanitarium at Poorundhur, 19 Miles 
 distant from poona, latitude n. 18' 12, longitude e. 73-54, 
 Altitude 4200 Feet. — Established in 1852. 
 
 1. Table showing the Atmospheric Pressure, the Temperature, the Dryness, 
 the Bain-fall, and the Direction of the Winds at Poorundhur. 
 
 
 
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 !! 
 
 Direction of Winds. 
 
 
 
 
 S 
 
 S 
 
 I-* 
 
 
 
 
 
 
 Of 
 
 Dryn 
 betwei 
 Bulb 
 
 c 
 
 
 
 
 
 
 
 
 Inches. 
 
 
 January 
 
 26-022 
 
 66-8 
 
 71-0 
 
 61-8 
 
 17-3 
 
 0-5 
 
 SE. NW. W. NE. 
 
 February . . 
 
 26-023 
 
 73-3 
 
 76-6 
 
 66-6 
 
 244 
 
 0-30 
 
 Variable. 
 
 March . . . 
 
 25-940 
 
 76-7 
 
 81-0 
 
 69-6 
 
 26-4 
 
 0-20 
 
 NW. 
 
 April . . . 
 
 25-958 
 
 781 
 
 83-0 
 
 70-6 
 
 28-3 
 
 0-50 
 
 NW. 
 
 May . . . 
 
 25-883 
 
 72-9 
 
 78-4 
 
 68-0 
 
 12-1 
 
 5-70 
 
 NW. 
 
 June 
 
 25-795 
 
 69-8 
 
 80-0 
 
 654 
 
 3-2 
 
 10-18 
 
 NW. 
 
 July . . . 
 
 25-806 
 
 669 
 
 70-8 
 
 65-2 
 
 1-1 
 
 22-98 
 
 SW. and NW. 
 
 August . . . 
 
 25-837 
 
 654 
 
 68-2 
 
 64-4 
 
 0-7 
 
 16-34 
 
 SW. and NW. 
 
 September 
 
 25-844 
 
 67-4 
 
 72-6 
 
 65-4 
 
 2-1 
 
 7-39 
 
 NW. 
 
 October . . 
 
 25-946 
 
 712 
 
 74-2 
 
 670 
 
 10-6 
 
 6-54 
 
 SE. 
 
 November . 
 
 26-041 
 
 693 
 
 73-2 
 
 65-2 
 
 18-8 
 
 0-67 
 
 SE. 
 
 December . 
 
 26-011 
 
 64-1 
 
 69-8 
 
 59-2 
 
 13-2 
 
 1-36 
 
 E. and SE. 
 
 Mean . . 
 
 25-925 
 
 70-1 
 
 74-9 
 
 65-7 
 
 132 
 
 72-21 
 
 Total inches. 
 
 The Pressure, Temperature and Dryness are taken from the Eeport for the years 
 1852-53, and are therefore to be regarded merely as an approximation. The Eain- 
 fall is the average of six years' observation : the greatest was in 1854, viz. 97 - 24 
 inches; the least in 1856, viz. 44-76 inches. The hill is more or less covered with 
 fog in June, July, August, and September ; in greatest degree in July and August. 
 
 2. The object of this Sanitarium is to promote the restoration to health 
 and strength of soldiers who have become debilitated from the effects of 
 climate, or from recurrences, or from long duration of various forms of dis- 
 ease, and thus to increase their efficiency, lessen their liability to suffer 
 from severe types of disease, and add to the probabilities of lengthened 
 service. 
 
748 SANITARIUM AT POOEUNDHUE. 
 
 3. These beneficial results occur with greater certainty hi convalescents, 
 in whom there exists no internal organic disease, or marked tendency to 
 it. It will, therefore, be found that the young soldier derives more benefit 
 from the climate of Poorundhur than the soldier of ten years 1 service and 
 up wards in India. 
 
 4. From the commencement of the month of March to the middle of 
 November is the season during which these advantages will be gained. 
 The period of residence required for complete restoration of strength will 
 vary in different cases, and its determination should be left to the discre- 
 tion of the Medical Officer in charge of the Sanitarium. 
 
 5. Though in the class of invalids adverted to in the 3rd paragraph, 
 the hill climate from the middle of November to the end of February 
 might not prove injurious, still it possesses no advantages over that of 
 Poona, and the season is suitable for return to this latter station and to 
 duty. 
 
 6. The class of convalescents hitherto referred to as likely to be bene- 
 fited by this climate, are : 1st. — Those who have become reduced in 
 strength from recurrences of intermittent or remittent fever at Poona, or 
 other adjacent stations, in June, July, August, and September, may, with 
 advantage, reside at Poorundhur from the beginning of September to the 
 middle of November. After this period, however, such cases had better 
 be returned to Poona ; for, from the middle of November to that of Feb- 
 ruary, there will be a greater liability to re-attacks of fever in the hill 
 climate than at Poona. 2nd. — Those who have suffered from recurrences 
 of malarious (intermittent or remittent) fever in October, November, 
 December, January, and February, may be sent to the hill with every pros- 
 pect of benefit, in the month of March ; the duration of residence in each 
 instance being prolonged or not according to necessity. 3rd. — Yotuig 
 recruits debilitated from attacks of common continued fever (febricula) in 
 March, April, and May, will, after convalescence has fairly commenced, be 
 benefited by the climate of Poorundhur. 4th. — Those whose health and 
 strength have become enfeebled from the general effects of a tropical cli- 
 mate or from strumous or allied diathesis, and in whom chronic lymphatic 
 glandular swellings, or indolent external ulcerations are present, are likely 
 to derive advantage from a residence, more or less prolonged, between the 
 beginning of March and middle of November. 
 
 7. The months in which invalids may resort to Poorundhur are : 1st. — 
 From the commencement of September to the middle of November, — 
 regard being had to the character of the monsoon weather, in different 
 years, in the first named month. From the middle of November till to- 
 wn n is the end of February, convalescents of all kinds are probably better 
 in Poona than at Poorundhur; and, as already stated, it will generally be 
 expedient to return to the former station invalids who have been sent to 
 
 the hill in the September and October immediately preceding. 2nd. 
 
 Though invalids already at Poorundhur, and who have been resident there 
 for some time previously, are generally improved by the climate of July 
 and August, it is, nevertheless, unadvisable to send them there in these 
 
SANITARIUM AT POORUNDHUR. 749 
 
 months. 3rd. — March, April, and May are the months most suitable for 
 the transfer of convalescents to Poorundhur. A greater variety of cases 
 may be sent at this period, and they can have the advantage, if necessary, 
 of a continued beneficial residence of eight months and a half, viz. to the 
 middle of November. In many cases more or less of the climate of March, 
 April, and May is necessary to fit the constitution for deriving benefit 
 from the monsoon months. 
 
 8. The more precise application of the climate of Poorundhur will be 
 best explained by reference to some of the chief forms of disease. 
 
 I. Fevers. The convalescent, from all forms of uncomplicated fever, 
 will be benefited from March to the middle of November. Individuals 
 Avho have suffered from frequent attacks of malarious fever are liable to 
 have the disease re-excited — chiefly in the tertian form — by external 
 cold in the months of December and January ; this liability (the degree of 
 predisposition in both instances being assumed equal) is greater at Poo- 
 rundhur than at Poona ; therefore the former locality should, under these 
 circumstances, be avoided in these months. Such individuals are also 
 liable to re-attacks in July, August, September, and October ; this liability 
 would seem to be greater at Poona than at Poorundhur, probably in con- 
 sequence of the great equability of temperature of the latter not favouring 
 cold as a determining cause, and the more continuous moisture preventing 
 the generation of malaria. Therefore, the predisposed to intermittent fever 
 may pass the rains with advantage at Poorundhur, provided he has resided 
 there a month or six weeks of the hot season just preceding. Convalescents 
 from malarious fever, in whom some degree of splenic enlargement is present, 
 may resort to Poorundhur at the suitable seasons without risk of injury, 
 and with eveiy prospect of advantage, provided appropriate care and man- 
 agement be at the same time adopted. A similar remark may be applied 
 to those in whom, with the febrile recurrences, there has been tendency to 
 hepatic congestion, provided the disease has not been of long duration, nor 
 the subject of it long resident in India. For it is reasonable to infer that 
 where congestion of the spleen or of the liver is coincident with, and in a 
 measrue consequent on, the febrile recurrence, and diminishes or ceases 
 with its intermission, the tendency of a climate which prevents the return 
 of the febrile paroxysm must be gradually to remove the dependent con- 
 gestions and their consequences, if appropriate medical treatment and 
 management be at the same time had recourse to. It follows, then, from 
 these observations, that benefit from the climate of Poorundhur to con- 
 valescents from fever will be contingent on accuracy of diagnosis as respects 
 absence, nature, and degree of organic complications. 
 
 II. Dysentery and Diarrhcea. The convalescent from uncomplicated 
 dysentery or diarrhcea may with propriety be sent to Poorundhur in 
 March, April, and May, and his stay there prolonged or not according to 
 circumstances. 
 
 III. Hepatitis. Individuals who have recently suffered from attacks 
 of acute hepatitis, and who are consequently predisposed to recurrence, 
 should, as a general rule, avoid this climate at all seasons, though probably 
 
750 SANITARIUM AT POORUNDHUR. 
 
 there is still room for experiment as to whether the monsoon season at 
 Poorundhur may not, under these circumstances, be useful in young, pre- 
 viously sound, and at the time thoroughly convalescent constitutions. 
 
 IV. Cirrhosis. The hill climate is unsuitable for the soldier in whom 
 this condition of the liver is suspected to be present. 
 
 V. Dyspepsia. When the symptoms to which this term is applied are 
 related to debilitated states of constitution, or to chronic irritation of the 
 mucous membrane of the stomach, the climate of Poorundhur, with due 
 attention to diet and medical treatment, is in general very useful. When, 
 however, they are dependent on cirrhosed liver, or other allied visceral 
 change, benefit is not to be looked for : such cases, indeed, have been 
 erroneously classed. 
 
 VI. Pulmonary Affections. In the incipient and early stages of 
 phthisis, good will probably result negatively in March, April, and May 
 from avoidance of the debilitating influence of the heat of the plains. The 
 soldier, generally of some length of service in India, suffering from chronic 
 bronchitis or asthma, is not likely to be improved by a residence at 
 Poorundhur ; on the contrary, these affections are liable to be increased. 
 
 VII. Affections of the Heart. Organic disease of the walls or 
 valves of the heart will, it need hardly be observed, derive no benefit. 
 The symptoms consequent on the embarrassed action of the organ will 
 generally become aggravated. Yet there are cases of disease, occasionally 
 erroneously named Carditis, characterised chiefly by palpitation, often 
 distinctly traceable to frequent exposure to the sun, or to alcoholic or 
 other intemperance, which may be improved by avoidance of the hot 
 season of the plains. In selecting such cases, however, careful attention 
 to diagnosis is essential. 
 
 VIII. Cerebral Congestive, Inflammatory, or Structural Disease 
 is liable to be aggravated by the climate of Poorundhur. 
 
 IX. Rheumatism. — Cases of pain, with or without slight swelling of the 
 joints, occurring in cachectic constitutions, provided the cachexia is not 
 decidedly syphilitic, often derive benefit if sent to the hill after the begin- 
 ning of March ; and if the improvement has been considerable in the 
 months of April and May, it will probably be increased and perfected by a 
 residence continued during the monsoon months. 
 
 X. Secondary Syphilis. — There is no quality of the climate of 
 Poorundhur calculated to aid in the eradication of the syphilitic virus. 
 Still, in cases in which treatment has been inefficacious in the plains, and 
 in which the cachexia is rapidly advancing, it may be reasonable enough 
 to expect greater benefit from treatment conducted at Poorundhur in 
 March, April, and May. In some instances syphilitic eruptions have im- 
 proved during the monsoon months. This climate will also be useful to 
 the debilitated convalescent from syphilis, just as it is in similar conditions 
 of constitution consecutive on other forms of disease. 
 
 9. It may be inferred from the general tenor of these observations, 
 that complete restoration to health and strength from a residence at 
 Po •nmdliur will be chiefly found to occur in the soldier of a few years' 
 
SANITARIUM AT POORUNDHUR. 751 
 
 service in India, in whom a proclivity to attacks of malarious fever has 
 not become firmly established, and organic disease is as yet slight and 
 remediable in character. If such as respects previous disease be also the 
 conditions of the soldier of ten years' service and upwards, then to him 
 also the climate of Poorundhur will prove beneficial. The tendency 
 of the advantage thus gained, will be to maintain and increase the vigour of 
 the constitution, to render it less predisposed to the severer forms of disease, 
 and thus prolong the period of the soldier's efficient service in India. 
 But when the soldier has served in India ten years and upwards, and 
 during that period has frequently suffered from disease, and the question 
 of invaliding has arisen, then, though it may be of advantage to him to 
 pass at Poorundhur the period that it may be necessary for him to remain 
 in India ; still it is not to be expected that residence there will be in any 
 respect, under these circumstances, a substitute for invaliding, or will 
 lessen the number of unfits of this class. 
 
 10. The transfer of sick in states and stages of serious disease at the 
 time requiring care and medical treatment, in the hope that these may be 
 condiicted with more advantage at Poorundhur, was not in contemplation 
 when the Sanitarium was established ; and there has been nothing in ex- 
 perience there since to justify this proceeding, but much to dissuade from 
 it. It is, doubtless, disheartening and unsatisfactory to watch disease 
 progressing, notwithstanding our best efforts to remove it ; but this evil 
 is not to be prevented by the heedless transfer of sick from station to station. 
 It is to be lessened: 1st. — By such sanitary measures in regard to barracks, 
 hospitals, dress, rations, duties, amusements, and judicious use of hill and 
 other Sanitaria, as shall maintain the health and vigour of the soldier at as 
 high a point as practicable, and, therefore, less prone to the severer tvpes 
 of disease. 2nd. — By such careful study of the pathology and rational 
 principles of treatment of disease in India as shall teach us to distinguish, 
 at the earliest periods, all serious forms, and to conduct the cure with 
 watchful care and steady judgment. 
 
 1 1 . There are diseases, as recurring malarious fevers with or without 
 splenic and hepatic complication, idiopathic affections of the liver and 
 bowels, pulmonary, cardiac, nephritic, and rheumatic affections, for which 
 the climate of Poona from the middle of November to the end of February 
 is not favourable, and for which that of Poorundhur at the same season is 
 still more adverse. For these a Sanitarium on some well-selected site on 
 the sea-coast would be a great boon to the suffering soldier, and, conse- 
 quently, a great advantage to the Government, It would, further, be useful 
 in those forms of hepatic disease for which both Poona and Poorundhur 
 are unsuited also in the hot months of the year. 
 
 *** This Memorandum was prepared by me, when Superintending Surgeon of the 
 Poona Division, after full consideration of the Eeports of the several Medical Officers, 
 and careful personal inspection of the Sanitarium and of the Invalids at the time 
 (May 1858) resident there, in the hope that it might be useful to Medical Officers in 
 charge of European troops, more especially those who had recently arrived in the 
 Poona Division. It makes no pretension to having exhausted or fully developed the 
 subject, and was intended to be suggestive, not dogmatic. 
 
LIST OE CASES. 
 
 The Numeral at the end of the Title of each Case is that of the Case in the 
 First Edition, and is now 'added to facilitate Reference from one Edition to the 
 other. Those without a second number are ■published for the first time in this 
 
 edition. 
 
 CHAPTER III. 
 
 ENTERMTTTEXT FEVET?. 
 
 1. Abnormal precordial dulness from en- 
 larged spleen. 8. . . Page 36 
 
 2. Abnormal precordial dulness from en- 
 larged spleen associated with systolic 
 murmur, 9. . . . . -37 
 
 3. Abnormal precordial dulness from 
 splenic enlargement. Systolic murmur 
 present, 10. . . . . .37 
 
 4. Abnormal precordial dulness from en- 
 largement of the spleen. Sj-stolic mur- 
 mur present, 11. . . . .37 
 
 5. Extended precordial dulness, with 
 systolic and venous murmurs, without 
 splenic enlargement from anemia 
 alone, 12. ..... 38 
 
 6. Intermittent fever complicated with 
 hepatitis. Death from cholera. Liver 
 in a state of vascular turgescence, 17. 44 
 
 7. Intermittent fever with enlargement 
 of the liver, 18. . . . _ ._ 44 
 
 8. Intermittent fever with gastric irri- 
 tation treated with quinine, 19. . 49 
 
 9. Intermittent fever, 20. . . .50 
 
 10. Intermittent fever, with chronic me- 
 ningitis. Symptoms chiefly during ac- 
 cession. Death from unexpected col- 
 lapse, 21 51 
 
 11. Intermittent fever: some of the par- 
 oxysms complicated with convulsive 
 fits, one of which terminated fatally. 
 Thickening and opacity of the arachnoid 
 membrane, 22. . . . .51 
 
 12. Intermittent fever complicated with 
 pericarditis and pneumonia. Re- 
 covery, 23. . . . . .54 
 
 13. Intermittent fever complicated with 
 asthma, 24 55 
 
 CHAPTER V. 
 
 TiE^nTTEXT FEVER. 
 
 14. Remittent fever fatal from unexpected 
 collapse, 25 Page 68 
 
 15. Great collapse in the course of re- 
 mittent fever. Recovery by stimu- 
 lants, 26 69 
 
 16. Exhaustion taking the place of exacer- 
 bation in remittent fever, 27- • • 70 
 
 17. Remittent fever. Death by coma. 
 Rright's disease of both kidneys, 28. . 77 
 
 18. Remittent fever, with adynamic sym- 
 ptoms. Serum underneath the arach- 
 noid and at the base of the cranium. No 
 coma. The liver much enlarged. Dark 
 rosy tint of the mucous coat of the 
 stomach, 29. . . . .78 
 
 19. Remittent fever with irregular sym- 
 ptoms in an intemperate man of very 
 corpident habit, and in whose head, 
 heart, liver, and kidneys there was ex- 
 tensive old organic disease, 30. . 78 
 
 20. Remittent fever in a person of very 
 intemperate habits, with symptoms in 
 some respects resembling delirium tre- 
 mens. Death by coma. Three ounces 
 of serum at the base of the skull ; liver 
 much enlarged. Commencing degenera- 
 tion of the kidney. Mucous coat of the 
 colon softened, with here and there 
 red patches, with a mucous follicle in 
 the centre of each discoloration. Sof- 
 tening of the mucous coat of the sto- 
 mach, 31 79 
 
 21. Remittent fever with adynamic sym- 
 ptoms. Obscure pneumonia. Death 
 without coma. Bright's disease of both 
 kidneys, 32 80 
 
 22. Remittent fever. Death by convulsion 
 and coma. Vascular congestion of the 
 
 3 c 
 
754 
 
 LIST OF CASES. 
 
 vessels of the pia mater. Rosy tint of 
 the substance of the brain. One ounce 
 of serum at the base of the skull. The 
 heart dilated and its tissue pale and 
 flabby. Partial redness, thinning, and 
 softening of the mucous coat of the sto- 
 mach. Peyer's glands enlarged. The 
 spleen enlarged and softened, and the 
 kidneys congested, 39 . . Page 82 
 
 23. Remittent fever in a man of intempe- 
 rate habits. Fatal with convulsion, 
 coma, and tumultuous action of the 
 heart. Considerable effusion of serum 
 in the head. Streaked redness and sof- 
 tening of the mucous membrane of the 
 stomach. Deep red tint of the endo- 
 cardium and muscular tissue of the 
 heart, 33 .83 
 
 24. Remittent fever in a man of intem- 
 perate habits. Death by coma. Increased 
 vascularity of the membranes of the 
 brain and considerable effusion of serum. 
 Softening and vascularity of the mucous 
 coat of the stomach and large intestine. 
 Commencing degeneration of the kid- 
 neys, 34 83 
 
 26. Remittent fever. Simulating delirium 
 tremens. Pia mater very vascular, with 
 bullae of air between the arachnoid and 
 pia mater and in the vessels, 35. . 84 
 
 26. Remittent fever proving fatal by col- 
 lapse and coma at the close of an exacer- 
 bation. No serous effusion in the head. 
 Dotted redness and softening of the 
 mucous membrane of the stomach. En- 
 largement of the mucous follicles of the 
 colon and of Peyer's glands. Lumbrici 
 in the small intestine, 36. . . 85 
 
 27. Remittent fever. Drowsiness and 
 coma. Considerable quantity of serum 
 effused in the head. Vascularity and 
 thickening of the mucous membrane of 
 the stomach, 37. . . . .86 
 
 28. Remittent fever. Coma from exhaus- 
 tion, 38. 86 
 
 29. Remittent fever. Meningitis. Effu- 
 sion of serum in the cavity of the arach- 
 noid and sub-arachnoid space. Opacity 
 and thickening of the arachnoid mem- 
 brane, 40. . • . . .87 
 
 30. Remittent fever admitted after a week's 
 illness. Head symptoms chiefly marked 
 by unsteadiness of manner, and latterly 
 drowsiness. Arachnoid membrane opaque 
 and thickened. Increased serous effu- 
 sion, 41. 87 
 
 31. Remittent fever admitted in an ad- 
 vanced stago. Death by coma. Exten- 
 sive lymph and serous effusion in the 
 sub-arachnoid space. Hepatisation of 
 both lungs, 42 88 
 
 32. Remittent fever with adynamic sym- 
 ptoms. Slight vascularity of the mem- 
 
 branes of the brain with air in the 
 vessels and beneath the arachnoid, Tur- 
 gescence and ulceration of Peyer's glands 
 at the end of the ileum, 43. . Page 89 
 
 33. Remittent fever. Symptoms adynamic 
 and badly-developed. Serous effusion 
 and slight vascular congestion in the 
 head, also air in the vessels. The colon 
 distended and in part displaced, 44. 89 
 
 34. Remittent fever, with head and gastro- 
 enteritic symptoms ; two or three ounces 
 of serum in the cranium. Firm granular 
 exudation on the mucous surface of the 
 colon. Dark redness of the end of the 
 ileum. The subject of a large hydro- 
 cele, 45. . . . . .95 
 
 35. Remittent fever. Peyer's glands en- 
 larged and ulcerated. Head symptoms 
 with moderate turgescence of the ves- 
 sels, 46 95 
 
 36. Remittent fever with jaundice. Drow- 
 siness. Biliary congestion of the liver. 
 Enlarged lymphatic glands in the course 
 of the common duct. Slight dilatation 
 of the hepatic duct. Gastro-duodenitis. 
 Granular exudation on the mucous sur- 
 face of the ileum and colon. Nodules of 
 pulmonary apoplexy; one softened into 
 a cavity, 47 98 
 
 37. Remittent fever with jaundice. Tender- 
 ness at margin of right ribs. Coma. 
 Gastro-duodenitis. Enlarged lymphatic 
 glands in the course of the common duct. 
 Biliary congestion of the liver, 48. 99 
 
 38. Fever with jaundice. Tenderness at 
 the margin of the right ribs. Drowsiness. 
 Biliary congestion of the liver. Ob- 
 struction of the hepatic duct by a lum- 
 brieus, of which there were many in tho 
 duodenum and stomach. No gastro-duo- 
 denitis. Enlargement of the lymphatic 
 glands in the course of the common duct. 
 Hepatic cells distinct, 49 . . .99 
 
 39. Remittent fever with jaundice. Ten- 
 derness at the margin of the right ribs. 
 Drowsiness. Enlarged lymphatic glands. 
 Enlarged head of the pancreas. No 
 duodenitis. Biliary congestion of the 
 liver, 50. ..... 100 
 
 40. Remittent fever with jaundice. Ten- 
 derness at the margin of the right ribs. 
 Death from exhaustion. Enlargement 
 and biliary congestion of the liver. 
 Gastro-duodenitis. Hepatic cells dis- 
 tinct, 51. . . . . .101 
 
 41. Remittent fever with jaundice in an 
 opium-eater. Tenderness at the epigas- 
 trium. No coma. Death from exhaus- 
 tion. Enlargement and biliary con- 
 gestion of the liver. No duodenitis. 
 No enlargement of the lymphatic 
 glands, 52. .... 101 
 
 12. Remittent fever with jaundice. Ten- 
 
LIST OF CASES. 
 
 755 
 
 demcss at the margin of the right ribs. 
 Death from exhaustion. Cirrhosis. Gall 
 bladder distended. Enlarged lymphatic 
 glands around the common duct. Duo- 
 denitis. Granular exudation on the 
 mucous membrane of the ileum and large 
 intestine, 53 Page 102 
 
 43. Fever with jaundice. Died exhausted. 
 Biliary congestion of the liver. No en- 
 largement of the lymphatic glands. Con- 
 traction of the cystic duct. Distention 
 of the gall-bladder, mucous membrane of 
 gall-bladder and ducts normal, with ex- 
 ception of slight vascularity of common 
 duct at point of entrance into duodenum. 
 Hepatic cells distinct, 54. . . 103 
 
 44. Remittent fever with jaundice. Drow- 
 siness. Enlarged lymphatic glands in 
 course of common duct. Constricted cys- 
 tic duct, Gall-bladder full, 55. .104 
 
 45. Remittent fever with jaundice. No 
 tenderness at margin of ribs. Drowsi- 
 ness. No enlargement of lymphatic 
 glands. Dark-redness of mucous mem- 
 brane of duodenum, 56. . . 104 
 
 CHAPTER XIV. 
 
 DYSENTERY. 
 
 46. Under treatment nine months. Dy- 
 sentery alternating with rheumatism, 
 probably syphilitic ; terminating in gen- 
 eral cachexia with febrile symptoms. 
 The lungs, liver, mucous coat of stomach 
 and intestines presented morbid appear- 
 ances of various characters, 131. . 239 
 
 47. Chronic dysentery, discoloration with 
 thickening of parts of the mucous mem- 
 brane of the large intestines. Com- 
 mencing degeneration of kidneys, 133. 
 
 239 
 
 48. Melanosis of the colon. No ulceration. 
 Tubercles in the liver, 134. . . 240 
 
 49. Membranous mucous exudation on the 
 inner surface of the large intestine, 240. 
 
 50. Chronic dysentery in an opium-eater. 
 The mucous coat of the colon lined with 
 a firm granular layer. The lungs tuber- 
 cular. Cartilaginous contraction of the 
 pyloric orifice of the stomach, 135. 241 
 
 51. Diarrhcea tedious. Granular yellow 
 exudation on the mucous surface of the 
 large intestine with thickening of the 
 tunic, 136 .242 
 
 52. Dysentery with adynamic febrile sym- 
 ptoms. Granular exudation on the mu- 
 cous coat at the end of the ileum. Sloughy 
 ulceration of the large intestine, 141. 246 
 
 53. Granular exudation on mucoiis surface 
 of ileum and colon, with irregular ulcera- 
 tion of the latter. No disease of the liver. 
 Displacement of the colon, 162. . 247 
 
 54. Dysentery alternating with febrile ac- | 
 
 3 c 
 
 cessions. Bands of granular deposit at 
 the end of the ileum. Sloughy ulceration 
 of the colon, 143. . . . Page 247 
 
 55. Dysentery. Sloughy ulceration of large 
 intestine. Gramdar deposit in transverse 
 bands in the ileum. Peritonitis and 
 matting of the omentum. An opium- 
 eater, 144 248 
 
 56. Probable scorbutic taint. Dark, irre- 
 gular, ragged, internal surface of the 
 colon, with thickening. Granular de- 
 posit on mucous membrane of ileum, with 
 thickening, 145 249 
 
 57- Thickening and sloughy ulceration of 
 large intestine, with here and there a 
 small encysted abscess in the thickened 
 tissue. Gramdar deposit on inner siir- 
 face of ileum. Peritonitis. Old peri- 
 carditis and heart disease, 146. . 249 
 
 58. Dysentery. Sloughy ulceration in 
 transverse bands, and the follicles of the 
 colon in different stages of disease. In- 
 sensibility for an hour before death. Two 
 ounces of serum at the base of the skull, 
 147 250 
 
 59. Dysentery neglected for thirteen days, 
 attended with abscess in the liver. 
 Sloughy ulceration of the mucous coat 
 of the colon, with fringe of granular 
 exudation, 148 250 
 
 60. Acute dysentery. The large intestine 
 ulcerated in transverse ridges. The 
 mucous follicles enlarged. Considerable 
 effusion of serum in the head without 
 sj-mptoms, 149 251 
 
 61. Acute dysentery. The ulceration in 
 transverse ridges. Considerable effusion 
 of serum in the head, without symptoms, 
 150 251 
 
 62. Dysentery in an advanced state ob- 
 scured by secondary peritonitis. Gra- 
 mdar deposit on the mucoiis surface of 
 the large intestine, 151. . . 252 
 
 63. Several attacks. Colon thickened. 
 Sloughy ulceration, with granular deposit 
 on other parts of the mucous surface of 
 the colon. Slight peritonitis, 152. 252 
 
 64. Dysentery admitted in the last stage. 
 Peritonitic inflammation. Sloughy ul- 
 ceration of the mucous coat of the 
 colon, 153 _ .253 
 
 65. Patches of submucous puriform in- 
 filtration in colon, 161. . . . 255 
 
 66. Sloughy patches of mucous mem- 
 brane of colon, with submucous 
 cedema, 162. .... 255 
 
 67. Numerous small follicular ulcerations 
 of the colon, 163 256 
 
 68. Chronic dysentery in a person ol 
 broken constitution. Numerous folli- 
 cular ulcers in the large intestine, many 
 of them cicatrising. Serous effusion in 
 the head without symptoms, 164. 256 
 
756 
 
 LIST OF CASES. 
 
 69. Dark-grey discoloration, with some 
 degree of thickening of mucous mem- 
 brane of colon, with numerous circular 
 ulcers, 165. . . . Page 257 
 
 70. Circular and transverse ulcers of the 
 large intestine. Matting of the omen- 
 tum over the colon, with displacement. 
 Liver healthy. Distention of the iu*inary 
 bladder, 167 257 
 
 71. Dysentery. Death in early stage by 
 cholera. Gangrenous patches of mucous 
 membrane of large intestine, but no 
 separation ..... 258 
 
 72. Dysentery. Sloughs of the mucous coat 
 passed before death. Much displace- 
 ment of the colon to the left side. Ab- 
 scess in the liver, 169. . . . 258 
 
 73. Acute dysentery. Extensive sloughy 
 iilceration of the inner surface of the 
 large intestine. Dark-red grumous dis- 
 charges, 170. . . . ,259 
 
 71. Dysentery. General peritonitis be- 
 fore the fatal termination. Serous effu- 
 sion in the head; no head symptoms. 
 The mucous coat of the colon in pro- 
 cess of separation from the other 
 tunics, 171 260 
 
 75. Sloughy state of mucous membrane 
 of the colon. Submucous puriform in- 
 filtration, forming little cavities. Ge- 
 neral peritonitis. Matting of omentum. 
 Eetention of urine, 172. . . 260 
 
 76. Mucous membrane of colon sloughy 
 and separating in shreds. General 
 peritonitis and matting of the omen- 
 tum, 174 261 
 
 77. Dysentery attended by general peri- 
 tonitis. The ulcers in different stages 
 of progress, some cicatrised, one per- 
 forating, but patched up, 176 . . 263 
 
 78. Chronic d3 r sentery. Enlarged me- 
 senteric glands. Mucous coat of the 
 colon firm and thickened. The cica- 
 trices of ulcers, 177. . . . 264 
 
 79. Pleuritis cured, succeeded by hydro- 
 cele radically cured ; followed by rheu- 
 matism, succeeded by dysentery, ca- 
 chexia, and recurrence of dysentery. 
 Colon ulcerated, 178. ." . .264 
 
 80. Sloughy ulceration of colon. Ge- 
 neral peritonitis and matting of the 
 omentum, 181. .... 266 
 
 81 Sloughy ulceration of largo intestines 
 wiilmiii thickening. Commencing ab- 
 scesses in the liver. Peritonitis, 182. 266 
 
 82. Sloughy ulceration and thickening of 
 large intestine. Matting of omentum. 
 Dysuria. Peritonitis of bladder, 183. 267 
 
 83. Much sloughy destruction of the 
 colon. Peritonitis and matting of the 
 omentum. Former attack of hepatitis. 
 Puckered fibrous hands in liver, 1 84. 267 
 
 81. Thickening of the colon. Numerous 
 
 deep ulcers. Matting of the omen- 
 tum. Liver with fibrous puckered 
 bands, 185. . . . Page 267 
 
 85. Thickening and sloughy ulceration of 
 large intestine. Matting of omentum. 
 Congestion of the liver, 186. . . 268 
 
 86. Habitual constipation. Colon con- 
 tracted in parts and strictured by a band 
 of the omentum. Tubercular infiltration 
 of the lungs. Ulceration of the ileum 
 and ccecum, probably from softening of 
 tubercles, 187 268 
 
 87. Chronic dysentery. A palpable tu- 
 mour of the ccecum. The lungs studded 
 with tubercles not suspected during 
 life. Considerable effusion of serum in 
 the head, 188 269 
 
 88. Dysentery. Perforation of the cce- 
 cum, with consequent formation of a 
 circumscribed sac, with gangrene of the 
 muscles and integuments, 189. . 270 
 
 89. Circular ulcers with sloughs in mu- 
 cous membrane of colon and stomach. 
 No thickening, 190. . . .271 
 
 90. Grey .softening, with a few ulcers of 
 the mucous lining of the stomach and 
 colon. Cicatrices of ulcers in the 
 former, 191. .... 272 
 
 91. Dysentery. The use of purgatives 
 too much abstained from. The lower 
 end of the ileum distended from thin 
 feculence, 192 301 
 
 92. Good effects of opium, in the treat- 
 ment of some states of dysentery, illus- 
 trated, 199 303 
 
 93. Acute dysentery in a child. Treated 
 with ipecacuanha and blue pill, 194. 315 
 
 CHAPTEE XV. 
 
 HEPATITIS. 
 
 94. Abscess in the brain not suspected 
 during life. Abscess in the liver, with 
 pneumonia of the lowest lobe of the right 
 lung, revealed by symptoms. Vascular 
 turgescence of liver, 195. . . 330 
 
 95. Hepatitis. Several abscesses in the 
 right lobe. Nodules in the left lobe. 
 The mucous coat of the colon ulcerated. 
 Serous effusion in the head without 
 symptoms, 196. . . . 331 
 
 96. Dysentery complicated with delirium 
 tremens. Milkiness of the arachnoid. 
 Matting of the omentum over the colon. 
 Numerous sloughy ulcerations of the 
 mucous coat of the ccecum. Many ab- 
 scesses in liver, 179. . . . 331 
 
 97. Illustrates formation of abscesses from 
 breaking down of lymph deposit. Pus 
 tinged with bile. The corpuscles gra- 
 nular and broken down. Surrounding 
 turgescence, 198 .... 331 
 
LIST OF CASES. 
 
 757 
 
 98. Hepatitis. Abscesses, in one. break- 
 ing clown of the parenchyma; in the 
 other the deposit in the interstitial tissue 
 had not yet broken down into pus. 
 Mucous coat of the colon dark-red, and 
 covered with firm granular exuda- 
 tion, 199. . . . Page 332 
 
 99. Hepatitis. An abscess lined by firm 
 membrane in the right lobe. Several 
 nodules- in different places of the liver ; 
 in some siippuration commencing at the 
 centre. Traces of ulceration in the 
 colon. Granular exudation on the mu- 
 cous coat of the rectum, 200. . 332 
 
 100. Hepatitis. Two large abscesses from 
 degeneration of lymph and tissue. The 
 liver mottled buff. The mucous coat of 
 the colon dark-grey with red patches, 
 and several ulcers. The kidneys mal- 
 formed, 201 333 
 
 101. Abscess in the liver. Sac smooth 
 without floerali. Large intestine, with 
 sloughy ulceration of the mucous coat. 
 Complicated with intermittent fever, 
 which, at the commencement, was the 
 prominent feature. Several lymph 
 nodules, 202 333 
 
 102. Large hepatic abscess, with shreddy floe- 
 eulent walls and surroundingvascular tur- 
 gescenee. Nointestinalulceration,204. 33-1 
 
 103. Abscess in liver discharged by the 
 lung, followed by convalescence. Pro- 
 ceeded to England, and died shortly after 
 arrival No account of the post mortem 
 appearances, 205. .... 336 
 
 101. Hepatic abscess attributed to blows. 
 Opening into the lung. Improvement. 
 Record as to the issue incomplete, 206. 336 
 
 105. Hepatic abscess opening through the 
 lung. Result of the case not recorded, 
 207 336 
 
 106. Hepatic abscess communicating with 
 the lung (?). Result not known, 208. 337 
 
 107. Dysentery, Secondary hepatic ab- 
 scess forming obscurely. Opening into 
 the lung. No ulceration of the intes- 
 tine, 209 337 
 
 108. Large hepatic abscess with brick-red 
 pus. Smaller one opening into lung. 
 Brick-red sputa. No diarrhoea till just 
 before death. Intestines not examined. 
 A spirit-drinker, 210. . . .338 
 
 109. Hepatic abscess opening through the 
 lung. Causing pleuritis and effusion. 
 Also presenting externally, but not 
 opened, 211. . . , .339 
 
 110. Hepatitis, ending in abscess discharged 
 through the lung. An abscess in the 
 third lobe of the right lung, communi- 
 cating freely through the diaphragm with 
 the abscess of the liver. Mucous coat of 
 the large intestine ulcerated. Many of 
 the ulcers cicatrised. 214. . .840 
 
 111. Two hepatic abscesses. One opening 
 into the lung, with expectoration of deep 
 bile-tinged puriform sputa, Page 215. 340 
 
 112. Abscess in the liver opening through 
 the diaphragm into the sac of the pleura, 
 and causing purulent effusion there, 217. 
 
 341 
 
 113. Abscess in the left lobe of the liver 
 opening into the stomach. No vomiting. 
 No detection of pus in the intestinal dis- 
 charges. No intestinal ulceration, 221. 
 
 343 
 
 114. An abscess of the liver communi- 
 cating with the colon. Others in process 
 of repair by absorption, 223. . . 344 
 
 115. Hepatic abscess, recovered from, by 
 probable opening into the colon, 222. 344 
 
 116. Hepatic abscess opening into the 
 colon (?). Recovery. . . . 345 
 
 117. Hepatic abscess opening into the colon 
 and stomach (?). Recovery. . .345 
 
 118. Two hepatic abscesses in process of 
 absorption. Death from cholera. Pain- 
 fid decubitus on right side explained by 
 the situation of one of the abscesses. Ul- 
 ceration of colon, 224. . . . 346 
 
 119. Four hepatic abscesses. General pe- 
 ritonitis, but no evidence of abscess rup- 
 ture. Two of the abscesses in process 
 of cure by absorption, 225. . . 347 
 
 120. Hepatic abscess in process of cure by 
 absorption. ..... 348 
 
 121. Hepatic abscess. Absorption (?). Re- 
 covery. ..... 348 
 
 122. Purulent sac between the liver and the 
 diaphragm, communicating with the left 
 lung. No hepatic abscess. . . 349 
 
 123. Amputation of the right hand, fol- 
 lowed by general bad health and chronic 
 hepatitis. A purulent sac between the 
 liver and the ribs filled with fcetid pus. 
 Hepatisation of the lower part of the 
 right lung, 226 349 
 
 124. Abscess in the liver. Also one ex- 
 ternal and circumscribed commiuiicating 
 with former. Dark-red colour of mucous 
 surface of large intestine, which con- 
 tained much clotted blood, 227. . 350 
 
 125. Hepatitis. Abscess bounded beyond 
 by a firm sac. A circumscribed abscess 
 in the peritoneal cavity over the edge of 
 the liver. Siibstance of the liver mottled 
 red and white, 228. . . . 350 
 
 126. Abscess in the liver communicating 
 with purulent deposit in the right iliac 
 region. Habitual constipation. The 
 sigmoid flexure of the colon much con- 
 tracted, 230 351 
 
 127. A circumscribed sac between the liver 
 and the ribs. An abscess in the sub- 
 stance of the right lobe. The mucous 
 coat of the colon studded with circular 
 ulcers, 231 351 
 
 3 c 3 
 
758 
 
 LIST OF CASES. 
 
 128. Abscess in the liver. Empyema of 
 the right pleura. Symptoms not well 
 marked. Dejection of a pint of clotted 
 blood before death. Mucous coat of the 
 colon dark-red, with ulceration, 232. 
 
 Page 353 
 
 129. Abscess in the liver. Effusion of 
 four pints of serum, with lymph in the 
 right pleura. Ulcerated colon. No 
 coma. Serum between the pia mater 
 and arachnoid, and two or three ounces 
 at the base of the skull, 233. . . 353 
 
 130. A small purulent sac circumscribed 
 in part by the base of the right lung and 
 by the diaphragm, and extending to the 
 fissure between the second and third 
 lobes of the right lung, mistaken for 
 hepatic abscess, 235. . . . 354 
 
 131. Hepatitis. Abscess in the liver. 
 Five pints of pus in the sac of the right 
 pleura. A layer of lymph on the sur- 
 face of the heart and inner surface of the 
 pericardium. General peritonitis, with 
 effusion of lymph and sero-purulent 
 fluid, 236 354 
 
 132. Pericarditis. The inner surface of 
 the pericardium and the outer side of the 
 heart covered with a thick layer of ir- 
 regular lymph. Also effusion of serum 
 and displacement of the liver, partly 
 caused by the distended pericardium. 
 Abscess of the liver, 237. . . 355 
 
 133. General peritonitis. Abscess of the 
 liver following head symptoms. Serous 
 effusion in the head with thickening of the 
 arachnoid membrane. The kidneys had 
 undergone yellow degeneration, 239. 356 
 
 134. General peritonitis. Matting of the 
 omentum over the coecum. Round ulcers 
 in the colon, and an abscess in the liver, 
 240 357 
 
 135. General peritonitis, with sero-purulent 
 effusion and abscess in the liver, 241. 357 
 
 136. Probably small superficial abscess of 
 under surface of lobulus Spigelii, leading 
 to puriform sac in gastro-hepatic omen- 
 tum, and this by rupture to general 
 peritonitis. Jaundice, 245. . . 358 
 
 137. Large abscess in right lobe, floeculent 
 walls, communicating with branch of he- 
 patic vein. Lumbricus in the abscess. 
 Pus orange-coloured. No ulceration of 
 largo intestine. Jaundice, 249. . 364 
 
 138. A large abscess in the liver. No 
 dysenteric symptoms. No ulceration. 
 No projection of liver below the ribs, 
 260 366 
 
 139. Hepatitis. Abscess in the right lobe. 
 Mucous coat of the large intestine dark 
 red without ulceration, 261. . 366 
 
 140. Chronic pneumonia of upper part of 
 left lung. Secondary hepatitis and ab- 
 scess, with flocculent walls, and perito- 
 
 nitic inflammation. No intestinal ulce- 
 ration, 265 Page 367 
 
 141. Three abscesses in different stages of 
 progress. Pus bile tinged. General 
 peritonitis without rupture. No ulcera- 
 tion of the intestine, 269 . . . 367 
 
 142. Hepatic abscess. No ulceration of the 
 intestine ..... 368 
 
 143. Hepatic abscess. No ulceration of the 
 intestine ..... 368 
 
 144. Slight dysenteric symptoms of some 
 days' duration, followed by febrile sym- 
 ptoms. Those of hepatic inflammation 
 coming on obscurely, and ending in ab- 
 scess, 281. . • . . . .379 
 
 145. Diagnosis doubtful: whether right 
 pleiiritic effusion, or large hepatic ab- 
 scess, or both conjoined. 282. . . 381 
 
 146. Hepatic abscess. Mistaken for pleu- 
 ritic effusion ..... 382 
 
 147. Asthenic pneumonia mistaken for 
 communicating hepatic abscess, 283. 384 
 
 148. Whether asthenic pneximonia or 
 communicating hepatic abscess. Doubt- 
 fid, 284 384 
 
 149. Hepatic abscess pointing at the epi- 
 gastrium and successfully punctured. 
 Trocar used, 285 393 
 
 150. Hepatic abscess pointing at the epigas- 
 trium, punctured successfully, 286. 394 
 
 151. Hepatic abscess pointing between the 
 eighth right rib and umbilicus, success- 
 fully punctured, 287. . • .394 
 
 152. Hepatic abscess, punctured. Re- 
 covery, 288 394 
 
 153. Hepatic abscess, punctured at the 
 point of the right ninth rib. Recovery, 
 289 394 
 
 154. Hepatic abscess pointing between the 
 right ninth rib and umbilicus, punctured. 
 Case not followed to the close, b\it in all 
 probability successful, 290 . . 395 
 
 155. Hepatic abscess pointing at the epi- 
 gastrium, punctured. Result not known ; 
 probably successful, 291. . . 395 
 
 156. Chronic hepatic abscesses. One was 
 punctured and healed, but there was no 
 adhesion to the abdominal wall at site 
 of puncture found after death. Ulcera- 
 tion of colon; but dysentery clearly 
 secondary. Second abscess and death, 
 292 396 
 
 157. Abscess in the liver pointing be- 
 tween the right seventh and eighth ribs. 
 Opened into the lung and also exter- 
 nally. Gangrene of the integuments 
 around the orifice, also of the inter- 
 costal muscles, and necrosis of a rib, 
 293 397 
 
 158. Hepatic abscess punctured over the 
 last right false rib. Gangrene and 
 sloughing around the wound. Death. 
 No inspection, 294. . . .398 
 
LIST OF CASES. 
 
 759 
 
 159. Large hepatic abscess punctured. 
 Death from exhaustion, with sloughing of 
 the wound. No examination after death, 
 295 Page 398 
 
 160. Superficial abscess of right extremity 
 of the liver leading to circumscribed 
 sac between the organ and lateral abdo- 
 minal walls. Punctured between the 
 tenth and eleventh rib. Sloughy state of 
 wound. Necrosis of rib, and death from 
 hectic fever, 296 398 
 
 161. Abscess in the liver punctured. Carious 
 ribs projecting into the abscess. At 
 first superficial and leading to circum- 
 scribed sac between liver and diaphragm. 
 Also empyema of right pleural sac with- 
 out communication, 297. . . 399 
 
 162. Two large hepatic abscesses. One 
 deep, the other a sac between the sur- 
 face of the liver and abdominal walls, 
 originating probably in rupture of a 
 small superficial abscess, there being 
 lymph nodides in the part of the liver 
 adjoining. This abscess punctured. 
 Sloughing. No ulceration of intestine, 
 298 400 
 
 163. Hepatic abscess punctured at the 
 epigastrium. Gangrene and sphacela- 
 tion around the orifice. Death. No 
 inspection, 299. .... 401 
 
 164. Hepatic abscess pointing at the epi- 
 gastrium, punctured. Extensive sphacelus 
 around the opening. Death, 300. . 401 
 
 165. A single abscess at the thin edge of 
 the left lobe of liver existing for five 
 months, punctured. Gangrene of the 
 orifice. Dysenteric symptoms latterly. 
 Ulceration of mucous membrane of the 
 colon, 301 402 
 
 166. Two hepatic abscesses. One punc- 
 tured with increase of febrile symptoms. 
 Attributed to fist blows. Habits tem- 
 perate. Diarrhoea, with redness of 
 mucous membrane of colon. No ulcera- 
 tion. Commencing gangrene at the 
 opening in the abscess, 302. . . 402 
 
 167. Hepatic abscess pointing at the epi- 
 gastrium, punctured. Sloughing around 
 the wound. Death, 303. . . 403 
 
 168. Cirrhosis of liver. Abscess in thin 
 edge of liver punctured. Purulent sac 
 between liver and diaphragm. Ulcera- 
 tion of large intestine. Death, 304. 403 
 
 169. Hepatic abscess in epigastric region, 
 punctured ; veiy little discharge. Dysen- 
 teric symptoms, secondary. Died. No 
 examination, 305 404 
 
 170. Abscess partly of right and left 
 lobe, punctured. Death from dysentery 
 clearly secondary. Ulceration of large 
 intestine. Effusion iu both pleural 
 Bacs, 306 405 
 
 171. Pleuritic effusion. Abscess in the 
 
 liver punctured. Attributed to a blow. 
 Death the day after the abscess was 
 opened. No examination after death, 
 307 ... . Page 406 
 
 172. Large abscess of right lobe of liver 
 punctured with trocar. Several abscesses 
 in left lobe in different stages. Also 
 lymph nodules, 308. . . 406 
 
 173. Large abscess in the right lobe. The 
 liver free of abnormal adhesions. The 
 cicatrices of former idcers in the colon. 
 Jaundice. Enlarged glands in the course 
 of the ducts, 309 413 
 
 174. Aneurism of the abdominal aorta. 
 Acute pain of right hypochondrium and 
 shoulder. The edge of the liver dis- 
 tinct. Treated four times for disease of 
 the liver, 310 416 
 
 175. A tumour, situated between the edge 
 of the liver and the transverse colon, 
 311 416 
 
 CHAPTER XVI. 
 
 CIKEHOSIS, ETC. 
 
 176. Cirrhosis, with enlargement. Ascites. 
 No kicbiey or heart disease. Jaun- 
 dice, 312 422 
 
 177. Ascites. Liver small and indurated. 
 Cirrhosis. Considerable effusion of 
 serum in the head, 313. . . . 423 
 
 178. Abscess in the liver. Cirrhosis. 
 Sloughy perforations, patched, of large 
 intestine, but no thickening of its coats 
 noted, 314 424 
 
 179. Abscess in liver with cirrhosis, not- 
 withstanding ptyalism. Displacement of 
 colon. Adhesion of it to the left side of 
 diaphragm. Sloughy ulceration of large 
 intestine, without thickening, 315. 425 
 
 180. Abscess in liver, notwithstanding 
 ptyalism. Cirrhosis. Ccecum and as- 
 cending colon thickened and ulcerated, 
 316. . . . . . .425 
 
 181. Dysentery complicated with delirium 
 tremens. Abscess and cirrhosis of the 
 liver, 318 426 
 
 182. Remittent fever. (Edema of the 
 liver 428 
 
 183. Treated for supposed dyspeptic sym- 
 ptoms. Numerous cancerous tubera dis- 
 seminated throughout the liver. One 
 had opened into the stomach, 320. 429 
 
 184. Phthisis pulmonalis. Lungs tuber- 
 culated, hydatid sac in the abdomen, also 
 in the liver. Peritoneum studded with 
 miliary transparent tubercles, 321. 430 
 
 185. Hepatitis. Abscess. Inflammation 
 of the external and internal surface of 
 the gall-bladder. Sudden collapse, con- 
 tinuing with varying symptoms for 
 several days, 322. . . . .431 
 
 3c4 
 
760 
 
 LIST OF CASES. 
 
 186. Fever with jaundice. Gall-bladder 
 distended, seemingly, from inflammation 
 of the common duct. Little improye- 
 ment from treatment, 323 .Page 432 
 
 187. The gall-Lladder, distended, reached 
 to the umbilicus. Gastritis. Colon con- 
 tracted, 324 432 
 
 CHAPTER XVII. 
 
 PERITONITIS, ILEUS AND COLIC. 
 
 188. General peritonitis from a penetrating 
 wound of the liver and effusion of blood 
 into the abdomen. Considerable effu- 
 sion of serum in the head without sym- 
 ptoms, 325 444 
 
 189. Fracture of both thigh bones. Ab- 
 domen bruised by a fall. Death in 
 fifty-four hours, .under symptoms of 
 peritonitis. General redness and effu- 
 sion of lymph on the peritoneal sur- 
 faces. A pint of turbid serum in the 
 cavity, 326 ■ .444 
 
 190. Wound of the abdomen with protru- 
 sion of intestine. Vascularity of, and 
 lymph-exudation on, the peritoneum, and 
 the protruded intestine, 327. . . 445 
 
 191. Peritonitis. Purulent effusion into the 
 cavity of the abdomen. Lymph general 
 on the peritoneal surfaces, 328. . 446 
 
 192. Peritonitis after parturition, but pro- 
 bably caused by blows, 329. . .446 
 
 193. Partial peritonitis leading to forma- 
 tion of a large circumscribed purulent 
 sac, 330 446 
 
 194. General peritonitis. The lungs 
 studded with crude tubercles. The 
 mesenteric glands tuberculated. The 
 end of the ileum, the ccecum, and colon 
 ulcerated. Considerable effusion in the 
 head, 331 448 
 
 195. Extensive ulcer on the groin. Mili- 
 ary tubercles in the lungs and under- 
 neath the peritoneum throughout its 
 whole extent. Follicular idceration of 
 the large intestine. Three ounces of 
 scrum in the cavity of the cranium. No 
 bead symptoms, 332. . . . 449 
 
 196. Chronic peritonitis. Tubercular. 
 Much effusion and complete durness on 
 percussion, 333. .... 450 
 
 197. Effusion in chest and abdomen. Ac- 
 cess of cholera. Disappearance of the 
 effusion. Bright's disease of the kidney 
 and tubercular peritonitis, 99. . 451 
 
 198. Ileus, with granular effusion on the 
 inner surface of the ileum. Biliary 
 calculi, 334 1,V| 
 
 199. Ileus. Strangulation of pari of the 
 intestine by old peiitonitic adhesions, 
 335. 4 54 
 
 200. Colica-pictonum. The colon was much 
 distended and displaced. Death with 
 head symptoms. Only slight serous effu- 
 sion at the base of the skull, 336. Page 456 
 
 CHAPTER XVIII. 
 
 AFFECTIONS OF THE STOMACH. 
 
 201. Poisoning by arsenic, admitted in the 
 stage of collapse, after the active sym- 
 ptoms of gastritis were passed, 337 . 458 
 
 202. Poisoning from arsenic in which sym- 
 ptoms of narcotism were prominent at the 
 commencement, 338. . . . 459 
 
 CHAPTER XIX. 
 
 BRIGHT'S DISEASE OF THE KIDNEY. 
 
 203. A diver by occupation. Anasarca 
 ascites. Urine of low density and albu- 
 minous. Dilatation of the right ventricle 
 of the heart. Hypertrophy, and dilatation 
 of the left. Kidneys enlarged, lobulated, 
 in a state of yellow gramdar degenera- 
 tion, 340 468 
 
 204. Dropsical symptoms. Urine of low 
 density and albuminous. -Bronchitis, 
 diarrrhcea, periostitis, erysipelas, as se- 
 condary affections. Kidneys large, and 
 in a state of yellow granular and fatty 
 degeneration. An opium eater, 341. 469 
 
 205. Gastro-enteritis, anasarca, and ascites. 
 Urine of low density and albuminous. 
 Paracentesis. Death from peritonitis. 
 Kidneys small, in a state of yellow gra- 
 nular degeneration, 342. . . 470 
 
 206. Anasarca and ascites. Urine of low 
 density and albuminous. Was eight 
 times tapped. Kidneys in a state of 
 yellow granular degeneration, 343. 471 
 
 207. Anasarca and ascites. Urine of low 
 density and very albuminous. Sunk 
 under diarrhoea. The kidneys in a 
 state of yellow granular degeneration. 
 The mucous coat of the colon and ileum 
 with dotted red patches and granular de- 
 posit. A spirit drinker. Cirrhosis, 344. 472 
 
 208. Anasarca with ascites. Urine of low 
 density and generally albuminous. Died 
 comatose. Kidneys small, with cysts 
 and excess of cortical portion. Cirrhosis. 
 Thrice admitted, 345. . . . 472 
 
 209. Febrile symptoms, followed by ana- 
 sarca, ascites, and dysenteric symptoms. 
 Urine of low density and albuminous. 
 Death by coma. The kidneys in a 
 state of yellow granular degeneration. 
 The mucous membrane of the large 
 intestine ulcerated, and with granular 
 exudation, 346. .... 474 
 
 210. Vesicular emphysema of both lungs. 
 Displacement of the heart. Dilatation 
 and hypertrophy of the ventricles. Athe- 
 
LIST OF CASES. 
 
 761 
 
 romatous deposit, with ulceration, in the 
 aorta. Granular degeneration of the 
 kidneys. Urine once noted, albuminous. 
 Dropsy. 348. . . Page 474 
 
 211. Admitted in an advanced state of 
 disease. Hepatisation of both lungs. 
 Circumscribed pleuritic effusion of the 
 right side. Kidneys enlarged, and in a 
 state of yellow granular degeneration. 
 Urine not tested, 349. . . .4 75 
 
 212. The subject of intermittent fever, 
 followed by bronchitis, and slight ana- 
 sarca. Urine of low density, and very 
 albuminous, 351 476 
 
 213. Febrile symptoms and dropsy after 
 exposure to cold and wet. Traces of 
 albumen in the urine, slight throughout, 
 finally disappeared. Addicted to _ the 
 occasional use of spirits and opium. 
 Finally sunk under increasing asthenia. 
 Granular degeneration of the kid- 
 neys, 352. . . . . _ . 476 
 
 214. Dropsical symptoms with diarrhoea, 
 following exposure to cold and wet. 
 Urine very albuminous. Drowsiness 
 coexisting with sinking pulse, removed 
 by stimulants, did not recur. Death 
 by exhaustion. Kidneys large and 
 granular. Spirit-drinking not ad- 
 mitted, 353. .... 477 
 
 215. Syphilis, primary and secondary. 
 Mercurial influence. Slight dropsy. 
 Albuminous urine, pain of loins, dysen- 
 tery. Fatal. Bright's disease. Ulcera- 
 tion and granular exudation on intes- 
 tinal mucous membrane. Cirrhosis. 
 A cretified guinea-worm encysted be- 
 tween the right lung and the peri- 
 cardium, 354. .... 478 
 
 216. Dysentery. Dropsy. Albuminous 
 urine, with fat globides, in an old 
 spirit-drinker and opium-eater. Fatal. 
 Ulcerated intestines. Kidneys enlarged. 
 Fatty degeneration, 355. . . 479 
 
 217. Dropsy. Albuminous urine. Death 
 from dysenteric sj-mptoms. Kidneys en- 
 larged with fatty degeneration. Redness 
 in patches of the intestinal mucous 
 lining. Habits not known, 356. . 480 
 
 CHAPTER XX. 
 
 ABX0E3IAL STATES OF THE EEIXE. 
 
 218. Urine thick, white, opaque, coagulat- 
 ing with heat and nitric acid. No im- 
 provement under the Use of varied 
 remedies. Recovery by attention to 
 the general health, chiefly by change of 
 air. 398 500 
 
 219. Urine thick, white, opaque, coagulat- 
 ing with heat and nitric acid. No im- 
 provement from medical treatment. Re- 
 covery from change of air, 399. . 501 
 
 220. Urine opaque and white, occasionally 
 coagulating spontaneously. Recovery 
 from change of air, 400. Page 501 
 
 221. Urine, milky, coagulating by heat and 
 nitric acid, becoming clear by addition 
 of sidphuric ether. No improvement 
 from treatment. Change of air recom- 
 mended. Residt not known, 401. 501 
 
 222. Chylo-serous urine, removed by change 
 of air 502 
 
 223. Chylo-serous urine, removed twice by 
 change of air. .... 502 
 
 224. Diabetes. Symptoms improved some- 
 what under the use of creosote and mu- 
 riate of morphia, 402. . . . 503 
 
 225. Diabetes. No improvement from pre- 
 parations of iron, permanganate of po- 
 tass, and opium, 403. . . . 504 
 
 226. Diabetes. Not improved by treat- 
 ment, 404 504 
 
 227. Diabetes. No improvement from 
 permanganate of potass, or from creosote 
 alone, but marked benefit from addition 
 of opium, 405. .... 504 
 
 CHAPTER XXI. 
 
 PNEOIOXIA. 
 
 228. Pneumonia extensive of right lung. 
 Grey induration with cavities formed 
 in upper lobe by rnolecidar gan- 
 grene, 413. ..... 524 
 
 229. Grey, almost cartilaginous, induration 
 of the lower part of the right lung, with 
 several excavations by process of gan- 
 grenous rnolecidar softening. The seve- 
 ral stages of the process well shown. 
 Bright's disease of the kidney, 414. 525 
 
 230. Grey and red induration of the upper 
 lobe of the right lung with gangrenous 
 excavation, 415 525 
 
 CHAPTER XXIV. 
 
 PERICARDITIS AND ENDOCARDITIS. 
 
 231. Pericarditis. Friction nmrmur dis- 
 tinct, and then altogether disappearing. 
 He was cured. Eight mouths afterwards 
 death from cholera. Opaque patches on 
 the surface of the heart. No pericardial 
 adhesions, 448. . . . .573 
 
 232. Phthisis pulmonalis. Secondary pe- 
 ricarditis. Friction murmur, distinct 
 for twenty days. Death eighteen months 
 afterwards. Firm pericardial adhesions. 
 Bright's disease of the kidney, 450. 574 
 
 233. Asthenic pneumonia, leading to red 
 induration of the upper lobes. In its 
 course, pericarditis and endocarditis of 
 the left ventricle and auricle, causing 
 structural disease of the mitral valve. 
 Not traced to rheumatism. Dilatation of 
 all the cavities of the heart, 4G1. 576 
 
7G2 
 
 LIST OF CASES. 
 
 234. Empyema of the right side of chest. 
 Secondary pericarditis. Friction mur- 
 mur. Lymph effusions found after death, 
 462. . . ._ . Page 577 
 
 235. Acute arachnitis and pericarditis 
 leading to considerable effusions, coagu- 
 lating into a jelly-like mass when re- 
 moved from the body. Friction mur- 
 mur. In a pregnant female, 463. . 577 
 
 CHAPTEE XXV. 
 
 ORGANIC DISEASE OF THE HEART. 
 
 236. Contraction of the orifice of the pul- 
 monary artery, probably congenital. 
 Much hypertrophy, without dilatation of 
 the right ventricle of the heart. No 
 disease of the leftside, 236. . .582 
 
 237. Dilatation of both ventricles. Hy- 
 pertrophy of the left. Disease of aortic 
 valves, and the well-marked results of 
 pericarditis and endocarditis, consecutive 
 on rheumatism, related to syphilis, 464. 
 
 583 
 
 238. Aneurism of the left ventricle of the 
 heart, consequent on endocarditis and 
 pericarditis, 467. . • - .583 
 
 239. Rheumatism, followed by pericarditis 
 and endocarditis. Disease of the mitral 
 valve. Dilatation of the right side of 
 the heart. Dilatation and hypertrophy, 
 with circumscribed aneurism of the left 
 ventricle. Death expedited by acute 
 general peritonitis, 468. . . 584 
 
 240. The former subject of rheumatism. 
 Dilatation of the left ventricle. Disease 
 of the mitral valve. Much thickening 
 of the endocardium. An aneurismal 
 sac at the apex. Also the marks of 
 former pericarditis, 471. . . 586 
 
 241. Kupture of the heart from fatty de- 
 generation, 479. .... 587 
 
 242. Great dilatation of the ascending aorta 
 and the arch. An aneurismal tumour at 
 the commencement of the descending 
 aorta. There was no external swelling, 
 but the other signs of the disease were 
 very well marked, 494. . . . 588 
 
 243. Aneurism of the abdominal aorta. 
 Death by rupture, 493. . . 589 
 
 244. Acute rheumatism. Pericarditis and 
 endocarditis/ Dilatation of the right 
 side of the heart. Dilatation and hyper- 
 trophy of the left ventricle. Ossific 
 state of the mitral valve. Hepatic con- 
 gestion, 465. .... 596 
 
 215. Aortic and mitral valvular disease. 
 Hypertrophy, with dilatation of the left 
 ventricle. General dropsy. Rapid relief 
 from elaterium. Discharged, 489. . 599 
 
 CHAPTER XXVII. 
 
 ON DELIRIUM TREMENS. 
 
 246. Meningitis. Effusion of lymph and 
 
 serum in the sub-arachnoid space. Sym- 
 ptoms of delirium tremens, 564. Page 645 
 
 CHAPTER XXVIII. 
 
 ON CEREBRAL DISEASE AND PARALYSIS. 
 
 247. Acute hydrocephalus, 506. . 653 
 
 248. Amaurosis of both eyes, headache, 
 fatuity, convulsions, tumour in the brain, 
 with much softening of the cerebral 
 substance, 507 654 
 
 249. Hemiplegia of the right side. Soften- 
 ing of the left corpus striatum, 508. 661 
 
 250. Apoplexy. Hemiplegia of the right 
 side. Death. General congestion of 
 the membranes of the brain. Red 
 softening of the left corpus stria- 
 tum, 509 661 
 
 251. Hemiplegia of the right side. Soften- 
 ing of the left corpus striatum. Disease 
 of the mitral valve, 510. . .661 
 
 252. Symptoms of inflammation of the 
 brain, followed by hemiplegia of the 
 right side, and death by coma. Red 
 softening of the left corpus striatum 
 found after death. 511. . . . 662 
 
 253. Hemiplegia of the right side. Me- 
 ningitis and softening of the anterior 
 and middle lobes of the left cerebral 
 hemisphere. The premonitory symptoms 
 well marked, 512 662 
 
 254. Incomplete paralysis of the left side. 
 Improvement. Disease of heart and 
 valves. Death hastened by diarrhoea. 
 Puriform softening of part of anterior lobe 
 of right cerebral hemisphere, 513. . 662 
 
 255. Hemiplegia of the left side. White 
 softening in the right cerebral hemi- 
 sphere, 514. ..... 663 
 
 256. Abscess in the left hemisphere of the 
 brain; for some time general febrile 
 symptoms. Hemiplegia of the right side 
 some days before death, 515. . . 664 
 
 257. Apoplexy, followed by hemiplegia of 
 the right side. Gangrene of the left 
 foot and leg, apparently from obstruc- 
 tion of the femoral artery, 516. . 664 
 
 258. Hemiplegia of left side, persistent. 
 Facial palsy of the right side, con- 
 secutive and transient, 517. . . 665 
 
 259. Division of the left half of the spinal 
 cord by a wound. Paralysis and anaesthesia 
 of the left lower extremity, 519. 669 
 
 260. Paralysis from arsenical poisoning. 
 Pneumonia also present, 520. . 670 
 
 CHAPTER XXIX. 
 
 ON TETANUS. 
 
 261. Tetanus. Treated with quinine, ex- 
 tract of hemp, wine, and nourishment. 
 Recovered, 521. .... 686 
 
 262. Idiopathic tetanus. Treated with 
 quinine, hemp, wine, and nourishment. 
 Recovery, 522 686 
 
LIST OF CASES. 
 
 763 
 
 263. Tetanus in a child. Though fatal, 
 the good effects of treatment with 
 quinine, hemp, and attention to nourish- 
 ment were very apparent, 523. Page 686 
 
 264. Tetanus treated with chloroform. 
 Fatal, 524 687 
 
 265. Tetanus fatal on the 21st day. Whe 
 ther traumatic or idiopathic doubtful" 
 Treated with quinine, hemp, nourish- 
 ment, and stimulants. Fatal. Spinal 
 veins congested, 525. . . . 687 
 
 CHAPTEE XXX. '■ 
 
 ON HYDROPHOBIA. 
 
 266. Hydrophobia. Three months after 
 the bite, 526 690 
 
 267. Hydrophobia, treated with chloro- 
 form, 527 690 
 
 268. Hydrophobia. Chloroform used, but 
 obliged to be discontinued, 528. . 690 
 
 269. Hydrophobia in a Parsee boy, 529. 691 
 
 CHAPTEE XXXI. 
 
 ON BLOOD DISEASES. 
 
 270. Fever. Several abscesses. Small 
 puriform cysts in lungs. No trace of 
 phlebitis, 535 694 
 
 271. Adynamic fever. Several abscesses. 
 Puriform cysts in the lungs. One in the 
 kidney. Small suppurating wound of heel. 
 No trace of phlebitis, 536. Page 662. 694 
 
 272. Adynamic remittent fever. Small 
 abscess on the forehead. Carbuncle on 
 the back. Numerous puriform cysts in 
 the lungs and kidneys, 537. . . 694 
 
 273. Many abscesses. Fever. Death by 
 exhaustion. No puriform deposits in 
 the internal viscera, 538. . . 694 
 
 274. Adynamic fever. Several abscesses. 
 Eecovery, 539 694 
 
 275. Beriberi. Eecovery, 549. . . 710 
 
 276. Beriberi. Slight discoloration of the 
 gums. Eecovery, 550. . . .710 
 
 277. Beriberi. Anasarca. Death. No kidney 
 disease. Liver congested. Cavities of 
 the heart full of thin blood, 551. . 711 
 
 278. Beriberi. Anasarca. Gums disco- 
 loured. Hydrothorax. Fatal. Cavities 
 of the heart full of fluid blood, 552. . 711 
 
 279. A small dog bitten by the Phoorsa 
 snake. Fatal, 553. . . .717 
 
 280. A horse-keeper bitten by the Phoorsa 
 snake. Fatal, 554. . . .717 
 
 281. Parsee woman bitten by Phoorsa 
 snake. Eecovery, 555. . . . 718 
 
 282. Dog bitten by Phoorsa snake. Fatal. 
 Post mortem examination, 556. . 718 
 
STATISTICAL AND METEOROLOGICAL TABLES. 
 
 Table I. — Admissions and Deaths, -with 
 Per-centage, from all Diseases, in the 
 European General Hospital at Bombay 
 for the Five Years from July, 1838, to 
 July, 1843 ■ . . . . Page 13 
 
 Table II. — Admissions and Deaths, -with 
 Per-centage, from all Diseases, in the 
 European General Hospital at Bombay 
 for the Five Years from 1844 to 1848 14 
 
 Table III. — Admissions and Deaths, -with 
 Per-centage, from all Diseases, in the 
 European General Hospital at Bombay 
 for the Five Years from 1849 to 1853 14 
 
 Table IV, — Admissions and Deaths, with 
 Per-centage, from all Diseases, in the 
 Jamsetjee Jejeebhoy Hospital at Bom- 
 bay, for the Six Years from 1848 to 
 1853 15 
 
 Table V. — Admissions and Deaths, with 
 Per-centage, from Fever of all kinds, in 
 the European General Hospital at Bom- 
 bay, for the Six Years from July 1838 to 
 July 1843 171 
 
 Table VI. — Admissions and Deaths, with 
 Per-centage, from Fever of all kinds, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from 1844 to 
 1848 171 
 
 Table VII. — Admissions and Deaths, with 
 Per-centage, from Fever of all kinds, in 
 the European General Hospital at Bom- 
 Lav, for the Five Years from 1849 to 
 1853 172 
 
 Table VIII. — Admissions and Deaths, 
 with Per - centage, from Intermittent 
 Fever, in the European General Hospital 
 at Bombay, for the Five Years from July. 
 1838, to July, 1843 . . .173 
 
 Table IX. — Admissions and Deaths, with 
 Per-centage, from Intermittent Fever, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from 1844 to 
 1848 173 
 
 •Table X. — Admissions and Deaths, with 
 Per-centage, from Intermittent Fever, in 
 the European General Hospital at Bom- 
 
 bay, for the Five Years from 1849 to 
 1S53 .... Page 174 
 
 Table XI. — Admissions and Deaths, with 
 Per-centage, from Ephemeral Fever, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from July, 1838, 
 to June, 1843 . . . .174 
 
 Table XII. — Admissions and Deaths, with 
 Per-centage, from Eemittent and Inter- 
 mittent Fever, in the Jamsetjee Jejee- 
 bhoy Hospital at Bombay, for the Six 
 Years from 1848 to 1853 " . .176 
 
 Table XIII. — Admissions and Deaths, with 
 Per-centage, from Intermittent Fever, in 
 the Jamsetjee Jejeebhoy Hospital at 
 Bombay, for the Six Years from 1848 to 
 1853 177 
 
 Table XIV. — Admissions and Deaths, with 
 Per-centage, from Eemittent Fever, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from July, 1838, 
 to June, 1843 . . . .178 
 
 Table XV. — Admissions and Deaths, with 
 Per-centage, from Eemittent Fever, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from 1844 to 
 1848 178 
 
 Table XVI. — Admissions and Deaths, with 
 Per-centage, from Eemittent Fever, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from 1849 to 
 1853 179 
 
 Table XVII. — Admission and Deaths, with 
 Per-centage, from Eemittent Fever, in 
 the Jamsetjee Jejeebhoy Hospital, at 
 Bombay, for the Six Years from 1848 to 
 1853 180 
 
 Table XA 7 III. — Admission and Deaths, 
 from Intermittent and Eemittent Fever, 
 in the Byculla Schools, for the Seventeen 
 Years from 1837 to 1853 . . 181 
 
 Table XIX. — Admissions and Deaths, with 
 Per-centage, from Epidemic Cholera, in 
 the European General Hospital at Bom- 
 bay, for the Six Years from 1838 to 
 1843 233 
 
766 
 
 LIST OF STATISTICAL TABLES. 
 
 Table XX. — Admissions and Deaths, with 
 Per-centage, from Epidemic Cholera, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from 1844 to 
 1848 .... Page 234 
 
 Table XXI. — Admissions and Deaths, with 
 Per-eentage, from Epidemic Cholera, in 
 theEuropean General Hospital at Bombay, 
 for the Five Years from 1849 to 1853 234 
 
 Table XXII. — Admissions and Deaths' 
 with Per-centage, from Epidemic Cholera, 
 in the Jamsetjee Jejeebhoy Hospital at 
 Bombay, for the Six Years, from 1848 to 
 1853 235 
 
 Table XXIII. — Admissions and Deaths, 
 with Per-centage, from Epidemic Cholera 
 in the Byculla Schools, at Bombay, for 
 the Seventeen Years from 1837 to 
 1853 235 
 
 Table XXIV. — Admissions and Deaths, 
 with Per-centage, from Dysentery, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from July, 1838, 
 to June, 1853 . . . .318 
 
 Table XXV. — Admissions and Deaths, 
 with Per-centage, from Dysentery, in the 
 European General Hospital at Bombay, 
 for the Five Years from 1844 to 
 1848 318 
 
 Table XXVI. — Admissions and Deaths' 
 with Per-centage, from Dysenterj 7 , in the 
 European General Hospital at Bombay, 
 for the Five Years from 1849 to 
 1853 319 
 
 Table XXVII. — Admissions and Deaths, 
 with Per-centage, from Dysentery, in the 
 Jamsetjee Jejeebhoy Hospital at Bom- 
 bay, for the Six Years from 1848 to 
 1853 319 
 
 Table XXVIII. — Admissions and Deaths' 
 with Per-centage, from Diarrhoea, in the 
 Jamsetjee Jejeebhoy Hospital, at Bom- 
 bay, for the Six Years from 1848 to 
 1853 320 
 
 Table XXIX. — Admissions and Deaths, 
 with Per-centage, from Diarrhea and 
 Dysentery, in the Byculla Schools, for the 
 Seventeen Years from 1837 to 1853 320 
 
 Table XXX. — Admissions and Deaths, with 
 Per-centage, from Hepatitis, Acute and 
 Chronic, in the European General Hos- 
 pital at Bombay, for the Five Years from 
 1838 to 1843 . . . .418 
 
 Table XXXI. — Admissions and Deaths, 
 with Per-centage, from Hepatitis, Acute 
 and Chronic, in the European General 
 Hospital at Bombay, for the Five Years 
 from 1844 to 1848 .... 418 
 
 Table XXXII. — Admissions and Deaths, 
 with Per-centage, from Hepatitis, Acute 
 
 and Chronic, in the European General 
 Hospital at Bombay, for the Five Years 
 from 1849 to 1853 . . Page 419 
 
 Table XXXIII. — Admissions and Deaths, 
 with Per-centage, from Acute Hepatic 
 Affections, in the Jamsetjee Jejeebhoy 
 Hospital at Bombay, for the Six Years 
 from 1848 to 1853 . . . .419 
 
 Table XXXIV. — Admissions and Deaths, 
 with Per-centage, from Chronic Hepatic 
 Affections, in the Jamsetjee Jejeebhoy 
 Hospital at Bombay, for the Six Years 
 from 1848 to 1853 . . . ' . 420 
 
 Table XXXV. — Admissions and Deaths, 
 with Per-centage, from Pneumonia, in 
 the Jamsetjee Jejeebhoy Hospital at 
 Bombay, for the Six Years from 1848 to 
 1853 547 
 
 Table XXXVI. — Admissions and Deaths, 
 with Per-centage, from Bronchitis, in the 
 Jamsetjee Jejeebhoy Hospital at Bom- 
 bay, for the Six Years from 1848 to 
 1853 553 
 
 Table XXXVII. — Admissions and Deaths, 
 with Per-centage, from Phthisis Pulmon- 
 alis, in the Jamsetjee Jejeebhoy Hospital 
 at Bombay, for the Six Years from 1848 
 to 1853 560 
 
 Table XXXVIIL— Admissions and Deaths, 
 with Per-centage, from Delirium Tre- 
 mens, in the European General Hospital 
 at Bombay, for the Five Years from July 
 1838 to June 1843 . . . .646 
 
 Table XXXIX. — Admissions and Deaths, 
 with Per-centage, from DeHrium Tremens, 
 in the European General Hospital at 
 Bombay, for the Five Years from 1844 
 to 1848 646 
 
 Table XL. — ■ Admissions and Deaths, with 
 Per-centage, from Delirium Tremens, in 
 the European General Hospital at Bom- 
 bay, for the Five Years from 1849 to 
 1853 647 
 
 Table XLI. — Admissions and Deaths, with 
 Per-centage, from Paralysis, in the Jam- 
 setjee Jejeebhoy Hospital at Bombay, for 
 the Six Years from 1848 to 1853 
 
 Table XLII. — Admissions and Deaths, 
 with Per-centage, from Tetanus, in the 
 Jamsetjee Jejeebhoy Hospital at Bom- 
 bay, for the Six Years from 1848 to 
 1853 688 
 
 Table XLIII. — Admissions of Guinea- 
 worm into the Hospital of Her Majesty's 
 4th Light Dragoons at Kirkee, during 
 Eight Years from 1827 to 1834 . 72;5 
 
 Table XLIV. — Admissions and Deaths 
 with Per-eentage, from Dracunculus, in 
 the Jamsetjee Jejeebhoy Hospital at 
 
LIST OF METEOROLOGICAL TABLES. 
 
 767 
 
 Bombay, for the Six Years from 1848 to 
 1853 . . . . Page 725 
 
 Table XLV. — Admissions from Dracun- 
 culus, iii the Bombay Army, in the Year 
 1832 . . . . . .726 
 
 Table XLVI. — Admissions from Dracun- 
 cnlus, in the Bombay Anny, for the Year 
 1833 727 
 
 Table I. — Observations on the Temperature 
 at Bombay 743 
 
 Table II. — Observations with the Wet 
 Bidb Thermometer, at Bombay. Page 744 
 
 Table III. — Barometric Observations at 
 Bombay 745 
 
 Table IV. — Observations on the Rainfall 
 and the Direction and Force of the 
 Winds at Bombay .... 746 
 
 Table showing the Atmospheric Pressure, 
 the Temperature, the Dryness, the Rain- 
 fall, and the Direction of the Winds at 
 Poorundhur 747 
 
INDEX. 
 
 Abscess, Hepatic. — Pathology; formation 
 of, 328; opening into lung or pleural 
 sac, 335 ; into stomach and intestine, 
 342 ; into pericardium, 345 ; into hepatic 
 duct, 345 ; into peritoneal sac, 345 ; fatal 
 without rupture, 329, 380; recovery by 
 absorption, 345 ; character of contents, 
 359. — Causes ; pyaemic theory discussed, 
 365. — Symptoms of, 370. 384 ; pointing 
 towards diaphragm, 380 ; opening into 
 lung, brick-red sputa, 382. 384. — Treat- 
 ment of, 384; question of puncture fully 
 considered, 393 ; hepatic abscess not un- 
 common with cirrhosis, 424. 
 
 Antimony — potassio-tartrate, use of, in 
 intermittent fever, 28. 53 ; remittent 
 fever, 110. 118; ardent continued fever, 
 166 ; pneumonia, 537 ; delirium tremens 
 with opiates, 631'; cerebral disease, 649. 
 
 Aorta— aneurism of, 587. 
 
 Apoplexy — cerebral, 650. 
 
 Arsenic — acute gastritis from, 458 ; liquor 
 in intermittent fever, 32 ; paralysis from, 
 670. 
 
 Asthma — relation to malaria, 55 ; to em- 
 physema, 553. 
 
 Astringents — in cholera, 223 ; in chronic 
 dysentery, 304. 308. For particulars 
 see these. 
 
 Auscultation — importance of, in fevers in 
 India, 532, note; in rheumatism, 562. 
 
 B. 
 
 Barkers — alluded to, 669. 
 
 Eeebeeblne — use in intermittent fever, 34. 
 
 Beriberi — name objected to, 155, note. — 
 
 Symptoms, 705 ; author's views of its 
 
 Pathology explained, 706. Treatment, 
 
 708. 713. 
 Bile — defect of so-called torpor of the 
 
 liver, 441. 
 Biliary Calctli, 433 ; ducts, inflamma- 
 
 tion of, 98. 431 ; compression of by 
 enlarged lymphatic glands as cause of 
 jaundice, 97. 435. 
 
 Blisters — use of, in remittent fever, 119 ; 
 121. 140; dysentery, 308; hepatitis, 391; 
 pneumonia, 541 ; pericarditis, 578. 
 
 Blood-letting — general and local, in in- 
 termittent fever, 28; cold stage of, 124; 
 remittent fever, 110. 112. 114. 115. 118. 
 122 ; continued fever, 166 ; cholera epi- 
 demic, 225. 229 ; dysentery, 293 ; hepa- 
 titis, 385. 386 ; pneumonia, 534. 536 ; 
 pericarditis, 578 ; cerebral disease, 649. 
 
 Brain — affections of, 648 ; congestion of, 
 and determination to, in remittent fever, 
 70. 81. 118; serous effusion on, 90. 
 
 Bright's disease. See Kidneys. 
 
 Bronchitis — complicating, intermittent, 
 fever, 52; idiopathic. 552 ; tabular state- 
 ments of, in the Jamsetjee Jejeebhoy 
 Hospital, 553. 
 
 C. 
 
 Calculus — urinary, 505. 
 
 Calomel — cholagogue action in remittenl 
 fever, 110; epidemic cholera, 228; in 
 dysentery, 296 ; hepatitis, 386 ; abuse 
 in intermittent and remittent fever, 34. 
 125 ; Annesley's supposed sedative ac- 
 tion of large doses of calomel dissented 
 from, 136. 
 
 Cancer — of liver, 429. 
 
 Cai-ses — of disease, predisposing and ex- 
 citing, general notice of, 1. 9 ; of par- 
 ticular diseases, will be found under 
 name of. 
 
 Change of Air and of Climate, in inter- 
 mittent and remittent fever, 42. 150 ; 
 dysentery, 312; hepatitis, 414. 
 
 Chicken Pox, 200. 
 
 Children — fevers in, 168; dysentery, 314; 
 hepatitis, 415. 
 
 Cholera — bilious — not common in numer- 
 ous classes in India, 211. 140. 
 
 3 D 
 
770 
 
 INDEX. 
 
 Cholera, Epidemic — prevalence of, in 
 Bombay, 202 ; causes of, 204 ; symptoms 
 of, 208 ; different degrees of severity, 
 209 ; rate of mortality from, 215 ; rela- 
 tion of mortality to age, 216 ; to period 
 of epidemic, 217 ; to duration on ad- 
 mission, 217 .—Pathology of ", 218.— Treat- 
 merit of preliminary diarrhoea, 221 ; stage 
 of collapse, 224 ; of secondary affections, 
 226 ; by general blood-letting, 229 ; hot 
 bath, 229 ; emetics, 230 ; hot saline ene- 
 mata, liniments, injection into reins, 
 inhalation of vapours, 230 ; galvanism, 
 cold effusion, wet sheet envelope, 231 ; 
 recapitulation, 232. Statistics of, in 
 Em'opean General Hospital and Jamset- 
 jee Jejeebhoy Hospital, Bombay, 233. 
 
 Cirrhosis. See Liver. 
 
 Colica Pictorium, 4-56 ; colique vegetal?, 
 455. 
 
 D. 
 
 Datura poisoning, in Bombay, 641, note. 
 
 Delirium Tremens — prevalence of, and 
 mortality from, in European General 
 Hospital, Bombay, 624. Symptoms and 
 Treatment, division into two species, 625 ; 
 first species, 627 ; second species, first 
 stage, 628 ; second stage, 629 ; cold affu- 
 sion, 630 ; tartar emetic and opium, 631 ; 
 stimulants, 632 ; importance of food, 633 ; 
 objections to treatment with free opiates 
 and to expectant method stated, 633. 
 639; third stage, 635. Remarks on blood- 
 letting, 637 ; purgatives and emetics, 
 638 ; general management, 638. Patho- 
 logy — with remarks on principles of treat- 
 ment, and diagnosis, 641 ; complicated 
 with meningitis, 645 ; in natives of 
 India, 645 ; statistics of, in European 
 General Hospital at Bombay, 646. 
 
 Diabetes — saccharine, 502. 
 
 Diaphoretics — in fever, 28. 110; dysen- 
 tery, 302. 
 
 DlARRHOZA, 316. 
 
 Dlvthesis — general notice of importance of, 
 2 ; great prominence given to it in the 
 etiology of all the diseases treated of. 
 
 Diet in remittent fever, 149 ; dysentery, 
 311. 
 
 Diuresis, 505. 
 
 Duodenitis — in remittent fever in relation 
 to jaundice, 98. 
 
 Dracuxculus — prevalence of, in Bombay 
 Presidency, 720; obscurity of origin, 722; 
 management, 724 ; statistics, 725. 
 
 Dropsy, in Bright's disease, 481 ; cardiac 
 disease, 593; in scorbutic diathesis Be- 
 riberi, 704; in ascites from cirrhosis of 
 liver, 421. 
 
 Dysentery — prevalence of, 236. — Pathology 
 — general remarks, 237; morbid appear- 
 
 ances, change of colour of mucous mem- 
 brane of large intestine, 239 ; exudations 
 on free surface and into tissue, 240 ; im- 
 plication of follicles and solitary glands, 
 242 ; different forms of idcer, transverse, 
 245 ; circular, 253 ; puriform infiltration, 
 253 ; cedema and sloughing erysipelatous, 
 258; tubular sloughs of mucous membrane, 
 258 ; intussuscepted gut, 262 ; cicatrisa- 
 tion of idcers, 263 ; complication of in- 
 flammation of mucous membrane of large 
 intestine with peritonitis, 265 ; adhesions 
 of omentum, 265 ; tumefaction of region 
 of ccecum or sigmoid flexure, 269 ; dis- 
 placement of the colon, 270 ; complicated 
 with lesions of small intestine and stomach, 
 271; with enlargement of mesenteric 
 glands, 272 ; part of intestine chiefly 
 affected, 272 ; microscopic morbid ana- 
 tomy of dysentery, 272. — Etiology of— 
 preliminary theoretic remarks, 273 ; im- 
 portance of noting both predisposing and 
 exciting causes, 273 ; exciting causes, 
 cold, 273 ; much importance attached to 
 predisposing causes, 275 ; common be- 
 lief that malaria is an exciting cause, 
 dissented from, 276. — Symptoms, 280. — 
 Treatment — general principles, 288 ; de- 
 tails of treatment, 291 ; blood-letting, 
 general and local, 293 ; cholagogue action 
 of calomel, principle explained, 296 ; 
 mercurial influence, induction of, con- 
 demned, 297 ; use of ipecacuanha, 298 ; 
 purgatives, 300; diaphoretics, 302; opium, 
 principles of use explained, 302 ; chloro- 
 form, 304 ; astringents and tonics, 304 ; 
 bael fruit, 306; acetate of lead, 306; 
 trisnitrate of bismuth, quinine, sulphate 
 of copper, nitrate of silver, 307; prepara- 
 tions of iron, 307 ; vegetable astringents, 
 307; fomentations, blisters, 308; large 
 warm water enemata, principles con- 
 sidered and dissented from, 308; diet, 311; 
 change of air and climate, 312; dysentery 
 in children, 314. Statistical tables, 318. 
 Dyspepsl*. — functional notice of, brief, and 
 chiefly inculcating, in reference to etiology 
 and treatment, its character as symptom- 
 atic of diathetic states, 462. 
 
 E. 
 
 Elephantiasis — arabum, 698. 
 
 Emetics, use in intermittent and remittent 
 
 fever, 28. 110. 140; in cholera, 230. 
 Emphysema of the lungs, 553. 
 Encephalitis, 604, note. 
 Endocarditis. See Pericarditis. 
 Eryslpelas, 200. 
 Etiology — considered in reference to each 
 
 disease, which heads see. 
 
INDEX. 
 
 771 
 
 Febrictla — 162. 
 
 Fever, prevalence of, in India, 16 ; Arch at, 
 continued, 164. — Symptoms, 16.3. — Path- 
 ology and Treatment, 166. 
 
 Fever — intermittent types of, 17. — Simple 
 Symptoms of, 20. — Pathology, 24; mor- 
 tality. 24. — Treatment in different stages, 
 use of quinine, arsenic, bebeerine, muriate 
 of narcotine, mercury condemned, from 
 28 to 35. — Complicated, -with splenic 
 enlargement; Symptoms of, 36; abnormal 
 precordial duLness and cardiac murmur, 
 36. — Pathology of, 38; laceration of spleen, 
 427, note. — Treatment of, 40; liability to 
 dysentery and cautions therefrom, 41; use 
 of bromine, iodine, 41 ; injurious effects of 
 mercury, 41 ; with hepatic affection — 
 Pathology, 44; Treatment, 45 ; with jaun- 
 dice and affection of stomach and bowels, 
 47; with cerebral affection, 49; with 
 bronchitis, pneumonia, rheumatism, scor- 
 butus, pericarditis, asthma, 52 ; relation 
 of asthma to malaria, 55 ; intermittent 
 fever in children, 168 ; statistics of, in 
 European General Hospital andJamsetjee 
 Jejeebhoy Hospital, 174, 176. 
 
 Fever. Remittent ; causes of, same as of in- 
 termittent fever, 56 ; diagnosis of, from 
 intermittent and ardent continued, 56.— 
 Symptoms of Ordinary remittent, 58 ; 
 inflammatory, 60 ; adynamic, 62 ; con- 
 gestive, 64 ; badly developed, 66 ; unex- 
 pected collapse, 67 ; occasional pecu- 
 liar symptoms, 69 ; of Complicated, cere- 
 bral, 70; irritability of stomach,72; gas- 
 tric and bilious remittent, 73 ; pneumonia 
 and bronchitis, 73 ; diagnosis from hectic 
 and symptomatic fever, 74. Pathology — 
 mortality from, 75 ; importance of dia- 
 thesis or pre-existing structural disease, 
 76 ; complicated with cerebral determina- 
 tion, 81 ; cerebral inflammation, 86 ; cere- 
 bral adynamic, 88; import of cranial serous 
 effusion analysed, 90 ; gastric irritabibty, 
 93 ; bilious remittent, 93 ; complicated with 
 affection of bowels, 94; hepatic and splenic 
 affection, 96 ; jaundice, 97 ; parotitis, 105 ; 
 Treatment — contrast of principles with 
 those of zymotic continued fever, 105 ; of 
 ordinary form, 109; inflammatory, 113; 
 congestive, 115 ; continued and adynamic, 
 116 ; badly developed symptoms, 117 ; of 
 complicated, with cerebral affection, with 
 question of mercurial treatment in, 118, 
 120; gastric irritability, 121; jaundice, 
 121 ; hepatitis, dysentery, 122 ; remarks 
 on blood-letting, 122 ; mercurial treat- 
 ment, author's opinion of, 125 ; opinion 
 of other writers on, 128 ; origin and history 
 of, 130 ; on cold affusion, 137 ; wet sheet 
 
 packing, 137; purgatives, 138; emetics, 
 140 ; blisters, 140 ; opiates, use of, dan- 
 gers from, 140; quinine, 143; question of 
 large doses examined, 146 ; Warburg's 
 drops, 148, note; diet, 149; change of air, 
 use and injudicious application of, 150 ; 
 question of lunar influence, 154, note. 
 Infectious Adynamic Remittent — Pali 
 disease, 155 ; statistics of remittent fever 
 in European General Hospital and Jam- 
 setjee Jejeebhoy Hospital, Bombay, 177, 
 180 ; Byculla schools, 181. 
 
 Fever — European relapsing, typhus, un- 
 known as yet in India, 16. 
 
 Fever — typhoid, of occasional occur- 
 rence, further research necessary, 160. 
 
 Females — hepatitis in, caution in respect 
 to, 415. 
 
 G. 
 
 Gall-Bladder — inflammation and disten- 
 tion of, 431. 
 
 Gangrene of lung, 523, note. 
 
 Gastritis — acute, 458 ; chronic, 460. 
 
 Gastro — enteritis, 316. 
 
 Glossitis — efficacy of application of ni- 
 trate of silver in, 461. 
 
 H. 
 
 Headache — paroxysmal, functional, and 
 organic, diagnosis of, 654. 
 
 Heart — organic disease of, in natives in 
 the Jamsetjee Jejeebhoy Hospital, 581 ; 
 dilatation of both ventricles, 5S1 ; dila- 
 tation and hypertrophy of left ventricle, 
 581; hypertrophy of right ventricle, 582; 
 aneurism of left ventricle, 583 ; valvular 
 disease of, 586 ; previous pericarditis and 
 endocarditis, 586; rupture from fatty 
 degeneration, 587 ; aortic disease, 587 ; 
 pulmonary complication, congestion, oede- 
 ma, hepatisation, emphysema, 589 ; re- 
 lation of, to sex, caste, age, occupation, 
 habits of Life, season, 590, 591, 592; to 
 pericarditis, endocarditis, Bright's disease, 
 592 ; leading symptoms and signs, dys- 
 pnoea, 593 ; dropsy, 593 ; precordial 
 pain, 593 ; pain below margin of right 
 ribs, 593 ; scapular pain, 594 ; character 
 of pulse, 594 ; precordial fulness, 595 ; 
 increased impulse, 595 ; precordial dul- 
 ness, 595 ; dulness below right costal 
 margin, 595 ; character of cardiac mur- 
 murs, 595; precordial thrill, 599. Treat- 
 mi at, 599 ; illustrative cases, 599 ; heart 
 disease in Europeans in India, 600. 
 
 Hemlplegh. — in natives, 658 ; relation 
 to age and caste, 658, 659. — Pathology aS, 
 660; illustrative cases, GOO; symptoms, 
 665. 
 
772 
 
 INDEX. 
 
 Hepatitis — anatomical position and rela- 
 tion, important, 321 ; terms hepatitis and 
 cirrhosis preferred to suppurative and 
 adhesive inflammation, 324. Pathology 
 
 — question of which capillaries affected, 
 considered, 325 ; inflammation of capsule 
 and substance, 327 ; turgescence, 327 ; 
 lymph exudation, 327; formation of 
 abscess, see "Abscess; " secondary peri- 
 tonitis, puriform sacs, 348 ; secondary 
 pleuritis, general and circumscribed em- 
 pyema, 352 ; secondary pericarditis, 352 ; 
 general secondary peritonitis, 355 ; re- 
 lation of secondary serous inflammation 
 •with suppuration to cachectic states, 
 359. Causes — not uncommon in na- 
 tives of India, 323 ; exciting, cold and 
 heat, 361 ; special influence of, 363 ; in- 
 temperance not proved, 363 ; predisposing 
 causes, cachectic states, but not evidence 
 to relate to particular cachexia, 363 ; re- 
 lation of hepatic abscess to dysentery 
 considered, 365 ; primary hepatitis, se- 
 condary dysentery, 369 ; hepatic abscess 
 without intestinal ideeration, cases of, 
 365 ; dysentery preceding abscess, 369. 
 
 — Symptoms of acute hepatitis, pain 
 of side, 370 ; of right shoulder, 371 ; 
 import of enlargement of liver, 372 ; 
 tension of right rectus muscle, 373 ; 
 altered states of biliary secretion, 373 ; 
 jaundice of no value as a symptom, 
 373; fever, 374; occasional obscurity. 375; 
 of formation of abscess, see " Abscess." 
 
 — Treatment of early stages, 384 ; general 
 blood-letting, 385; local blood-letting, 
 mercurial and other purgatives, ipeca- 
 cuanha, 386 ; caution in regard to relapse, 
 3S6 ; treatment of exudation stage, 388 ; 
 mercurial influence, principles of, 389 ; 
 blisters, 391 ; after abscess formed, see 
 "Abscess;" hepatitis iu females and 
 children, 415 ; occasional difficulties in 
 diagnosis, 416 ; statistics of, in European 
 General Hospital and Jamsetjee Jej eebhoy 
 Hospital at Bombay, 417, 420. 
 
 Hepatic phlebitis, 361. 
 
 Hill Sanitaria in Decean — Mahubulesh- 
 wur, Pannehgunnee, Porrundhur, Sing- 
 hur. Principles applicable to all Hill 
 Sanitaria in India, 728 — 740. 747. 
 
 Hooping Cough — 201. 
 
 Hydatids — in liver, not common in India, 
 430. 
 
 Hydrocephalus — acute. 652 ; chronic. 654. 
 
 Hydrophobia — as observed in Bombay, 
 illustrative cases, 689. 
 
 Llbus — 453. 
 
 Lpecacuahha — use of, in dysentery, 298. 
 
 Iron — preparations oft in splenic enlarge- 
 
 ment, 40 ; dysentery, 307 ; cachexia of 
 Bright's disease, 494. 
 
 Jaundice — complicating remitting fever, 
 73, 97. 121'; idiopathic Pathology, 433. 
 — Causes, IZG.— Trttitm-nt, 438; of no 
 value as a symptom of hepatitis, 373. 
 
 Kidneys — Bright' s disease, prevalence of, 
 in some classes of the native community, 
 465 ; want of data in respect to Eu- 
 ropeans, 466 ; summary statement of 
 morbid anatomy of, 467; illustrative cases, 
 468 ; dropsical symptoms, 4S1 ; secondary 
 head symptoms, believed not to be so 
 common in India, 481 ; the same state- 
 ment of secondary cardiac affection, 
 482 ; the ursemic theory of the secondary 
 affections discussed, 483; altered relation 
 of albumen in the blood and urine con- 
 sidered, 485 ; remarks on the proximate 
 cause of albumen in the urine, 486. — 
 Causes — Relation to cachectic states, 
 487 ; external cold, 490. — Symptoms 
 — Relative to the kidney, 491; con- 
 dition of the urine, 492. — Treatment — of 
 the kidney disease, 492 ; of the secondary 
 affections, dropsical, 493 ; inflammatory, 
 495 ; reference to diagnostic value of 
 epithelial debris, tube casts and oil glo- 
 bules in urine, 492. 
 
 Laryngeal affections in phthisis puhno- 
 nalis, 558. 
 
 Leeches — sizes of, used in Bombay, note, 
 294. 
 
 Leprosy — tubercular and anaesthetic; ar- 
 rangements for care of lepers in Calcutta, 
 Madras, and Bombay, 695. — Symptoms, 
 696.— Pathology, 697. 
 
 Liver — cirrhosis of: PatkologyA2l. — Symp- 
 toms, 422.— Treat mint, 422; illustrative 
 cases, 422 ; congestion of the liver, 426 ; 
 cancer and hydatid formations of, 429. 
 430 ; fatty degeneration of, 428 ; lardace- 
 ous, 427 ; so called torpor of, 441 ; inflam- 
 mation of. (See Hepatitis.) 
 
 31. 
 
 Malaria — applied in this work exclusively 
 to the miasmatic cause of intermittent 
 and remittent fever : summary statement 
 of existing knowledge, 4 ; in relation 
 
INDEX. 
 
 773 
 
 to intermittent fever, IS. 19, note; toremit- 
 tent fever, 60, note ; a predisposing cause 
 of dysentery, but not an exciting one, 
 276, 279 ; the cause of many obsciu-e de- 
 rangements, 153 ; modifying influences 
 on inflammatory symptomatic fever, 278, 
 371, 327, 576, 542. 
 
 Measles — account of in Byculla Schools 
 and elsewhere, 194; mortality rate, 198. 
 
 Meningitis — complicating remittent fever, 
 86 ; idiopathic, 652. 
 
 Mercury — constitutional effect of, injurious 
 in splenic enlargement, 41 ; use of, in re- 
 mittent fever fully discussed and con- 
 demned, 125 to 136; in dysentery also 
 disapproved, 297 ; use of, in hepatitis ex- 
 plained, 386, 389; also in pneumonia and 
 in pericarditis, 538, 579. 
 
 Meteorology of Bombay, 7-il ; of Deccan 
 Hill Sanitaria. 729, 74*7. 
 
 Mumps, 198. 
 
 Myelitis, 667. 
 
 O. 
 
 Officers, European — diseases of: remit- 
 tent fever, 75 ; small-pox, 190 ; measles, 
 197; dysentery, 237, table; peritonitis, 
 443 ; Bright" s disease, 466 ; pneumonia, 
 508 ; phthisis pulmonalis, 554 ; cerebral 
 affections, 650; tetanus, 673. 
 
 Opium — use of: in remittent fever, 110, 
 140: cholera. 222, 225; dysentery, 302; 
 delirium tremens, free and routine use 
 cautioned against, 633. 
 
 Paralysis — from arsenic, 670 ; facial, 671. 
 (See Hemiplegia and Paraplegia.) 
 
 Paraplegia, 668 ; case of wound of spinal 
 cord, 669. 
 
 Pericarditis and Endocarditis — analysis 
 of 25 cases : proportion of pericarditis 
 and endocarditis, 561 ; result, 563 ; re- 
 lation to sex, caste, age, occupation, 
 habits, season, 564 to 567 ; relation to 
 rheumatism, cachexia, pulmonary in- 
 flammation, 567. — Symptoms and signs 
 — Pain at margin of left ribs and pre- 
 cordial region, 568 ; increased impulse, 
 568 ; character of pulse, 569 ; febrile 
 symptoms, remittent character of, 569, 
 570 ; dyspnoea, 570 ; anxiety of coun- 
 tenance, 570 ; delirium, 570 ; increased 
 precordial dulness, 571 ; purring tre- 
 mor, precordial fulness, friction mur- 
 mur, 571; duration and causes of friction 
 murmur, 571 ; jogging movement of 
 hearty 578. — Treatment — General and 
 local blood-letting, 578 ; blisters, 578 ; 
 
 mercurial influence, 579 ; illustrative 
 cases, 573. 
 
 Peritonitis. — 'Pathology — Rarity of idio- 
 pathic sthenic form, 443 ; traumatic, 443 ; 
 sero-puriform, 445 ; chronic tubercular, 
 447 ; chronic form 'with effusion observed 
 at Aden, 452. 
 
 Phthisis Pulmonalis — not unfrequent 
 either in Europeans or natives, 554. — 
 Causes — influence of rainy season, question 
 of malarious influence, 554. — Symptoms, 
 556. — Pathology — Question of rapidity 
 of course in India, 556 ; stage in which 
 hospital patients admitted, 557 ; which 
 side most affected, 557; co-existing pleu- 
 ritis, 558 ; pneumonia, 558 ; laryngeal 
 complication, 558 ; intestinal ulceration, 
 558 ; frequency of diarrhoea, 558 ; tuber- 
 cular peritoneum, fatty liver, 559. Treat- 
 ment, 559; statistics of the Jamsetjee 
 Jejeebhoy Hospital, 560. 
 
 Pleuritis, 548. — Symptoms, 548. — Causes, 
 549. — Pathology, 549. — Treatment, 551. 
 Question of Paracentesis of Chest, 551. 
 
 Pneumonia — rare in Europeans, 508 ; com- 
 mon in asthenic natives, 508 ; division 
 into primary and complicating remittent 
 fever, considered together, analysis of 
 103 clinical cases, 509. Etiology — rela- 
 tion to sex, age, caste, habits, constitu- 
 tion, season, 509 — 512. Pathology — 
 Preliminary remarks on question, which 
 capillaries affected, 512 ; rate of mor- 
 tality, 515 ; duration of illness before 
 admission, 517 ; stage of disease, 518 ; 
 which lung affected, 518 ; residence in 
 hospital, 520 ; morbid anatomy, sum- 
 mary of, 521 ; illustrative cases, 524. 
 Symptoms. — Fever, remittent character 
 of, 527 ; pain of side, 529 ; pain below 
 margin of right ribs, 529 ; dyspnoea, 531 ; 
 cough, 532 ; delirium, 5S3 ; character of 
 the sputa, 533 ; physical signs, 554. — 
 Treatment — Blood-letting, general prin- 
 ciples explained, those of some previous 
 writers dissented from, 534 ; local blood- 
 letting, 536 ; tartar emetic, 537 ; mer- 
 curial influence, 538 ; blisters, 541 ; qui- 
 nine, utility and principles explained, 
 542 ; liquor potassa?, 543 ; stimulants, 
 543 ; concluding remarks on general 
 principles of treatment relative to die 
 use of antiphlogistics and tonics in pneu- 
 monia and inflammatory disease gene- 
 rally. 544 ; statistics of, in Jamsetjee 
 Jejeebhoy Hospital, 547. 
 
 Purgatives — use in remittent fever, 138 ; 
 dysentery, 300 ; hepatitis, 386 ; pro- 
 bable injurious effects from, in hepatitis, 
 366. 
 
 Py.emia, 692, 693 ; illustrative cases, 
 question of relation to hepatic abscess, 
 365. 
 
774 
 
 INDEX. 
 
 Q. 
 
 Quinine — disulphate, use in intermittent 
 and remittent fever, 29, 114, 143 ; 
 prophylactic use, 149 ; in pneumonia, 
 both febrile and idiopathic, 542. 
 
 K. 
 
 Rheumatism, 561. 562, note, 592. 715. 
 
 S. 
 
 Scarlatina — very rare if not unknown in 
 India, 199. 
 
 Scdbvt — not uncommon in India, 701. 
 
 Ska-coast — Sanitaria, 738. 751. 
 
 Small-Pox — as observed in Jamsetjee 
 Jejeebhoy Hospital, 182 ; prevalence of, 
 in Bombay, 187; prevention of, 189. 
 
 Snake-bite — Phoorsa snake, on Mahubule- 
 shurr Hills, 716. 
 
 Spinal Coed — disease of, 668 ; wound of, 
 669. 
 
 Spleen — inflammation of, rare, 36, note; en- 
 largement of, 36 ;— Pathology, 38 ; Treat- 
 ment, 37 ; abnormal precordial dulness 
 from heart, displacement by enlarged 
 spl sen, 37 ; laceration of, by injury, 427, 
 note. 
 
 Statistics — see list of tables; injury to 
 medical science from use of imperfect 
 statistical data, 12, note; 311, note; 
 516, note. 
 
 Sunstroke, 603. — Symptoms, 606. Patho- 
 logy, 611. — Etiology, 614.- —Prevention 
 and Treatment, 619. 
 
 Tetanus — prevalence of, 672. Pathology, 
 673. Causes, 678. Symptoms, 680. 
 Treatment, 683 ; illustrative cases, 686 ; 
 statistics of, in Jamsetjee Jejeebhoy Hos- 
 pital, 688. 
 
 Tonics — regimen, 10; remedies in dysen- 
 tery, 304 ; remarks on general prin- 
 ciples, 544. 
 
 r 
 
 Urine — imperfect acquaintance with nor- 
 mal standard of, in India. 497 ; chylo- 
 serous, 498 ; saccharine, 502 ; with excess 
 of urates, oxalates, phosphates, 505. 
 
 Vaccination; 189, imperfect in Nativ< 
 Army, 190. 
 
 w. 
 
 Warburg's Fever drops, 148, note. 
 Wet Sheet packing, in fever, 137. 
 
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 INDEX. 
 
 Abbey fe 5 Overtoil's English Church History 14 
 
 Acton s Modern Cookery 20 
 
 A. K. H. B. Essays of 7 
 
 Allen s Flowers and their Pedigrees n 
 
 Arnott's Elements of Physics 9 
 
 Alpine Club Map of Switzerland 17 
 
 Guide (The) 17 
 
 Amos' s Jurisprudence 5 
 
 Primer of the English Constitution 5 
 
 50 Years of English Constitution 5 
 
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 Miscellaneous Works 15 
 
 Sermons 15 
 
 (T.) English Literature 6 
 
 Atelier (The) du Lys 18 
 
 Atherstone Priory 18 
 
 Autumn Holidays of a Country Parson ... 7 
 
 Ayre's Treasury of Bible Knowledge 20 
 
 Bacon's Essays, by Whaiely 5 
 
 Bacon's Life and Letters, by Spedding ... 5 
 
 Promus, edited by Mrs. Pott 5 
 
 Works 5 
 
 Bagchot' s Biographical Studies 4 
 
 Economic Studies 6 
 
 Literary Studies 6 
 
 Bailey's Festus, a Poem 18 
 
 Bain's James Mill and J. S. Mill 4 
 
 Mental and Moral Science 5 
 
 on the Senses and Intellect 5 
 
 Emotions and Will 5 
 
 Practical Essays 5 
 
 Baker's Two Works on Ceylon 17 
 
 Ball's Alpine Guides 17 
 
 Bauerman's Mineralogy n 
 
 Beacon sfield's (Lord) Novels and Tales ... 18 
 
 Speeches 1 
 
 Wit and Wisdom 6 
 
 Becker's Charicles and Gallus 7 
 
 Beesly's Gracchi, Marius, and Sulla 3 
 
22 
 
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 Black' s Treatise on Brewing 20 
 
 Blackley's German-English Dictionary 7 
 
 Boultbee on 39 Articles 14 
 
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 Bourne's Works on the Steam Engine 14 
 
 Bowdler's Family Shakespeare 19 
 
 Bramley-Moore' s Six Sisters of the Valleys . 18 
 
 Bramston & Leroy's Historic Winchester . 2 
 
 Brande's Diet, of Science, Literature, & Art 11 
 
 Brassey's Sunshine and Storm in the East . 17 
 
 Voyage in the ' Sunbeam' 17 
 
 Bray's Elements of Morality 16 
 
 Browne's Exposition of the 39 Articles 14 
 
 Buckle's History of Civilisation 2 
 
 Bucket's Food and Home Cookery 21 
 
 Health in the House 12&21 
 
 Bull's Hints to Mothers 21 
 
 Maternal Management of Children . 21 
 
 Burgomaster's Family (The) 18 
 
 Burton's My Home Farm 21 
 
 Cabinet Lawyer 20 
 
 Calvert's Wife's Manual 16 
 
 Capes's Age of the Antonines 3 
 
 Early Roman Empire 3 
 
 Carlyle's Reminiscences 4 
 
 Life 4 
 
 (Mrs.) Letters and Memorials ... 4 
 
 Cates's Biographical Dictionary 4 
 
 Changed Aspects of Unchanged Truths ... 7 
 
 Chesney's Waterloo Campaign 2 
 
 Christ our Ideal 16 
 
 Church 's Beginning of the Middle Ages ... 3 
 
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 Commonplace Philosopher 7 
 
 Conder's Handbook to the Bible 15 
 
 Conington's Translation of Virgil's ^Eneid 19 
 
 Prose Translation of Virgil's 
 
 Poems 19 
 
 Conta?iseau s Two French Dictionaries ... 7 
 
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