: ^3L V-^.'.,.:, n a. ^,~ A SYSTEM OF CLINICAL MEDICINE. SYSTEM OF CLINICAL MEDICINE. BY ROBERT JAMES GRAVES, M.D., M.R.I.A., ~>ne of the Physicians of the Meath Hospital and County of Dublin Infirmary; formerly Professor of the Institutes of Medicine; Honorary Corresponding Member of the Royal Medical Society of Berlin, the Imperial Medical Society of Vienna, and of the Medico-Chirurgical Societies of Hamburgh, Tubingen, Bruges, Montreal, etc, etc. WITH NOTES AND A SERIES OE LECTURES, BY W. W. GERHARD, M.D., Lecturer on Clinical Medicine to the University of Pennsylvania ; one of the Physicians to the Pennsylvania Hospital, etc., etc., etc. THIRD AMERICAN EDITION. PHILADELPHIA: ED. BARRINGTON AND GEO. D. HASWELL. 1848- AHHEK '■■t 7 7 b> ca I842ol [Entered, according to Act of Congress, in the year 1848, by Barrington and Haswell, in the Clerk's Office of the District Court for the Eastern District of Penn- sylvania.] TO WILLIAM STOKES, M.D., ONCE HIS PUPIL, NOW HIS COLLEAGUE, EVER HIS FRIEND, WHOSE WORK ON DISEASES OF THE CHEST HAS DESERVEDLY ACQUIRED A MORE THAN EUROPEAN REPUTATION } AND TO FRIEDRICH W. OPPENHEIM, M.D., FORMERLY HIS FELLOW-STUDENT, EDITOR OF THE HAMBURGH MEDICAL JOURNAL, AND THE WRITER OF MANY VALUABLE SURGICAL TREATISES, THIS VOLUME IS DEDICATED BY THE AUTHOR. PREEACE THIRD AMERICAN EDITION. Since the last edition of Dr. Graves's lectures was published in this city, a new one, considerably enlarged, has been pub- lished by Dr. Graves, in Europe: from this edition the present one is printed. It contains the whole of the lectures, which make a very large volume; but some detached papers which were not printed in the former editions, and were first published in the present one, are not reprinted. These essays the pub- lishers will probably issue in a separate form. The demand for a new edition is the best proof of the high character these lectures have gained in the United States, and of the very extended re- putation they have justly attained. The additional lectures, which, at the requestof the publishers, were appended to the last edition of the work, have been revised, and some new matter on the subject of Typhus Fever has been added. The lectures were originally delivered as a part of a clinical course, or rather of several clinical courses, at the Phi- ladelphia Hospital, most of them were printed in a medical jour- nal some years since, but they were for the first time published in a collective form in the last edition of Dr. Graves's lectures. The only important subject on which the editor differs from Dr. Graves, is that of typhus fever. This has been, for some years, a contested point between the English and French phy- sicians ; in reality, however, the difference of opinion has arisen from one simple fact. The typhus fever of England and Ireland was unknown in France, at least at Paris, where the continued fever had been for many years confined to typhoid fever; the same had been the case "for many years in this country until in the year 1836, when we had a disease similar to the genuine typhus fever of the British islands. Since that time we have 8 PREFACE TO AMERICAN EDITION. had many cases, imported directly from England, perfectly iden- tical with the same class of fevers. On the other hand, the ty- phoid fever of France is much less frequent in the British islands than on the continent, and is, to a certain extent, con- founded with the much more common form of typhus fever. Such at least seems to me to be the best explanation of the con- fusion which has existed in the statements of writers, relative to these two allied but not identical diseases. Philadelphia, August, 1848. PREFACE. Having been, for many years, engaged in giving Clinical Instruction at the Meath and Sir Patrick Dun's Hospitals, I thought it to be my duty occasionally to publish the results of my observations in the form either of detached Essays, or successive series of Lectures ; the former were printed in the Dublin Hospital Reports, and the Dublin Medical Journal, the latter appeared in various English periodicals, but chiefly in that ex- cellent publication, the London Medical Gazette. Many of the detached papers were subsequently translated into French, German, and Italian, and several courses of the Lectures were published by Doctor Robley Dunglison, in a separate volume at Philadelphia. This has encouraged me not only to continue my exertions in the cultivation of practical me- dicine, but to revise what I had written and compress the whole within the limits of a single volume. It is necessary to mention that the Lec- tures were all originally delivered extempore, and were printed from notes taken by a short-hand writer. The reader being made aware of this cir- cumstance, will kindly make due allowance for the many imperfections of style, and the redundancy and repetition which occur but too frequently in this work. In revising the whole, I have been at more pains to im- prove the substance than to polish the surface, and have rigorously ex- cluded every assertion and conclusion which my subsequent experience has not verified. It should likewise be borne in mind that this volume has no pretensions to the title even of Outlines of the Practice of Physic, for many most im- portant diseases are not mentioned at all, none are fully described, and nowhere is treatment considered in all its bearings ; my object in lectur- iug has, in truth, been always strictly clinical, and except where the sub- ject was very tempting, and its discussion seemed to promise some useful and novel result, I have seldom allowed myself to deviate from the legi- timate pursuit of that object; on the subject of Fever, perhaps, I may appear to have enlarged far beyond the limits of my prescribed plan, but a very sufficient explanation of this apparent exception may be given, for as the wards of our Hospitals are never without fever cases, every suc- cessive season suggested some new remarks on that disease, and when the task of consolidating these courses of Lectures was undertaken, it be- came necessary to collect the various scattered observations on Fever, which occurred in almost every Lecture, and consequently (although many insulated cases of Fever, and the remarks they at the time called forth, I 10 PREFACE. have been omitted), when the materials already printed on that important affection were arranged in a certain connected order, and were elucidated by facts observed since their former publication, the mass of matter thus gradually accumulated was found to be much greater than was expected —still I must beg leave to remind the reader, that these Lectures are not intended to embrace the whole subject, even of Fever, and indeed it will be obvious from a cursory glance that my observations were generally dictated by some case actually under treatment, and were not intended to constitute any thing like a full and complete history of the Symptoms, Pathology, and Treatment of Fever. In attempting to form a continuous and connected series of reasoning on this disease, it became necessary not merely to reprint what I had published at various dates, but to remodel the whole, by adding much, and omitting more, and thus it has happened that the Lectures on Typhus in this work have assumed an entirely new form. For many years, several of the doctrines I promulgated respecting Fever, were opposed to those taught by other Lecturers and generally advocated by authors ; and consequently I was then obliged to dwell on such disputed questions at greater length than perhaps their intrinsic im- portance would now seem to warrant: formerly I stood almost alone in resisting the inflammatory theory of Fever, as successively brought into fashion by Armstrong, Clutterbuck, and Broussais, and my opinions re- specting contagion, the use of mercury, purgatives, of wine, diet, &c, were different from those then generally entertained : and therefore it was that such topics occupied so considerable a space in the original Lectures, and are treated of at some length in the present volume. While engaged in the task of preparing for the press, I have consulted many of my me- dical friends, both in Dublin, and the Provinces, on various subjects, and by this means having been enabled to avail myself of the experience of others where my own was deficient, much valuable information has been gained, and the courtesy of my professional brethren has produced com- munications which will no doubt be received by the public with a degree of favour proportioned to the gratitude the Author feels to his friends for their valuable assistance. Some of my readers may perhaps think, that the strictures my Introductory Lecture contains on the Physiological and Pathological Theories, founded on Liebig's chemical researches, are too severe, but a calm reconsideration of the subject convinced me that the Theories in question are calculated to retard the progress of Medical Science, and consequently ought to be energetically opposed. CONTENTS. LECTURE I. Introductory Lecture.—Proper method of studying Medicine—Importance of studying: Chronic Diseases—Medical Schools of Edinburgh and Dublin—German method of giving Clinical Instruction—Its great superiority—Notice of the new Medical Institutions, with remarks on the curriculum of study pursued at each—These views on Medial Education, strongly advocated in the Medical Gazette, &c. , Page 17 LECTURE II. Second Introductory Lecture (for Session 1834-5).—Proper method of studying Patho- logy and Physiology—Notice of the doctrines of Brown, Broussais, and Rasori—Study of Morbid Anatomy attended with difficulty—Doctrines of the Nosologists—How likely to lead to error—The Irish contributors to Medical Science . . . . .23 LECTURE III. Third Introductory Lecture (Session 1836-7).—General Observations—Students are perplexed by the variety of subjects to which they are compelled to attend—Proper prelimi- nary education for those intended for the Medical Profession—Time misspent in learning Botany and other collateral branches of medicine—Confusion arising from the frequent changing of medical terms and names of medicines—Chemistry throws but little light upon Physiology or Pathology—Notice of Liebig's theory of Metamorphosis—Dr. Watson sub- scribes to Liebig's theory—Reasons for dissenting from both—Liebig's theory of Animal Heat—Facts are wholly irreconcileable with Liebig's doctrines—Great responsibility con- nected with the teaching of Medicine in Great Britain . . . .35 LECTURE IV. Fever—General Observations—Reports of Mortality from Fever in Ireland—Dr. Cowan's Reports showing the comparative frequency of Fever in different parts of Great Britain— Opinions of Dr. Lombard—Mr. Chadwick's inquiries—There does not appear to be any connection between Typhus Fever and Epizootic diseases—Principal features of the epi- demic described by Cheyne and Barker—Contagious nature of Typhus Fever—Dr. Christi- son's arguments in support of—Opinions of Dr. Perry—Importance of the study of Fever— Proper choice of a Nurse and Assistants—Air of a sick chamber—Necessity of attending to Diet, &c. &c. . . . . • • • • - .50 LECTURE V. General treatment of fever—Dietetic management—The starvation system may produce organic disease—Proper food for fever patients and convalescents—Allaying of thirst—Sedatives— Expergefacients—Efficacy of green tea in a case of narcotism—Flagellation effectual in a case of poisoning with opium . . . . . . . .69 LECTURE VI. Treatment of Typhus Fever—Tympanitis often the consequence of inattention to diet, or to overdosing with purgatives—The uses of air in the Intestines—Treatment of Tympanitis unaccompanied by Intestinal Inflammation—Utility of Spirit of Turpentine in such cases— Tympanitis with Inflammation and Congestion of Intestines—Acetate of Lead best remedy —Turpentine in Iritis . . . . . . . .75 12 CONTENTS. LECTURE VII. Thirst in fever frequently dependent on the state of some internal organ—Blisters, employed as stimulants and evacuants, excite the vital action of the capillaries—An important remedy where cerebral affection is apprehended—Signs of approaching cerebral symptoms—Tartar emetic, solution and ointment—The latter used with success in some desperate eases 81 LECTURE VIII. Further remarks on the treatment of Fever—Management of delirious patients—Advantages of tartar emetic in the form of enema—Subsultus tendinum sometimes from disturbance of the nervous extremities, independently of the brain or spinal cord—Vomiting and purging at the commencement of fever, indicative of cerebral affection—Scrofulous inflammation of the brain—Chronic scrofulous fever . . . . • ' .90 LECTURE IX. Morbid appearances after Delirium in Fever—Treatment in anticipation of cerebral symptoms —Great advantage of Blisters judiciously employed—Notice of the okl mode of Blistering 95 LECTURE X. On Epidemics—On the use of Emetics in the commencement of Fever—Not so well adapted to a later period—Domestic remedies for feverish colds—These colds prove to be fevers, and time is lost*-Protest against the abuse of purgative medicine in fever—The idea of curing fever by purging is absurd—Treatment where the bowels have become almost paralyzed after the cure of preceding diarrhoea—Venesection as a means of checking fever—Beneficial even within the first twelve hours after seizure by typhus—Various cautions respecting leeching and cupping-glasses—Mode of applying leeches when pneumonia or hepatitis supervenes on fever . . , . . . , . ,102 LECTURE XI. Fever—Application of cold to the head ; particular apparatus for this—Warm appfications recommended—Use of mercury in fever—Effects of Intemperance—Illustrations afforded by particular eases>—Necessity of active attention to cerebral symptoms—Occasional absence of morbid appearance after death—Contraction and dilatation of the pupils—Coup de soleil— Flatulent distension accompanied by 3 o j* a 3 55 o a 2 »j ^^^f^rr^^^^???? 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S rs '-5> O 000iO-*»COVI«MC»;00CC-MO- cnto — ^.^.tooo — toe; inc-. — to co Jl^JOlCOOD — MOUaoi(3IOi.u — to — acoffltjaoo-vioMMcc — — — ■_> co _- OitOK/tOi— tncocooooc-. oi O! - 0? —'SOOl^U^MMOaOlOO- t0tD^0lr-WSli-HUi05M0563O — to i- to to----to JO — OStO — — a oo i> a oi » - ua^KXviu^ - 3q From this document it follows that the mortality from fever in Leinster amounts to a fraction less than one-tenth of the whole mortality, whereas in London the fever deaths do not amount to more than one-fiftieth of the total deaths. This difference becomes more striking from considering that deaths in Dublin from fever are actually nearly double the deaths from the same cause in London. The last census made the population of London amount, I believe, to one million and a half, while that of Dublin is three hundred and sixty-two thousand. The admirable papers of Dr. Cowan have thrown much light upon the comparative frequency of fever in different parts of Britain, and his tables prove that Glasgow is more unfavourably situated, as regards fever pv» than Dublin; for in 1835, 1836,1837, the deaths from fever alone were FEVER. 55 412, 841, 2,180, being, in the relation to the mortality from all diseases, one in 15-6, 10, and 4-7 annually: but as the year 1837 was remarkable for a fearful epidemic, this mortality is over the average, for Dr. Cowan in another place shows, that while in Glasgow, with a population of 200,000, the annnal average of fever, deduced from seven years, ending with 1836, has been 1842 cases; in Manchester, with a population of 228,000, it has been for the same period only 497 ; in Leeds, with a population of 123,000, only 274 ; and in Newcastle, with a population of 58,000, so little as 39. These numbers bring out, in striking contrast with Ireland, the immunity from fever enjoyed by large English towns, and corroborate the remark already made, that the eastern and central parts of Britain, enjoying a climate more different from that of Ireland, so likewise are much freer from fever than the western parts of Britain, whose climate approximates more to the Irish. It is curious that in those towns in England which have greater intercourse with Ireland, as Liverpool, Manchester, Bristol, typhus predominates more than others not similarly circumstanced. It was on this account that Dr. Lombard* concluded that maculated typhus fever was imported into England and Scotland by Irish labourers, who go over in such numbers every year to reap the harvest. But from the statistical reports of Dr. Cowan and others, it appears that, as regards Scotland, this explanation is any thing but satis- factory, and it seems more probable that the west of England, Scotland, and Ireland, in which the climate is almost the same, possess the same combinations of circumstances which produce typhus. Nothing, indeed, can be more remarkable than the facility with which a simple cold (which in England would be perfectly devoid of danger) runs into maculated fever in Ireland, and that, too, under circumstances quite free from even the suspicion of contagion—in truth, except when fever is epidemic, catching cold is its most usual cause. Much has been said and written about epidemics among cattle being simultaneous with human epidemics, and we have the testimonies of Homer and Herodotus in support of the popular belief. I am qiite sure that various diseases, such as ague, remittent and bilious fever, &c. &c, may be brought on by miasmata, which, emanating from the earth, may likewise produce epidemics among cattle. Mr. Chadwick's work contains the following striking statement:— " In the course of inquiries as to what have been the effects of land drainage upon health, one frequent piece of information received has been that the rural population had not observed the effects on their own health, but they had marked the effects of drainage on the health and irnprove- ment of the stock. Thus the less frequent losses of stock from epidemics are beginning to be perceived as accompanying the benefits of drainage in addition to those of increased vegetable production." Dr. Edward Harrison, in a paper in which he points out the connection between the rot in sheep and other animals, and some important disorders in the human constitution, observes :— " The connection between humidity and the rot is universally admitted, by experienced graziers; and it is a matter of observation, that since the brooks and rivulets in the county of Lincoln have been better managed, and the system of laying ground dry, by open ditches and under-draining, has been more judiciously practised, the rot is become far less prevalent. * Dublin Medical Journal, vol. x. 56 ON CLINICAL INSTRUCTION. Sir John Pringle informs us, that persons have maintained themselves in good health, during sickly seasons, by inhabiting the upper stories of their houses ; and I have reason to believe that, merely by confining sheep on high grounds through the night, they have escaped the rot." " The late Mr. Bakewell was of opinion that, after May-day, he could communicate the rot at pleasure, by flooding, and afterwards stocking his closes, while they were drenched and saturated with moisture." The sanatary effects of road-cleansing, to which house-drainage and road-drainage are auxiliary, it appears is not confined to the streets in towns and the roads in villages, but extends over the roads at a distance from habitations on which there is traffic. Dr. Harrison, whose testimony has been cited on the subject of the analogy of the diseases of animals to those which affect the human constitution, in treating of the prevention of fever or the rot among sheep, warns the shepherd that, if after providing drained pasture and avoiding " rotting-places" in the fields, all his care may be frustrated if he do not avoid, with equal care, leading the sheep over wet and miry roads with stagnant ditches, which are as pernicious as the places in the fields designated as " rotting-places." He is solicit- ous to impress the fact, that the rot, i. e. the typhus fever, has been con- tracted in ten minutes, that sheep can at " any time be tainted in a quar- ter of an hour, while the land retains its moisture and the weather is hot and sultry." He gives the following instance, amongst others, of the danger of traversing badly-drained roads. " A gentleman removed ninety sheep from a considerable distance to his own residence. On coming near to abridge which is thrown over the Barling's river, one of the drove fell into a ditch and fractured its leg. The shepherd immediately took it in his arms to a neighbouring house and set the limb. During this time, which did not occupy more than one hour, the remainder were left to graze in the ditches and lane. The flock were then driven home, and a month afterwards the other sheep joined its companions. The shepherd soon discovered that all had contracted the rot except the lame sheep ; and as they were never separated on any other occasion, it is reasonable to conclude that the disorder was acquired by feeding in the road and ditch bottoms." The precautions applicable to the sheep and cattle will be deemed equally applicable to the labouring population who traverse such roads. With reference to this question I may remark, that althouo-h I have carefully watched the progress of fever in Ireland for more than°quarter of a century, I have not been able distinctly to connect its epidemics with any epizootic disease,—true it is, that occasionally typhus fever is prevalent at a time that some fatal epidemic affects horned cattle, pigs, and sheep and from such an occurrence an incautious reasoner might be led to assume a natural connexion between the two epidemics as both proceeding from one cause ; a more protracted series of observations will, however ^dispel this illusion, for he will then see that the connexion is only accidental— of this the years 1841 and 1812, afforded a remarkable example • for dur- ing both the cattle of Ireland were decimated by a most malignant epi- zootic, while during the same period I never recollect a greater immunitv from typhus ; in fact, the wards of the Meath Hospital were often destitute of a single specimen of that disease. I have already stated that when a person gets a feverish cold in Ireland it is more apt to pass into continued fever than it is in England • this is especially the case when fever prevails as an epidemic, in which case the FEVER. 57 transition into fever takes place on account of one or other of the follow- ing causes: First—the patient had been exposed to contagion, whose effects might never have become perceptible, had not his constitution been assailed by the feverish cold. Secondly ; in many cases there has been no previous exposure to contagion, and yet a feverish cold will finally determine the breaking out of fever, no doubt under the action of the pre- vailing epidemic influence. Thirdly, individuals who are debilitated by excesses, night watching, and bodily fatigue, are of all others the most liable to slide from feverish cold into fever; if in addition to these causes, mental anxiety, or intellectual labour have been harassing the individual, the fever generally assumes a most dangerous form, being attended with want of sleep, raving, and early, often violent delirium. The well-known fact that several had sickened on the spot on smelling the effluvia from a patient's person or evacuations, has led to the suppo- sition that the contagion of fever influences the system through the nerves, and in support of this opinion many refer to Prussic acid, which, they say, kills by its action on the nerves, and before it has been absorbed. Another class of inquirers assert that the blood is the seat of the first morbid change, and with equal confidence refer to the action of vegetable poisons, which they assert never produce any effect on the system, until they enter the circulation.* In the present state of our knowledge it is quite impossible to determine in what manner the poison acts, and, hap- pily, it is equally unimportant. This much is certain, that changes in the nature of the secretions, as in the sweat, sputa, mucus of the tongue, feces, and urine, take place simultaneously with changes in the blood, and they are all the result of some common unknown cause. Of course once the blood is changed, the secretions become more rapidly altered, and when the secretions are changed, the blood is more quickly deteriorated ; but the knowledge we thus obtain leads to no satisfactory explanation or practical result. Lately the investigations of chemists respecting the composition of the blood in fever and other diseases, have excited hopes that we are on the eve of discovering some more secure basis for our practice, founded on the analysis of that fluid. I must confess, that however I applaud these efforts of science, I entertain no hopes that they will be followed by the expected beneficial consequences ; for, except the good effected in dia- betes mellitus, by diminishing the quantity of starch in the bread such patients eat, and the advantage derived from medicines and articles of diet, in certain derangements of the urinary functions, such as the phos- phatic and lithic diatheses ; except in these instances, I know of no im- provement in practice for which we are indebted to chemistry ; and even here the result was obtained not by an examination of living, but of secreted fluids ; and, in truth, it is vain to look for remedies founded on chemical principles, when these principles cannot even approximate to affording us an explanation of the mode of action of our best established medicines. When chemistry reveals why tartar emetic vomits, jalap purges, or opium causes sleep—when chemistry detects palpable changes in the blood produced by these remedies—then we may begin to hope that this science can conduct us still further, and may even, by disclosing the morbid changes which the blood undergoes in disease, become useful * Blake's Experiments, Baley's Elements of Physiology, vol. i., page 246, quoted by Dr. Hudson, vide "Med. C/iir. Review" April, 1841. 58 ON CLINICAL INSTRUCTION. to us in searching for remedies capable of counteracting and even prevent- ing these changes. The different theories of fever, as they have been called, have much and often injuriously affected practice. The speculations of Brown, Cullen, Clutterbuck, Broussais, Rasori, Armstrong, and our Indian physicians, have successively introduced the stimulant, diaphoretic, general antiphlo- gistic, leeching, tartar emetic, mercurial plans, each of which has in its turn been pushed to a most deleterious excess. For my own part, I have long abandoned every hope of being able to frame any satisfactory theory of fever, and confine myself altogether to a diligent study of its symptoms, watching how they are grouped, and in what order they follow each other, and observing closely the effects of treatment on their progress ; and in my choice of remedies I am guided either by experience, or an analogy derived from the action of medicines, in other diseases which present the greatest similarity to the complications that occur in fever. Fever in this island exhibits a great variety of character, and even during the same epidemic remarkable differences are observable, as ap- pears from the subjoined summary, taken from Cheyne and Barker's valua- ble wrork on fever—vol. i., p. 431:— " Delirium ferox was observed in Limerick, and other symptoms indi- cating a determination of blood to the head, namely, hemorrhage from the nose, which, in some instances, took place to a very considerable extent. " As to the organs chiefly affected in the progress of the disease, some variety seemed to exist. In most instances the brain has been reported as the organ which suffered chiefly. In some instances, as at Ennis, the lungs were not all affected, during the early periods of this epidemic fever ; but in other places the lungs next to the brain principally suffered ; this was observed in Listowel. The same remark was made at Tralee, and Dr. Bishop observed at Kinsale, that the lungs were frequently affected in children. At Ennis it was noticed as a peculiarity in the fever, that pro- fuse perspiration occurred in its earlier stages without any relief to the patient ; and it was remarked at Waterford, as stated in the report at page 251, that copious perspiration often afforded no relief. Yellowness of the skin and tunica adnata of the eyes, was frequently noticed at Cork. The head and biliary system were more than usually affected. " As the disease advanced, it was observed in most or all parts of the province, that eruptions of different kinds, either closely allied to, or varieties of, those termed petechial, very generally accompanied it. In some instances the eruption was papular, or a motley appearance of the skin, or a rash somewhat resembling the measles showed itself. At Cork, Dr. M. Barry remarked that in the species of fever wThich he termed syno- chus, petechia^ seldom occurred earlier than the fourth or fifth day ; but his observation, if it does not express it directly, at least implies that their occurrence was frequent. They were generally of a bright red colour, some- times small, at other times large. He did not consider them dangerous nor find it necessary to abstain from those measures of depletion which were useful when high excitement prevailed. In a communication from Clonmel, Dr. Fitzgerald states, that petechia? occurred in four cases out of five. At Fermoy, petechia? appeared very generally among the poor. At Kinsale, a red rash, we believe of the kind above mentioned as re- sembling that of the measles, was common, and petechia? were more in- clined to red than brown in that neighbourhood. At Listowel, petechia? FEVER. 59 were so common, that Dr. O'Connel did not see six cases of fever unat- tended by a petechial eruption, which often appeared early in the disease. The frequency of petechia? was noticed also at Waterford, as well as of the eruption resembling measles already mentioned. The frequency of an eruption resembling measles was noticed at Bandon by Dr. Clarke and Dr. Jenkins. At Clonmel petechia? were common even amongst children, in whose cases this eruption was not indicative of peculiar danger, but on the contrary, often attended a mild disease. It was observed in the neighbourhood of Tramore, and we believe the same to have happened in every part of Ireland, that one member of a family had petechia? and aggravated symptoms of typhus, whilst the relatives in the same room had fever in the mildest form. In many instances, particularly in the more advanced stages of the epidemic, the lungs were observed to suffer, as at Fermoy,Listowel, and Mallow, according to the authorities already quoted ; but both at Cork and at Ennis, places very remote from each other in this province, the lungs, at least at the commencement of its epidemic progress, were but rarely affected in this fever. " As the epidemic advanced, gastric symptoms were observed, and mention has been already made of dysentery, which, in many parts of Munster, kept pace with fever. Dr. Grogan, of Limerick, remarked, that pains resembling those of rheumatism were common ; and he also noticed a symptom, which there is reason to believe was not unfrequent in most parts of Ireland, namely, that the tongue, which in most febrile diseases is white or altered in colour and other appearances, in many cases exhi- bited no morbid change, and remained moist and clean during a great part of the disease. From the same authority we learn that increased heat of surface, which is generally considered peculiarly characteristic of fever, was, in many instances at Limerick, altogether wanting ; this absence of the usual febrile heat is observed in the worst kinds of fever." Farther on, the report states that, " Dr. Milner Barry, of Cork, in his account of the fever in that city, relates that the disease presented itself under different forms, which he arranges under the following heads :—1. Synochus ; 2. S. Cephalica ; 3. S. Pulmonica ; 4. S. Hepatica ; 5. S. Gas- trica; 6. S. Enterica ; 7. Typhus gravior ; 8. Typhus Mitior; 9. Febri- cula. From the arrangement which Dr. Barry here adopts it is evident that a determination to particular organs was at Cork, as at other places, of frequent occurrence." For more than twenty years I have in my lectures advocated the doctrine, that morbid anatomy had not served to reveal the cause of fever, which I looked upon to be an essential disease; or to use the words of Fordyce, " Fever is a disease which affects the whole system; it affects the head, trunk, and extremities; it affects the circulation, absorption, and the nervous system; it affects the body, and it affects the mind; it is therefore a disease of the whole system, in the fullest sense of the term. It does not, however, affect the va- rious parts of the system uniformly and equally, but, on the contrary, some- times one part is more affected than another." "This excellent view of fever seems to be borne out completely by modern pathology, and parti- cularly the last part, where he says, that in cases of fever one part is more affected than another. We have, for instance, cerebral fevers, nervous, bilious, gastric, and catarrhal fevers, by which, it is to be observed, we do not mean to imply that there is nothing more than simple disease of the brain, or nerves, or liver, or bowels, or respiratory system, but that in each 60 ON CLINICAL INSTRUCTION. of these fevers disease predominates in some particular part. So that when we speak of these fevers, we speak of such a fever as Fordyce has de- scribed, in which one part of the body is affected more than the rest.'" I am happy to find that the views I have so long entertained in oppo- sition to the great majority of writers both in Britain and on the Conti- nent, are now generally acknowledged to be correct, as will appear by the following passage taken from the able essay on continued fever by Dr. Christison in the " Library of Medicine." "Anatomical characters of continued fever.—The pathological anatomy of continued fever remained, until lately, in a very crude and unsatisfactory condition. But no other topic has attracted so much attention during the last five-and-twenty years, or has been investigated with more success, so far as the accumulation of facts goes. Whether the result has been hitherto beneficial in reference either to pathological doctrine or medical practice, is a question which admits of some doubt. A very great variety of mor- bid appearances have been indicated as occurring in fever. Of these many are plainly incidental, because they do not by any means present themselves regularly, others, however, have been held to be invariable ; and consequently authors have sought for the nature and essence of fever, in the local morbid action which gives rise to such appearances. On taking into account the general result of the observations of all patholo- gists of credit, it seems impossible to avoid the conclusions, that no mor- bid appearance is invariable except congestion of internal organs ; that every other pathological fact which has been observed is not constant and is therefore the effect of a secondary disease ; and that, in all the obser- vations hitherto made on the pathological anatomy of fever, we must be content with discovering its consequences, not its causes. The information which has been amassed is important in a practical point of view, as turn- ing the attention of practitioners to the necessity of studying and treating these secondary affections, which in various circumstances are the occa- sion of suffering, danger or death. But it does not seem to throw much light on the real essence of fever, and by being rashly assumed to furnish that light, it has led to grave, theoretical and practical, errors." In fact, gentlemen, the knowledge we possess of the pathology of typhus fever, is of a negative character. Pathology teaches us what typhus is not, rather than what it is ; it shows us that it is neither cerebritis, meningitis, pneumonia, pleurisy, gastritis, or enteritis, for it may exist without any of these, and they may exist without typhus fever ; but it also shows that one or other of these lesions frequently arises in the course of that fever, and these require special attention. It is difficult to classify the different varieties of fever that are observed in this city. The following are the most remarkable of the distinct varie- ties that have come under my notice :— 1st, Simple continued fever, without macula?, or any notable determi- nation to particular organs. 2d, Continued fever, without macula?, with determination to some organ. 3d, Continued fever, with macula?. 4th Continued fever, accompanied/?*omMe very beginning with gastric derange- ment, and epigastric tenderness. 5th, The last-mentioned species, but in a more intense form, having black vomit and yellowness of the skin superadded. 6th, Continued fever, with petechia?. * Stokes's Practice of Physic (American Edition, page 409). FEVER. 61 I have observed each of these varieties of fever constituting epidemics, which lasted for longer or shorter periods ; but with us the dominant type of epidemics is the maculated. This species, too, confers more immu- nity upon the sufferers than any variety of fever, and in this respect, as well as in its well-marked eruption, it approaches in character to the exanthemata ; like the exanthemata, too, this species of fever seems to be the most contagious. Concerning contagion, the physicians of Ireland and Scotland are nearly agreed in attributing that quality to fever. The fever wards of the Meath Hospital are by no means crowded, and are both well ventilated and cleanly, while the building itself is placed in the most salubrious part of the vicinity of Dublin, being built upon the site of Dean Swift's garden ; and yet it almost invariably happens, that when a patient, labouring under any other acute disease, or any chronic disease, is admit- ted into a fever wTard, he gets fever in the course of a fortnight, or even sooner. This happens the more surely if the patient is placed in the immediate vicinity of a maculated case. Among the pupils who attend the hospital, the greater number are sooner or later attacked by fever ; and the same is true of the porters, laundry-maids, and nurses. I have great pleasure in recommending Dr. Christison's observations on this subject, and shall here quote briefly some of the arguments ad- vanced by him in support of the contagious nature of the disease. In the first place he says, that in districts thinly inhabited, fever is generally very rare, whereas in large towns, where numbers of people are living in a crowded state, typhus fever is never absent. When it becomes epi- demic in a large town, it never bursts forth with impetuosity, like the diseases of undoubted miasmatic origin; but extends gradually, and always the more slowly the larger the city, so that many months may elapse be- fore it reaches its full height. It then begins to decline, retires as gradu- ally as it commenced, and finally resumes its natural condition, affecting only a few individuals here and there, and at distant intervals. At the commencement of an epidemic, fever is found to spread at first, not by scattered unconnected cases occurring at a distance from one an- other, but by slow degrees around one or more invalid localities as foci ; first creeping from one individual to another of a family, then from family to family, according to their proximity, relationship, or general intercourse, and at length to the surrounding population promiscuously. But a further argument of very great weight may be drawn even from the very violations of this general rule. For sometimes the disea>e is seen suddenly to arise, and gradually to spread in parts of a town where it had not previously existed ; and this in concurrence with the arrival of the disease by importation from a previously invaded locality. " Another argument, more powerful perhaps than any other, and upon which alone the doctrine of the communicability (Dr. C. uses this word in preference to contagion or infection) of fever might be rested, is, that in circumscribed localities, inhabited by crowded bodies of men, fever is observed invariably to spread among the healthy, when it is introduced to a great extent from without, but never materially at any other time. This is a general mode of expressing the history of such institutions as infirmaries and fever hospitals. During the last twenty years the Infirmary of Edinburgh has been the receptacle of a large proportion of fever cases in three epidemics, which have lasted between three and 62 ON CLINICAL INSTRUCTION. four years ; and there have been two intervals varying from three to five years in duration. During the intervals, when fever cases from without were few, fevers originating within the hospital were extremely rare among any classes of individuals attached to its service. But during the prevalence of the several epidemics fever abounded in every department of its service : physicians, clinical clerks, general servants, nurses, washer- women, apothecary's assistants, all suffered more or less, and some to an excessive degree. The same facts were observed even more remarkably in an institution which was, during the same interval, occasionally occu- pied as a fever hospital. In these epidemics it was made use of for this purpose ; and at various periods during the last twenty-five years, it has also been occupied, when fever did not prevail epidemically in the city, by crowded bodies of men, first by soldiers as a barrack, then as a retreat for some hundreds of poor people, who were turned out of their houses in winter by an extensive fire, next as a quarantine house during the preva- lence of cholera, and for some years past, during the worst epidemic of fever which has yet prevailed in the city, it has been occupied by about 300 of the very lowest of the community, namely, as a house of refuge for vagrants and other persons. Now, on each occasion, when it was occupied as a fever hospital, the people on service in the institution suf- fered to an extraordinary degree, scarcely a single individual escaping an attack, who remained a moderate length of time in it. But on other occasions, fever was either absolutely unknown, or the cases were rare and distant, and easily referable to the particular manner of life of the individuals composing the population of the establishment. It is also worthy of notice, in reference to both chains of facts here mentioned, that neither around the infirmary, nor around the late fever hospital, did fever ever prevail to any material extent during any of its epidemic visitations." It is unnecessary to allude to the many instances of fever occurringamongst nurses, porters, and clinical clerks in different fever hospitals, which strongly bear out the view that typhus fever is eminently contagious. Another interesting point connected with the contagion of fever has lately been inquired into, viz., to determine the particular period of the disease when this character is most remarkable. Dr. Perry, of Glasgow, was the first, I believe, who advanced the opi- nion that the stage of convalescence was the most infectious in typhus fever. He considers typhus fever as a true exanthema. He says, " I have some years entertained the opinion, founded upon an extensive series of observations, that contagious typhus is an exanthematous disease, and is subject to all the laws of the other exanthemata ; that, as a general rule, it is only taken once in a life-time, and that a second attack of typhus does not occur more frequently than a second attack of small-pox, and judging from my own experience, less frequently than a second attack of measles or scarlet fever." From numerous observations and experiments I am satisfied that it is not contagious before the ninth day, perhaps not till after a later period of the disease. Among many circumstances which establish this opinion, I may mention one experiment which I made upon a pretty extensive scale. The fever wards of the Glasgow Royal Infirmary are each capable of con- taining twenty patients. The beds are arranged in two opposite rows and are pretty near each other. While the patients are in the acute wards' they are not allowed the use of their clothes, though they may be able to FEVER. 63 sit up ; they are, therefore, almost constantly confined to bed, except when rising to stool; and there is about one close stool to every three patients. Into the fever-house are admitted cases of measles, scarlet fever, and small- pox : and patients are very frequently sent in labouring under bronchitis, pneumonia, erysipelas, and other local inflammatory -affections. I found by experience, that when the latter class of patients were sent to the con- valescent ward, where they necessarily mixed with the others, almost all of those who had not a previous attack of typhus fever were either seized with it before leaving the house, or returned soon after their dismissal labouring under it; the period intervening between the time of their being sent to the convalescent ward, and the attack, never being less than eight days. Although means were taken to keep those recovering from small- pox, scarlatina, &c, in a separate room from those convalescent from typhus, the rooms being adjoining the non-intercourse was incomplete, and the result was, that these diseases occasionally spread among the typhus convalescents, and the convalescents from small-pox and scarla- tina caught typhus. In consequence of these observations, I adopted the practice of not sending, as formerly, to the convalescent wards, those patients affected with inflammatory diseases, unless I ascertained that they were secured against the disease by having had a previous attack of typhus ; but kept them in the acute fever wards till they were so far recovered as to go to their own houses, and the result was (and the prac- tice was continued for several months), that not one of those detained in the acute wards caught the disease while there, or returned with it after- wards. From the above and other observations, I have adopted the opi- nion, that typhus, like measles, small-pox, &c, is chiefly spread during the period of convalescence. In the paper already noticed, I have men- tioned the desquamation of the cuticle, which usually takes place when a patient is convalescent from typhus. Do the fine scales thrown off in this state contain the poison which, by adhering to the clothes and hair of the patient, are carried about with him, and being rubbed off are, while float- ing in the atmosphere, applied to the mucous surface, or inhaled by a sus- ceptible recipient, in whom it produces, after a certain time, the specific disease ?* I shall now, in pursuance of my intention, proceed to speak of the treat- ment of fever. I may observe here, that we are now at a point of time possessing no common interest for the reflection of medical observers, t It is now nearly two years since my attention was first arrested by the appear- ance of maculated fever, of which the first examples were observed in some hospital patients from the neighbourhood of Kingstown. This form of fever has lasted ever since, prevailing universally, as if it had banished all other forms of fever, and being almost the only type noticed in our wards. Within the last four days, however, a change appears to have taken place. Scarcely any cases of maculated fever have been admitted within the last fortnight, and the majority of fever patients at present under treatment are free from cutaneous eruption, so frequently observed during the last two years. The cases which we have recently admitted present no spots, or macula?, and have been termed, perhaps improperly, simple typhoid fever. And here permit me to observe, that it would be very wrong to conclude, from this circumstance, that our recent cases are of a more favourable de- * Dublin Medical Journal, vol. x. f This lecture was delivered at the beginning of the session 1836-7. 64 ON CLINICAL INSTRUCTION. scription than those which preceded them ; the disease, it is true, appears to have lost a character which is always looked upon as bad and unfavour- able, but it may be just as dangerous a modification of fever as the erup- tive typhus. During the predominance of the latter form, all cases with- out macula? were in general simple and free from danger: but it is proba- ble that this is not the case at present. There are two cases of this non- maculated typhus in the female ward, which are of an extremely doubtful character, and in which ifwould be difficult to predict the result. Indeed, were I to make any prognosis, I should say that the chances, if not against them, are at least very fairly balanced. Now, gentlemen, as it appears we have come to a change, and that we may have to treat a new modification of fever, it behooves us to be ex- tremely vigilant. I invite you to watch and study, with the closest atten- tion, the cases of fever which come before you. Let us, in the first place, endeavour to ascertain whether we have seen the close of one epidemic, and are now at the commencement of another. The number of cases of simple typhoid fever have, you perceive, increased in a very remarkable manner, and the number of cases of eruptive typhus have become remark- ably scarce. But there is another and a more important reason why we should study these cases with all due diligence and attention. They may be the first examples of a new epidemic, and every new epidemic, as it has its peculiar characters, so has it its peculiar treatment. We cannot fol- low the same track which we have pursued for the last two years—we cannot apply our remedies with the confidence of experience—we must now strike into a new path, and for some time our practice must be ten- tative and experimental. It was only after a good deal of experimental observation that we were able to arrive at a plan of treatment adapted to meet the exigencies of the maculated form of fever : and it is very probable that this new fever may prove at first extremely difficult to manage ; and it maybe some time before the diminished rate of mortality will show that we have at length discovered its true character, and the remedies best cal- culated to arrest its progress. Let me now direct your attention to some practical points connected with the treatment of the maculated fever which has prevailed for the last two years, and which has spread to a very considerable extent in this city and its environs, attacking alike the upper, middle, and lower classes of society. It is not my intention to enter into a detailed history of the origin and progress of this fever, its varieties, symptoms, and pathological pheno- mena ; my purpose is to furnish you with a brief but comprehensive out- line of its treatment, and of the remedies which have been found most suc- cessful in its removal, as well as the most appropriate time and mode of their application. Having made these general observations, I may observe, in addition, that in the whole range of human maladies there is no disease of such sur- passing interest and importance as fever; and I cannot dwell too much on the necessity of your applying most attentively to the study of its pathology and treatment. If you compare the mortality from fever with that result- ing from any other disease in this country, you will be struck with the overwhelming fatality of this affection, and will readily admit the inesti- mable value of a thorough knowledge of its nature and treatment. Re- collect, too, that fever is a disease which numbers among its victims per- sons chiefly in the prime of life, and during the most active and useful FEVER. 65 i stage of existence,—fathers and mothers, persons who are the ornament or the stay and support of their families, the intellectual, the industrious, the efficient,—those whose lives are most valuable to their friends and to so- ciety. This gives an additional interest to the study of fever, and should stimulate you to endeavour to arrive at a correct knowledge of its nature and treatment. And here let me observe, that there is nothing more un- true than the assertion, that the treatment of fever is a matter of indiffe- rence. It has been the custom to look upon every plan of treating fever as idle and absurd, and until very lately there were many persons in this country who believed that patients recovered not from having had the ad- vantage of treatment, but from goodness of constitution or some favourable accident; and it was usual with such persons to appeal to the experience of Dr. Rutty, who, in recording the history of the epidemics of his own time (1741), observes, " the poor abandoned to the use of whey and God's good providence recovered, while those who had generous cordials and great plenty of sack, perished." And, indeed, I must admit that the treatment of some of the cases of fever which I witnessed when a student, would seem to justify the quaint and sarcastic observation of Dr. Rutty. At that period, whether it was from bad treatment, or from w-hat has been termed the nimia diligeniia medici, it is a fact that the maximum of mortality was among the rich, and that those who were most attended to, died most speedily. In the epidemics of 1816, 1817,1818, and 1819, it was found by accurate computation, that the rate of mortality was much higher among the rich than among the poor.* This was a startling fact, and a thousand different explanations of it were given at the time; but I am inclined to think that the true explanation was, that the poor did not get so much medicine, and that in them the vis medicatrix had more fair play.f I could appeal to the practice of those times in proof of this opinion, and as we go along I shall have an opportunity of alluding to this part of the subject again, and contrasting the practice of the present day with that which was generally followed thirty years ago. If you look to Dr. Cheyne and Dr. Barker's Synopsis of the plan of treatment employed by the physicians of those days, you will be prepared, from a mere inspection of it, to admit that it was at least as hard to escape the physician as the disease. Since that period our practice has greatly improved, and things are much changed ; the preponderance of fatal cases is now to be. found among the poor, and the mortality among the rich, or those who have proper medical advice from the commencement, is not one-third of that which is found among the indigent, who are generally neglected at the commencement of the disease. I am therefore fully prepared to deny that, in the present state of medical knowledge, our practice is a matter of indifference; on the contrary, there is no disease in which diligent attention and skilful treatment are more frequently successful than in fever,, nor is there any * " The rich are less frequently affected with epidemic fevers than the poor, but more fre- quently die of them. Good fare keeps off diseases, but increases their mortality when they take place."—Fletcher's Pathology, p. 27. j- " Un the whole the mildest and simplest treatment seems to he the most generally suc- cessful, and the result of a certain Lady bountiful's practice forms its best commentary. She begins with an antinionial emetic ; the patient is washed every morning with soap and water, gets every second day half an ounce of sulphate of magnesia, on the seventh day a blister to the neck, and if necessary some diluted wine, this seldom and sparingly ; of 120 in fever, treated after this mechanical plan, not one died."—Cheyne and Barker's- Report, p. 444* 6 66 ON CLINICAL INSTRUCTION. affection of equal importance in which our therapeutic means are more efficient and valuable. Now, when called on to treat a case of fever, there are several things which require your attention. In the first place, you should examine the state of the family arrangements. This is a matter which men are apt to overlook or treat as a matter of indifference, but in my mind it is of no ordi- nary importance, and should always be attended to. You should never, if possible, undertake the treatment of a case of fever where the friends or re- lations of the patient supply the place of a regular fever nurse. The mis- taken tenderness of relatives, and their want of due firmness, presence of mind, and experience, will frequently counteract your exertions and mar your best efforts. Affection and sorrow cloud the judgment, and hence.it is that very few medical men ever undertake the treatment of dangerous illness in the members of their own families. The sympathy which a nurse should have for her patient should be grounded on a general anxiety to serve, and a strict sense of duty, as well as a laudable desire of increasing her own reputation ; it is, in fact, a sympathy analogous to that which should actuate a physician. Again, it will not do to have a nurse who has been usually employed in other diseases ; your assistant must be a regular fever nurse, and the man who undertakes the treatment of a long and dangerous case of fever without such an assistant, will often have cause to regret it. I could mention to you many cases illustrative of the truth of this assertion. I could tell you, that where I have permitted the con- tinuance of the services of one of the family, or of a common nurse, I have been almost invariably annoyed and disappointed. I now make it a general rule to refuse attending any dangerous and protracted case of fever with- out a properly qualified nurse. In the next place, when treating a case of bad typhus, do not think that it will be sufficient to see your patient once a-day. But you will say, perhaps, that our hospital patients here do very well, and yet they are visited only once in the twenty-four hours. True—but then we have experienced nurses to look after them at all hours; we have the valuable surveillance of our apothecary, Mr. Parr; we have the attendance of the resident pupils, and of the gentlemen who take charge of the cases. You see then that they do not depend on a solitary visit. How often has Mr. Parr, or the resident pupil, found it necessary to change the treatment adopted at the morning visit ? How often have the remedies of which we had only given a hint in the morning, been actively and energetically employed before the close of the day ; and how often have lives been saved by the valuable attentions to which I have just alluded ? No one should attend a case of fever without having proper medical assistants. My practice, in general, is to visit my fever patients two or three times a- day ; and, when I have a bad or a dangerous case to manage, I always have a competent medical assistant to stay by the patient and watch every change of his malady. I do not know how they manage this matter else- where, but in this city we have so many zealous, intelligent students, so many young medical friends, and so many well-educated apothecaries, that we are never at a loss for an assistant. This fact is, I think, a sufficient answer to the objections put forward by Dr. Johnson, in the last number of the Medico-Chirurgical Review. He says that tartar emetic is a two- edged sword—an agent powerful alike for good or evil, and in the admin- istration of which no ordinary circumspection is demanded. All this I FEVER. 67 am willing to admit; there is no remedy capable of producing more mis- chief when abused, but when properly watched it is, I am confident, the means of saving many valuable lives. He says, also, that Dr. Graves cannot give that share of attention to his patients which the employment of such a remedy demands. He is quite mistaken on this point. I am never at a loss for some skilful person to remain with the patient, watch the operation of each dose, and modify or change it according to circum- stances. The want of proper assistants may be elsewhere an objection to the administration of tartar emetic, but this objection does not hold good with respect to Dublin. One or two more observations of a general nature. Some persons have such a terror of foul air, in cases of fever, that you will find all the windows in the house thrown open, not even excepting those of the patient's bed- chamber, and wherever you turn you are sure to meet with a current of air. Now, this is an unnecessary practice, likely to entail disease on the family and local inflammation on the patient. The bed-room of a patient labouring under fever should be well aired, but without what is termed thorough air ; and it should, if possible, be a quiet back room, away from the street. In the next place, it should be sufficiently large to hold two bedsteads conveniently ; and you should order the attend- ants to have two well-aired beds in readiness, from one of which the patient should be changed to the other every twelve or twenty-four hours. You can scarcely have an idea of the comfort this affords to a person in fever. The room can be kept properly ventilated by a fire, and the temperature can be regulated by a thermometer. Some persons are in the habit of constantly sprinkling the room with vinegar—others with the chlorides. I do not know that it is necessary, and I think the use of chlorine is doubtful, if not improper, and may prove injurious to the patient. Having made these few general observations on the steps to be taken by those who enter on the treatment of typhus, I shall now proceed to speak of diet and medicines. In a disease like fever, which lasts fre- quently for fourteen, twenty-one, or more days, the consideration of diet and nutriment is a matter of importance, and I am persuaded that this is a point on which much error has prevailed. I am convinced that the starving system has, in many instances, been carried to a dangerous excess, and that many persons have fallen victims to prolonged abstinence in fever. This was one of the errors which sprung from the doctrines of those who maintained that fever depended on general or topical inflam- mation. They supposed that fever arose from inflammation, and imme- diately concluded that, to treat it successfully, it was necessary to reduce the system by depletion and low diet, and to keep it at this point during the whole course of the disease. Hence the strict regimen—the diete absolue—of the disciples of the physiological school, and of those who looked on inflammation as the essence of fever. The more the symptoms appeared indicative of inflammatory action, the more rigorous was the abstinence enforced. If a patient's face was flushed, or his eyes suffused, no matter what the stage of the fever was, they said, " here is inflamma- tion of the brain, and nourishment will exasperate it." If he had red or dry tongue, and abdominal tenderness, they immediately inferred the existence of gastro-enteritis, and all kinds of food, even the lightest, were strictly forbidden. That this proceeds from false notions on the nature of 68 ON CLINICAL INSTRUCTION. fever is beyond doubt, and I pointed out this fact many years ago, long before the appearance of Piorry's work. Let us, in the first place, examine the results of protracted abstinence in the healthy state of the system. Take a healthy person and deprive him of food, and what is the conse- quence ? First, hunger, which after some time goes away, and then returns again. After two or three days the sensation assumes a morbid character, and instead of being a simple feeling of want and a desire for food, it becomes a disordered craving, attended with dragging pain in the stomach, burning thirst, and some time afterwards, epigastric tender- ness, fever and delirium. Here we have the supervention of gastric disease, and inflammation of the brain as the results of protracted starva- tion. Now, these are in themselves very singular facts, and well deserv- ing of being held in memory. Read the accounts of those who perished from starvation after the wreck of the Medusa and the Alceste, and you will be struck with the horrible consequences of protracted hunger. You will find that most of the unhappy sufferers were raging maniacs, and ex- hibited symptoms of violent cerebral irritation. Now, in a patient labouring under the effects of fever and protracted abstinence—whose sensibilities are blunted, and whose functions are deranged—it is not at all improbable that such a person, perhaps also suffering from delirium or stupor, will not call for food, though requiring it; and that if you do not press it on him, and give it as medicine, symptoms like those which arise from starvation in the healthy subject may supervene, and you may have gastro-enteric inflammation, or cerebral disease, as the consequence of protracted absti- nence. You may, perhaps, think that it is unnecessary to give food, as the patient appears to have no appetite and does not care for it. You might as well think of allowing the urine to accumulate in the bladder, because the patient feels no desire to pass it. You are called on to inter- fere where the sensibility is impaired, and the natural appetite is dormant; and you are not to permit your patient to encounter the horrible conse- quences of inanition, because he does not ask for nutriment. I never do so. Alter the third or fourth day of fever, I always prescribe mild nourishment, and this is steadily and perseveringly continued through the whole course of the disease.* * In the preceding lecture frequent mention has been made of petechial fevers, particularly in the passage cited from Cheyne and barker's woik, respecting the fever of 1816 and 18)7 ; and, in compliance with the generally received opinions, 1 have set down this fever as a dis- tinct species. 1 must acknowledge, however, that I myself have never seen petechial fever epidemic in Ireland. I was clinical clerk at ir-Mr Patrick Dun's Hospital during the great epi- demic of 1816 and 1817. The eruption consisted of macula?, somewhat resembling measles, frequently dark and livid in bud cases ; but except in a very few instances indeed there were no true petechia?. In 1822 1 had the charge of a large district in the town of Galway, when fever was committing great ravages; then too the eruption was maculated. I cannot account for so many witnesses testifying the contrary to this statement, except by supposing them to have been misled by appearances ; for it must be confessed that although true petechia: are rare, truejtea-bites are common in Ireland. Most observers, too, seem to have been very inac- curate in their phraseology, as is evident from the above quotation from (J hey ne's work. Dr. Barry plainly uses the word petechix very loosely—" They were generally of a bright red colour, sometimes small, at other times large." Surely this is quite descriptive of macula?, but totally inapplicable to petechia?; and the same may be said of the other observers, most of whom, I verily believe, overlooked the true eruption, and noted down flea-bites as petechia? ! Connected with the question first raised by Dr. Perry, whether maculated typhus should be considered as an exanthema, the fact is deserving of notice, that children exhibit the eruption much less frequently than adults, although they are quite as liable to the fever, when it is epidemic. This fact is the more remarkable, because in measles, scarlatina, &c, the true exan- themata, the eruption is more constant in children than in adults. FEVER. 69 LECTURE V. General treatment of fever—Dietetic management—The starvation system may produce organic disease—Proper food for fever patients and convalescents—Allaying of thirst—Sedatives— Expergefacients—Efficacy of green tea in a case of narcotism—Flagellation effectual in a case of poisoning with opium. At my last lecture I spoke of some preparatory steps which should be taken before you enter on the treatment of a case of fever. I stated that one of the most essential requisites was a good nurse ; that you can readily find persons to undertake this office in every family, but that it is rare to meet with any individual among the patient's relatives properly qualified to discharge so important a duty. There is a vast difference between readi- ness to undertake and ability to perform. Some persons are always a-doing, but never do right; always attempting but never successful. There are many nurses who are extremely attentive, but inexpert and injudicious, and their ill-judged attentions are frequently prejudicial to the patient. A fever nurse has a vast deal in her power ; if an enema is to be administered, the patient will be much less disturbed and annoyed than if it were given by an unskilful person. The mere handling of a patient—the moving of him from one bed to another—the simple act of giving him medicine or drink—the changing of his sheets and linen—the dressing of his blisters—and a thousand other offices, can be performed with advantage only by an experienced nurse. Always bear in mind that it is of the utmost importance to economise the patient's strength in fever. The very act of lifting him up, or moving him from one side to another, tends to produce exhaustion. In the advanced stages of fever, the services of a properly qualified nurse are inestimable. Then there is the moral management of the patient, and this is an office which no one can under- take unless qualified by experience, and a correct knowledge of the habits of persons labouring under such forms of disease. Every one admits the value of moral superintendence in the treatment of the insane. Now there are very few patients who are not in a state analogous to insanity, for a longer or shorter period, during a course of typhus fever. There is a necessity for moral management in fever as well as in insanity, and this is understood only by an experienced nurse. Friends or relatives are seldom found capable of discharging this office. If they chance to discover from the physician's remarks or questions the weak points of the patient's case, they generally contrive to let him know them in some way or other. If the patient is restless, for instance, the ill-judged anxiety of his friends will most certainly prevent him from sleeping. They steal softly to his bed, draw the curtains, move the candle so as to make the light fall on his eyes, and wake him perhaps at the moment he is settling down to rest. If he happens to take an opiate, and that they are aware of the nature, of his medicine, they inform him of it, and his anxiety for sleep, conjoined with their inquiries, prevent its due operation. Hence, when you pre- scribe an opiate, you should not, in any case, say any thing about it; and it should not be administered in such a way as to lead the patient or his friends to expect decided benefit from it. It is only where I have to deal 70 ON CLINICAL INSTRUCTION. with prudent persons that I break through my rule of concealing both the nature of the medicine and the results which I expect from its operation. One of the best ways of giving an opiate is to administer it in the form of an enema. The patient's attention is then turned away from the consi- deration of loss of rest—he supposes that the enema is to act on his bowels, and in expecting a motion he drops asleep. You will often, too, succeed in producing sleep in this way, where you would fail in bringing it on by an opiate administered by the mouth. Another recommendation attached to this mode of exhibiting opiates is, that it can be employed in cases of delirium, where the patient obstinately refuses to swallow any kind of medicine. Let me give you here another caution. Do not let the patient know the situation or extent of his danger, however you may feel bound to act in reference to these matters towards his relatives or friends. If you apprehend mischief in the brain, do not commence by examining the head, or putting your questions in such a manner as to lead him to suspect the seat and nature of the affection. The same remark may be applied to the examination of the thorax and abdomen. At my last lecture I endeavoured to impress upon you, that persons have been occasionally starved to death in fever, and laid before you some re- markable facts connected with the influence of protracted abstinence on the general system, as well as on the brain and digestive tube. I endea- voured to show that long-continued denial or want of food generates symp- toms bearing a very close resemblance to those which are observed in the worst forms of typhus. Pain of the stomach, epigastric tenderness, thirst, vomiting, determination of blood to the brain, suffusion of the eyes, head- ache, sleeplessness, and, finally, furious delirium, are the symptoms of pro- tracted abstinence ; and to these we may add, tendency to putrefaction of the animal tissues, chiefly shown by the spontaneous occurrence of gan- grene of the lungs. It has been shown by M. Guislain, physician to the hospital for the insane, at Gand, that in many instances gangrene of the lungs has occurred in insane patients who have obstinately refused to take food. Out of thirteen patients who died of inanition, nine had gangrene of the lungs. You perceive, then, that starvation may give rise to symp- toms of gastric disease, to symptoms of cerebral derangement, and to mor- tification of the pulmonary tissue. It is not, therefore, wrong to suppose that when a system of rigorous abstinence has been observed in fever, and when food has been too long withheld, because, forsooth, the patient does not call for it, and because his natural sensibilities are blunted and im- paired—it is not, I say, unreasonable to infer that gastric, cerebral, and even pulmonary symptoms may supervene, analogous to those which re- sult from actual starvation.* An attentive consideration of the foregoing arguments has led me in the treatment of long fevers, to adopt the advice of a country physician of * The following interesting case is very illustrative of the views advanced in the text :__ Huxhaini gives the history of a gentleman " who obstinately starved himself to death and would not, for many days, either by force or persuasion, swallow any kind of food, or a drop of liquor. He soon grew feverish, flushed in his face, and very hot in his head ; his'pulse was small, but very quick, in four or five days his breath became exceedingly offensive, his lips dry, black, and parched, his teeth and mouth foul, black, and bloody, his urine vastly hVh-coloured and stinking as much as if it had been kept a month; at length he trembled continually could not stand, much less walk, raved and dozed alternately, fell into convulsive agonies frequently in which he sometimes sweated pretty much about the head and breast, though his extremities were quite cold, pale, and shrivelled ; the sweat was of a very dark yellow° colour and of a most nauseous stench." FEVER. 71 great shrewdness, who advised me never to let my patients die of starva- tion. If I have more success than others in the treatment of fever, I think it is owing in a great degree to the adoption of this advice. I must how- ever observe, that great discrimination is required in the choice of food. Although you will not let your patient starve, do not fall into the opposite extreme: you must take care not to overload the stomach. When this is done, gastro-enteric irritation, tympanitis, inflammation, and exasperated febrile action are the consequences. I have witnessed many instances of the danger of repletion in febrile diseases. A case of this kind occurred some time ago in this hospital, in a boy who was recovering from perito- nitis. In another case, in private practice, an incautious indulgence in the use of animal food was followed by a fatal result. A young lady ate some beefsteak, contrary to my orders, at an early period of convalescence from fever, relapsed almost immediately, and died of enteritis in thirty-six hours. Food must be given with great care and judgment, particularly in the beginning of fever. For the first three or four days, particularly if the patient is young and robust, water, weak barley-water, and whey will be sufficient. After this it may be well to begin with some mild nutri- ment. What I generally give is some well^boiled gruel, made of groats, and flavoured, if there be no tendency to diarrhoea, with sugar and a small quantity of lemon juice. The ordinary oatmeal gruel does not answer suf- ficiently well for this purpose, for it is apt to produce griping and diarrhoea, symptoms which are extremely disagreeable in the commencement of fever, and which often lead to others of a more troublesome and formidable cha- racter. I am also much in the habit of ordering a little thin panado, morn- ing and evening, during the latter part of the first, and the beginning of the middle stage of fever. A small slice of bread is slightly toasted, and boiling water poured on a tablespoonful of the crumbs, in sufficient quan- tity to make a thin panado, of which the patient takes a tablespoonful two or three times a-day. It may be flavoured with a very small quantity of lemon juice and sugar, if there is no tendency to diarrhoea; but where this exists, or where you are administering mercurials, I think you should be cautious in the use of acids. Although medical men of the present day do not object to giving acids during the use of mercurials, I think the practice is not entirely devoid of danger, and I think our predecessors were right in withholding them under such circumstances. You will begin, then, on the third, fourth, or fifth day, according to circumstances, with a little gruel; and after two or three days you may add a little panado, giving, as I have already observed, a spoonful of either every third hour. As the fever advances you may add some mild animal jelly or broth; and one of the best kinds of nutriment in the middle and latter stages of fever, is chicken broth. I do not speak here of chicken water; I mean good and well-made chicken broth. Give this, but give it in small quantities, and with great caution at first. Watch the effects of the few first spoonfuls; it may act injuriously, and you should give it up, at least for some time, if it produces any bad effects. If it brings on heaviness, sickness of stomach, flushing of the face, excitement of pulse, and increased feverishness, give it up, and return for some time to the gruel and panado. You can try it again in a day or two ; for although your patient does not bear it to-day, he may to-morrow or the day after; and it is a most fortunate circumstance when it agrees with him, for, as I have already observed, it is the best kind of nutriment you can give in the middle and latter stages of fever. 72 ON CLINICAL INSTRUCTION. Recollecting the tendency to diarrhoea and intestinal irritation m fever, you will be extremely cautious in allowing your patient the use of fruit. Indulging patients in the use of grapes and oranges is a very popular, but, in my mind, very hazardous and improper custom. I have on many occa- sions seen persons injured by fruit of this description. Stewed and roasted apples are still more dangerous; they are apt to produce tormina, flatu- lence, diarrhoea, and intestinal inflammation. All acid or raw fruit have a tendency to produce irritation of the stomach and bowels, and should be avoided altogether, or very sparingly used. One general observation as to the administration of food and nutriment in fever. All kinds of food and nutriment should be given by day, and the patient should, if possible, be restricted to the use of fluids by night. The natural habit is to take food by day and not by night, and in sick- ness as well as in health, we should observe the diurnal revolution of the economy. With respect to drinks, the mildest, of course, should be preferred: on this point most persons are generally agreed, and it will be unnecessar) for me to detain you with any particular observations. There is one error, however, which is very frequently committed in the use of drinks in fever; patients are generally allowed to drink too much. It maybe urged that they have a strong desire for fluids; but they should not be gratified in every thing they wish for. They labour under a constant state of nervous irritation and restlessness, and will beg of you to do twenty different things to relieve their immediate feelings; but it would be just as improper to give them large quantities of drink every time they desire or call for it, as to indulge them in any momentary whim which may be the offspring of their disordered and changeable fancy. The continued swilling of even the most innocent fluids will bring on heavi- ness of stomach, nausea, pain, and flatulence, and predisposes to conges- tion and intestinal irritation. From the mere ingestion of a large quantity of the simplest fluid, you will frequently see well-marked symptoms of gastric irritation arise during the course of fever. This is not a picture drawn from imagination ; I have witnessed it on many occasions during the course of my practice. It is extremely painful, indeed, to be obliged to refuse drink to a patient labouring under intense thirst; but you should never allow them to take a large quantity of fluid at a time : you should impress upon them the danger attendant on such a practice, and tell them that a spoonful or two, swallowed slowly, allays thirst more effectually than drinking a pint at a time. The sensation of thirst, as you all know, is almost entirely confined to the fauces and upper part of the pharynx, and it is as much relieved by a small quantity swallowed slowly and gradually, as by a large quantity gulped down at once. Besides the simple fluids, there are other drinks required in fever. Beer, ale, porter, wine, tea, and coffee, are also frequently used in the treatment of fever, and are of the utmost value when employed on appro- priate occasions ; they are adjuvants of the highest importance in the dietetic management of fever, and it will require some time to explain the rules by which you should be guided in their administration. I shall therefore speak of them according to the indications with which they are given ; and, first, of tea and coffee. You are aware that we give seda- tives and narcotics to tranquillise, to produce a species of exhaustion of the mental faculties, and to bring on sleep; and I do not see any reason why we should not also administer expergefacients, or remedies calculated to maintain intellectual activity, and keep the patient awake. Among FEVER. 73 the remedies most frequently employed for the latter purpose, are tea and coffee. You have lately seen an infusion of green tea useful in a case of narcotism which occurred in the fever ward. A man in the latter stage of fever, and labouring under great nervous excitement and total loss of sleep, was ordered an opiate enema, after we had tried various other means without success. During the course of the evening he got twelve drops of black drop, with two ounces of mucilage of starch, in the form of enema, and soon after fell into a sound sleep. WThen we came next morning and inquired after him, every thing was reported to have "-one on well ; the opiate enema had answered the purpose completely, and the man was still sleeping deeply. We found, however, on a more accurate examination, that he was in a kind of lethargic state, and could scarcely be roused. When addressed in a loud tone of voice, he raised himself heavily and slowly, half opened his eyes, gave a brief answer to our questions, and then, leaning back on his pillow, dropped asleep. Observe here the danger connected with this state. He was in an ad- vanced stage of fever, had been restless and sleepless, and had suddenly passed to an opposite state. The rapidity with which coma had super- vened on sleeplessness, and the danger of fatal congestion of the brain coming on, gave me considerable alarm. There was no use, however, in thinking of what had been done ; the man's state called for prompt and decided measures, and we proceeded at once to attack the symptoms of our own creation. One of the gentlemen went down and got some green tea, of which he made a strong infusion, and administered a strong dose of it to the patient. This had the desired effect ; the symptoms of coma gradually disappeared, and when I came to see him in the after- noon, he was quite out of danger. Green tea was first introduced here as an expergefacient in the treatment of coma by Dr. Edward Percival, son of Dr. Percival of Manchester; and some years ago he read a paper at a meeting of the College of Physicians, in which he brought forward seve- ral cases of coma and stupor, in which green tea had produced the most favourable effects. On the continent they generally use strong coffee for the same purpose. Whether these beverages produce this effect by their influence on the circulation, or on the nervous system, I am not prepared to say ; but'there cannot be a doubt of their efficacy and value in many cases of this description ; and I am frequently in the habit of using both with this intention. While on the subject of expergefacients, I shall beg leave to read for you a very curious case from the 13th number of the Boston Medical and SurgicalJournal, in which an expergefacient of a less agreeable character was employed to rouse a patient from the lethargic stupor brought on by a large dose of laudanum. There are some transatlantic peculiarities of expression in the detail of this case, but I have no doubt of its being cor- rect. It is entitled " a case of successful treatment by flagellation, where a large dose of laudanum had been taken." And the author, Dr. Joseph Barret, of Middleton, Connecticut, proceeds as follows: " Tincture of opium is not unfrequently resorted to for destructive pur- poses. It isaiso, unfortunately, and too frequently, taken by mistake, and proves fatal before efficient means can be adopted to counteract its delete- rious effects on the system. I am induced, therefore, to offer a short state- ment of a case of poisoning with laudanum that fell under my care seve- ral years since, for the following reasons : first, the success that attended 74 ON CLINICAL INSTRUCTION.' the mode pursued, and, secondly, from not having met with any such means recorded, to my knowledge,* either in works on medicine, or in treatises on poisons." Observe, it is not I that am speaking here, but Dr. Barrett, of Middle- ton, Connecticut. " In the year 1822, February 23d, I was called on to see Mr. Wright Harris (this was in the state of New York), who had intentionally taken a large dose of laudanum for the purpose of destroying himself. He had committed this act during his absence from home, under circumstances which it is not important to relate. Much time, about three hours, was therefore lost, before any effectual measures could be adopted for his relief. His case, as I found him, appeared to be altogether hopeless. Before my arrival, emetics and various drinks had been tried, besides frictions, and constant, though ineffectual attempts, had been made to irritate the oeso- phagus by feathers. All these means had failed, and the patient was in such a profound sopor, that apparently nothing but warmth remained to indicate that life had not already become extinct. The quantity of lauda- num taken was ascertained to be one ounce and a half. The case appear- ing so desperate, justified me in the course of treatment which I was, under existing circumstances, then obliged to adopt. " Internal remedies having entirely failed, there was no chance left but for high external excitements. I therefore determined to use vigorous measures. I commenced with flagellations, using long pliant, fresh twigs, to the palms of the hands and solesof the feet. These were briskly applied, and in a short time gave indications of uneasiness and pain. This treatment was unremittingly pursued till the man spoke, and complained of being pained by the whipping, when this severe appliance was relaxed ; but on so doing, he instantly sunk into a profound stupor, from which he was again only roused by the severity of the whipping. It required the aid of a number of men to take turns in the flagellation, as well as to support and walk him about; for a cessation of the use of the rods was followed by instantaneous stupor. After about six or eight hours under this course, the stupor was lessened, and the severity of the flagellation mitigated;; but as the case required constant high excitement, it was still repeated 'at inter- vals, till eventually the exercise of walking was sufficient to keep him awake. This was in about twelve hours from the commencing with the flagellation. He afterwards experienced but little inconvenience from his hands and feet, and was perfectly restored in a few days to his usual health. I would here state that the first proposal made by me to adopt flagellation, as the only hope, was objected to by the persons present, from its carrying with it the semblance of unkindness towards what was re- garded by them as a corpse ; and it was not till the application of the rods by myself, in the first instance, that I obtained the aid of those pre- sent ; but as soon as the patient began to move, and at last spoke, they took hold with alacrity, and by dividing themselves into relief parties thev very cheerfully, and rather amusingly, kept up the caseation so lone continued tranquil throughout. Thus, it was very curious to see a patient with a skin of a natural temperature, a perfectly natural pulse, tranquil respiration, clear eye, no headache, a soft and fallen abdomen, without the slightest ten- dency to epigastric tenderness; it was very curious, I say, to see such a patient in a state, nevertheless, of extreme danger, passing both feces and urine under him; raving, incoherent, or with a low muttering delirium ; subsultus daily increasing until it became excessive; the greatest possible degree of debility; a dark macular efflorescence, and at length total sleep- FKVER. 137 lessness. How many theories of fever were refuted by such a case ! Usually, as the disease continued, and when the patient was in a very dan- gerous state—but seldom or never before that—the intestines began to be inflated, and the belly gradually became tympanitic; a circumstance of bad omen, and which was often the precursor of hiccup. When the symptoms did not yield to the efforts of nature or of art, the congestion of the intes- tinal mucous membrane, indicated by these symptoms, was soon followed by indubitable evidence of cerebral congestion—such as restlessness, suf- fusion of the adnata, and contraction of the pupils; this last was the most fatal of all symptoms. In two or three cases—as, for instance, that of Mr. Cookson—the cerebral congestion produced repeated fits of convulsions on the thirteenth day, and yet he recovered. The same happened in a young woman in Sir P. Dunn's Hospital, in whom the convulsions occurred on the fifteenth day, and were more violent on the right side than on the left, producing strabismus and insensibility of the pupil of the affected eye. This girl lost the use of her left side on that day, but recovered it on the following; and eventually, though with difficulty, was completely cured. Frequent fits of convulsions, affecting the right side more than the left, took place on the seventh day in the daughter of a clergyman residing in the Liberty, and were followed by a stupor bordering on coma, which lasted for many hours. All these patients were covered with ma- culse. I am thus particular in dwelling on the symptoms manifestly denoting a combination of primary general nervous excitement with a secondary cerebral congestion ; for, on the successive development of these states the treatment during the latter stages hinged. I wish you clearly to un- derstand, that, after the headache and cerebral excitement which accom- panied the very commencement of the fever had been subdued, or had ceased, after sleep and calm had returned, and had continued for many days, then a new order of things commenced—subsultus, watchfulness, muttering, raving, involuntary discharges, &c,—all denoted great de- rangement of the nervous system ; but still there was no proof that this derangement depended on cerebral conges'tion. After a few, or after many days, however, unequivocal symptoms of the latter set in ; the face and eyes became suffused and flushed ; the pupils manifested a tendency to become contracted, and occasionally convulsions took place ; the pa- tient became totally sleepless. When the latter and dangerous period of the fever was accompanied by the former nervous group of symptoms alone they yielded to wine, musk, porter, and opiates ; but when the symptoms indicating cerebral congestion were superadded, then it was that the case assumed so great and striking a similarity, as far as the func- tions of the nervous system were concerned, to the well-known variety of delirium tremens, accompanied by cerebral congestion—to that variety of delirium tremens, in fact, which only can be successfully treated by the judicious but bold exhibition of tartar emetic combined with laudanum. It is the discovery of the utility of this practice in the advanced stages of spotted fevers, that I claim peculiarly as my own ; for there is not in the writings of any author on the subject, the slightest trace of such a method of treatment to be found. As this method has manifestly saved many, many lives, under a combination of circumstances apparently hopeless, I cannot avoid congratulating myself upon being the first to propose a prac- tice which has not only diminished the rate of our hospital mortality in 138 CLINICAL MEDICINE. a remarkable manner,* but has been the means of saving many of my friends and pupils ; for, without its adoption, our class at the Meath Hos- pital would have been more than decimated, whereas at present we have to regret the loss of but one pupil. One word more as to the circumstances under which this plan was ap- plicable. They were exactly the circumstances which formerly would have been believed to demand the fresh application of leeches to the head, of cold lotions, and of blisters ; for it was formerly argued, and justly, we have in this advanced stage of fever not merely debility to combat—not merely general nervous excitement to overcome—but we have also to con- tend with cerebral congestion. Thelatter is the most formidable of the whole: let us meet it boldly ; let us leech, let us purge, &c, &c. I need not repeat to you the details of cases illustrating the ill effects of this practice. Suffice it to remark, that you might as well attempt to cure delirium tremens with mere leeching, purging, and blistering. Observe, I am now speaking of the advanced stages of fever ; for where cerebral congestion takes place in the beginning or the middle of fever, then is there no room for opium —then will the practitioner have recourse to the well-known remedies for active cerebral congestion ; viz., purging, leeches, cold lotions, ice to the head, &c, &c. In the preceding sketch of the present epidemic, many important features have been omitted. The outline is only complete in such parts as were required to be filled up for the purpose of illustrating the principles which directed me in devising and employing this new plan of treatment. I shall conclude these observations with a few details of Mr. Thomas O'Flaherty's case. This young gentleman was seized with the usual symptoms of maculated fever, of an insidious character, and not attended with any appearance of danger during the commencement of the disease. His pulse never rose above 100, and before the seventeenth day of the fever, it had fallen to 70, at which it remained during the period of greatest danger. The only circumstance which excited alarm in my mind, at an early period of his illness, was a great degree of mental apprehension manifested in his anti- cipating an unfavourable result, together with a tendency to sleeplessness from the beginning. On the tenth, abdominal tympanitis was observed, but this was removed in two days by appropriate remedies. On the twelfth day he was very restless, and although he was perfectly rational in his answers to questions, and did not complain of headache, nor had flushing of face, or heat of the integuments of the head, yet he frequently talked incoherently when left alone, and towards the latter part of the day began to make repeated attempts to get out of bed. On one occasion he succeeded, and walked down stairs, from his bed-room to the parlour. His tongue was brown and dry. Under these circumstances, I ordered him the mixture containing four grains of tartar emetic and one drachm of laudanum, in eight ounces of camphor-mixture ; of this he took 5»j- every second hour. The effects produced by this medicine were not very rapid, but still they were decidedly beneficial, for he gradually became calmer, wandered less, did not attempt to get out of bed, and, during the * Seventy-three fever patients—namely, forty-one males and thirty-two females, were treated in the clinical wards at Sir P. Dun's Hospital during the months of February, March and April. Of these, more than fifty were cases of maculated or spotted fever, and yet we lost but two females and one male. The latter was in a hopeless condition when brought in, and one of the former was attacked by varioloid just after the crisis of long-continued spotted fever. FEVER. 139 night, got some sleep. His bowels being confined, the mixture was now laid aside, and purgatives exhibited : I should have remarked that the tartar-emetic mixture caused profuse sweating. On the fifteenth day of the fever, his bowels having been acted on, he was ordered twenty drops of Battley's solution of opium at night, which produced a comfortable night's rest, the first he had enjoyed since his illness. On the sixteenth, the sweating continued, belly was fallen, and he was quite rational, but had marked subsultus ; he got another dose of Battley, but it produced no sleep ; he had been allowed chicken-broth, beer, &c, for some days. On the seventeenth day, the sweating had ceased, and his skin had be- come hot and dry ; great restlessness, constant muttering, delirium, sub- sultus, tremors, picking the bed-clothes, involuntary discharges. Porter in small quantities, chicken-broth, fetid injection, and twenty drops of Battley at night. On the eighteenth, he was reported to have had no stool from the injection, and no sleep whatsoever. He answered inco- herently, thought his bed was covered with lancets, some of which he collected carefully, and reserved for me ; belly not tumid, but obstinately confined ; pulse 100. The whole of that day, and the following, were employed in procuring alvine evacuations, preparatory to again giving opium : in the mean time, all his symptoms were aggravated, and when I visited him on the evening of the nineteenth day, his state was anxious in the extreme, as he had enjoyed no sleep for many days and nights, and was in a melancholy state of mental incoherence, raving, tremor, and subsultus. Here came the crisis as to treatment. I remember well the time when a patient so situated would have been again purged, his head would have been shaved, a few leeches applied to the temples, and a blister to the nape of the neck, while perhaps wine and musk would have been exhibited internally. How many persons have I seen so treated by the most eminent physicians, and how unsuccessful was the practice! To have talked of giving opium under such circumstances, and when the marks of cerebral congestion were so evident, would have been regarded absurd ; my experience on former occasions, however, determined me to give opium, and, as the danger was imminent, I gave it boldly. To the eight-ounce mixture, with four grains of tartar emetic, we added one drachm and a half of laudanum ; of this he took one ounce every second hour, from eight in the evening until he had taken five doses. This pro- duced copious sweating ; the skin became cooler, he raved less, but still no sleep ; at four on the following morning, his pulse became 70, and re- spirations tranquil ; he got twenty drops of Battley, and at half-past five in the morning, twenty-five drops more. He had now taken, within a short time, about one drachm of laudanum, and forty-five drops of Battley, combined with nearly three grains of tartar emetic. He was tranquil, but did not close his eyes, and muttered occasionally ; subsultus less. His pupils now became more and more contracted, his eyes less expressive and duller, and when I came at eight in the morning, he was evidently deeply narcotised, although not yet asleep. I thought that all was lost ; but still, observing the respiration to be tranquil, and the pulse regular, I indulged a faint hope that sleep might still supervene. His eyes now became still more inexpressive, the lids gradually closed, his breathing became prolonged and deep, and at half-past eight he was buried in a profound and tranquil sleep, which continued for nine hours, when he awoke, spoke rationally, said he had no pain in the head, took some 40 CLINICAL MEDICINE. drink, and fell asleep again. Next morning not a single symptom of fever remained. I need scarcely observe,, that the proportions of the two powerful medi- cines which compose this mixture must vary according to the circum- stances of the disease, and the age of the patient. In young persons of tender age, the opium must be given in smaller quantities. In conclusion I shall only mention, that since this practice was first proposed, it has continued to afford me the greatest satisfaction, and that I have reason to believe that those who have employed it in this country, and at the other side of the channel, have had no reason to lose confidence in it. In a paper on typhus fever, by Dr. Kilgour, we find that the experience of Dr. Dyce, of the Aberdeen Infirmary, is strongly in favour of this prac- tice. He says, "For months together the pulmonic symptoms prevailed almost entirely, then came those marked by gastric and intestinal irrita- tion, and less often, though still continuing for a length of time in suc- cession, those with high cerebral action. The first set, as is too well known, were by far the most intractable and fatal ; the last, though suffi- ciently alarming, and always requiring restraint, were more amenable to treatment than either of the others, if anticipated in their approach, or seen soon after their onset. By the way, the medicine I solely relied on in this latter class, you do not include among your list—I mean tartar emetic given as described by Dr. Graves; I have found it eminently successful, and have the greatest confidence in it."—Edin. Med. and Surg. Journal, No. cxlix. Nov., 1841. And in the Eleventh Volume of the Dublin Medical Journal, the reader will find an interesting paper on "Certain Remedies in Typhus Fever," by Dr. Hudson, of Navan. Speaking of the treatment by tartar emetic and opium, he says, " It seems best adapted to that restless kind of delirium tremens, in which the patient cannot be restrained from attempting to leave his bed, and walk about his ward ; when every muscle is tremulous, the eye is red from want of sleep, the tongue dry, and the patient pre- senting that kind of spurious excitement which might induce the attendant (injudiciously, no doubt) to order the local abstraction of blood, by leech- ing the temples, or opening the temporal artery. I could here give re- ports from my note-book of several cases thus treated, but that I consider it would be rendering tedious a paper already too long. In prescribing this medicine, I find it advisable to use great caution in two ways: 1st, Not to give it after it has produced sleep ; 2d, To follow it up by the prompt and frequent exhibition of wine, and such nourishment or cordials as the more or less advanced stage of the disease, and debility of the pa- tient may require ; as it seems to me that there is increased risk of the patient sinking unless timely supported after sleep thus induced." There is one circumstance connected with this epidemic, but which I have also frequently witnessed in other sporadic and epidemic fevers, to which I wish forcibly to draw your attention ; it is the existence of ten- derness generally over the body ; and which causes the patient to shrink from the pressure of the finger, applied to any part of the integuments. This tenderness arises from an irritated state of the nervous system gene- rally, and is usually accompanied by severe dorsal or lumbar pain, indi- cating spinal congestion. Now, in a practical point of view, this tender- ness requires attention ; for if it be overlooked, and if the physician applies FEVER. 141 pressure, in such cases, only to the epigastrium, he will be deceived inio the belief that the tenderness he there discovers is confined to that part, and indicates the application of leeches to the pit of the stomach. Having spoken so much of the salutary effects of opium in certain stages of fever, it may not be irrelevant to our subject to introduce to your notice a remarkable case of violent enteric inflammation, attended, as such cases always are when exceedingly intense, with cholera-like col- lapse in the very onset of the disease. This case was saved by means of thirteen or fourteen grains of opium, given in the course of twenty-fours, a plan of treatment which I first proposed, and which has since been very generally adopted. I shall take the liberty of reading to you the following letter, from my friend, Dr. Nolan. " My dear Doctor,—The following is an abstract of my notes upon the case of my servant Horan :— " On Monday evening, 27th February last, he casually complained of pains in his bowels ; they had not been freed on that day, and supposing it an instance of mere indigestion, I ordered him five grains of calomel, and a draught of castor-oil. For that night I heard no more of him, but early on the following morning I was hastily summoned by one of his fel- low-servants, who reported that he was dying. I found him labouring under severe but intermitting pain of the belly, particularly about the umbilicus,viole?d and frequent cramps, especially in the lower extremities, and occasional vomiting. The surface was perfectly cold ; features sunken ; eyes surrounded by a dark areola ; voice subdued to a whisper ; pulse 140, small and feeble; abdomen tender, though not at all tumid. He told me he passed the night in great torture, and that the bowels were still unmoved. I immediately ordered ten grains of calomel, to be fol- lowed in two hours by an oil and turpentine draught, a turpentine enema, bathing, &c. " Three hours subsequently—temperature restored ; cramps less violent; vomiting less frequent, but bowels obstinate ; face and pulse equally unpro- mising as before ; abdominal pain increased. Was this incipient inflamma- tion? And what is the cure for inflammation? Bleeding? Well,I did bleed ; but scarcely had four ounces been taken, when I was very glad to tie up the arm ; the prostration alarmed me. Something,atall events,oughttobedone, and I ordered a sinapism to the abdomen, a repetition of the enema (for I confess I have not much confidence in frequent or powerful purgatives), a powder, composed of calomel two grains, opium quarter of a grain, to be taken every fifteen minutes. Towards evening, 1 thought my patient rallied a little ; his countenance was better ; pulse firmer; his abdominal pain not increased, and he vomited but once ; the injection brought away with it a little mucus but no more. Repetat haustus terebinth. Repetat quoque enema. During the night, there was just a trace of feculent mat- ter, but vomiting returned, and I found him in the morning (the second of his illness) suffering an increase of pain ; the abdomen, too, was now not only extremely tender, but decidedly swollen ; the pulse remained quick and weak as ever. I could not discover that he passed water. Would you not call this inflammation ? But would you bleed for it ? I did, unfortunately, to as great an extent as I could, which was about eight ounces, and the cadaverous look, the cold clammy surface, in short, the 142 CLINICAL MEDICINE. absolute collapse which succeeded, and continued for hours, gave me strong reason to regret it. It produced no impression upon the pain. I had read, with great interest, the invaluable observations of >ourself and Dr. Stokes, as well as the publications of Armstrong, Griffin, Gooch,&c, wherein the applicability of opium, to certain modifications of abdominal inflammation, is forcibly demonstrated, and I thought my patient precisely in the condition in which you would probably have had recourse to that powerful agent. I therefore commenced exhibiting half a grain of opium, and two of calomel, every half-hour. Alter the second hour, I substituted for the calomel three grains of carbonate of ammonia, which, with the opium as before, I continued during the day and the wThole night. In the morning (the third) I had the satisfaction of ascertaining that the pain and swelling had considerably subsided, and that the bowels had been twice opened ; his countenance now spoke promisingly, and pulse began to fall. I, however, persevered in my plan of treatment for the day, and, indeed, for the two following nights and days (gradually increasing the interval between each dose, however), until all trace of pain and obstruction had disappeared. The bowels continued to act from time to time, although I never ventured upon another purgative ; the dejections were at first largely mixed with blood and mucus, but soon assumed every character of health. Of the sequel (may be the consequence) of this interesting case, you most kindly undertook the management, and I shall add nothing to this meagre statement of facts, which Mr. O'Donnel, (of Keane's in Suffolk Street), to whose humanity and care I am deeply indebted, wit- nessed as well as myself. I shall leave you to speculate upon the pro- priety of bleeding at all, under such circumstances. I shall also leave you to decide whether the increase of inflammation, which certainly occurred when I first gave up the opium plan (on the first night) for the sake of interposing a purgative, was to be attributed to the change or not. May not the case throw some light on the abuse or use of purgatives? But I am doing more than I intended, and more than is useful. " I remain, my dear Doctor, " Yours most truly, "J. Nolax. " April 19, 1835.—10, College Green." APPENDIX. FURTHER OBSERVATIONS ON THE USE OF TARTAR EMETIC IN THE DELIRIUM OF FEVER. [The two following papers on the use of Tartar Emetic and Opium in Fever, were published subsequent to the appearance of my lectures in London, in the 9th vol. of the Dublin Medical Journal; I shall therefore make no apology for introducing them in this place.] ARTICLE I. The subject of the following observations is treated at some length in the preceding lectures, and I have been induced to notice it again, be- cause subsequent experience has enabled me to collect many additional facts, illustrative of the practice then recommended. FEVER. 143 It is well known that delirium tremens requires very different modes of treatment, varying according to the constitution, strength, age, and habits of the patient. In the young and robust it often assumes a form exceedingly resembling that of delirium arising from sudden congestion or inflammation of the brain or its membranes, and then demands strictly antiphlogistic measures, such as venesection, leeching, cold to the head, and very active cathartics. These remedies will often speedily arrest the progress of the disease. On the other hand, we very frequently meet with delirium tremens calling for a totally opposite plan, for when it occurs in the old, debilitated and confirmed drunkard, who has been repeatedly subject to its attacks, we are often obliged to exhibit opium from the very commencement, and that in large doses combined with porter, punch, or some other cordial; these two form the extremes, between which there are many intermediate varieties, each requiring a special modification of practice. Thus, some must be treated rather actively, on the antiphlo- gistic plan at firsthand immediately afterwards opiates may be used with advantage ; while in others, opiates cannot be given alone at any period of the disease, so prominently marked are the symptoms of cerebral con- gestion ; and yet these cases cannot be cured without narcotics. How then are they to be exhibited ? Do we possess any medicine capable of modifying and diminishing their injurious effects when given where cere- bral congestion exists ? Undoubtedly we do ; tartar emetic will accom- plish this desirable object, and in delirium tremens the value of its com- bination with opium is recognised by every practitioner of experience. Tartar emetic, boldly exhibited, often is itself our sheet anchor in delirium tremens, especially when the evidence of active determination to the head is undoubted. Then tartar emetic alone, in repeated doses, often powerfully contributes to produce tranquillity and sleep ; but there are other, more mixed cases, where we cannot cure without adding opium, sometimes in larger, sometimes in smaller quantities, to the solution of tartar emetic ; and so it is with the delirium and sleeplessness, so often met with in continued fever. Every one is acquainted with the indica- tions denoting the propriety of adopting the antiphlogistic practice when these symptoms make their appearance in the commencement of fever. Then the lancet, leeches, purgatives, cold applications to the head, and finally, repeated doses of tartar emetic tend powerfully to reduce vascular action, and diminish the violence of symptoms depending on cerebral congestion and excitement. Here the lancet and tartar emetic are our best opiates, our best restoratives of tranquillity and sleep. As the fever progresses, and when we have arrived at a more advanced stage of the disease, when maculse make their appearance on the skin, and symptoms of general debility announcing the typhoid type begin to predominate, then we must proceed with more caution, even though our patient is totally deprived of sleep and is violently delirious. The lancet cannot now be resorted to; leeches, indeed, may be applied, but their effects must be carefully watched, as the patient will not bear copious depletion of any sort; tartar emetic may, nevertheless, still be given boldly, and will be found to answer our expectations. But if we have to contend with want of sleep and delirium at a still more advanced period of fever, we now often recognise that very combination of symp- toms, the union of general debility, and cerebral congestion, which in certain varieties of delirium tremens we have seen so successfully treated 144 CLINICAL MEDICINE. with tartar emetic and opium ; who will refuse to acknowledge the simi- larity between these cases of fever delirium and many varieties of delirium tremens? are there not in both, the same tremor and subsultus of the extremities ; the same trembling of the tongue when the patient endea- vours to put it out; the same starting and sleeplessness; the same ramb- ling, delirium or incoherence, combined nevertheless with the power of answering rationally when spoken to ; the same character of the mental wandering, for in both they are extremely apt to rave as if employed in their ordinary occupations, and as if surrounded with their usual asso- ciates ; in short, can any greater resemblance exist between two diseases arising from the operation of remote causes so different? We need not, therefore, be surprised, at finding the same treatment applicable to both. Since the delivery of the clinical lectures in which the preceding cases are detailed, several others have occurred both in hospital and private practice, to some of which I now beg leave to direct attention, observing that I have in every instance been particular in mentioning the names of other professional gentlemen who witnessed the progress of each case ; a precaution tending to prevent exaggeration either in detailing symptoms or describing the effects of remedies. The case of Mr. William Murphy, an extremely diligent and intelligent pupil at the Meath Hospital, is well worthy of notice. The father of this gentleman, a practitioner of well-known reputation at Fermoy, where he has been Physician to the Fever Hospital for many years, arrived in Dublin the very day his son's state appeared to be hopeless, soon after the consultation, when Doctor Stokes and I agreed to use the tartar emetic and opium; Doctor Murphy admitted afterwards that he never felt so much surprised as he was at this treatment, but having intrusted the care of his son to us, he very properly expressed no opinion on the subject, a mode of proceeding he has never since ceased to congratulate himself on, for had he opposed us, the case was apparently so desperate, that it may be doubted whether we would have ventured to put the plan into execution. Mr. Murphy, aged 20, having been engaged in the diligent study of the fever cases in the Meath Hospital, was attacked with violent symptoms of fever on the 6th of January last. He took a dose of calomel and James's powders, and went to bed ; early next morning he was worse, and although he took a purgative draught which operated freely on the bowels, he complained much of headache, and was very feverish ; a copious sweat broke out, but was unattended with relief, notwithstanding that it con- tinued with more or less interruption for several days. His thirst was excessive, and he was very restless, depressed, weak, and nervous ; the antimonial powder and calomel were persevered in during the second day, and on the third he took more purgative mixture, and twelve leeches were applied to the temples, but they gave little or no relief to the pain in the head. In short, he grew worse, and was found to be extremely prostrated. On the 4th, his tongue was foul and dry, his stomach irri- table, often rejecting his medicine, and producing a vomiting of bilious matter, the pulse quick, and his air unpromising. I saw him on the 5th day, when every thing was still worse, and the pain of head much com- plained of. I directed a continuation of the James's powder, and effer- vescing draughts. On the 6th day he was still worse, and was reported to have raved a good deal during the night; his bowels were loose, and FEVER 145 now for the first time the perspiration entirely ceased, and his skin became hot and dry. I gave him small doses of Dover's powder and chalk. On the 7th day his countenance expressed great anxiety, and in addition to an aggravation of all the other symptoms, his skin became covered with a measles-like eruption of maculse, a circumstance which induced me to give the liquor of the chloride of soda, in doses of twelve drops, every fourth hour, in an ounce of camphor-mixture. He got mild diet, as arrow- root and chicken-broth, with a little stale bread sopped in tea, night and morning. On the 8th day, no improvement ; much raving during the night. On the 9th, symptoms as before, except that the occurrence of some abdominal tympanites and slight epigastric tenderness induced me to apply six leeches to the pit of the stomach The bleeding from the leech-bites was moderate, but seemed nevertheless to exhaust him. It seemed to check the tympanitic tendency. On the 9th day, was still worse, much stupor, incipient subsultus ; towards evening a very hurried and laboured breathing supervened, and he lay entirely on his back, helpless and weak, respiring about 45 times in a minute. As he had not the slightest affection of the lungs or bronchial tubes, this hurried breathing excited the greatest alarm in my mind, and induced me to apply six leeches behind the ear, with a view of relieving the now increasing stupor, and the evident cerebral congestion. On the 10th day, I had the benefit of Doctor Stokes's advice. We found our patient in a state truly appalling. He lay panting on his back, restless and without sleep, every muscular fibre in his face and limbs was agitated with spasmodic twitches, giving rise to the greatest possible degree of subsultus, which distorted his face, caused him to bite his under lip every instant, rendered him quite unable to put out his tongue, although he endeavoured to do so. The subsultus prevented us from being able to feel the pulse, now weak and rapid, at the wrist. In the mean time, though he often moaned and raved, he muttered indistinctly ; he evidently understood what was said to him, and as far as we could collect, he seemed to suffer much less from pain in his head. Still the temporal arteries were turgid, and his eyes suffused. He had retention of urine, and since yesterday it was drawn off with the catheter. What was now to be done ? Cold lotions to the shaved head had failed—a blister to the nape of the neck had proved useless—we could not venture to rely on more blistering of the scalp—some more powerful remedy must be instantly brought to bear, or our patient was lost. Alvine evacuations had been pushed to the fullest extent ; leeches could not even be proposed, so great was the debility. Opium we dared not venture on, seeing that so recently the pain in his head had been urgent, and that the temporal arteries and the conjunctiva still seemed to indicate cerebral congestion ; under these circumstances we resolved to try tartar emetic, and we ordered the fol- lowing mixture:— R. Tartar Emetici gr. ii. Mos-mi gr. xxx. Mucilaginis Syrupi Simplicis aa, 5L aquse fontis 5X. M. Sumat ^ss. omni hora. After he had taken about six doses of this medicine, he seemed rather better, and the symptoms of determination to the head appeared less marked ; we therefore added fifteen minims of patent black drop to the remaining nine ounces of the mixture, and directed small quantities of porter and chicken-broth to be given repeatedly during the night. On 11 146 CLINICAL MEDICINE. the 11th day, we found a change for the better truly surprising: the pulse had diminished remarkably in frequency, and had become softer and fuller; a warm sweat had broken out, he had raved but little, and had slept tranquilly. We ordered a continuance of the same nourishment and medicines, the latter at much longer intervals ; the case need not be further detailed, as Mr. Murphy rapidly recovered and enjoyed a speedy con- valescence. Here then is a case which would assuredly have been lost but for the well-tried application of the new method of treatment. I say this emphatically, for Mr. Glyssan, Mr. Boyton, Mr. Clarke, and Doctor Murphy, all anxious and competent observers, assured us that from the moment he began the bottle, its good effects were apparent, and increased after each dose. Case II.—John Doyle, admitted into Meath Hospital, May 21st, 1835; three or four days ill, a strong young man; the symptoms were attended with considerable reaction at the beginning, his face being flushed, eyes wild, and head aching; he raved much during the night from the 4th day, and had then a full bounding pulse at 105. Venesection was or- dered, but he fainted when four ounces of blood had been drawn. Leeches were then applied to the epigastrium. On the sixth day of his illness, his thirst was great, no sleep, skin moist, belly soft, pulse 120, pain in head severe, copious eruption of maculse. His head was now shaved, and six leeches applied behind the ear, and were repeated three times. He was ordered the liquor of the chloride of soda on the 7th day, as the vascular excitement had then diminished, and the maculse con- stituted a prominent feature in his case. On the 8th day he was not worse, but his skin was still very hot. On the 9th day, eyes suffused, face flushed, much thirst, no sleep, bowels free, belly soft, some epigas- tric tenderness, tongue loaded, but moist, cold lotions to the head. 10th day, delirium violent during the night, strait-waistcoat necessary, eyes suffused, belly soft, skin very hot, pulse 120, respirations 40, considerable subsultus. Six leeches to be applied behind the ear three times suc- cessively. R. Tart, emetici gr. iv. aquae fontis lb. i. M. Sumat ^ss. omni hora. 11th. Slept very little, delirium less violent, one very large stool, heat of skin less, eruption copious. R. Misturae camphorse gviii. Tartar emetici gr. iv. Tinctura? opii ^i. M. Sumat 5SS. 2a q q. hora. 12th. Slept five hours, seems better, but still he passes his stools under him ; pulse 120, eyes suffused, skin hot, tongue cleaning, belly soft, bow- els loose, maculse numerous. The same prescription, except that the tincture of opium was increased to ^iss. in the eight-ounce mixture. 13th. The medicine was continued for several hours, when he fell asleep, and slept so much and so tranquilly, that it was not thought ne- cessary to repeat it. Pulse 110 ; subsultus not near so violent; does not rave ; knows every one, and answers rationally ; light nourishment. 14th and 15th. Improvement continues, but still there is much fever and many maculse. About the 21st day he was free from fever, but he got no medicine after the night of the 12th. This case exemplifies the treatment adapted to the three different stages —1st, Bleeding, leeches, cold lotions; 2d, Tartar emetic in large doses, FEVER. 147 combined with leeching; 3d, Opium boldly administered in combination with tartar emetic. Case III.—The following, communicated by my friend Mr. Knott, whose own case I have already referred to, excited much interest among the practitioners of the neighbourhood :— On the 20th of July last, I was called to see a comfortable farmer, re- siding near Boyle, in the county Roscommon, named J. K----. He was aged 30 years, and had been ill 21 days. His fever commenced with rigor, headache, and pains in the loins, the headache being particularly severe. In the commencement of the fever he had raved incessantly ; slept but little ; had frequent retching ; his bowels were confined ; for these symptoms, he was purged with black bottle to excess, and bled largely and frequently, but without any permanent alleviation. On the 21st day of his fever he presented the following appearance and symp- toms :—his countenance was expressive of great anxiety and ferocity ; his eyes were bloodshot and wild ; teeth covered with sordes ; tongue brown and furrowed with clefts ; he raved violently and attempted to get out of the bed several times ; great excitement and subsidtus ; his skin was very hot and dry ; all the secretions much diminished ; urine high-coloured ; no eruption ; no epigastric tenderness ; abdomen slightly swollen and tympanitic, but pressure seemed to give no pain ; his bowels had not been open for three days. That night he was ordered 40 drops of the tincture of opium, at the same time that an enema was exhibited ; the bowels were once opened ; he slept none during the night, and the excitement was, if any thing, greater than before. Under these circumstances it was thought advisable to administer the tartar emetic and opium in the manner I had seen it exhibited, whilst acting as clinical clerk under Doctor Graves in the Meath Hospital. He got an ounce of a mixture, consisting of eight ounces camphor-mixture, four grains tartar emetic, and a drachm of lau- danum every second hour, and after he had taken the third dose he had a large watery evacuation ; after he had taken the fourth dose he fell into a calm sleep, in which he continued for nearly twelve hours ; he awoke much refreshed and covered with a profuse perspiration. He was able now to recognise his friends ; the subsultus and general excitement was greatly, but not entirely, allayed ; his pulse, which had been 120, small and wiry, had fallen to 98 ; he continued his medicine during the next night with the greatest benefit. From this period this man's recovery was rapid and unexpected, and at the end of three weeks he was able to attend to his business. Case IV.—(Reported by a Pupil.)—Ellen Uowden, aged 18, admitted in the Meath Hospital on the 8th of June, states that she has been ill 12 days. Her illness commenced with the usual symptoms ; headache ; rigor ; loss of rest and appetite : previously to her admission she had been purged freely without any relief. On the day of her admission she was flushed ; skin dry and very hot; the whole body was covered with ma- culse ; she was heavy and stupid ; answered questions incoherently ; her eyes were slightly suffused ; called out continually for drink; her tongue was dry, brown, and rough ; seemed to have much pain on making pres- sure on the epigastrium ; the belly was swelled and tympanitic ; bowels confined ; no cough or headache ; pulse 108, wiry ; applicentur hirudi- ness octo epigastrio ; head to be shaved and cold lotion to be applied. U. Hydrargyri c. creta, gr. x. Pulv. ipecac, comp. gr. ii. M. Fiat. pulv. quater in die sumend. 148 CLINICAL MEDICINE. 9th. Much worse to-day; slept for about one hour yesterday evening ; lies continually on her back ; seems to take no notice of what is going on about her; raved occasionally during the night; teeth and mouth covered with sordes ; tongue very dry, rough, and coated with brown ; pulse fallen to 80, very small, but less wiry than on yesterday ; her bowels were opened twice copiously ; belly soft and fallen ; epigastric tenderness much relieved, headache gone, maculse less. R. Sol. chlorid: sodas gtts. xv. Mist, camph. gi. GuUse nigrse. gtt. i. M. Fiat, haust. quater in die sumend. To have a pint of beer and arrow-root. 10th. Raved the whole night ; subsultus general and violent; pulse 120, sharp ; slightly dicrotous ; slept none ; face much more flushed than on yesterday ; eyes suffused, passed under her; maculse much diminished ; has no headache ; bowels rather free ; lies on her back with her feet drawn up ; has no chest symptoms ; respiration natural ; ordered ice in bladders to the head, with a mixture composed as follows:— R. Mist, camph. gviii. Tart, emetic, gr. i. M. Sumat gss. omni semihora. 11th. When seen yesterday evening she was very violent; endeavoured to get out of bed ; screamed loudly, and complained of bad treatment ; she had slept none at this period, her bowels had been freed copiously, but she still continues to pass under her ; she endeavours to throw the ice bags off her head, and requires some violence to hold her in bed ; sub- sultus extremely violent; face much flushed ; eyes red ; she was ordered the following :— R. Mist, camph. ^viii. Tart, emetic, gr. iv. Tinct. opium, £i. M. Sumat 5SS. secundis horis. She had taken but two tablespoonfuls when she began to sleep ; she has continued to doze to the hour of visit ; she is much improved in every respect; she answers questions rationally ; her face is not so much flushed ; eyes less suffused ; has no headache ; pulse 120, not so sharp ; skin still very hot; tongue moist and cleaning. She was ordered not to take any of the mixture if she continues better. Enema emolliens statim. Im- provement went on steadily until convalescence was established. Case V.—"My dear Doctor,—In compliance with your request, I send you an abstract of the case of Stephens. It was one of spotted fever oc- curring in a young man of temperate habits, setting in with languor fol- lowed by rigor. I saw him on the 4th day, when there was unpleasant heat of surface, with general tenderness all over the body, particularly remarkable over the epigastric region ; the chest, and hands, studded with florid maculse; headache and pain of back distressing; light disagreeable ; pulse 108 ; tongue moist. He had an oil draught, followed by small doses of hyd. c. cret. c. pulv. Dover. On the 6th day of his lever, being very restless and sleepless, eyes slightly suffused, and pulse 120, I gave him an eight-ounce mixture, containing four grains of tartar emetic, and a drachm of tincture of opium; two tablespoonfuls to be taken in the evening, and one every hour afterwards. On the next day the report was, that he had slept a good deal during the night, having fallen asleep after the third dose, three hours after which a fourth was administered. He is dozing; FEVER. 149 pulse 120 ; skin hot and dry ; bowels four times moved ; ordered to con- tinue his mixture, watching its effects. On the 8th day, in consequence of severe purging having set in (he had taken but two doses of the mix- ture since last report), the epigastrium becoming very tender, and pulse 132, his medicine was omitted, and a cretaceous mixture ordered instead, a small quantity of port wine diluted, and a blister to the abdomen ; the blister was not applied, yet the purging was checked. On the evening of the 9th day, as he complained much of want of rest, and there was no headache, I directed him to have two doses of the tartar emetic and opium mixture, within an interval of two hours. I was compelled at this period to give up attendance on this case in consequence of an accident; it was, however, taken up by my friend Dr. Grant, who kindly kept notes, and with whom I had daily conferences. He reports our patient, on the 10th day, to have suffered an accession of fever, seemingly caused by abdomi- nal irritation ; he complained much of headache ; the eyeswere injected; skin hot and dry ; tongue brown and crisp ; pulse 144; respiration 49; throbbing of the temporal arteries ; when undisturbed, raving and moan- ing, but answers rationally ; abdomen full and tense, tenderness in region of colon, with some tenesmus; sleeplessness. He was given calomel, gr. iv. ext. hyosciami, gr. iii. followed by an oil draught; a blister was applied to the abdomen ; cold to the head, and warmth to the feet. The medicine acted well, producing a number of dark-coloured motions, with some relief of the symptoms ; the sleeplessness, however, still continuing. On the 12th, raved considerably the previous night, with great restless- ness ; headache, with darting pain ; pulse 120 ; still answers rationally, but raves when left to himself; abdomen soft; he was again put on the use of the tartar emetic and opium mixture, to have one tablespoonful every hour for three doses, and then only every second hour. On the following day there was a considerable improvement; he had slept well, and perspired freely in the night ; no raving; headache gone ; pulse 96 ; heat of skin less ; to continue his mixture. On the 14th day he was much better ; he wished for food. On the 15th day he suffered a relapse from his appetite having been imprudently indulged ; he was given an oil draught, and directed to resume his mixture when the bowels acted. He continued from this time to improve, the interval between the doses of his mixture was gradually lengthened ; and on the 17th day he was conva- lescent. " In this case, the good effects of this mixture were evidenced by perspiration and rest. This lad's mother and sister were just convalescent from spotted fever ; the former four weeks, the latter a fortnight. In the mother's case, I was not applied to till the 10th day ; it went on to the 21st. There was not any organ particularly implicated ; she was treated with stimulants, carb : ammonise, porter, and blisters. In the daughter, the fever was very severe to the 11th day, when it terminated by profuse perspiration. She suffered principally from pain in her head and back, with intolerance of light, and was treated with mild aperients, followed by diaphoretics with hyoscyamus. In neither was sleeplessness distress- ingly remarkable. Another brother was seized with the same form of fever a few days after the subject of this case had taken ill ; he was on the 5th day transferred to Sir Patrick Dun's Hospital. " I experienced marked benefit from this form of prescription in a case of melancholia, occurring in a female aged 45, consequent on a severe 150 CLINICAL MEDICINE. domestic affliction. The exhibition of it here, however, was followed by considerable debility, requiring stimulants. This effect I consider to have been, in some degree at least, attributable to the patient having for some days previous to its exhibition refused food, and possibly been suf- fered to remain too long under the sedative influence of this medicine without having been offered nourishment. " Hoping that you will excuse the hurried manner in which this case has been thrown together, " Believe me, my dear Sir, yours, "Henry Dwyer. " Cumden-street, July 10, 1836." Case VI.—John Dillon, aged 15, a servant, admitted 5th June, 1835, several days ill. On the day of his admission he had headache, thirst, heat of skin, loss of appetite and rest ; his face was flushed and bloated ; eyes suffused, red, and prominent; skin hot and dry ; he complained of slight epigastric tenderness and violent headache ; pulse were 120, full and bounding ; his whole body was covered with maculse; bowels regu- lar ; tongue brown, furred, and dry. Ordered, R. Aquse fontis, §i. Liquoris (,'hlorid. Sodse j.tt. x. M.fiat haustus quartis horis sumendus appl. hirudines, xii. pone aurem, et reietatur applicatio si opus. 7th. The leeches bled freely ; head appears to be relieved ; he raved a good deal during the night ; his pulse has fallen to 100, but still very full; has a slight cough, and some bronchitis. Ordered to repeat the draught, and apply four leeches to the larynx. 8th. Slept very little; does not appear improved; very irritable; raved, and was rather violent during the night ; cough better ; tongue very brown and dry ; bowels confined ; pulse 100 ; respiration rather hurried. Ordered to repeat the draught, and to have an emollient enema in the evening. 9th. Epigastric tenderness much increased ; raved continually during the night ; slight subsultus; eyes very red, wild and staring ; pulse 114, very full ; tongue dry and brown ; teeth covered with sordes. To repeat the draughts, and apply eight leeches to the epigastrium. 10th. Appears better to-day ; epigastric tenderness much relieved by the leeching ; his strength is much prostrated ; wishes for more food ; pulse 100, and still full; slept none. Ordered arrow-root, and to repeat the draughts. 11th. The fever is again much increased ; raved violently durino-the night ; great prostration ; slept none ; subsultus very violent ; great thirst ; pulse 130; complains of a heaviness, but no pain in head : skin very hot and dry ; eruption undiminished. Ordered to repeat as before. 12th. All the symptoms much aggravated, face flushed and red ; eyes suffused and ferrety ; teeth covered with sordes; lips parched and cracked ; tongue black and very dry; subsultus general and violent; does not sleep either by night or day; exceedingly irritable; pulse 130 and jerking; pupils contracted ; he lies on his back with legs drawn up ; extremi- ties rather cold. He was ordered warm applications to his feet and the following prescription : — R. Tartar emetici, gr. ii. Mistura? camphors, 3viii. Tincturae opii, Qii. M. Sumat coch- leare, i. amplum 2a q.q. hora. FEVER. 151 13th. The nurse reported that after he had taken the mixture three times, he slept calmly for nine or ten hours, the first time for the last week. It operated largely after the second dose, the stools being thin and bilious. He has ceased to rave ; the suffusion has quite disappeared ; tongue is moist and cleaning. He slumbers continually, subsultus completely sub- dued ; answers questions rationally ; pulse has fallen to 98 and soft; ordered to repeat the mixture. 14th. Slept continually since last report ; general appearance much improved ; perspired profusely during the night. He was perfectly sen- sible from this day till the 17th. He continued to improve rapidly in strength and appearance. 17th, convalescent. Case VII.—Mr. S.----, residing in College, was attacked with head- ache, on the 3d Feb. 1836, and fever commenced on that or the follow- ing day. He was judiciously treated by Mr. Barker, of Britain-street, until the 4th day of the fever, when an increase of headache and pain in or behind the ball of the right eye, induced him to call me in. A bleed- ing from the arm much relieved the pain, and he spent a tranquil night. He got calomel and James's powders in small doses. On the 5th no change. 6th day of fever, macula? began to appear, and his state became more alarming. 7th day, maculse abundant, restlessness, debility, very frequent sighing, thirst, &c, with a sharp pulse, and return of headache. Leeches to head and nostrils were ordered ; the latter because of an evi- dent tendency to epistaxis. 8th. Sir Henry Marsh saw him along with us. 9th and 10th. Grain doses of Dover's powders added to his medi- cine four times in the night, but did not produce rest. 11th. Perfectly sleepless night and day ; ordered in the evening, one grain tartar emetic, 4 ounces of camphor-mixture, and one scruple of laudanum ; 1 table- spoonful every second hour. 12th. Moisture on skin ; began to sleep after second dose, and slept several hours tranquilly ; is to-day quite free from muttering and raving, which had commenced on the 10th day, and increased on the 11th ; so that when left to himself he lay on his back constantly speaking, but not in a loud or boisterous manner, his eyes being all the time open ; when addressed, he answered quite rationally, but on our quitting the room began again immediately to ramble. This group of unpleasant symptoms having disappeared, we did not continue the medicine, but ordered palliatives and mild nourishment; in the even- ing it was judged right to apply a blister to the nape of the neck. 13th day, maculse very abundant; was quiet during the night, but did not sleep at all ; exhausted and nervous ; other symptoms moderate ; pulse 104 ; tongue moist ; abdomen a little swollen and slightly tympanitic ; turpentine injections ; continued palliative diuretic draughts ; chicken- broth ; claret and water. At 5 p.m. I again saw him, and found him still quite sleepless, but without headache; bowels moved, but still slightly tympanitic. Fearing the continued exhaustion from want of rest, I now ordered a mixture consisting of one ounce of mucilage of gum arabic, seven ounces of camphor-mixture, three grains of tartar emetic, and one drachm by measure of laudanum ; half an ounce every second hour until sleep comes on. At ten Sir Henry Marsh and Mr. Barker saw him ; he had slept an hour ; appeared drowsy, and did not complain of headache; two doses of the medicine had been given ; he remained awake until eleven, when another dose caused him to sleep until three ; at four ano- ther was given, after which he slept until eight, and awoke much refreshed, 152 CLINICAL MEDICINE. and much improved in every respect; his belly had not been moved, and was still slightly tympanitic, a symptom which yielded to the administra- tion of two drachms of castor oil exhibited in the form of an aromatic emulsion. In the evening he was ordered to take four drops of black drop, but this procured no sleep during the night. On the morning of the 15th day we found him somewhat exhausted from a sleepless night, but with much less fever and no headache ; pulse 94, soft; for the first time we remarked subsultus ; a family idiosyncrasy rendering musk pe- culiarly disagreeable, or even intolerable, we ordered a draught containing two drops of black drop, and fifteen of Hoffman's liquor, every fourth hour. In'the evening he had slept very little, so that I resolved again to recur to the antimonial opiate ; two spoonfuls of which produced sound refreshing sleep for several hours. In the morning he again got castor oil; and on this, the 16th day, his pulse was only 70; but still, though the subsultus was diminished, a remnant of it could be perceived, so that he could not be pronounced out of all danger. The conclusion of this case is peculiarly instructive, and proves how insidious is the progress of fever, and how unsafe the condition of a patient whose brain and nervous system have received a violent shock, even al- though the immediate consequences of that shock have been averted by the employment of decided treatment. On the 16th day we have seen an abatement, or rather a disappearance of almost every symptom of the dis- ease, save and exc.ppt a slight, a scarcely perceptible remnant of the sub- sultus. Great care was taken to prevent his being disturbed, and the strictest attention as to diet was enjoined; indeed he was remarkably dis- inclined to taking food, and it was with great difficulty that we could get him to consume a sufficient quantity of mild farinaceous diet. On the night of the 16th day he slept tolerably. The 17th day was passed without any change; but he slept none that night. The 18th day he was perfectly free from fever; pulse 70; tongue moist ; bowels opened by medicine. That day he conversed too much to his friends about his removal to the coun- try, his future plans, &c. ; but nevertheless he slept several hours towards evening. This sleep was disturbed and chequered by dreams, and on awaking about eleven o'clock, he was wandering, and got eight drops of black drop, which procured no rest; on the contrary he got several times out of bed, and spoke incoherently. The raving had all subsided at 10 a.m. on the 19th day, when I was in hopes it was entirely owing to temporary excitement, and would not return ; an opinion rendered proba- ble by a total absence of all symptoms of general or local vascular excite- ment, of headache, &c. In this expectation, however, I was disappointed, for early in the afternoon he became incoherent; raved more and more every hour; complained of headache ; could not bear the light; and when I saw him at seven, he was quite irrational; supposed himself to be travel- ling; and when questioned he seemed not to understand ; his pulse had fallen below60; was soft, irregular, and intermitted very frequently; skin not hot; feet cold ; features contracted ; tip of nose cold ; he had eaten stirabout in small quantity twice during the day, but in a voracious unnatural manner: his eyes were a little red, and every thing wore a most threatening aspect. What was now to be done? In directing his head to be shaved anew, and in applying blisters to his scalp and temples, I felt I wras proceedin» on sure grounds; but the indications for the internal treatment were less obvious. We had arrived at the 19th day, and he had gone throuo-h a debilitating fever, and had been submitted to a very active mode of treat- FEVER. 153 ment. Were we to leech the head? were we to apply cold? and should we immediately endeavour to mercurialize the system by means of mer- curial preparations, given internally and applied externally? Such would have been the treatment a patient, under similar circumstances, would have undergone at the hands of any practitioner a very few years ago ; and I have no doubt that a treatment of this nature would have speedily brought matters to a fatal termination. The writings of Gooch, however, who pointed out the diagnosis and treatment of certain cases, usually confounded with inflammatory hydrocephalus, and the influence of the truth of Dr. Gooch's statement, as illustrated by several examples in our own practice, determined Sir Henry Marsh, Mr. Barker, and myself, to rely on the severe blistering locally, while internally, we ordered a draught consisting of two grains of carbonate of ammonia, twenty drops of Hoffman's liquor, and one ounce of camphor-mixture, to be taken every third hour. Warmth was applied to the feet, and he was supplied with warm whey. Shortly after our visit he fell asleep, slept with little interruption for about seven hours, and awoke perfectly rational; and at eight o'clock next morning, being the 20th day, we found him much better in every respect; the only vestige of this alarming attack that remained being some intermission in the pulse, which had become in other respects much more natural, and fuller. The bowels had not been opened; a circumstance I mention be- cause, no doubt, some would have ordered purgatives on such an emer- gency, a practice which the fallen, soft state of the belly did not seem to us to call for, and which our view of the nature of the case prevented us from proposing. We ordered farinaceous diet, and a repetition of the draughts, at longer intervals. In the evening of the 21st day the pulse had lost all remnant of irregularity or intermission, and the disturbance of the nervous system had entirely subsided: from that period his convales- cence commenced. One fact connected with the cases just related is very striking, viz. the small quantity of laudanum which, in most of them, was sufficient to induce sleep; a circumstance only to be accounted for by the presence of the tar- tar emetic, which no doubt exerts, when given in duly regulated doses, a powerfully tranquillizing effect on the nervous system. It is also deserv- ing of remark, that the medicine very seldom gives rise to any of the un- pleasant symptoms that so frequently arise when opium alone, or any of its preparations, are given with a view of producing sleep at an advanced period of fever. The addition of one ounce of mucilage, and one ounce of simple syrup to the mixture, seems to render it less likely to disagree with the stomach. Towards the termination of fever, it not unfrequently happens that a sudden or gradual determination of blood to the head arises, and which requires a repetition of a modified system of antiphlogistic treat- ment, aided by blisters. This state, I have reason to believe, may be often prevented from occurring, by a timely attention to procuring sleep; for a patient in fever, who has passed several sleepless nights, is on the verge of cerebral congestion or inflammation, as is testified by headache, wan- dering, and the redness of the conjunctiva. Here it is that the treatment I recommend is so advantageous, when timely applied; for if it be de- ferred until cerebral inflammation has set in, opium in any shape is worse than useless. I have notes of several other cases, equally strong, in favour of the utility of tartar emetic and opium in the advanced stage of fever, but think 154 CLINICAL MEDICINE. it unnecessary to bring them forward, as the above seem sufficient for my present purpose. The particular state of the nervous system to which this combination of remedies is best adapted, may occur, along with other symptoms produced by functional or organic lesions of various organs, and which prevent it from producing the wished for beneficial result. Thus when the belly is tense and swollen, this remedy will generally fail; but I think that I am warranted in asserting that in fevers, properly treated from the first, tympanitis may commence, but will never become consider- able; for, if the attention of the practitioner be applied to this symptom the moment it begins to show itself, he can in most cases succeed in arrest- ing its progress. I have likewise seen several cases of fever, where I ex- pected benefit from the tartar emetic and opium, and in which no good result followed the exhibition of these medicines; such failures must always occur with respect to every remedy we apply in disease, but they do not invalidate the evidence of facts, such as I have brought forward in proof of their frequent utility. In connection with this subject, I beg leave to draw the attention of practitioners to the occurrence of delirium traumati- cum in fevers, in consequence of the irritation produced by blisters, a spe- cies of delirium apt to be mistaken, especially in children, for the delirium ushering in hydrocephalus. It is unnecessary to do more than advert to this subject, as I have spoken of it at some length in the lectures before referred to. To conclude, it is right to remark, that the relative propor- tions of tartar emetic and laudanum in the mixture must be varied accord- ing to circumstances. When congestion of the brain is known to exist, or is feared, the tartar emetic must not fall short of four grains in the eight ounces, while the laudanum should not exceed half a drachm; but where nervous symptoms predominate, the laudanum may amount to one drachm, and the tartar emetic to two grains: no general rule, however, can be laid down, and the practitioner must in all cases watch the effects of this medicine, from hour to hour, until he ascertains whether it agrees with the patient or not. Where a life is at stake, we must spare no pains, and must not reject a remedy because its powers render it an instrument of good or evil, accord- ing as it is administered carefully or otherwise. ARTICLE II. The following cases occurred since the publication of the last number of this Journal, and I hasten to publish them, for many reasons. In the first place they prove that tartar emetic, in considerable doses, may be admi- nistered with advantage at a period of fever in which it was usually thought to be inapplicable, and to an extent which even now I cannot but consider as remarkable. In my former communications upon the use of tartar emetic and opium, I had not pushed the former remedy with the boldness and decision I have since done, for my experience only gradually accustomed me to a method of proceeding contrary to preconceived opinions, and my views of the powers of the remedy only gradually en- larged as I became more confident of its safety. It is but right to add, and I do it with gratitude, that I received much assistance and encourage- ment from the views of Dr. Marryatt of Bristol, published in 17^S, but of which I and the profession in Ireland, and I may add in England, were generally ignorant until they were noticed in the last April Number of the British and Foreign Medical Review. This notice of a work, of which I FEVER. 155 had never before heard, and the testimony it contained that tartar emetic maybe exhibited in considerable doses, and with advantage, at advanced stages of malignant fever, led me to attach more importance to this re- medy alone, and uncombined with opium, and determined me to adopt a bolder line of practice in future, a determination which the event fully justified. Some there are who will take occasion to remark that I can have no claim to originality on this occasion. But all who have watched my practice in the hospital, nay, all who have taken the trouble of reading my lectures and successive publications on this subject, will at once ac- knowledge that I proceeded on this path of investigation with no other guide but an analogy derived from an observation of the effects of tartar emetic and opium in delirium tremens, a disease undescribed in the time of Marryatt. Every one the least conversant with the treatment of fever in private and in hospital practice in Dublin, London, and Edinburgh, will allow that no one during the present century ever taught or practised the exhibition of tartar emetic at the stage of typhus fever in which I have recommended it. Not a single hint at such a treatment is given in any of the numerous contributions on the treatment of typhus, which form the valuable work edited by Dr. Barker and Dr. Cheyne. Where is there even one allusion to this practice in Armstrong, Smith, Tweedie ? And what is said of it in Good, Thomas, Mackintosh, or in the Cyclopsedia of the Practice of Medicine? Where is it mentioned or inculcated in the Edinburgh Medical and Surgical Journal, or in Johnson's Medico-Chi- rurgical Review ? Nowhere ; although the treatment of fever is often the subject of anxious discussion. So far suffices with regard to the novelty of the matter, for it is useless to argue with persons so stupid as to confound the practice I recommend with the well-known and popular use of tartar emetic as an emetic or a diaphoretic in the commencement of febrile diseases generally. That I did not come upon this method sooner, I regret infinitely, for since its adoption, my practice in hospital and in private has been much more for- tunate than formerly. Nay, shortly before Mr. Cookson's illness, I lost several of my friends, relatives, and patients, who would in all probability have recovered if so treated ; and among the rest a gentleman, the very week before the first trial I made of the practice in Mr. Cookson's case. I mention this fact as the strongest and most convincing proof that I had never even thought of this method until Mr. Cookson's case occurred, for had I done so I would have surely been inexcusable in allowing my pa- tients to perish without even trying its effects. But it is time to proceed to the cases themselves. The first case occurred very lately in the Meath Hospital, where its progress was anxiously watched by many students and several practitioners, all of whom concurred in the opinion that the patient must have died had he been treated according to the plan usually followed under similar cir- cumstances. This patient was attended under my directions by Mr. Har- nett, who took the following notes of its progress, and visited the patient with unremitting attention both by day and by night. Joseph Taylor, aged twenty-one, a strong young man, of temperate habits, admitted into hospital on the 7th May, 1836. Ill seven days; sickness commenced with rigors, headache, pains in loins, &e. On ad- mission he complained of headache, tinnitus aurium ; face was flushed ; 156 CLINICAL MEDICINE. eyes slightly suffused ; was constantly frowning ; skin hot and dry, slightly maculated ; abdomen full and soft ; bowels confined. Habeat Haustum Rhei. 9th. Slept pretty well; raved little; ringing in ears continues; head- ache increased ; eruption of maculse much more copious ; slight cough ; some bronchitic rales over both lungs ; abdomen in every respect natural; bowels regular; pulse 100, distinctly dicrotous and sharp ; tongue brown, dry, rough, and furred ; had slight epistaxis three days ago. R. Pil. Hydrarg. gr iii. Pulv. Ipecacuanha; gr. ss. M. Ft. pilula 4tis horis sumenda, applicentur Hirudines ii. naribus et repetatur applicatio hirudinum vesperi si opus. Tenth day of fever. Slept tolerably well ; bled copiously from nares ; pain in head diminished ; countenance still flushed and hot ; temperature of rest of body lower than natural ; feet very cold ; pulse 112, dicrotous and wiry ; tongue parched and furred, dark brown, great difficulty in pro- truding it. Stupes to feet, blisters to prsecordial region ; blisters to calves of legs in the course of the day. R. Mist. Camphorae ^i. Liquoris Hoffmanni gi. M. Ft. Haustus 4tis horis sumendus. Eleventh day. Became very violent yesterday evening; attempted to get out of bed frequently, but when spoken to by the nurse, he remained quiet for a short time ; was constantly raving and gnashing his teeth du- ring the night ; had no sleep ; a short time before visit this morning, had a fit of an epileptic character, which lasted about ten minutes, in which he worked violently, and foamed at the mouth ; at the hour of visit, nine in the morning, the countenance was flushed, anxious, and expressive of great ferocity; eyes wild and suffused ; pupils natural ; complains of dim- ness of vision ; eye-brows contracted ; breathing hurried ; is constantly tossing himself from one side of the bed to the other, and tearing the dressings off the blistered surface ; skin hot and dry ; abdomen soft ; no tympanitis ; bowels loose ; tongue parched and furred ; he is incessantly protruding and biting it, and gnashing his teeth ; pulse dicrotous, very quick, and somewhat hard, but small. R. AntimoniiTart.gr vi. Aqua? Fontis 5X. Mucilaginis Syrupi Papav. albi ai ^i. M. Ft. Mistura, sumat ^ss. omni semihora. Three o'clock, p.m. Has taken half the mixture, was nauseated by the second dose, but not since ; he still continues very violent ; fancies he has a bone in his mouth which he is constantly biting ; is in a copious perspiration since he commenced taking the medicine. Mr. Harnet ordered ^i. of the mixture every half-hour. Six o'clock, a.m. Appears a little calmer ; has taken the whole of the medicine, no nausea produced ; has bitten his tongue and lip severely ; perspiration continues ; has passed a large quantity of urine in bed ; pulse soft and full. R. Antimonii Tart. gr. iii. Aqua? Fontis 5vss. Syrupi Simplicis^ss. M. Ft. Mistura cujus sumat ^ss. omni semihora.. Eleven o'clock, p.m. Has taken all his medicine without being nau- FEVER. J 57 seated; countenance less flushed; is constantly raving; pulse 100, full and soft. R. Antimonii Tart. gr. iv. Mist, camphorae 3viii. Tinct opii. gi. M. Ft. mistura < ujus capiat §ss. omni semihora. 12th. Continued raving through the night; had no sleep ; appears much quieter this morning ; face less flushed ; eyes still wild and staring, but very slightly suffused ; brows contracted ; pupils natural ; speaks rationally; pulse 80 and regular, has lost the dicrotous tone which it had yesterday ; bowels confined. Habeat enema emolliens, rept. mistura ; to have one pint of porter and chicken-broth. Three o'clock, p.m. Having taken the whole of the mixture, contain- ing tartar emetic and opium, the simple tart, emetic mixture was again prescribed ; after taking two doses of which he fell into a tranquil sleep, in which he is at present. Eight o'clock, p.m. Has slept continually all day, awakes occasionally, but falls into a deep sleep very soon again. Omittatur tinct. opii. 13th- Slept soundly during the night ; appears calm and collected ; conversation quite rational; maculse have disappeared ; pulse 84, soft and regular ; omit medicine ; a glass of porter ; light nourishment. He has taken more than twenty grains of tartar emetic within thirty hours, and has been nauseated but once. There are some circumstances in this case which require to be con- sidered more at length. In the first place it is well to bear in mind that the patient was affected with genuine maculated fever, the true typhus, in the form many years present in Great Britain and in Paris ; for in the latter city this peculiar eruption, somewhat resembling measles in the crescentic shape of the blotches, is considered quite pathognomonic of typhus.* This is important, particularly with reference to the use of tartar emetic in such large quantities ; again it is worthy of remark, that symp- toms of collapse, so alarming as to excite considerable apprehensions, and calling for the immediate application of blisters and the use of stimulants, occurred on the 10th day of the fever. It was immediately after this col- lapse that the violent cerebral excitement commenced, and certainly this previous collapse left an impression on my mind that no directly evacu- ating remedies could be borne; that they would, at least, be attended by great danger of speedily reproducing a fatal degree of debility ; for this reason I did not repeat the application of leeches. The delirium in this patient was extremely violent, requiring the use of the strait waistcoat, * [This remark of Dr. Graves is certainly erroneous. The eruption of rose-coloured spots on the abdomen and thorax is, it is true, one of the pathognomonic symptoms of the typhoid fever of Paris, but at the same time it is very different from the abundant eruption of maculse resembling measles which occurs in true typhus fever. The latter covers the whole body, and is not confined to the abdomen, thorax, and occasionally ihe upper part of the thighs.—W. W. G.] 158 CLINICAL MEDICINE. and the constant superintendence of the nurse ; the contortions of face, and the ferocity of his countenance, the constant biting of his tongue and lips, presented a frightful picture of excitement, which evidently could not be controlled except by the prompt and energetic use of powerful remedies. As the blistered surface on his chest seemed to add much to the state of excitement, for he was constantly tearing it, I did not think of applying blisters to the head, being persuaded that they might aggra- vate the evil, since in many they seem to act so as to produce a sort of delirium traumaticum. His pulse being frequent and sharp, together with the evident determination to the brain, seemed to indicate the exhibition of tartar emetic, nor was there any thing in the state of the intestinal canal to forbid its being given in frequently repeated doses. The result more than realised our expectations, for during its use the delirium gradually abated, and the pulse, becoming much less frequent, changed its character from a short and small, to a full soft stroke. This prepared the way for the safe trial of opium, which was not commenced until he had taken twelve grains of the tartar emetic. The opium was afterwards laid aside, and the tartar emetic alone completed the cure ; but it may be doubted whether alone it would not have induced sleep. I have made these remarks for the purpose of rectifying an erroneous impression, which I fear has gone abroad concerning the use of tartar emetic and opium in the delirium of fever, and to prevent, as far as I can, the exhibition of opium, except when certain precautions have been taken by the practitioner to remove or diminish cerebral congestion by means of proper evacuations or tartar emetic. No man can justly be held re- sponsible for the abuse by others of remedies he recommends ; but since the publication of my paper, in the last number of the Dublin Journal of Medicine, I have had lamentable proofs that I have been misunderstood ; and lately was called to see a gentleman in the vicinity of Dublin, who, the practitioner in attendance vsaid, had been treated according to my method, whereas the patient was killed, according to his own, by opium injudiciously given during delirium with evident cerebral congestion. It has been asserted, that after all, this case was not so dangerous, nor its recovery very remarkable. For a full refutation of so groundless an opinion, I refer with confidence to the written history of the case itself, a history which is far from laying before the reader an adequate picture of the deplorable state of the patient at the time that my treatment was about to be commenced, but which, nevertheless, is still faithful enough to con- vince every one at all acquainted with the symptoms and progress of fever, that the case was almost hopeless. What! is it possible that any one can be found, who has witnessed fifty cases of bad fever, and who is bold enough to say, that because the patient is young and was previously healthy, he could not be considered in imminent danger, when on the tenth day of spotted fever, a state of collapse requiring blisters and stimu- lants is followed on the eleventh day by delirium of the most violent de- scription, rendering it necessary to tie the patient down in bed, and accompanied by a fit of convulsions of frightful violence, lasting more than ten minutes, and resembling an epileptic seizure ? This last symptom alone is more than enough to denote extreme dan- ger. For the truth of this assertion, I appeal to my own experience, to the experience of every practical man, and to the writings of every author who has written on fever. Hippocrates has four aphorisms, all testifying FEVER. 159 the danger of convulsions in fever; and in his book of prognostics, he says, that various causes may, in fever, produce convulsions in children under seven years of age, without great danger to life ; but he adds with great emphasis, in adults, convulsions never take place unless " when nineteen years and three months old, the catamenia became irregu- lar, occurring only every second month, and even then scarcely percep- tible ; since the catamenia became so irregular and scanty, the fits of ner- vous terror and epilepsy became more frequent and severe, generally occurring every day, and sometimes three or four times daily ; occasion- ally absent for several days, but always returning with a force stronger in proportion as they were longer absent. " In the milder form these fits consisted in an overpowering feeling of terror, in its stronger form a loss of consciousness and convulsive action ; in one of these last she fell into the fire and her cheek still bears evidence of the fact. " 23d August—Yesterday, the 22d, she had a trifling manifestation of the catamenia, being then six weeks since they last appeared, and as nature usually in healthy cases continues this action during three succes- sive days, I did not hesitate to apply the electro-magnetic current this day to the region of the uterus in my usual manner. " 24th—Found that yesterday's application, being in the proper time, had the desired effect, and the catamenia were renewed and larger in quantity than she had ever had them. This day also (being the third day of the menstruation), the catamenia still continue, and are equal in quan- tity to that which attends a healthy woman. "26th—Feels light and well, countenance natural, and has had no return of the fits since my first application of electricity to her, although previous to that time she had them each day since her admission to hos- pital. " 29th—Continues well and much improved in appearance. " Richard Brennan, labourer, aged 55—temperament, sanguineous— admitted, 12th July, 1842—discharged, cured, 27th August. Disease, lumbar rheumatism and sciatica, with neuralgia adjacent to the rectus femoris, vasti and other anterior and interior femoral muscles. Has been afflicted in this manner for more than three years ; attributes it to working when standing up to his hips in cold water. His case resisted all the usual treatment from the 12th ult., or nearly one month ; on the 8th, 9th, and 12th inst., I applied electricity (secondary current). " 12th August—Perfectly cured and continued well up to the day of his discharge ; namely, 27th inst. This was a most successful case. " Edward Murphy, labourer, admitted, 22d August ; discharged, 30th August, 1842 ; late of Liverpool and Manchester Railway. Disease, pain in the left side ; also in the os frontis, sternum, and clavicle ; also intense neuralgia, particularly at night, along the anterior and interior femoral muscles, as rectus, vasti, &c, &c, of right side, also pain in right knee. These pains usually became excruciating as soon as be became warm in bed, generally obliging him to leave his bed and attempt to walk, but at such times he could only do so by leaning on the hospital bedstead : there always remained in the morning a soreness of the part, yet it was not a cramp. " 23d—This day could not walk without a stick ; and having yesterday gone down stairs, could not return for nearly two hours, owing to the 368 CLINICAL MEDICINE. pain. Had severe pain this day, previous to my applying magnetic electricity, which relieved it much. " 24th—Learned that the pain did not return as usual on his going into bed, and only appeared lightly near morning, and then did not deprive him of use of the limb. He is much pleased at success of the electricity. " 25th—Found him free from pain, neither had he any on the pre- ceding night. Applied electricity as before. " 26th—Continues well. Electricity no longer necessary. This was a most successful case, and was quite similar to that of a man named Ryan, a Castle messenger, whom I treated equally successfully, in Saint Vin- cent's Hospital, in May last. This case had resisted the usual medical treatment. "John Kelly, aged 40—temperament, bilious—admitted 28th July, 1842. Disease, paralysis of lower extremities, with enlargement of plantar arch of left foot, particularly anterior and inferior to inner ankle—late servant to Mr. John Little, of Carrick-on-Shannon. About two years ago, appetite began to fail; soon afterwards, felt as if stockings were gartered too tightly, which sensation lasted for nearly twelve months, during which time general lassitude was very distressing. This was suc- ceeded by a giddiness in the head, lasting about three-quarters of an hour each morning, and subsequently by pain in the instep and inner ankle of left foot, and an enlargement inferior and anterior to it. In December, 1840, this enlargement became very considerable and hard, and the entire left lower limb became swollen, and was bandaged by a physician in Carrick-on-Shannon. About this time he lost the power of moving the lower extremities for three months; he had also inability to pass urine, except by an instrument, for a month ; the arms were partially paralyzed at the same time, and he had moxas applied to the spine : he had six weeks previously been cauterized on each side of the dorsal spine, near its upper part, by a practitioner in Birr (King's County), without effect. The moxas were applied to the origin of sciatic nerve ; this took place in March, 1841, and by June of that year, he could walk on flat ground, but not safely up or down stairs ; and from June, 1841, to the present time, nearly fourteen months, continued in the same state, able to walk (on flat ground only) about one mile, with much stiffness of limbs, but unable to ascend or descend stairs safely, and therefore unable to follow his usual duty of servant. " No treatment, whatever, was given to this man except electrical. He has been electrified by me, since the 8th inst. (now the 29th), thirteen times, and is now nearly cured of paralysis. He moves with much more freedom, and not only walks up stairs, but is able to run up, taking*two of the large stone stair-steps at each spring, touching, however, the banister with his hand as he springs. The enlargement of the plantar arch is a good deal diminished, and I expect a perfect cure will be made in another week." REMARKS ON MEDICAL AND ATMOSPHERIC ELECTRICITY. BY EDWARD S. CLARKE, M.R.I.A. IN A LETTER TO DR. GRAVES, M.R.I.A. ETC. " Dear Sir—In accordance with your wish I send herewith brief notes of all the cases in which I have applied magnetic and voltaic electricity ELECTRO-MAGNETISM. 369 to patients in the Meath Hospital during the past three months, and also of two cases which I undertook in St. Vincent's Hospital. " I need hardly add that my private practice, under the guidance of yourself, Sir Philip Crampton, Sir Henry Marsh, Dr. Stokes, Surgeons Cusack, Smyly, Kirby, and other distinguished members of the profession in Ireland, would furnish additional instances in abundance of the very high importance of the various forms of electricity in the treatment of many otherwise incurable diseases. " With reference to the apparatus I employ in such cases it varies much with the nature and extent of the disease. In most instances I use the secondary current developed either by a permanent magnet, or an electro- magnet, the magnetism of this latter being occasionally excited by a voltaic sustaining battery of the form described by me in Sturgeon's Annals of Electricity and Magnetism ;* and sometimes by a very potent thermo-electric arrangement, which I have lately devised, and which of itself promises to be productive of very important results in many cases where electricity of very low tension is desirable. All these instruments transmit their electric currents by directors furnished with moistened sponges instead of steel needles as formerly used with Cruikshank's form of battery ; a construction which I now rarely employ, and never transmit its current through any except platina needles. " The electricity derived from friction of glass, as the aura, sparks and shocks, I have not discarded, on the contrary I find the latter (sparks and shocks) to effect good service when other forms have failed, as in some varieties of catamenial suppression, in some rheumatic cases, and as resolvents of scirrhous and indolent tumour. The results in the Meath Hospital cases include—amaurosis; ptosis ; complete paralysis of right lower extremity ; partial paralysis of both lower extremities ; complete paralysis of right arm ; lumbar rheumatism ; sciatica ; neuralgia, femoral and brachial; edema ; catamenial suppression and irregularity ; spinal irritability. In fine, even in the short time I have had the honour to act under the guidance of the physicians of Dublin (only three months), I have verified nearly all the efficacy which has hitherto been attributed to this science, and great as I have shown its importance as a medical agent to be even in the narrow limits as yet assigned to it by the profession, I feel assured that it will soon be found applicable to a far more extensive range of diseases, and that higher triumphs await its progress, when it shall, by the profession, have been employed to stimulate the functional performance of more important organs found on a deliberate consideration of the theory which has led to its adoption as a medical agent, namely, its identity with the nervous influence ; and, perhaps, in illustration of this view you will permit me to take a hasty retrospective glance upon the causes which have gradually led to the introduction of electricity among medical agents. " Even before the present century, when that form of electricity was alone known which is developed by the friction of glass and silk, the rapidity with which volition was transmitted along the nerves to the mus- cles, had induced many persons to suppose that this was the agent em- ployed by nature to traverse the high road of the nerves as the messenger of its will, and it was then remarked by these observers, that these latter bodies were by far better conductors of electricity than any other portion * " Sturgeon's Annals of Electricity and Magnetism, vol. iii-, p. 84. 25 370 CLINICAL MEDICINE. of the human frame. It was subsequently observed that a strong spark or passage of electricity along any nerve called its dependent muscles into action ; these facts, combined with others, led many, even at that early period, to believe that the nervous influence and electricity were identi- cal ; still it was difficult to conceive how electricity of such high tension could exist in the human body, the fluids of which endow the entire with power of electrical conduction. But when the genius of Volta had at the commencement of the present century unfolded to the world a new form of electricity of tension so low that, with the exception of the nerves, which are excellent conductors, the animal solids would transmit it with difficulty, and when it was further seen that this new form of electricity, thus developed in a state of tension so low as to be quite consistent with the structure of the human body, exerted on the muscles, when transmitted to them by the nerves, a stronger action than frictional electricity had ever done; and further still, that animal matter alone, independent of metals, could constitute an arrangement capable of developing this elec- tricity, the electro-nervous theory received a great accession of probability. And when at a period a little later our own countrymen* had shown that this electricity of low tension was capable of decomposing saline fluids, and of eliminating their acid constituent at one extremity of the arrange- ment and their alkaline at the other,f it was soon seen that the secretion of our most important organs, as of the skin, stomach, liver, intestinal canal, &c, might be the result of the electrical condition of these organs impressed upon them at birth by Divine power; and hence, after the dis- covery of electro-magnetism by Oersted, the galvanometer was proposed as a means of discovering whether or not these organs, whose secretions are characterised by opposite chemical qualities, were not also in opposite states; and the result of this beautiful test was strongly confirmatory of this theory,| for these organs all indicated opposite electric states whose secretions were of opposite chemical natures. Thus the skin, whose se- cretion is acid, indicated positive electricity when examined by the gal- vanometer, the intestinal canal indicated negative electricity, and its se- cretion has been proved to be alkaline, except in the stomach where it is acid, and there it indicates positive electricity. The stomach was found to be in one electric state, the liver in the other, the chemical nature of the secretions of each organ always according with that character which should result from the peculiar electric polarity in which the organ was found by the galvanometer to be. " Thus it was shown that in all human probability these hydro-electric currents detected by the galvanometer were the cause of all the secretions of our organs. At a still later period that accomplished electrician, M. Becquerel, showed that the acid and alkaline secretions of our various organs reacting on each other through the medium of the muscular and nervous tissues, must of necessity give rise to hydro-electric currents be- tween these organs, and hence the primary electric state of these organs having been impressed upon them at birth by Divine power, the first result was alkaline or acid secretion of each organ according to the electric con- dition impressed upon each—these secretions reacting on each other de- * " «ir Humphrey Davy, Wollaston, Cruikshank, and others. f "Transactions of Royal Society of London, 1814, p. 583; also of 1809. Philosophical Magazine (old series), vol. xxxii., p. 488. $ " Becquerel Traite d'Electricite et du Magnetisme, Tome i., p. 322 to 327. ELECTRO-MAGNETISM. 371 velop electric currents which again produce the secretions and maintain them during life, or so long as the electric condition of the organ con- tinues in its normal state. " In this stage of the electro-nervous theory I might 'easily adduce in its support the opinions of some of the most illustrious names of which philosophy and medicine can boast; but I must not trespass on the page of your valuable labours, and shall only remark that it followed from their opinions, as a matter of course, that at least in many cases abnormal se- cretion was the result of abnormal electric condition of the organs. "The valuable experiment of Dr. Wilson Philip, of Worcester* (made in presence of Mr. B. C. Brodie), on the identity of the nervous influence and electricity, added many converts to the electro-nervous theory. This experiment consisted in the proof that the functions of digestion and respi- ration of which a rabbit had been deprived by cutting the eighth pair of cerebral nerves, namely, the par-vagum or pneumogastric of the modern French school, could be restored by connecting the portions of these nerves which remained attached to the diaphragm with a voltaic battery instead of with the brain, from which the division and turning back of these nerves had separated it. This experiment showed the strong probability—that the secretion and functional action of the gastric juice as well as the action of the lungs, and the motions of the respiratory muscles are dependent for their existence on hydro-electric currents, and if it'did not strictly prove the identity of the nervous influence and electricity, it gave great weight to that opinion, and proved that the latter could be substituted for the former without inconvenience to the animal economy, and lastly, it aided in directing the public mind to the important conclusion, that when dis- ease has impaired the action of these important functions, it probably does so by altering the normal state of the natural electric sources, and that the action of these on the system, which is so essential to our most important secretions, may be supplied by electricity, if this latter be made to resemble that of nature in quantity, direction, and intensity. " We are thus led by the experiment of Dr. Philip, and the amply proved existence of hydro-electric currents circulating between the organs of secre- tion (as proved by Le Donne, Marianini, Orioli, and Becquerel), to see that the processes of secretion and digestion are hydro-electric phenomena, and thence to appreciate the importance of judiciously administered elec- tricity of low tension in restoring a healthful condition to the secreting and digestive organs, and to witness the greatly increasing probability that in all cases of secretion, digestion, sensation, and motion, electricity is the great natural agent and is identical with the nervous influence. It is true that as yet I have not brought forward any argument to prove that electri- city attends, and is the cause of all human motion, a proof which appeared necessary to be given before we could be called upon to acknowledge its identity with the nervous influence. This proof, which could not be af- forded until the connection between the sciences of electricity and magne- tism was well understood, has recently been afforded to a great extent by Dr. Favio and Professor Zautedeschi, in Italy,f who have shown that in- dependently of the electro-chemical currents just alluded to as ruling the secretions, there exists (at least in all warm-blooded animals) another class of electric phenomena, of at least equal importance, presiding as they do * " Transactions of Royal Society of London, 1822, part I, p. 2. + " Bulletin de l'Academie Royale des Sciences ct belles Lettres de Bruxelles, T. vii,, partie 2, p. 43. 372 CLINICAL MEDICINE. over all voluntary motion. These phenomena consist in the passage of an electric current along the nerves of each limb to their corresponding mus- cles, they exist only during the motion of the limb, are detected by the galvanometer, and as they differ both as to source and direction from the hydro-electric currents which, under the guidance of life, cause the secre- tions, their discoverers have named them ' electro vital,' or 'neuro elec- tric' currents. " The experiments of these gentlemen consisted in attaching a metallic stilet to each end of the wire of an exquisitely delicate galvanometer, one of which stilets was kept (by its insulated handle) in contact with the nerve leading to any limb, whilst the other was sunk deeply into the body of the muscle, of which the action was to move the limb. The animal was then excited to move the member, when it became evident, that at the instant of every movement a current of electricity passed along the nerve and gal- vanometer in the direction of from nerve to muscle. This experiment was certainly very beautiful, and its results, if free from ambiguity, would be most valuable; yet, as so much of difficulty is opposed to obtaining accu- rate results under such circumstances, particularly as the stilets were of oxydizable metals (iron or silver) on which the animal fluids could exert chemical action, and, therefore, generate hydro-electric currents indepen- dent of any vital action. I think that we cannot rest with such confidence upon them, as on the* apparently decisive experiments of M. Prevost, of Geneva, lately communicated by M. De La Rive, to the Royal Academy of Sciences of France.* M. Prevost's experiment consisted in showing, that when a sewing-needle had been inserted into the crural muscles of a frog, and parallel to the longitudinal direction of the muscular fibres, and, therefore, at right angles to the capillary termination of the nerves distri- buted to these muscles, it became sufficiently magnetic to attract light par- ticles of the filings of iron whenever contraction was excited in the muscles by stimulating the cerebro-spinal origin of its motor nerve. This was in- deed the most complete proof imaginable, that a vital current of electri- city is actually sent along the nerves to the muscles from the cerebro-spinal origin (of the former) whenever motion is produced; for the magnetization of the needle which took place at every motion of the limb could be pro- duced by no other means than the passage of an electric current along the nerve, and is precisely that which we should expect from the well-known electro-magnetic law, first made known by Professor Oersted, namely, that magnetism is always developed in any conducting substance placed at right angles to an electric current. " Thus is made manifest to the sense of vision, the truth of that beau- tiful theory, which assigns to the motor nerves the office of conductors to that electricity which the brain sends to the muscles as the messengers of its will for the production of all corporeal motion. Hence we have reason to believe, that the vital electric current, which M. Prevost has shown to accompany motion in the living animal, is really the cause of all human motion, and are led to look with confidence to the use of artificial elec- tricity as a means of restoring the powers of voluntary motions to such parts of the human body as have become partially and recently deprived of it, in consequence of paralysis of the motor nerves, arising either from slight structural alteration, or deficient power of setting into motion the natural electric fluid at their origin. * " Philosophical Magazine, vol. xii., p. 294 (new series). ELECTRO-MAGNETISM. 373 " The general results of the experiments alluded to, seem to indicate a division of the nervous system into two classes, of which one presides over the muscles of voluntary motion ; the other over those of involuntary motion and organs of secretion. The influence of the first is produced at pleasure from its cerebro-spinal origin—that of the second owes its power to hydro-electric action ; and if so, it is wisely, indeed, ordained by the great Creator, for if the secretions had depended on our will, and on the action of the mind, our first night of repose would be our last of existence. It is true that the secreting organs have cerebral and spinal nerves, and this may account for the influence of the mind on the digestive organs ; but to a great extent the distinction appears well founded. " I must apologise for this trespass upon a province not properly my own, and close this hasty sketch of the reasons which induced many to adopt the opinion, that the nervous influence and electricity are identical, by remarking, that the practical result which has followed its adoption on the Continent, in the hands of Magendie,* Marianini,f Palaprat, and Orioli, and in this country by yourself, Sir Philip Crampton, Sir Henry Marsh, Dr. Stokes, Surgeons Cusack, Smyly, and others (whose humble instrument I had the good fortune to be), is such as to confirm this theory in a very remarkable degree. But as I have already said, I feel that we are as yet but in the infancy of the application of this science, and that the time will soon arrive, when the suggestion first thrown out by Pro- fessor Orioli,| °f remedying abnormal secretion, by altering the electric state of the secreting organ, will soon be carried into full effect; neither will the task of reaching these organs be found so difficult as might at first be supposed, when it shall be understood that it is not necessary that the part whose electric state we desire to alter, should form a part of the electric circuit, but that on the contrary, the electric current is not limited to the space which lies between the poles of the apparatus, but passes beyond it, following the course of the nerve so as to affect parts below, and quite exterior to the space supposed to be the passage of the electric current. Thus if one director be placed on the origin of the sciatic nerve, and the other on the popliteal space, the current will not be confined to the portion of the nerve which lies between the directors, as one might expect, but will act forcibly much below it, even to the plantar extremi- ties ; and I am often obliged to adopt such a course, where the nerve of the part to be acted upon is deep seated in that part, but is more super- ficial in some point nearer to its origin. " With reference to the facility with which electricity removes various forms of disease, I believe I may remark that I have found it to act more quickly in neuralgia than in any other, as it occasionally cures some varieties of this disease in two or three applications, but in others, often requires a feeble electrical current for many successive days. "Next in order of facility come rheumatism and sciatic cases, then cases of deafness. After these come some varieties of catamenial sup- pression. It acts also readily on certain curable forms of amaurosis, then in partial paralysis, and with greater difficulty in hemiplegia than in almost any other form ; as this disease requires many weeks of daily, and, perhaps, constant application, by means of the sustaining battery. * " Gomptes rendus premier Semistre. No. 24, Annee, 1840. f " Bibliotheque Universelle, T. Iii., p. 351. i '• Becquerel Traite d'EIectricite et du Magnetisme, T. i., p. 325. 374 CLINICAL MEDICINE. And here I may mention, as an instance of the value of electric treatment, that in this disease I have always found those muscles soonest restored to voluntary power, to which electricity had been the more constantly applied. " There is no doubt, that the application of electricity to the head and its neighbourhood (after the symptoms of cerebral inflammation have subsided), requires great caution, otherwise, the most dangerous conse- quences might follow ; needles should never be employed as directors to this part. Even when simple voltaic electricity is employed, the current from two or three pair of plates only an inch and a half square, would be attended with extreme danger if needles be employed ; yet with care and attention to circumstances as they arise, the electro-magnetic current may safely be applied, through the medium of sponges, from the first cervical vertebra to the foot, varying the treatment as the disease demands. " As a fellow member of the Royal Irish Academy, you have been aware of the laborious series of meteorological observations and researches which I have made, at the recommendation of the council of that learned body,* with a view to discover the connection which exists between atmospheric electricity and other natural agents ; such as temperature, barometric pressure, hygrometic condition of the air, both as to free or uncombined moisture, and as to the absolute quantity of aqueous vapour existing therein, in what state soever of dryness it might be ; so as to deduce from the action of one or all of these agents the natural law which causes the diurnal changes of atmospheric electricity, and to give a correct statement of the condition of all these atmospheric agents at each hour of the day and night. You have requested me to say in this place a few words upon the subject, in order that you may compare the progress of the diurnal changes of atmospheric agents with the periods which you have observed to affect the daily stages of acute diseases. " I have, therefore, to observe, that atmospheric electricity has one gradual ascent from 3, a.m., which is its minimum, to 3, p.m., which is its maximum hour; excepting, however, from this statement the fact, that there occurs a slight sudden ascent from 8 until 10, a.m., and a con- siderable ascent from 5 until 7, p.m., when the intensity even exceeds that of 3, p.m. This intensity, however, speedily subsides, and we may regard 3, p.m., as its diurnal maximum. " The quantity of aqueous vapour in the atmosphere as indicated by the dew point, after all necessary corrections are made, has also its mini- mum at 3, a.m., and its maximum at 3, p.m. " The thermometric curve exhibits its maxima and minima at the same hours, namely, minimum at 3, a.m., maximum at 3, p.m. " The barometer curve exhibits two maxima and two minima in each twenty-four hours, namely, a diurnal maximum at 10, a.m., and minimum at 4, p.m., and its nocturnal oscillations occur at the same hours. These variations in the height of the mercurial column amount, according to my observations, to -020 of an inch, which is equivalent to an alteration of pressure, amounting to 4-2 ounces on each superficial inch of the human body. This considerable reduction in the amount of the external atmo- spheric pressure, whilst the internal pressure of the animal fluids remains unchanged, would seem to lead to the conclusion, that the hour of 4,p.m., must be distressing to invalids, but still more so that of 4, a.m., when the * " Proceedings of Royal Irish Academy, 1839 and 1840, part 4. ELECTRO-MAGNETISM. 375 reduction of external pressure also exists, and the stimulating sources of electricity and external heat are both at their minima, and the aqueous vapour of the atmosphere is in its most uncombined condition, depositing itself insensibly on the surface of the body, and thus tending to lower its temperature at a moment when the vital forces are least able to resist this action. " The foregoing meteorological results are deserving of every reliance, having been obtained by a most laborious series of observations made by me during twelve months, at which time the electricity of the atmosphere was observed at intervals of fifteen minutes, during, at least, fifteen suc- cessive days in each month, and from five to ten nights, the temperature of the air was observed as frequently ; the height of the barometer was noted each half hour during the same time, and the dew point was taken hourly with a Daniel's hygrometer during the same period as the other instrument. " The electrometer employed was one of my own invention, and not a mere hygroscope, as all the former gold leaf electrometers were, but one ca- pable of measuring, with accuracy, the slightest change of intensity, as well as of giving indications of electricity so feeble as to escape observation with ordinary instruments.* The barometer, thermometer, and hygrome- ter, were also accurate instruments, constructed with every care for the occasion. The result has been satisfactory in the same proportion, point- ing out, as I think it clearly does, the law which in nature regulates the diurnal variations of atmospheric electricity, and its intimate connection and dependence upon two out of the three great natural agents, with which I had proposed to myself to investigate its connection. This law- will clearly appear when we remember the experiment of Volta, in which it was shown that whenever water, not absolutely pure, is evaporated from an insulated vessel composed of materials similar to those which compose the crust of our earth, the vessel from which the evaporation takes place is left in the negative electric state, in consequence of a portion of its natural quantity of electricity being taken up in the latent state by the vapour, as it forms, whilst this same vapour manifests all this extra sup- ply of electricity when it becomes condensed on the surface of a cold and insulated body, which latter then appears strongly positive, because the aqueous vapour, in the act of condensation, has set free that redundant quantity of electricity which it had previously taken up in a latent form from the insulated vessel, out of which it had been evaporated, and which was only necessary to its aeriform existence. " Thus we see that the electricity of the earth (when uninfluenced by the inductive action of passing positive clouds) is negative,! relative to that of the surrounding atmosphere, in proportion to the quantity of aque- ous vapour which has been evaporated from its surface. This ought to make the indications of their relative difference, as exhibited by an elec- trometer, greater in proportion to the sun's altitude, or rather in propor- tion to the temperature of the respective hours ; and this I have found to be the case, with the exception of the slight sudden increase of tension, * " vSee a description of this instrument in the proceedings of the Royal Irish Academy, 1839 and 1840, part 4. An instrument of this description has since been taken out with the Niger expedition; it was furnished by Watkins Hill (to Dr. M'William, surgeon to the Albert) according to my drawings.—E. S. C. f " This fact of the earth being negative, relative to the air, has been acknowledged to be true by every observer. 376 CLINICAL MEDICINE. which occurs from 8 until 10 in the morning, and of the sudden but con- siderable increase which occurs from 5 until 7 in the evening (always speaking of the mean curve of each day, as derived from the annual ave- rage). This sudden increase of tension at those hours arises from the condensation of the aqueous vapour, in the form of dew,* which, as before shown, must liberate its previously latent electricity. " The foregoing opinion relative to the time and cause of the diurnal variations of atmospheric electricity is valuable because that is not the expression of any pre-conceived ideas which might have influenced my reading of the results of my researches, but on the contrary, was quite unexpected as to the hours themselves; and the cause only then occurred to me when I held in my hand the various annual curve charts of the hygrometric and thermometric condition of the atmosphere at each hour, and observed their obvious connection and dependence. Indeed, I had been insensibly led by the high character attributed to the observations and researches of Professor Schiibler, of Stutgard, to anticipate very dif- ferent results, as that philosopher made the minimum hour to occur at 2, p.m., and thus expresses himself as to the want of influence of temper- ature on the diurnal variations of electricity :—f " 'It is necessary to remark that these diurnal periods correspond very little with the advance of diurnal temperature in the same place, and that in this regard there cannot be a question of the smallest parallelism. If the first minimum of atmospheric electricity manifests itself a little before the rising of the sun, when the temperature of the day is lowest, the second presents itself, on the contrary, from 2 to 4 or 5, p.m. ; that is to say, in the warmest part of the day. But if there is but little analogy in this regard, there is so much the more under that of the humidity and visible vapours in the atmosphere. We observe the maximum of the daily period after the rising and setting of the sun, at hours when the air presents the greatest quantity of vapours, as well to the hygrometer as to our view.' "But as that gentleman only made two observations daily, we need not wonder that the disturbing inductive influence of passing clouds marked the true hours of variation, and consequently its true causes. My explanation of the cause of this diurnal variation differs also from that given by De Saussure and his followers ; namely, the conducting state of the aqueous vapour. The electric tension being supposed to be strong at the maximum hour, because neither too great dryness or too much moisture then prevailed, the former of which would prevent the aerial electricity re- turning to the earth through our instruments, and the latter would neutralize their electric states by its too great conducting power, whilst my explana- tion, as already shown, rests not on the conducting power of the vapour, as influenced by its state of combination, but on the absolute quantity of aqueous vapour, as indicated by the dew point, when all necessary cor- rections for temperature have been made, the relative electric condition of the earth and its atmosphere being always most different when the greatest quantity of aqueous vapour is indicated by the dew point. But this result is not to be discovered by contemplating the progress of electric intensity * " See Pictet Essai Sur le fue, S. 35; also Bibliotheque Universale Sciences et Arts, 93. —On morning as well as evening dew. | " Reserches Sur L'Electricite Amospherique par M. Schiibler (Bibliotheque Univeiselle Sciences et Arts). ELECTRO-MAGNETISM. 377 and advance of the dew point upon individual days, but only first by the monthly curves, and still more clearly by the annual curve, the natural law becoming more evident in proportion as the observations are more numerous, for when very few observations are made, the chances of their being falsified by the disturbing influence of passing clouds, is very great indeed. " As it is interesting to trace (so far as our limited knowledge can) how few the primitive agents are, which the Almighty uses for the production of the numerous and important phenomena dependent on creation, em- ploying these few in such endlessly varied forms that we no longer recog- nize their existence ; whilst some of the numerous secondary agents, aris- ing from that mutual connection and dependence, appear to work out natural phenomena, with so much apparent energy and singleness, that we frequently believe them the original agents under Providence, thus erroneously multiplying causes, by considering effects as such, whilst in reality the infinite wisdom of the great Creator, foreseeing all possible de- pendencies and changes, used but a few principles to accomplish all his marvellous productions. As he has formed all substances upon this our habitable earth out of such few materials as that even with our present imperfect chemical skill, we have been able to reduce them to 52 elements, and it is likely, as our progress in chemical analysis advances, we shall find this number much reduced, so, in this same point of view, it is in- teresting to notice that electricity of the atmosphere, that invisible and extraordinary agent which is at once the terror and the ornament of the sky, as developed in auroras or in lightning—which is, with much proba- bility, believed to be the safety of the mariner on the boundless ocean,* which is essential to the purity of our atmosphere, and formed the crys- taline beauty and treasure of the mineral kingdomf thus bowing chemical effects to its power, is the result of the action of one body on wrater, and that body the same which maintains the planets in their orbits—the sun— the centre of the planetary system. When I say so many effects are thus seen to result from the action of one body (the sun), and when we know that its light and heat are necessary to the existence of every organised being in the planetary system, what an idea becomes impressed upon us of the wisdom of the great Disposer of all things, and well may we ex- claim in the language of the poet, " ' His wisdom guides the rushing wind, And tips the bolt with flame; His goodness breathes in every breeze, And warms in every beam.' " Neither is this universality of action peculiar to the great luminary we have been speaking of, but is common to all the great agents in nature (and even those of a secondary character). Thus we see the multiplied offices of the atmosphere, the moon, &c. &c; indeed this is so obvious, that I have great reason to apologise for the trespass upon your valuable time by the remarks which I have made upon it; but as the sun's action is not generally known to be the cause of the diurnal changes of at- * "Thermo-electric currents at the equator being believed to cause polar magnetism. f "See the results of Becquerel, Cross. Fox, and others, in producing mineral crystals (by means of electric currents of low tension), which chemistry had in vain previously attempted. 378 CLINICAL MEDICINE. mospherical electricity, I thought this digression not altogether out of place. "Believe me to be, Sir, "With unfeigned admiration and respect, "Your most obedient servant, " E. S. CLARKE. " 18, York Street." POSTSCRIPT TO MR. CLARKE'S CASES. John Kelly's Case {conclusion of), see page 427. " From the 29th August to the 9th September I applied electro-magne- tism of very high tension to this man five times ; on the 9th September he left hospital, but came to my house and was electrified daily until the 20th, by which time the enlargement, anterior and inferior to the malleolus internus, had almost entirely disappeared ; and he was able to walk with- out difficulty several miles each day over even a hilly and rough road ; and on the day last named, returned to the country to resume his duties with his former master, who, aware of his progress towards recovery, had kindly reserved his situation for him. Previous to his leaving Dublin he presented himself to Surgeon Porter, at whose instance I had attended him; and who has since expressed to me his great satisfaction at the cure which was thus accomplished. I have since heard of this man through — Thompson, Esq. (student under Surgeon Maurice Collis), who took a great interest in him ; he states that he finds no difficulty in walking or discharg- ing any of his duties as a servant. This man wTas electrified about thirty times. "Charles Crean, aged about 70, formerly butler and house-steward to the late Lord Bishop of Kilmore. Disease—paralysis of bladder. This man was quite unable to void urine, and it was accordingly drawn off with the catheter three times each day, by the resident surgeon. His mind has been astray during nearly the entire of the past twelve months. He was affected with this complaint (paralysis of bladder) for some weeks previous to his entering this hospital; it manifested itself suddenly during a paroxysm of mental aberration. "8th October—As directed by Dr. Stokes, I this day applied second- ary current from sacrum to pubis and along the course of the abdominal muscles. " 9th—This morning he voided naturally a few drops of urine. I ap- plied electricity in same manner as on yesterday. " 10th—Applied electricity as on preceding days; tone of the bladder seems about to return as he voided a little urine twice this morning either whilst being electrified or immediately afterwards ; in all about a wine- glassful; it was propelled at first nearly two inches from point of penis. " 11th—Applied electricity as before ; mind appears rather more wan- dering, projectile force of bladder rather less; but made, at four or five attempts, about the same quantity as yesterday. " 12th—Applied electricity this day from perinaeum to about half an inch above upper part of the pubis ; also occasionally in the former method. " 13th—Applied electricity in the same manner as yesterday; he voided more water, but mind is wandering, and he seems desponding and inac- tive as well as impressed with a great dread of some unknown danger. Catheter is still daily applied at his most anxious request, although becom- ELECTRO-MAGNETISM. 379 ing each day less necessary. This night he attempted to commit suicide (by cutting his throat), but fortunately did not make any dangerous inci- sion. As the bladder is evidently recovering its tone fast, and as he is so excitable, I have discontinued the electricity; it had, however, accom- plished its purpose as he daily voided urine spontaneously, and by the 16th inst. the catheter became unnecessary. I regard this as a most important case, particularly as no remedy was resorted to except electricity. " Luke Byrne, aged 33. Disease—paralysis of both lower extremities; he complains also of a sensation of a ligature around the abdomen, and refers his paralysis to this cause, which he also believes to have been much increased by excessive internal and external use of spirits of turpentine. Having applied electricity to this man for seven successive days without effect, I desisted from its further use, particularly as Dr. Stokes thinks it likely that he is affected with disease of the spinal canal. I feel, however, that other electric instruments ought to have been tried in this case, which could not be done for want of a room, especially devoted to electrical ope- rations, where instruments not very portable could be left and kept in order. Rubbing with mercurial ointment and other treatment has been resorted to, from the 14th inst. to this time, the 26th, the constitutional action of mercury has appeared, but the paralysis remains unaltered. " Theodosia Cunningham. Disease—amenorrhcea; recommended by Dr. Graves. This is the same individual whom electricity so effectually cured in hospital of paralysis of right lower extremity ; by reference to her case it will be seen that she suffered under suppression of the catamenial dis- charge for thirteen months preceding July last, but which fact I was not aware of until electricity produced its return on the 2d of July, whilst I was in the act of applying electricity to the glutaei and other muscles in the neighbourhood of the uterus; and it was remarkable that nature ad- hered in that case to the period of her usual action with this girl, namely, the 2d of the month, nor was electricity able to produce it until that time arrived, although applied to the same parts on many preceding days. The catamenial discharge was, however, very trifling, owing chiefly to the application not having been made to the appropriate parts in consequence of the reason already explained, and being then under the impression that it would be improper to renew the application on the following day lest it should alter the regularity of the natural periods, an instruction which I received from a physician accoucheur of considerable standing, the oppor- tunity was lost for that month ; and although the paralysis was cured the violent headaches continued. No attempt was made by nature to remove the catamenial discharge. On the succeeding period, under those cir- cumstances, experiencing constant and violent headaches and other hys- terical sensations, and especially dreading a renewed attack of paralysis, she again applied to Dr. Graves, who believed all her illness to result from catamenial suppression, which might be said to have then lasted fif- teen months, and for the temporary relief of the consequent symptoms blood had been in vain taken in the course of the preceding year, once from the nape of the neck by cupping, and twice from the arm by the lancet, and consequently requested me to apply electricity with a view to produce a return of the menses, accordingly I began at the period when she might, for their return being the 2d of September, I began a few days previously to apply a feeble secondary current, as usual in these cases, first on the 27th, then 29th and 31st, and on the 1st and 2d of September, more strongly, but without success. 380 CLINICAL MEDICINE. " 3d Sept.—In consequence of success not having attended the appli- cation of electro-magnetism even on the preceding day, I insulated her and connected her with the negative jar of a Nairnes electric machine of large size, and passed about ten shocks of moderate intensity in each of the directions I am accustomed to send the electro-magnetic current. Success followed before I had administered many shocks, menstruation began, but was small in quantity, and not sufficient to prevent me from continuing the application of the shocks. Having adopted the idea that it would be rational practice to apply the electric current on the second day of the menstruation, whenever the secretion should prove too scanty, I renewed the application of shocks on the following day, the 4th Sep- tember; on that day as on the preceding, the catamenial secretion made its appearance, not continually, but only every third or fourth hour, and this in very small quantities, whilst headache, sickness of stomach, with hysterical symptoms, were very distressing, under these circumstances I consulted Dr. Graves, and he advised a repetition of the preceding day's application, on Monday, the 5th September, being then the third day of her menstruation, but the fourth day removed from that of her usual period. " On coming this day to be electrified, she was exceedingly hysterical, whilst head and stomach were even more unwell than usual, on preceding days. Nevertheless, I passed two shocks, which produced a slight return of the menses. I also gave some sparks to her arm, which she believed was about to be visited with nervous paralysis. She left the house very sick, but had scarcely done so, when the catamenial secretion came on in greatly increased quantity. On reaching home, she discharged from her stomach a watery and greenish-looking liquor (as she described it), whilst the discharge became far more considerable than it had ever been, and such, both as to colour and quantity, as healthy women generally secrete. This discharge continued during the entire of Monday and Tuesday, as well as to a less extent until Wednesday morning, the 7th instant, when she felt quite well ; had lost her morning headaches; regained colour in her cheeks ; and lost the peculiar hysterical appearance of the eyes, which up to that time had characterized her. And, I think, that instead of being a victim to headaches and hysterical sensations, which threatened her with nervous paralysis, such as she had twice before been afflicted with, she may now expect to enjoy excellent health, being naturally of a robust constitution. " I regard this case as peculiarly important, as it establishes two facts fully : first—that although our efforts in the cure of this disease ought to be undertaken as near to the natural period in each individual as possible, that still it is a good practice to persevere for three or four days after that period, if the secretion be either absent or deficient in quantity. This woman always experiences pain in the back during the secretion of the menses. Secondly—that no catamenial case can be said to have over- come the power of electricity, until frictional, as well as magnetic, elec- tricity, shall have been both tried ; and hence, that in all probability, the only two unsuccessful cases of this disease which I have had in the hos- pital, and which are recorded in my notes, would not have been so, if a room expressly devoted to electricity had existed in the hospital—an opinion which my experience in many other diseases, such as rheumatism and paralysis, decidedly induces me to extend to them. ELECTRO-MAGNETISM. 381 " saint Vincent's hospital. " Anne Thrimback, formerly 110, Marlborough-street, admitted 25th April—discharged 20th June. Disease—paralysis of left arm, which was much wasted. " 1st June—applied secondary electric current, from origin of fourth curvical nerve to palm of hand, and occasionally to ulnar nerve ; also, through the trapezius, deltoid, biceps, flexor cubiti, and triceps extensor muscles. I repeated this application every second day (not having leisure for daily operations), until the 13th, from which time the application was made daily until the 20th, on which day she was discharged, being then quite cured. " Thomas Ryan (messenger in Dublin Castle), admitted 6th June— discharged 17th June. Disease—neuralgia of the sciatic nerve as far as the popliteal space, and of the anterior crural nerve ; pain intolerable at night in rectus femoris, vasti and other adjacent muscles. Had large blister over the loins without effect ; also used hydriodate of potass and camphorated mixture. " 10th June—applied secondary electric current from origin of sciatic to popliteal space ; also, from sciatic origin, and occasionally from the obdurator nerve and sciatic notch along the rectus femoris, vasti, and other anterior femoral muscles. On visiting him on the 12th, he stated that he had not been afflicted with any return of the pain, and, therefore, did not deem it then necessary to renew the application. But having experienced on that night a slight return of the pain, I applied the electric current as before, after which the pain returned no more, and he was dis- charged cured on the 17th instant. " Thus far I have given notes of the additional hospital cases, of which I esteem Crean's case, in which I was fortunate enough to cure paralysis of the bladder, as of very high importance, directly pointing as it does to the effective action of electricity upon organs essential to our existence, and which another case at present under my care confirms, as far as the bowels are concerned. I cannot, however, close these notes without calling attention to one case selected from your private practice, as indi- cative of the highly restorative action of electricity in hemiplegia. " The case I allude to is that of Master B.-----. This young gentle- man, age about 17, retired to bed in good health, on the 19th July last. During that night he was visited with apoplexy, and in the morning it was discovered that he was perfectly paralyzed throughout the entire of the left side. The voice was unaffected ; but whenever he attempted to put his tongue out, instead of going straight forward, it was protruded at the side of the mouth. On the paralyzed side the limbs were flaccid and motionless, and sensibility was entirely extinct; the bladder and rectum were also involved in the paralysis. " Previous, however, to your having directed the application of mag- netic electricity, you had by other treatment restored to a considerable extent the power of sensation ; but all power of motion was altogether absent. The tongue was still paralyzed ; the sphincters of the anus and rectum were also in the same state, the urine and fecal matter being still voided without his control. The sound side was unable to support the other which was paralyzed. The limbs were greatly wasted, particularly those on the paralyzed side, whilst the skin on same was withered and 382 CLINICAL MEDICINE. inanimate-looking. He was in this state on the 12th of August, when you directed the application of magnetic electricity to the lower extremity, at the paralyzed side, and along the spine daily, having determined on the trial of electricity unaided by any other remedies. During the first few days of application no remarkable change took place ; strength was grad- ually being restored ; the skin of the affected side began to lose its withered and inanimate appearance ; whilst the lower paralyzed and wasted extremity appeared to be increasing in fulness. This stage was followed by frequent involuntary movements of the lower limbs. And it is worthy of remark, that the muscles to which electricity was most fre- quently applied, were those which first manifested involuntary motions, and subsequently soonest became obedient to the will. After involuntary movements of the lower paralyzed limb, the intestinal paralysis ceased, and on the 3lst of August, or nineteen days after the first application of electricity, the flexor muscles of the paralyzed leg began to resume their power. After a lapse of nine days more, in all twenty-eight days, he could each morning execute one voluntary extension of the leg, but only one, and that only when just after waking, and in full power after a night of repose. Fear of cerebral inflammation being less urgent, I have for many days past applied electricity to the upper portion of the spine and arm, and by this time many involuntary movements took place in the arm, particularly at night, and on the 13th of September he could move the fore-arm and humerus upwards and inwards ; but the biceps flexor cubiti was then very weak in its contractile action, and the pronator radii teres being more powerful than the supinator, caused the fore-arm and hand to fall inwards and forwards when he attempted to raise his arms. The great toe, also (but none of the others), began to evince a power of withdrawing itself from a pinch of my finger, or from a strong electric spark. " On the 23d Sept. power began to return to the extensors of the leg, and on the same day he left his bed and sat up in a chair for an hour or more. " Application of electricity was discontinued on the 31st of September (seven weeks from its first application), owing to the patient appearing feverish. I saw him a few days ago (on the 20th of October): his strength has so much increased, that he can walk well by the aid of a stick, and his general health is good. There remained, however, an awkwardness in moving the left side, and certain muscles were comparatively inactive, which gave rather a paralytic appearance to his movements ; but as it is, I believe, intended to renew the application of electricity, and as his case in all its stages yielded gradually to this agent, I think that in all proba- bility even these defects will be removed. "In the progress, I have resorted to nearly all the known sources of electric power, as well as to many new forms of apparatus, and have for weeks together kept electric currents circulating through the paralyzed limbs (or such parts of them as it appeared advisable), both night and day, even during the sleep of the patient, and the result has been suc- cessful in proportion to the care and energy employed. It may be well also to notice, that the only parts to which voluntary power of motion had not returned when the application of electricity was discontinued, were the fingers and lesser toes, parts most distant from the nervous centre, in which the capillary circulation was necessarily difficult, and from which a very remarkable amount of moisture was constantly exhaling, attended of course with constant evaporation and tendency to reduction of tem- perature." SLEEPLESSNESS. 383 SLEEPLESSNESS. LECTURE XXXIV. Sleeplessness—Sleeplessness from anxiety, grief, &c.—Case of jaundice accompanied by sleep- lessness ; treatment—Remarks on purgative mixtures—On the proper time for administering opiates—Sleeplessness in delirium tremens—Chronic variety of delirium tremens ; treatment —Sleeplessness in fever ; case—Failure of different modes of treatment—Use of opiate injections—Delirium traumaticum—Constitutional irritation from blisters; treatment— Sleeplessness in hypochondriacs and hysterical females—On the use and abuse of cold appli- cations to the head. Twro cases which have been recently under treatment in this hospital demand your particular attention,—the man who has been labouring under a severe attack of jaundice, and the boy who is recovering from fever. A remarkable symptom in both of these patients, and which must have repeatedly attracted your notice, was a total privation of sleep. In the former case the sleeplessness continued for a week, in the latter for nine or ten nights. Sleeplessness is a very curious result of disease. It accompanies cer- tain morbid conditions of the system brought on by active disease or by grief, care, and various other forms of mental disturbance, continues to harass the unhappy sufferer night after night, and frequently resists the most powerful and decided narcotics. I do not intend to enter into any inquiry respecting the different states of the constitution in which it oc- curs ; my purpose is merely to offer a few practical remarks on the more obvious and striking examples, with the view of illustrating the cases to which I have directed your attention. There is a form of sleeplessness which is frequently the precursor of insanity, and which has been well described by my friend, Dr. Adair Crawford. The watchfulness in such cases is accompanied by the well- known symptoms of incipient mental derangement, and its treatment is therefore inseparably connected with that usually resorted to in cases of threatened insanity, and embraces the employment of means, moral as well as physical. Of these it is not my intention to speak; I may observe, however, that Dr. Crawford has found opium, gradually increased to very large and frequently repeated doses so as to produce sleep, the best remedy. In the case of jaundice, the patient passed several nights without any sleep. He was just beginning to recover from the jaundice when this new symptom appeared, and I directed your attention particularly to the circumstance, because every manifestation of nervous derangement con- nected with jaundice should be carefully watched. It frequently happens that jaundiced patients sleep too much, and in some cases the disease is accompanied by convulsions, succeeded by coma, most alarming symp- toms, and almost invariably the harbinger of a fatal termination. Dr. Marsh was the first who directed our attention to the great fatality of those cases of jaundice in which convulsions occur; I have seen but one instance of recovery. It was in the case of a gentleman labouring under icterus, very considerable hepatitis, with enlargement of the liver and anasarca, 384 CLINICAL MEDICINE. with ascites. He was treated by Dr. Osborne and myself, and had at least a dozen long and violent convulsive paroxysms, ending in coma, succeeded by temporary forgetfulness and fatuity. Repeated leeching of the right hypochondrium, active purgation, and mercurialization of the system removed all the symptoms of disease, and he slowly but perfectly- recovered. A very able and original writer, Dr. Griffin, of Limerick, has detailed the particulars of some interesting cases of this nature in the Dublin Medical Journal. You perceive, therefore, that in jaundice every thing denoting an unusual state of the nervous system, whether it be too much sleep or too little, demands your attention. In this man's case the jaundice was the result of an attack of hepatitis. We treated it with leeches, blisters, and the use of mercury, and in the course of a few days the stools became copiously tinged with bile, and symptoms of improving health appeared. At this stage, the dejections being bilious, but the jaundice still remaining, he began to exhibit symp- toms of restlessness and nervous irritability, and finally became perfectly sleepless. Here, gentlemen, we had to deal with a new symptom, ex- tremely harassing to the patient, and likely to react unfavourably on the original disease. As a preliminary step, I determined to evacuate the bowels, and for this purpose I prescribed a purgative draught, consisting of five ounces of infusion of senna, half an ounce of sulphate of magnesia, a drachm of tincture of senna, and a scruple of electuary of scammony. My object was to purge briskly, and then give a full narcotic. In all cases ' of jaundice depending on hepatic derangement, after you have succeeded in producing bilious evacuations, you should never omit prescribing an active aperient every second or third day for the space of ten days or a fortnight, with the view of carrying off the remains of the disease so as to prevent the occurrence of a relapse. Hence you will find such cases very much improved by the use of Cheltenham water, taken every day for three or four weeks after the reappearance of a bilious tinge in the alvine discharges. The stimulus of the purgative causes an increased flow of bile into the intestines, which removes the hepatic congestion, and carries off what is popularly termed the dregs of the disease, and promotes a rapid and complete recovery. It is a simple, but successful practice, and I would advise you never to omit its employment in cases of this description. With respect to purgative mixtures, I may observe that you should prescribe a larger quantity of the infusion of senna than is generally ordered, if you wish to secure its certain and decided operation on the intestines. Hospital nurses, who reason from facts and experience, know this, and when directed to give a senna draught, they always give a small teacupful. They administer from four to six ounces at a time, and I have observed that in this way the action of the medicine is more certain, and the benefit derived from it more extensive. I am convinced that the usual mode of giving this valuable purgative in private practice is bad ; the quantity given is too small, and consequently it is necessary to repeat the dose several times, a mode of proceeding apt to occasion much nau- sea and griping ; I would, therefore, recommend a quantity varying from three to six ounces, to be administered in all cases where the patient's condition will admit of free purging. A most accurate observer of the effects of medicines, Mr. Kirby, is in the habit of ordering purgative mixtures in chronic cases to be taken at bed-time, and not, as is usually SLEEPLESSNESS. 385 done, in the morning. He asserts that their action is milder and less irritating to the bowels when the patient lies in bed and is asleep until the period of their operation, than if he were up and about. After the purgative had produced four copious discharges, I prescribed eight minims of black drop, to be taken at a late hour in the evening. Whenever I give opiates to procure sleep, I always observe the rule laid down by Dr. M'Bride (a celebrated physician of this city), to select the period at which nature usually brings on sleep, and which varies accord- ing to circumstances and the habits of the patient. Whenever you have to deal with watchfulness in patients labouring under morbid states of the constitution, as, for instance, hectic, inquire when the tendency to sleep usually occurs, and administer your narcotic about an hour or two before its occurrence. It is between three and five o'clock in the morning that the inclination to sleep is strongest; it is about this time that sentinels are most apt to slumber at their post, and consequently attacks upon camps or cities, made with the intention of effecting a surprise, are usually undertaken about this period of the morning. How well marked is the periodic tendency to sleep at this hour in all patients labouring under hectic fever produced by whatever cause. How often do we hear the poor sufferer complain of restlessly tossing about in his bed until three or four o'clock in the morning, when at last sleep, welcome though uneasy, for a few hours separates the patient from his pains. If given at an early hour in the evening, the effect of the opiate is not coincident with this periodic attempt of the constitution, and it fails in producing sleep ; but if exhibited at a late hour, it begins to produce its soporific effect at the very time when nature inclines the harassed sufferer to repose, and the result of these combined influences is a deep, tranquil, and refreshing sleep. By observing this simple rule, I have often succeeded in producing sleep in cases where various narcotics had not only failed, but even added considerably to the irritation and discomfort of the patient. In cases of sleeplessness where you have administered an opiate with effect, be careful to follow it up for some time, and do not rest satisfied with having given a momentary check to the current of morbid action. To arrest it completely, you must persevere in the same plan of treatment for a few days, until the tendency to sleep at a fixed hour becomes deci- dedly established. You must give an opiate the next night and the night after, and so on for five or six nights in succession; and where the watch- fulness has been of an obstinate and persistent character, narcotics must be employed for a longer period and in undiminished doses. I do not allude here to the sleeplessness which accompanies confirmed hectic and other incurable diseases ; such cases require a particular mode of treat- ment, and generally call for all the varied resources of medicine. But in those instances of watchfulness, which are frequently observed towards the termination of acute diseases, it is always necessary to repeat the opiate for some time after you have succeeded in giving a check to this symptom. You need not be afraid of giving successive opiates, lest the patient should become accustomed to them, and a bad habit be generated, for the rapid convalescence and renewed health, which are wonderfully promoted by securing a sound and refreshing sleep, will soon enable him to dispense with the use of opiates. Another disease in which sleeplessness is a prominent symptom, is deli- rium tremens. We have had an example recently in our wards, and you 26 386 CLINICAL MEDICINE. have seen the means employed to overcome it. The patient came into hospital with symptoras of extreme nervous excitement and watchfulness, which had continued for some time, and were brought on, as is most com- monly the case, by repeated fits of intoxication, succeeded by a pause of perfect sobriety—in Irishmen the result of necessity or accident. In this man you must have remarked the signal benefit which attended the use of a combination of tartar emetic and opium, and how rapidly the watch- fulness disappeared. There is, however, one form of nervous irritability, frequently observed in persons who are in the habit of drinking freely, but without running into excess, and presenting, as it were, a shadow of delirium tremens, on which I shall make a few remarks. This curious state of the nervous sys- tem is generally found to exist in men about the middle period of life, and who consume a larger quantity of spirituous liquors than they are able to bear. Such persons, without suffering in appearance, or losing flesh, get into a chronic state of disturbed health, manifested by nausea, and even dry retching in the morning, loss of appetite, and impaired digestion ; but in particular by a deranged and irritable state of the nervous system, and by watchfulness. This forms one of the most distressing symptoms, and the patient generally complains that he cannot get any sound and refresh- ing sleep, that he lays awake for hours together, and that when he slum- bers his rest is disturbed by disagreeable dreams, or broken by slight noises. How are you to treat this affection? I can give you a valuable remedy for this deranged state of constitution—one which I have often tried, and which, from experience, I can strongly recommend. It is a mixture composed of tincture of columba, quassia, gentian, and bark—say an ounce of each; and to this is added a grain, or even two, of morphia. A compound tincture, somewhat analogous to this, is much in use among military gentlemen, and others, who have resided for a considerable time in India, where, from the heat of the climate, and the prevalence of intem- perate habits, the stomach becomes relaxed and the nervous system irrita- ble, so as to represent, in a minor degree, the symptoras which characte- rise delirium tremens. You perceive I combine several tonics to form this mixture, because they are well known to produce a more beneficial effect when combined than when administered singly ; and I add to these a narcotic, which has the property of allaying nervous excitement without derangement of the intestinal canal. The dose of this mixture is a tea- spoonful three or four times a-day, and the best time for taking it is about an hour before meals. It gradually removes the nausea and debility of stomach, lessens nervous irritability and watchfulness, and with a proper and well-regulated diet, and attention to the state of the bowels, 1 have seen it produce excellent effects. In such persons much benefit is derived from the use of the tepid shower bath. Fever is another disease in which sleeplessness is a symptom, frequently of an unmanageable character, and pregnant with danger to the patient. You witnessed this in the case of the boy who lies in the small Fever Ward, next to the man who is at present labouring under general arthritis. This boy had fever of a mild description, and unattended with any bad symptoms. His case scarcely required any attention, and he had almost arrived at a state of convalescence without the aid of medicine, when he began to lose his rest, and absolutely became sleepless for several nights. I beg your attention to this case for many reasons. In the first place, you SLEEPLESSNESS. 387 have seen that we tried many remedies without success, and afterwards fortunately hit on one which answered our purpose completely. Let us exa- mine the nature of the medicinesprescribed,and ourreasonsfor giving them. In the first place we gave, as in the case of jaundice, an aperient fol- lowed by a full dose of black drop. It failed in producing any sleep; we repeated it a second and a third time, but without the slightest benefit. I then remarked to the class, that, as I had noticed the good effects result- ing from a combination of tartar emetic and opium in the case of delirium tremens where opium alone failed in procuring sleep, it would be proper to give this remedy a trial. I observed, at the same time, that I was con- vinced that the preparations of antimony have a distinct narcotic effect, and that I had seen patients in fever whose watchfulness had been re- moved by antimony given in the form of tartar emetic or James's powder. I said it was my firm impression that tartar emetic, along with its other effects, exerts a decided narcotic influence on the system, and that it is this which makes it so valuable a remedy in treating the sleeplessness of fever and delirium tremens. Our predecessors were much in the habit of using an- timonial mixtures in the treatment of fever; and they did this because they knew, by experience, that these remedies worked well. It is at present too much the fashion to decry their practice, and in this instance, I think, with very little justice. In this boy's case, however, the combination of tartar emetic and opium did not succeed in producing sleep. Having thus failed in our first and second attempts, we had recourse to the liquor muriatis morphias—a pre- paration first brought into use by Dr. Christison, and which, in the form usually employed, is equal in strength to laudanum. It is an exceedingly valuable preparation for many reasons, and one which has the strongest claims to your notice. Being of the same strength as laudanum, it saves the trouble of learning and remembering new doses, and, in addition to this, it possesses the more important advantages of inducing sleep with more certainty, and not acting as an astringent on the bowels, or affecting the head so frequently as laudanum. You observe that I say so fre- quently; I do so because cases now and then occur in which even mode- rate doses of the liquor of the muriate of morphia produce quite as much headache as laudanum. I prescribed the former in doses of fifteen drops every six hours, so as to give sixty drops in the day, and continued this practice for two days, but without the slightest effect. Here you see three modes of inducing sleep completely failed. The boy remained for a day without taking any medicine, and then we made another attempt, which was more successful. We first prescribed a purgative enema, and after this had operated he was ordered an opiate injection, consisting of four ounces of mucilage of starch and half a drachm of laudanum. He fell asleep shortly after using the opiate injection, and did not awake until the next morning. The following night the opiate was repeated in the same form, and with equal success ; convalescence went on rapidly, and the boy's health is now quite re-established. Here, then, is a singular fact attested by this case, that opiates in the form of injection will succeed in producing sleep, where they have com- pletely failed when administered even in large and repeated doses by the mouth. Baron Dupuytren was the first who made this important obser- vation, and proved that narcotics applied to the mucous surface of the rectum exercise a powerful influence on the nervous system, always 388 CLINICAL MEDICINE. equal, and very often superior, to the effect produced by taking them into the stomach. He maintains that, in delirium traumaticum and de- lirium tremens, a certain quantity of opium, when prescribed in the form of enema, will act with more decided effect in allaying nervous excitement than the same or even a larger quantity, when taken by the mouth. I have no hesitation in giving full credit to this asser- tion, as the results of my experience tend strongly to confirm its truth. I have, not long since, published, in the Dublin Medical Journal, the case of a patient in Sir P. Dun's Hospital, who was reduced to the last stage of debility and emaciation from effects of mercury and syphilis. The torture which this man endured from nocturnal pains, and a total deprivation of sleep, was such that he swallowed enormous doses of opium ; in fact, he had, previously to his admission into Sir P. Dun's Hospital, exhausted all his means in purchasing opium. While in hos- pital, he used to take 150 drops of black drop in the course of a day, and yet, notwithstanding these excessive doses, he could only get a few minutes of unrefreshing slumber. After some time I changed the plan of treatment, and had the black drop administered in the form of enema. It succeeded in producing a decided soporific effect, and in a short time he was able to enjoy a sufficient quantity of repose, from taking only one- tenth of the quantity used by the mouth. I have also, in the same paper, adverted to the case of a medical gentleman who laboured under an affec- tion of his joints, which wras accompanied by spasms of the limbs and most excruciating pains. His agony was so intense that he used to swallow grain after grain of opium, until he had taken to the amount of thirty or forty grains, with the view of procuring some alleviation of his sufferings. He was prevailed on to give up altogether the use of opium by the mouth, and employ it in the form of enema, which he did with the most striking advantage—the quantity which succeeded in giving relief in this way being scarcely the twentieth part of what he ordi- narily used. It is unnecessary for me to enter here into any discussion with respect to the nature and treatment of delirium traumaticum, and the sleepless- ness which always accompanies it, as you will find this subject very ably treated in M. Dupuytren's works, and in a very instructive and elegant lecture delivered by Sir Philip Crampton (the surgeon-general) in this hospital, and published in the last volume of the London Medical and Surgical Journal. There is, however, one kind of sleeplessness, arising from irritation of the skin produced by blisters, which frequently assumes a very serious character, and on which it may be necessary to offer a few observations, as the subject has not been noticed sufficiently by practical writers. Trifling as the irritation resulting from a blister may seem, yet, under certain circumstances, it is a symptom of highly dangerous aspect, and becomes a source of just alarm. I have witnessed the loss of some lives from this cause, and many patients have, to my knowledge, been rescued from impending danger, by an early and proper share of attention being directed to its phenomena and treatment. The bad effects on the nervous system, occasionally produced by the application of blisters, are somewhat analogous to those which result from wounds and other external injuries, and to be accounted for on the same principle. Wounds and injuries sometimes make an impression on the nervous system, by no means proportioned to the importance of the injured DELIRIUM TRAUMATICUM FROM BLISTERS. 389 organ to life, or the extent of the mischief. An injury, produced by a body which strikes the sentient extremities of the nerves with great force, will sometimes produce very remarkable effects on the system. Thus, a musket-ball striking a limb may, without wounding any great artery or nerve, or destroying any part of importance to life, produce a train of nervous symptoms of an extraordinary character. The person, without feeling much pain, and scarcely knowing that he has been wounded, without being terrified or having his imagination excited by any appre- hended dangers, turns pale, gets a tendency to faint, and sometimes actually dies from an impression made on the nervous system. In the same way an external injury reacting on the nerves may bring on high mental excitement, delirium and a total privation of sleep, as we see exemplified in delirium traumaticum. I mention this with the view of establishing the proposition, that impressions made on the sentient ex- tremities of the nerves are sometimes reflected on the nervous centres, producing the most alarming effects. In this way we can understand how the irritation of blisters may produce sleeplessness, mental aberration, and a train of symptoms analogous to those which characterize delirium traumaticum. The delirium and sleeplessness arising from the irritation of blisters is by no means an uncommon disease. I have seen many examples of it in private practice, and 1 am anxious that you should be acquainted with its nature and treatment. It is generally met with in the case of children, in whom the cutaneous surface is extremely tender and irritable. I could relate several instances in which I have been called on to visit children labouring under fever, where symptoms of high nervous excitement were present, and where I found the little patients delirious, screaming, and perfectly sleepless from this cause. I have found this alarming affection generally occurring at an advanced stage of fever, and exhibiting a train of symptoms which closely resemble hydrocephalus. I have observed that after the application of a blister to relieve some suspected cerebral or abdominal or thoracic affection, jactitation, restlessness, constant applica- tion of the hand to the head, and delirium have appeared, and that these symptoms had been mistaken for incipient cerebritis or hydrocephalus, and treated with leeches and purgatives. When the blister has been applied to the nape of the neck, the soreness and irritation of the skin on that part cause the child to roll its head from side to side on the pillow with that peculiar motion and scream supposed to prove to a demonstration the existence of hydrocephalus. I have learned, also, that the above measures, so far from giving relief, have only tended to produce an exacerbation of the disease, and that the medical attendant has given up the case in de- spair. Now, gentlemen, if called to such a case, what should be your practice ? In four cases of this kind I gave my opinion frankly to the medical attendant, and told him he was pursuing a wrong course, that the disease was analogous to delirium traumaticum, and not to be treated by leeches or purgatives, and least of all by blisters. I observed to him that these symptoms had made their appearance shortly after the child had been blistered for suspected disease of the belly, or head, or chest; and that it was useless to attempt to remove the disease by leeches, or purga- tives, or blisters. The remedy I always proposed was opium, and it was acknowledged in four or five cases, that this remedy had succeeded not merely in relieving the existing symptoms, but in saving the patient's 390 CLINICAL MEDICINE. life. In such cases, particularly in young children, the opium must be given in small but frequently repeated doses, so as to insure its energetic but safe action, and the greatest care must be taken to soothe the irritated portion of the skin by ointments, poultices, &c, while unwearied diligence must be bestowed upon the task of pi-eventing the child from scratching the blistered surface. To effect this the child's hands must be muffled in ap- propriate gloves, and must be secured in the sleeves of a shirt made for the purpose. I beg your attention still further to this subject of sleeplessness and de- lirium. I wish to mention the case of a gentleman who was a pupil of mine. This gentleman studied hard, attended lectures regularly, and was constantly in the dissecting-room. While thus occupied, he happened to wound one of his toes in paring a corn, and afterwards wore a tight shoe on the injured foot. A small imperfect abscess formed in the situation of the corn, which was opened by one of his fellow-students: the incision gave very great pain, and was not followed by any discharge of matter. Next day he was feverish, and the lymphatics of the injured limb became extensively engaged, the inflammation ascending towards the glands of the groin and having a tendency to form a chain of insulated patches in different parts of the leg and thigh along the course of the lymphatics. This you will generally find to be the case in inflammatory affections of the lymphatics ; the inflammation is seldom continuous, but in the majo- rity of cases, is developed at certain insulated points, where small diffuse suppurations form very rapidly. After a few days, this young gentleman's fever increased to an alarming height, he became completely sleepless, and had incessant delirium. He was purged briskly, leeched extensively and repeatedly, his head shaved, and cold applications so constantly ap- plied, that he appeared half drowned and collapsed. Notwithstanding this very active treatment not the slightest relief was obtained ; neither were the symptoms mitigated by incisions made in the inflamed patches for the purpose of evacuating matter ; the sleeplessness continued, and the delirium was as wild as ever. I saw him on the seventh or eighth day, when all antiphlogistic measures had failed, and his friends were quite in despair. On being asked my opinion, I stated that I looked upon the case as one of delirium, not proceeding from any determination to the head or inflammation of the brain, but depending on a cause analogous to those which produce delirium traumaticum, and that instead of anti- phlogistics I would recommend a large dose of opium and some porter to be immediately given. Mr. Cusack, who visited the patient after me, concurred in this view, and a full opiate was administered in repeated doses. It succeeded in producing sleep and tranquilizing the nervous excitement. I may here observe that a few days afterwards this gentle- man had a return of the symptoms of cerebral disturbance with sleepless- ness, in consequence of omitting his opiate, and that the opiate and porter were again administered, and again succeeded in removing the delirium and watchfulness. By perseverance in the use of the same means, the disease was completely removed, and convalescence established. The last kind of sleeplessness to which I shall direct your attention, is that which is frequently met with in persons of a nervous and irritable disposition, in hypochondriacs and hysterical females. You will find such persons, although of active habits and with tolerable appetites, com- plaining of a total privation of their natural rest, and it is astonishing to COLD LOTIONS TO THE HEAD. 391 think how long they may continue subject to this harassing watchfulness. I have frequently observed this affection among females of nervous habit, who possessed strong feelings of attachment to the interest and welfare of their families, and who were remarkable for an exemplary and over anxious discharge of their domestic duties. It is also very often met with in the upper classes of life, where the susceptibility to nervous excitement is morbidly increased by fashionable habits. I shall not enter into the various moral causes which tend to produce this state of the nervous sys- tem, and will content myself for the present with giving you some hints for the treatment of this obscure affection. As yet I have not any distinct and accurate notions of the disease, and can only guess at the treatment; but this much I may state, that such cases are not to be cured by the means which I have already detailed. If they are to be cured by any means, I think it is by antispasmodics, and remedies which have a gen- tle stimulant, and, if I may so express myself, alterative effect on the nervous system. I have cured two cases of this kind by musk and assa- foetida, where every other remedy had failed. To one of these I was called by my friend, Dr. Neason Adams ; the patient was a lady of deli- cate constitution and hysterical habit; she was emaciated, and suffered from a total loss of rest, but had no other disease. All kinds of narcotics had been tried unsuccessfully, and opium in all its forms had failed in pro- curing sleep. I advised the use of musk in doses of a grain every second hour, and this means proved eminently successful. In another case I suc- ceeded by administering the same remedy in combination with assafcetida. I have also remarked that assafcetida alone, given in doses of two or three grains three times a-day, has very considerable effect in calming ner- vous irritation of this description, and restoring the patient to the enjoy- ment of more prolonged and refreshing sleep. In all such cases the physician must be most careful to have the appearance of not thinking the loss of sleep as a matter of much consequence, and the family of the patient must be directed to speak as little about the matter in his presence as possible ;—nay, so powerful is the operation of moral impressions, that in one case, which I attended along with Mr. Halahan, I succeeded in procuring sleep by ordering a musk pill to be given every second hour night and day, and by desiring the patient to be awakened, should she be asleep, at the time the pill wTas to be taken. I laid great stress on the importance of so proceeding, and thereby produced so strong an effect on the patient's mind, and inspired so great a confidence in the efficacy of the medicine, that she went to bed, not so much afraid of lying awake as afraid of being asleep at the hours when she ought to take a pill. The idea which had hitherto fixedly occupied her mind was displaced by a new impression, and relief was obtained the very first night. In affections of the head occurring in acute diseases, and attended with raving and loss of rest, it is a very usual practice to direct the application of cold lotions to the shaved scalp. Permit me, gentlemen, to make a few remarks upon this important sub- ject. I wish I could make myself well understood on this point, for I have seldom met with any person who seemed to bear in mind the true principle upon which cold is applied as a means of repressing local heat. In cases of determination of blood to the head occurring in fever, the common practice is to have the head shaved and cold lotions applied. Enter the room of a patient who is using cold applications, and you will 392 CLINICAL MEDICINE. observe the process conducted with great apparent nicety; the head is accu- rately shaved and carefully covered with folds of linen wet with a lotion to which spirit of rosemary or some odoriferous tincture has communi- cated an agreeable and refreshing smell; but when you come to examine the patient, you find his head smoking and the heat of his scalp increased. The nurse applies the lotion once every half hour, or perhaps not so often ; indeed, she seldom repeats the application until her notice is attracted by the steam rising from the patient's head, or until she herself, awaking from a comfortable sleep, and going over to examine the state of the patient's head, finds the folds of linen which cover it as hot and dry as if they had been hung before a fire. Whether applied to reduce local inflammation in any part of the body, or to cool the scalp in determina- tion to the head, cold lotions as ordinarily employed do infinitely more harm than good. The cold is applied at distant intervals, its effect soon ceases and reaction constantly takes place, leaving the part as hot or even hotter than it was before. If you put your hand into snow for a few moments, and then take it out, it quickly resumes its natural heat; and if you repeat this at consider- able intervals, so as to give time for reaction to occur, the vessels assume a more energetic action, and it becomes hot and burning. If you con- tinue to keep it in the snow for a long time, its heat becomes completely exhausted, reaction does not take place until after a considerable period, and very slowly, and the hand remains at very low temperature for a good while. Bear this in mind, for it will direct you in the application of cold to reduce local heat. If cold applications be used at such intervals as to allow the scalp to react and resume its heat, rely upon it, it is much better to forbid them altogether. Where you wish to apply cold with effect, let it be done by relays of folded linen, wet with any frigorific mix- ture, and repeatedly applied to the scalp so as to leave no smoking, or, what is much better, get three or four bladders, put into each a quantity of pounded ice, and apply one over the crown of the head, one on each side, and lay one on the pillow for the back of the head to rest on. There is a vast difference between a thing being done and its being well done : so it is with regard to cold lotions ; so difficult is it to insure their proper application, that I have entirely given them up in hospital practice, and rarely order them in private. I have been induced to abandon them in consequence of witnessing so many instances in which my directions were neglected, and consequently the cerebral congestion was augmented by their malapplication. Another serious inconvenience frequently arises from their use when applied in a slovenly manner, which is the danger of cold arising from the pillow and bed-clothes being wetted. It is a curious fact that the head is the only one of the three cavities with respect to which long-established custom has laid down the maxim, that when its contents are inflamed we may cool the surface over it, while in inflammatory affections of the thoracic or abdominal viscera this practice is avoided as dangerous and inapplicable. Latterly, however, some me- dical men have been inclined to question the grounds on which cold applications have been rejected in the two latter cases, and some have even declared that they have used ice poultices in inflammation of the chest and belly with great success and perfect safety. I am not as yet prepared to adopt this practice, although I must confess that a review of SLEEPLESSNESS. 393 the subject might incline me to give up my prejudices on this point. It is certainly but reasonable to think that what is true of the one may be also true of the other, and that the application of cold to the head and heat to the chest and belly has nothing in its favour beyond mere custom. It should be recollected, however, that the head and face are more accus- tomed to cold than the chest and belly, and hence are less liable to any mischief likely to arise from its application in an intense degree. Still, I am inclined to think that there is much prejudice connected with the practice of applying cold to the head ; and I have very little doubt that if the matter was properly investigated, and a number of experiments made, it would lead to the abandonment of cold applications in most inflammatory diseases of the brain. In fevers, I can say positively that in the majority of cases they are certainly injurious, as usually applied ; sponging the bare scalp with tepid or warm vinegar and water, or even frequently repeated steeping of the head and temples, will often succeed much better in abating the headache and restlessness of fever than any cold applications whatsoever. In 1832, a violent influenza, accompanied by most distressing headache, attacked thousands in Dublin ; this intense pain in the head was relieved by nothing so effectually as by diligent steeping of the temples, forehead, occiput, and nape of the neck, with water as hot as could be borne. I do not speak here of the application of cold to the head for the pur- pose of relieving local heat and inflammation, but to produce an effect on the whole system. Cold thus applied is of decided and unequivocal value. You are aware that in cases of fever accompanied by symptoms of high mental excitement and great heat of skin, the use of cold dashing has produced the most extraordinary effects. Again, if a patient has taken too large a dose of prussic acid or any other narcotic, the best mode of rousing him is by pouring water on his face or chest from a height. In Turkey, if a person happens to fall asleep in the neighbourhood of a poppy field, and the wind blows over it towards him, he becomes gradu- ally narcotised, and would die, if the country people, who are well ac- quainted with this circumstance, did not bring himtothe next well or stream, and empty pitcher after pitcher on his face and body. This occurred to my friend Dr. Oppenheim, during his residence in Turkey, and he owes his life to this simple but effectual treatment. To conclude, gentlemen, I may observe that sleeplessness in a chronic form is often produced by dyspepsia, and can only be relieved by the means suited to indigestion. Here it is that small doses of blue pill and tonic purgatives are of infinite service, combined with change of air, of scene, and an appropriate diet. In many females, sleeplessness is com- bined with menstrual irregularity, and can only be cured by means calcu- lated to invigorate the health and restore the catamenial discharge to its natural periods and quantity, for the nervous system suffers equally whether they be suppressed or overabundant. It is singular how long sleeplessness often continues in chlorosis without inducing those serious consequences that are produced by this symptom in other morbid states of the system. In such cases much is sometimes accomplished by means of the common preparations of morphia, or by the use of Hoffman's liquor (liquor rethereus oleosus), camphor, and other medicines that act upon the nervous system. It must be confessed, however, that these and every other expedient to obtain sleep often fail in chlorotic and hysterical females, 394 CLINICAL MEDICINE. in wThom relief is only obtained by a gradual improvement of the general health and menstrual function. Postscript.—Having in the preceding lecture alluded to the danger to be apprehended when any nervous symptom arises in a case of jaundice, I shall illustrate this view by introducing some very remarkable instances of this form of disease. The three following cases were sent to me by my friend Dr. Hanlon, of Portarlington, and are the more valuable as the author never expected their appearance in this work. With respect to the writer I can say, that during his pupilage he was remarkable for ex- treme diligence, assiduity, and zeal in the pursuit of professional know- ledge ; and I hope that my readers will value as I do his communication. Case 1—" Saturday, July 25, 1840, I was called to visit Miss Maria B----•, aged seventeen years. I was informed that she had been pre- viously healthy. On the preceding Wednesday she complained of languor, and in a few hours was attacked with bilious vomiting, which had returned three or four times in every twenty-four hours since. When the vomiting commenced, she became jaundiced, and the colour increased in intensity until it assumed a greenish-yellow tint. The bowels were constipated for two days before the vomiting began, and had remained so notwithstand- ing that the apothecary in attendance had given her repeated doses of purgative medicines. Effervescing draughts and other means intended to allay the vomiting had been given without success. " I found the tongue thickly coated with a yellow mucus ; tenderness of the epigastrium and right hypochondrium ; thirst; abdomen not tender on pressure ; urine scanty and high-coloured ; pulse 80 ; slight headache ; pupils natural; complains of want of sleep; and appears fretful and anxious. " Calomel combined with compound extract of colocynth and croton oil internally, aided by purgative enemata, caused a dark, small and offen- sive motion towards evening. Leeches were applied to the epigastrium and region of the liver, followed by stupes, three grains of calomel every fourth hour, and a purgative draught consisting of infusion of senna, and tincture of senna, jalap and cardamons after every second dose of calomel. " Sunday—Vomited twice since yesterday evening ; the bilious matter of a darker colour ; tongue still loaded ; thirst diminished ; tenderness of epigastrium and right hypochondrium much less ; bowels moved twice in the course of the night—motions larger but still very dark in colour; pulse 80; headache relieved; pupils natural; colour of skin the same; slept for two or three hours in the night; same treatment continued. " Monday morning, 5 o'clock—I was called up in haste to visit her. It appeared that two hours before my arrival she complained of violent headache and intolerance of light, vomited a dark brown matter resembling coffee grounds; soon afterwards became very restless, and gradually fell into a state of stupor. I found her in imperfect coma, the pupils exces- sively dilated and insensible to light, the eyelids closed. She flung her- self every minute or two from one part of the bed to another, and uttered a faint subdued scream ; she was very unwilling to be interfered with; pulse 60 and oppressed ; skin of a still deeper tint of greenish-yellow. " The assistance of Dr. Tabuteau and Dr. I. Jacob was procured in consultation. Fourteen leeches were applied to the temples; the head shaved and cold cloths applied to it; twelve grains of calomel in the NERVOUS SYMPTOMS IN JAUNDICE. 395 first dose, and five grains every second hour afterwards ; purgative enemata were employed every second hour. Cold affusion on the head was sub- sequently used, to a great extent, but without producing any change in the state of the pupils, or the coma ; mercurial inunction in the region of the liver and insides of the arms was commenced, and a large blister ap- plied to the scalp. "At 11 o'clock, a.m.—She was seized with violent convulsions, which lasted about a minute, and were accompanied with shrill screams; the right extremities appeared more strongly convulsed than the left, the mouth was drawn to the left side. The convulsions returned every thirty or forty minutes with same violence and screaming, until three o'clock, p.m., when they became less violent, but much more protracted in dura- tion, and gradually passed into a continued spasm, or jerking of the ex- tremities. She threw up occasionally a mouthful of the same dark matter which she had previously vomited. The administration of the calomel was relinquished, as every attempt to give it brought on a return of the convulsions. The mercurial inunction was assiduously continued, but no mercurial fetor could be detected on the breath ; the coma became more profound ; the pulse rose to 108, small, fluttering, and finally intermitting ; sordes collected on the teeth ; the urine and feces passed involuntarily ; the breathing, towards the close, became stertorous; and she expired at 11 o'clock the following morning. No examination of the body was per- mitted." Case 2—" Monday, March 29, 1841, I was requested to visit Miss Charlotte B----, aged 11 years; sister of the former. She had been previously healthy ; for the last two days has had the usual symptoms of a feverish cold, which is attributed to her having wetted her feet. I found the tongue loaded; tenderness of the epigastrium, none in the region of the liver; thirst; bowels confined ; urine scanty and high-coloured ; pulse 120; no headache ; pupils natural; no discoloration of the eyes or skin. Six leeches to the epigastrium, to be followed by stuping ; purga- tives ; diaphoretic mixture and diluents prescribed. " Tuesday morning, 9 o'clock—Appears better ; slept some hours in the course of the night; tongue cleaner; thirst diminished ; tenderness of the epigastrium much less ; no tenderness on strong pressure in the right hypochondrium ; bowels have been strongly acted on four times ; motions dark and offensive ; urine more copious and paler; pulse 92 ; no headache ; pupils natural ; no discoloration of the conjunctiva or skin. Having been absent from home during the day, I hastened, on my return at eight o'clock in the evening, to visit; and was greatly surprised to find her in the same state as her sister had been. It appeared that about three o'clock she became heavy and languid, the skin became slightly jaun- diced. She complained of headache and intolerance of light; vomited a dark-brown matter resembling coffee-grounds ; tossed about from one part of the bed to another ; refused to answer questions, and fell into a state of insensibility ; the bowels had been moved twice, the motions dark but not offensive. I found her in a state of imperfect coma, the eyelids closed, the pupils excessively dilated, and insensible to light; pulse 64 and op- pressed ; skin jaundiced. In a few minutes after my entering the room she was seized with violent convulsions, which were accompanied by shrill screams, and lasted about a minute. Pressure on the right hypo- chondrium appeared to give her pain. Upon my requesting that addi- 396 CLINICAL MEDICINE. tional medical aid should be procured, her friends declined having it, on the ground that the case appeared precisely the same as her sister's, and all our efforts on that occasion had been unavailing. Under these cir- cumstances I had recourse to the same plan of treatment as that adopted in the preceding case : cold affusion on the shaven head ; ten leeches to the right hypochondrium ; mercurial inunction on the right side and in- side of the arms, in the intervals between the convulsions ; strong purga- tive enemata frequently repeated, and a large blister on the scalp. The disease, quite uncontrolled by these means, pursued precisely the same course, in every particular, as the former one. The convulsions con- tinued most violent for two hours, when they began to be less violent, but much more protracted in duration, until they passed into continued twitch- ings of the muscles of the extremities. The coma became more profound ; the breathing stertorous ; sordes collected on the teeth ; and she expired at seven o'clock the following morning. " Her friends being now alarmed for the safety of her surviving brothers and sisters, became very desirous that the body should be examined. Dr. Tabuteau, who had seen the former case in consultation, assisted me in making the examination. The following are the results : examination made 30 hours after death ; surface of the body jaundiced. " Head.—Pacchionian glands preternaturally vascular; venous tumes- cence generally over the surface of the brain, with increased vascularity of the middle, and especially the left anterior lobes ; substance of the brain much more vascular than usual ; great vascularity of the chorou. plexus ; none of the optic thalami, or corpora pyramidalia ; the entire surface of the base of the brain highly vascular, particularly at the crura cerebri, pons varolii, and medulla oblongata ; no fluid found in the ven- tricles. " Abdomen.—Numerous spots of extravasated blood in the omentum ; several small patches of inflammation along the small intestines ; stomach apparently healthy. " Liver.—Size, natural; colour, externally of a dull yellow, with seve- ral dark spots about the size of a half-crown piece ; consistence, less than usual ; structure, minutely granular, and of a very peculiar crimson-orange colour, somewhat resembling what might be supposed to result from an intimate mixture of arterial blood and bile ;* gall-bladder distended with bile of the usual appearance. Thorax not examined. " I endeavoured to preserve portions of the liver in a dilute solution of corrosive sublimate and diluted alcohol, but they gradually lost their cha- racteristic appearance in both fluids." Case 3—" Friday, June 18, 1841,1 was called to visit Miss Jane B----, aged eight years ; sister of the two former. I was informed that she had been previously healthy. This morning she appeared languid and was attacked with bilious vomiting. No cause can be assigned for her illness. I found the skin jaundiced slightly ; the tongue loaded ; tenderness of the epigastrium and right hypochondrium ; thirst; bowels confined ; pulse 108 ; no headache ; no intolerance of light; pupils natural; urine scanty and high-coloured. Eight ounces of blood were immediately taken from the arm, which afterwards proved to be cupped and buffed ; eight leeches applied to the region of the liver followed by stuping ; twenty grains ot * This is very like the appearance of the liver described by Louis, as occurring in the fatal cases of yellow fever at Gibraltar. NERVOUS SYMPTOMS IN JAUNDICE. 397 calomel given at once, and a strong purgative draught every fourth hour until the bowels are fully acted on ; three grains of calomel and one and a half of James's powder every third hour after purgation ; cold to the head. "Saturday—Slept none; skin more deeply jaundiced ; tenderness of the epigastrium diminished ; heat of the right hypochondrium still re- mains ; tongue yellowish ; vomited twice since yesterday evening ; urine tinged with bile and more copious ; bowels moved four times ; motions dark and offensive ; pulse 110 ; headache and some intolerance of light ; considerable restlessness. Six leeches to the right side ; four to the tem- ples ; cold to the head ; a blister to the nucha, mercurial inunction ; five grains of calomel and one of James's powder every second hour. I now watched the case with the greatest interest and anxiety. " Sunday evening—Slight mercurial fetor of the breath ; tongue be- ginning to clean ; tenderness of the right side diminished ; bowels moved three times; motions less dark and offensive ; pulse 90, and soft ; head- ache and intolerance subsided ; restlessness entirely gone ; some return of appetite. Calomel and James's powder were continued every fourth hour until a slight salivation was established and cold carefully applied 1o the head. No unfavourable symptoms subsequently appeared. The tongue became clean, the pulse fell to the natural standard, the motions became more healthy in appearance, the appetite returned, and under the use of four grains of calomel at night, and a strong dose of black draught the following morning, repeated every third night for three weeks, the jaundice disappeared, and she has remained quite well up to this period." CASE 4.--JAUNDICE FROM INFLAMMATION OF THE GALL-BLADDER--NER- VOUS SYMPTOMS--DEATH—POST-MORTEM. " Anne Milton, a healthy fine young woman, aged 20 (servant), admitted into the Meath Hospital under Dr. Graves, November 1, 1841. About five weeks ago was attacked with pain in the right hypochondrium, ex- tending into the epigastrium, which lasted for a fortnight, and was followed by jaundice and high-coloured condition of the urine. She does not re- collect whether the feces were whiter than usual. After the skin got yel- low the pain in the side diminished ; but during the whole time it lasted she had constant vomiting and nausea. Three days after the setting in of pain, and ten before the appearance of the jaundice, she became affected with excessive itching of the skin, which prevented sleep; this itching ceased as soon as the jaundice appeared.* She had no pain in either shoul- der. At the time the skin became yellow, an eruption of an herpetic cha- racter appeared over the hepatic region. She was under no treatment for the pain; but to the eruption, a mixture of gunpowder and blood was applied. "Present Symptoms.—Skin and conjunctiva deeply jaundiced ; all ob- jects appear yellow ; urine high-coloured; feces white; no itching of skin; the linen over the eruption is stained yellow; tongue clean and moist; * The same phenomenon was observed in a man named Jones, who laboured under the most severe jaundice, in whose case the itching preceded the appearance of the jaundice for two months, and discontinued on the discoloration of the skin becoming established. These two cases are irreconcileable with the generally received opinion, that the itching depends on the deposition of the constituents of the bile in the texture of the skin. 398 CLINICAL MEDICINE. great thirst; appetite good; stomach not sick; no pain after taking meals; bowels confined ; sleeps badly; no headache ; pulse 80, full and soft; breath- ing hurried; no cough or physical sign of disease in either lung; the heart's action strong, but the sounds are normal and distinct; complains of no pain when the right hypochondrium is pressed, or when the ribs are pushed against the liver, but she has slight pain at a point between the right hypochondrium and epigastrium, greatly increased by pressure. There is some fulness of the latter region, but percussion does not give a dull sound; no enlargement of the liver noticeable or detected by percussion; the ab- dominal muscles are very irritable, and are thrown into spasm by the least effort to examine the abdomen minutely; she has no pain over either lum- bar region. Poultices to the eruption—xii. leeches to the painful part. R. pil. hydrarg. gr. x. Pulv. doveri gr. v. in pil. iii. st. i. 4tis. horis. Enema purgans. "November 5th—pain relieved by leeches ; no other change ; appetite extremely good. " November 6th—was attacked last night with pain in the stomach; no vomiting; pulse to-day fuller and quicker—100; breathing not hurried; 'feels unwell' to day; tongue clean; some thirst; appetite good; bowels confined; skin dry; no change in the jaundice ; complains of tenderness at the point before mentioned. R. pil. hydrargr. gr. v. ter in die. Hiru- dines xii. P. D. " November7th—On the previous evening she became delirious, and this morning (7th), at the hour of visit, was quite comatose, and soon after died. " Post-mortem.—The brain and abdominal viscera were the only parts examined. The liver was not by any means enlarged, and a section of it disclosed no excess of blood. It was of a light brown colour, tinged with yellow, as if from a superabundance of the colouring matter of the bile. The gall-bladder was distended, and on being opened was found completely filled by a dark green mass of a tenacious viscid nature, appa- rently lymph. This substance was of the same pyriform shape as the gall- bladder, and terminated by its narrow extremity at the commencement of the gall-duct. On its removal, the lining membrane of the gall-bladder presented a bright scarlet colour and villous appearance, and the natural and beautiful 'honeycomb' arrangement of the mucous membrane was com- pletely effaced. There was no softening or ulceration of the membrane, nor was the colour different in any part. It resembled very much the ap- pearance of the mucous membrane in acute laryngitis. The walls of the gall-bladder were much thickened. There was no obstruction of the ductus choledochus, the cystic or hepatic ducts, and their lining membrane was quite free from any unusual vascularity; the duodenum and stomach were stained with the colouring matter of the bile, but in other respects were healthy; no gall-stones or other obstruction; the kidneys were natural. " Cranium.—The dura mater was stained of a yellow colour ; there was no thickening or opacity of this membrane ; the arachnoid and pia mater were quite healthy ; the substance of the brain was firm and free from any unusual vascularity; no effusion of lymph in any part; the ventricles were not distended with fluid beyond what is normal, but the fluid, though in small quantity, was of a yellow colour, and the surface of the different parts contained in each ventricle was also of a light yellow colour; the nerves and all other parts of the organ were free from this staining. Case 5.—It may not be deemed superfluous to mention here the details INFLAMMATION —CAPILLARY CIRCULATION. 399 of a case which was lately under the care of my esteemed colleague, par- ticularly as it required some skill to distinguish the features which it pre- sented from the ordinary and so frequently fatal combination we have just spoken of. An old woman was admitted, in September, 1842, into the Meath Hospital, labouring under jaundice, purpura hemorrhagica, and palpitations of the heart. Her habits wrere very intemperate, and shortly before admission she had been indulging largely: and when first seen by Dr. Stokes, she presented, in addition to the symptoms already enu- merated, many of the features of delirium tremens. She was exceedingly feeble, and her legs were anasarcous. After being under treatment for some time she began to improve ; when one night she was attacked with violent delirium, convulsions, and imperfect paralysis of the right side, she lost the power of speech and the mouth was drawn frightfully to the left side. The face presented almost all the phenomena which attend Bell's paralysis of the portio dura, but the head was cool, she complained of no uneasiness in this region; the eyes were quite natural, and no increase in the strength of the pulsation of the carotid or temporal arteries could be detected. She lay sobbing and frequently sighing, and appeared extremely anxious to excite the sympathy of the spectators. These circumstances induced Dr. Stokes to make a most careful examination of the patient; and having premised to the class that the case differed in many particulars from the ordinary combination, and that should it appear that there was really a connection between the jaundice and the supervention of the cerebral symptoms, the prognosis ought to be most unfavourable. He ascertained after some time, from the nurse and the other patients, that this woman, though fifty years old, was extremely hysterical, and had had, during her sojourn in the hospital, many attacks somewhat similar, though much more mild ; and by a further reference to her husband, it was discovered that she had been subject to these hysterical attacks for the last 30 years, and that she had frequently been affected with con- vulsions, raving, and even temporary paralysis, for years before the occurrence of jaundice. The nature of the case was then quite evident, and the patient was saved the risk which might have attended the employment of remedies the supposed complication would have indicated. It may, with truth, be said, that this was a very unusual combination ; but it shows, in my opinion, the necessity of patiently investigating, and carefully scrutinizing the characters of any rare, or hitherto unnoticed symptom, or combination of symptoms, in any particular case, for who might not have mistaken the cerebral symptoras in the example before us for the common complication which occurs in jaundice ? LECTURE XXXV. ON INFLAMMATION AND THE MOTOR POWERS, WHICH CAUSE AND REGU- LATE THE CIRCULATION. Gentlemen,—The general laws which govern inflammatory action, and the relation which the vascular system bears to that process, constitute a 400 CLINICAL medicine. most important subject, which has engaged the attention of the ablest pathologists and practitioners in this country for the last half century. Since the date of the great John Hunter's celebrated work, which gave the first impulse to this investigation, many British and Continental writers have applied their talents to the illustration of the changes the vascular system undergoes duringtheprogressof inflammation. Thompson, Hastings, W7. Philip, James, Burns, and Marshall Hall, have performed numerous and interesting experiments, which throw light on its pheno- mena ; and we have gained much by the assiduity and research they have displayed, in endeavouring to illustrate a matter of such acknow- ledged difficulty. Still, these authors appear to have adopted some erroneous views, and to have misunderstood or overlooked some points of peculiar importance. I shall first direct your attention to the opi- nions of Dr. Marshall Hall, as explained in his lectures, now in course of publication in the Lancet. Dr. Hall, possessing extensive acquire- ments and high professional reputation, has cultivated the sciences of physiology and pathology with distinguished zeal, and made numerous experiments and microscopical observations, tending to illustrate the sub- ject of inflammation ; his opinions are, therefore, entitled to serious con- sideration. In the last volume of the Lancet* page 76, Dr. Hall, speaking of the inflammatory process, observes—" I conclude that each cause of inflam- mation first induces such a physical effect upon the internal surface of the capillaries, as leads to the adherence of the globules of blood to it, and to their ultimate stagnation. This stagnation augments as the inflamma- tion increases, and becomes more diffused, and seems to constitute the essential character of the disease." Here you perceive that the first step is the adherence of the globules of the blood to the internal surface of the capillaries, the consequence of which is, that the calibre of these vessels is considerably diminished, so that they become obstructed, and cause a stagnation of the blood, which Dr. Hall looks upon as the essential character of inflammation. Further on he says—" I have never been able to detect any action in the capillaries themselves. Tt is, probably, by the partial obstruction to the circulation in the capillaries, that the minute arteries become en- larged." Now observe, according to this mode of explanation, the cir- culation being obstructed in the capillaries, in consequence of the adhe- rence of the globules of blood to their sides, the arteries which supply them are propelling blood into obstructed vessels, and consequently be- come enlarged or dilated—and why? Dr. Hall says, " according to the well-known law, that muscular organs augment, with obstacles to their functions." Here I may, in the first place, observe, that Dr. Hall is not warranted in looking upon the minute arteries as muscular organs; but waiving this point, how can the law alluded to explain the supposed increase in the capacity of the minute arteries? It might, indeed, explain the increase of thickness in their parietes ; but is it not plain, that this very addition to the thickness of the arterial walls, so far from increasing, must diminish their calibre ? Again, he observes—"It is probably by the fact of stagnation that inflammation differs from blushing, eruptions, &c." Here, you perceive, * This and the following lecture were delivered in the last week of November, 1837. It will be seen that I have since added many references to books published in 1838. INFLAMMATION—CAPILLARY CIRCULATION. 401 he introduces the qualifying term, " probably." He continues—" It is generally asserted, that there is a series of vessels which only circulate the serum of the blood, and exclude the globules. This I believe to be mere hypothesis. Vessels which only admit of single globules will appear colourless. In inflammation, the minute arteries which only admit single globules at a time, enlarge, and admit a greater number, and then the red colour becomes visible." He goes on then to say—" This en- largement of the blood-vessels is not confined to the minute arteries, for the larger vessels in the immediate vicinity of the inflamed part also be- come enlarged. * * * * This is owing to the obstruction of the true capillaries." And he illustrates this by instancing the application of a ligature to an arterial trunk, the consequence of which is, that the col- lateral arteries of the part become increased in size, in consequence of the obstruction. We shall see afterwards, how little this admits of being proved. He says—" It is not known how far this enlarged state of the arteries extends from the seat of the inflammation ; but, in the case of an inflamed finger, the pulse at the wrist of the corresponding arm beats more strongly than it does on the opposite one." Such are Dr. Marshall Hall's views of the causes of inflammation, and the part which the capillaries and minute arterial vessels play in that in- teresting process. You perceive, by the brief outline which I have given, that he attributes all the phenomena to adherence of the blood-globules to the sides of the capillaries, the consequent obstruction of these vessels, and the enlargement of the minute arteries to which that obstruction gives rise. In this view of the case the vessels are regarded as passive, and are distended on purely mechanical principles ; in fact, their enlargement is a mere dilatation. Notwithstanding the respect I entertain for the learning, ability, and industry of Dr. Marshall Hall, I must say that I look upon his views as purely hypothetical, and am convinced, that he has arrived at unsound conclusions with respect to the nature of inflammation. I shall not, how- ever, take up your time by going over his positions seriatim, and showing their untenable character; but shall proceed at once to lay before you the opinions to which observation and reflection have led me, and which have been taught for many years in my lectures on the Institutes of Medi- cine. I shall not, like Dr. Marshall Hall, attempt to explain the nature of inflammation, or determine its proximate cause, but shall content my- self with endeavouring to arrange its phenomena, and point out their order, and the share which the capillaries have in the inflammatory pro- cess. Before entering on this subject, it may be necessary to premise a few observations on the circulation in general. The human body is composed of various parts, differing in their ulti- mate structure, chemical composition, and vital functions. There is a very remarkable difference between muscle and cellular tissue, and be- tween the latter and nervous tissue. If we examine these parts more closely, we find them differing, not only in their structural arrangements, but also in the ingredients or materials of which they are composed. In muscle we find a large quantity of fibrin and colouring matter; in carti- lage, fibrous membrane, and tendinous substance, we find more or less of the fibrous structure of muscle, but we do not meet With fibrin, and there is not the slightest trace of colouring matter. The same blood furnishes materials for the growth and nutrition of all, and conveys the nutrient 27 402 CLINICAL MEDICINE. particles to red and white tissues alike ; but the white parts require not red blood, and consequently receive none. Blood is a compound fluid, which contains, as it were, the raw material of all the tissues in a fluid state ; it is, in fact, flesh in a state of fluidity, and destined to combine with and support the solid portions of the frame. It is conveyed by the arteries all over the body, supplying each tissue with its appropriate ma- terials, and contributing to its growth, sustentation and repair, in the amplest, and yet in the most economical manner. It does not enter the tissue of every organ in that state which has been termed arterial, and in which it appears as a fluid of a bright red colour. This is an error of which nature is never guilty. It would be absurd if all parts of the blood were carried to all the different tissues indiscriminately ; and it would, moreover, be a great waste of vital and mechanical power. The chief bulk of the blood is made up of a transparent fluid or lymph, holding in solution various salts, besides albumen and fibrin. The red globules are immersed, but not dissolved, in this fluid ; and it appears from the ob- servations of Mayer, that in the minute vessels the red globules occupy the central part, surrounded by the transparent fluid. The colouring glo- bules are necessary for the nutrition of muscular, raucous, and some other tissues ; and are carried by the minute vessels wherever they are required. Every part of the blood is required in a muscle ; fibrin and colouring mat- ter for its essential fibre ; albumen, fatty matter, &c, for its cellular and adipose membrane. The white tissues, as I have already observed, re- ceive no red blood, because they require none—this is quite certain. Serous membrane, for instance, contains neither fibrin nor colouring mat- ter ; at what point of the circulation does the separation of the albumen take place ? Is it an act of nutritive secretion which separates it from the whole mass of arterial blood, or are only the serous portions of the blood carried to the white tissues ? " Serous vessels," says Muller, " that is, branches of the blood-vessels which are too minute to allow the passage of the red particles, and which are traversed, therefore, merely by the lymph of the blood, may possibly exist, but they have not been demon- strated." It seems to me, however, that it is by no means necessary for blood- vessels to be too minute to allow the passage of red globules, in order to make these vessels the vehicles of lymph alone. The entrance of the globules into them will be determined by other circumstances than their size. Already, as the blood approaches the capillary system, the micro- scope detects a tendency to a separation between its lymph and colouring globules ; and no doubt their complete separation is effected by vital agencies, independent of mere calibre. Hence we may explain the fact, that no red blood seems to circulate in serous membranes during health ; but the moment inflammation sets in, the natural play of vital energies is deranged, and the red globules, finding their way into unwonted channels, vessels innumerable, before filled with a transparent lymph, and therefore not visible, start suddenly into view, in consequence of their now containing an opaque and coloured fluid. According to Hall, Muller, and other physiologists, all minute vessels contain red particles, which, however, are believed to exert no influence on their colour, so long as these particles are only admitted singly, and not several at a time. But when inflammation comes on, according to Hall these vessels are enlarged in consequence of obstruction, and then INFLAMMATION —CAPILLARY CIRCULATION. 403 admitting a greater proportion of red globules, become visible. Now, gentlemen, observe how suddenly, when the conjunctiva connected with the sclerotic is irritated, numerous vessels appear filled with red blood. Here is no time for the adhesion of globules to the internal surfaces of the vessels—no time for the gradual enlargement of vessels previously too small for the admission of the red globules ; no, the vessels existed there, but they contained no red globules; they admitted none, because their admission would have proved unnecessary or injurious. I do not deny the sudden enlargement of minute vessels ; on the contrary, I believe in it most firmly, and am persuaded that the minute and capillary arterial branches which admit in health only lymph, may suddenly expand and increase in size. I do not, for reasons hereafter to be detailed, consider this expansion as passive; and I believe that the red globules made little or no part of the fluid previously circulating in these vessels. Indeed, it seems rather illogical to argue that, because red globules might be present without imparting a perceptible red colour to this fluid, that, therefore, they are present. When the contents of a vessel are to the eye colourless, the onus probandi lies with him who asserts the presence of red colouring matter ; and until that is proved in each particular case, the contained fluid must be regarded as colourless. As to the idea that lymph vessels could not exist unless their diameter was smaller than that of the red globules, it is too mechanical to deserve serious attention. The entrance of animal matters into, and their pro- pulsion along vessels, depend most assuredly on other conditions than mere size of particles. Indeed, Muller expressly says—" In the most minute capillaries which are not red, nor even yellow, but quite transparent, there is merely a single line of red particles, separated by unequal intervals, and from time to time no red particles are seen in these colourless vessels ; but I have seen no canals through which red particles did not occasionally pass, and which, therefore, deserved the name of vasa serosa, and WTede- meyer, who says he has seen such vasa serosa himself, confesses that some of the red bodies traversed them from time to time. Here, then, we have my argument confirmed by observation, and the fact proved, that the entrance and passage of the red particles does not depend on the mere size of the vessels. If we take an accurate view of the general circulation, we shall find, then, that there is a great circulation of red fluid containing the raw ma- terial of all the tissues ; which fluid, in its integral state, is destined chiefly for the muscles of voluntary and involuntary motion, into every part of which red vessels penetrate, and from which red blood returns. In fact, red blood forms as it were, a separate circulation, sweeping by the white tissues, to which it merely detaches its uncoloured lymph, while the red blood enters the capillaries of the red tissues. When the minute arteries arrive at the parts where red blood is no longer necessary, they send off smaller vessels which contain only white blood, mixed with compara- tively few, if any red globules, while the branches which carry red blood proceed to join the corresponding veins. I dissent from the common notion that the circulation of the blood goes on very rapidly. It has been computed that the heart expels from two to four ounces at each stroke of the left ventricle ; and if we compute the quantity of blood in the body to be from twenty to thirty pounds, we shall be led to conclude that the whole mass of the blood passes through 404 CLINICAL MEDICINE. the heart in a very short spaCe of time. This, however, is only taking a partial view of the matter. It is true that there is a rapid central current of red blood which accomplishes its circle through the body in a very short time, but a large proportion of the juices of the body circulates very slowly through the tissues it supplies, being detained in the capillary system for a considerable period before it is returned to the general mass of the circulation. If you compare the relative circulations of different classes of animals, you will find that they differ considerably in the com- position of their blood, as well as the rate at which it travels through the system. Some animals have only white blood and a capillary circulation, without any distinct arteries or veins. Others possess vessels correspond- ing to arteries and veins, but still no distinct organ like the heart. Finally, we arrive at a higher class, which have not only distinct arteries and veins, but also a heart. In each of these classes the circulation differs not only in the properties of the circulated fluid, but also in the velocity with which it travels. It is much slower, much more slug- gish, in the lower than in the upper classes of animals. In the same way, blood does not circulate so rapidly in tissues of a low degree of organiza- tion (as bone, cellular and fibrous membrane), as in the red parts of the body. It is, therefore, not unreasonable to suppose that bone lives at one rate, fibre at another, muscle at another, and nervous matter differently from all. These views are of importance when brought to bear on the subject of inflammation, and tend to explain the slow progress it makes in certain tissues. You must have perceived that, from the very beginning, I have rejected the idea that the blood is propelled through the system by the vis a tergo alone. If that were the case, the current, though diminishing in velocity as it receded from the heart, would be equable in vessels of the same size throughout the whole system. But, in my opinion, the current of circu- lation has many different rates, which depend not on the vis il tergo alone, or the distance from the heart and size of the vessels,* but on the vital energy of the vessels themselves. Hear what Miiller says on this subject: —" Wedemeyer's description of the course of the blood in the anasto- mosing capillaries agrees perfectly with what I have observed. Some- times, he says, the red particles flow rapidly from one current into an- other, as if by attraction. In other cases the current which they join is very rapid, but they are arrested, as it were, in the collateral current, and only from time to lime find means of entering. Sometimes a red particle is even thrown back out of the rapid current into a weaker stream, and is then again repelled. I have also remarked that the same anastomosing branch between two currents sometimes receives the blood in one direc- tion, and sometimes in the other, and that variations of pressure and posi- tion, and motions of the animal, are always the causes of these changes." Such is Miiller's testimony concerning the circulation in the capillaries, and it bears me out in the assertion, that a very great portion of the blood (using that word in its most comprehensive sense, and meaning thereby nutritive fluid) is comparatively stagnant in the capillary system ; but I must confess that I felt much astonishment at Miiller's assertion, that " all these variations in the capillary currents are, just as in currents of water in irrigated land, merely the result of mechanical causes." * The blood's velocity in its progress from the heart is diminished chiefly by two physical causes, viz., increase of friction, and the increasing capacity (considered as a whole) of the vessels which contain it. INFLAMMATION —CAPILLARY CIRCULATION. 405 Having made these preliminary observations, we are now better pre- pared to speak of the forces by means of which the circulation of blood is accomplished. Most authors, and with them Muller, have stated that the motion of the blood in the capillaries is wholly dependent on the heart's action. Now these vessels are mere simple membranous tubes, and there is no doubt that their membranous parietes must exert a strong power of endosmosis and exosmosis, as shown by Dr. Rogers, in the American Journal of Medical Science. This power must necessarily have a great influence on the motions of the blood contained in the capillaries, causing a mutual interchange of contents between vessels in contact with each other, and between the vessels and surrounding parenchyma of the organs. Again, it has been proved by Dr. Draper, in the same journal, that in capillary tubes and organic pores a motion of the contents must result when the contained fluid possesses certain physical properties, from its mere contact with the internal surface of vessels so minute. Here, then, are two sources of motive power, quite independent of the heart's action, and which must necessarily influence, in a most important manner, the capillary circulation ; but this is not all, for there resides in the small vessels connected with the capillaries, whether minute arteries or minute veins, a vital sensibility which enables them, by suddenly or gradually changing their calibre, to increase or diminish the quantity of fluid in any particular organ or tissue. . Facts in abundance may be brought forward in proof of this assertion. When a fatty or a fleshy tumour arises on any part of the body, we have new vessels, as it were, created ; and there is no reason to attribute their formation to any thing like a dilating vis a tergo. But the formation of the vascular system in the foetus affords the strongest proofs. Here the smaller and more minute parts are formed first, the development com- mencing with the capillaries, and extending to the minute arteries and veins, and then to the larger trunks ; until, at last, the heart is super- added, at first of an elementary, afterwards of a complicated structure. The best account of the development of the vascular system in the foetus, is contained in Von Baer's work, published in 1837, in Konigsberg.* He says (Part II. p. 126), that there is no doubt that the blood is formed before the vessels. The formation of blood goes on in every part of the body, and, when formed, it is put in motion by the agency of some un- known cause which impels it in the proper direction, until it at length reaches the central formation of blood, around which is developed a tubular canal, afterwards to be further modified and changed into the heart. In truth, the first motions of the blood are towards the heart, and consequently the first vessels formed, are the veins; a fact in itself sufficient to disprove the hypothesis that this motive power which presides over the circulation resides exclusively in the ventricles of the heart. What do we find occurring in the case of pseudo-membranes resulting from pleu- ritic inflammation ? Exactly what takes place in the development of the foetus. A large quantity of lymph is effused, which at first has no vascular connection whatever with the parietes of the chest. After some time, however, the effused lymph becomes organised, and vessels begin to form in its substance ; these extend gradually, and join the vessels of the tissue with which the lymph lies in contact. Of this formation of vessels in effused lymph there can be no doubt; I have often examined it with ad- * Uber Entwickelungsgeschichte der Thiere, &c, &c. 406 CLINICAL MEDICINE. miration, and it is likewise attested by Andral. When a mass of lymph, effused into the pleural cavity, is about to organise itself, and become vascular, a vast number of red points make their appearance throughout the mass, and are connected with very minute streaks, having a vascular distribution. In this lymph, then, red blood is manufactured, as in the foetal body at an early period of development, and vessels are formed ; and sanguineous circulation, no doubt, exists. These facts, I say, bear strongly on the question before us, proving beyond a doubt that the vital properties of living matter are capable of forming vessels, and of rapidly increasing their size when formed. To account for the sudden increase in the size of vessels belonging to an inflamed part, we must look to this fact, and not rely solely on increased vis a tergo, aided by obstruction. Now the whole of Dr. Marshall Hall's explanation depends on these two causes—vis d tergo, and obstruction. But I say that vessels may be formed, multiplied, and enlarged, independently of these causes, and in consequence of an altered vital action of the parts in which the process occurs. Let me refer to the case of the impregnated uterus. In the unimpregnated state, the womb is a small organ, with vessels and nerves so small as scarcely to admit of being satisfactorily traced. What takes place after conception ? It has now new and important functions to perform, and it becomes proportionally increased in magnitude and vital activity ; its arteries and veins become elongated and enlarged ; its walls become thickened, and its nerves increased in size. And yet we are told that this increase in the size of its vessels depends on obstruction. Where does the obstruction exist? What proof have we that there is any increased vis a tergo? Will any of these principles account for the augmented size of its nerves ? Tiedemann has proved beyond contra- diction that the nervous matter of the womb is augmented to a very remarkable degree, during the impregnated state, and that minute nervous filaments, scarcely discoverable with the aid of a microscope, enlarge into bands visible to the naked eye. The same thing occurs with respect to the minute arteries and veins ; from being but barely perceptible, they become large tortuous vessels carrying an abundant supply of blood, and performing their functions with extraordinary activity. I do not pretend to offer any explanation of these facts ; I merely place them before you, and show you the analogy which exists between the vascular and nervous development. The vessels increase in size and capacity, so do the nerves ; and the augmented size and capacity of both depend on the same unknown cause. The nerves are developed in the same order as the vessels, and, like the latter, they increase from the circumference to the centre. Nay, I am persuaded, that, did our means of investigating the matter possess the same advantages as those we enjoy in the examination of the vessels, we should find that, in inflamed parts, the nervous matter increases, in many cases, as rapidly, and to as considerable an extent, as the vascular. So far, gentlemen, I have endeavoured to lay before you proofs of the independence of the capillary circulation, a fact which I have long since brought forward in my public lectures, and of which I have written somewhat in detail, in my review of Dr. Joerg's work on Atelectasis of New-born Infants. These views, I am happy to state, have been further INFLAMMATION —CAPILLARY CIRCULATION. 407 confirmed by Dr. Houston, in a paper published in the 29th number of the Dublin Journal.* In that paper, which I recommend to the attentive perusal of every student, Dr. Houston gives an account of an extraordinary case of twins born of a healthy young woman, between the seventh and eighth month of her pregnancy. One of the children was, to all outward appearance, perfect in every particular, and of the full growth of its age ; the other, a female, and the subject of Dr. Houston's communication, was a monster, of somewhat smaller size than its companion. Both' were alive at the time of delivery, but died almost immediately after. There was a separate cord, and a separate set of membranes, for each foetus. The abnormal one had neither brain, heart, lungs, or liver ; the kidneys were of enormous size, nearly filling the abdomen, and extending to the apex of the cavity formed by the ribs. The umbilical vein, after quitting the cord, descended between the abdominal muscles and peritoneum as far as Poupart's ligament, and there opened into the external iliac vein, which became enlarged in size at this point. From this vein all the veins of the body were derived ; large branches passed to the pelvis, thighs, and kidneys, and smaller ones to the intercostal spaces, and the tumour which constituted the head. These veins were devoid of valves, and terminated in the capillaries. From the latter, the arteries began by fine roots, and gradually coalescing, united into a sort of aorta on the fore-part of the spine, which descending, divided into the iliac and hypogastric arteries in the usual way. No communica- tion existed between the arteries and veins, except at their capillary terminations. Such is the history of this very remarkable case, as given by Dr. Houston. I have not time at present to enter into his arguments ; but I think he has satisfactorily proved, that in this instance, the circulation was carried on without the aid of the heart of the other twin (as supposed by Sir Astley Cooper), or of the heart of the mother, and that it depended solely on the vital energy of the capillary and other vessels. Another case of a monster without a heart, is related in the American Journal of Medical Sciences, for February, 1838, by Dr. Jackson, of Boston. This was likewise a twin ; and there can be but little doubt that its circulation was quite independent of any assistance derived from the heart of its fellow. I have already spoken of the dilatation of the arteries and veins of inflamed parts, as being produced by something very different from mere distension ; and that it is not of a passive but an active nature. That the larger vessels actively dilate can scarcely be doubted by any one who has observed the state of the temporal arteries in phrenitis, or apoplexy ; that the veins have a similar power, may be observed on plunging the hands or feet into a hot medium, whether moist or dry. Blisters applied to the skin produce for the time increased size of the cutaneous veins ; and sores on the leg may, when considerable and long-continued, give rise to a varicose state of the veins. When a grain of sand falls into the eye, how sudden is the redness—how numerous the vessels which now appear gorged with blood ! This change takes place in a few seconds, and, in my opinion, can be much more satisfactorily accounted for, by- supposing that the capillaries and smaller vessels enjoy a wide range of * A full account of this foetus is given in a note to my lectures on Fever at the beginning of this work. 408 CLINICAL MEDICINE. size, if I may use the expression, and are capable of enlarging or dimi- nishing their calibre, according to the exigencies of the case and the state of the circulation. That the large arteries and veins do so, is acknow- ledged by all, and is proved by arterial trunks contracting on their con- tents so as to maintain their proper tension ; no matter how much blood is drawn from an animal. The larger veins are capable of a like contrac- tion and expansion : can similar properties be denied to the smaller arte- ries, possessing, as they do, an elastic coat proportionably thicker ? The vascular phenomenon attending a blush ought to have taught physiolo- gists how rapidly, how instantaneously, blood may be drawn to a particular part, and may again desert it; and that, under circumstances where the vis a tergo could not determine a flow of blood to the part in question, more than to any other in the body. Do we need microscope examina- tions on the capillaries of recently killed animals to instruct us, when such phenomena offer themselves, as it were, for the very purpose of illustra- tion ? WThen the child breathes for the first time, the air admitted into the lungs gives new energy to their capillaries, and at once the great current of blood flows through the pulmonary arteries, deserting the ductus arte- riosus. In a seven months' child the latter passage is still very large ; and yet, when the child breathes, its being open effects very little, if any thing, towards diminishing the flow of blood into the pulmonary arteries. Here, again, we observe how arteries grow independently of mere pressure from within ; for the pulmonary arteries and pulmonary veins are enlarging themselves long, long before they are called on to be chan- nels for a quantity of blood at all proportioned to their calibres. John Hunter observed the enlargement of the arteries of an inflamed part, and his observations, and those of others, have brought to light a periodical and remarkable increase in the size of the vessels destined to promote the growth of the stag's horns. Are we, in this case, to explain that enlarge- ment by obstruction, or by the vis a tergo ? It is impossible to do so ; and we must, then, look to the vessels of the part itself for a solution of the question. In such instances, as in the case of the pregnant uterus, these vessels are endowed with this power of growth and enlargement, quite independently of the general vascular system, or the action of its centre— the heart. I am the more anxious to impress on you this view of the subject, as the hypothesis of obstruction has been adopted by many late writers, as explanatory of the local changes of circulation attending inflammation. Thus Dr. Williams, in his admirable lectures published in the Medical Gazette (No. 528), says, " We cannot, in the present state of pathological knowledge, doubt that the circulation through the inflamed vessels is, to a certain degree, obstructed ; whilst, either as a consequence of this, or from some co-operating influence, the vessels leading to the part become dilated, and being thus more open than others to the pulse-wave of the heart, they become the seat of that throbbing hard pulse that has been mistaken for increased action of the vessels themselves." Now, gentlemen, you observe here that Dr. Williams expresses himself doubtfully about the dilatation of the vessels being caused by obstruction, and he even speaks of some co-operating influence. We shall, therefore, content ourselves with having recited his opinion on this point. I must observe, however, that the dilatation of the vessels, however caused, can, on no principle, account for their becoming the seat of throbbing, and a INFLAMMATION —CAPILLARY CIRCULATION. 409 hard pulse : their being more open than others to the pulse-wave from the heart, could, at the utmost, only place them in the situation of other arte- ries naturally of the size they have now attained to ; but we do not find that such arteries throb, or have a hard pulse. Arteries do not throb, or become the seat of a hard pulse, in proportion to their size. That is not the fact; and, consequently, Dr. Williams's explanation cannot be ad- mitted. Dr. Weatherhead, who has arrived at very nearly the same view of the subject with myself, says, " The first effect of an excitant, or irritant, ap- plied to any part of the body, is to attract the blood to the seat of irrita- tion, and to quicken its current in the capillaries." So far we perfectly agree. Here Dr. Weajherhead estimates the vital energy of the vessels of the part at its true value, and does not call in the aid of an increased vis a. tergo to account for an augmented determination of blood to any particular locality ; but to what follows I cannot accede. " If these effects be kept up beyond a certain period, or carried beyond a certain degree, the excitation continues to attract as much blood as before, while the power of the capillaries to forward it diminishes, by the exhaustion ensuing from their prolonged over-action." There seems but a weak analogy in support of the assertion, that increased vascular action must necessarily produce vascular exhaustion. It may be objected to my view, that dilatation of an active nature can- not be conceded to the capillaries, whose coats are quite thin and mem- branous ; but when the objects are so minute, it is quite impossible to determine the physical or vital powers of tissues ; and we should recollect that what is deficient in degree may, in the case of the capillaries, be made up by their number, which is immense in every part of the body. Still, so far as our observations do go, they seem to establish the property in question. Muller, whose opinion upon all physiological questions is of the greatest weight, has adopted on this subject an hypothesis which appears to me to be quite untenable. It is observable, that the first of the following paragraphs, which I quote from his work, proves, that when writing it, he felt conscious that the remarkable phenomena of vital tur- gescence are totally irreconcileable with the theory, which denies any per- manent circulating power but that of the heart, and which asserts that " the motion of the blood in the capillaries is wholly dependent on the heart's action !" Let us hear what he says concerning vital turgescence of the blood-vessels (p. 224):—" Although it be denied that the circulation is in any way aided by an attraction between the blood and the capilla- ries, the existence of such an attraction or affinity may, nevertheless, be admitted in the instance of the ' turgescence, turgor vitalis, or orgasm,' which is observed to take place in certain parts of the body, independent of the action of the heart. This condition of turgescence in animals is analogous to phenomena which are so evident in plants, such as the afflux of sap to the fruit-bud, which contains the impregnated ovum. " The mutual vital action, or affinity between the blood and the tissues of the body, which is an essential part of the process of nutrition, is, under many circumstances, greatly increased ; and an accumulation of blood in the dilated vessels of the organ is the result. It is seen, for example, in the genitals, during the state of sexual desire, in the uterus during preg- nancy, in the stomach during digestion, and in the processes of the cra- nial bones on which the stag's antlers afterwards rest, during the repro- 410 CLINICAL MEDICINE. duction of these parts. The local accumulation of blood, with the dila- tation of old, and the formation of new vessels, is, however, seen most frequently in the embryo, in which new organs are developed in succes- sion by a process of this kind ; while, on the other hand, other organs, such as the branchise of the salamander and frog, and the tail of the latter animal, become atrophied and perish as soon as the vital affinity which existed between the blood and their tissues ceases to be exerted. " The phenomena of turgescence have been supposed to be dependent on an increased action or contraction in the arteries. But arteries present no periodic contractions of muscular nature ; and a persistent contraction of the arteries, unless it were progressive (vermicular, as it were, or aided by valves arranged in a determinate direction), would be quite inade- quate to produce a state of turgescence of any part. " To explain the state of orgasm of the uterus during pregnancy, and of the bony processes which bear the antlers of the stag, we must presup- pose the existence of an increased affinity between the blood and the tis- sue of the organ. This condition may be excited very suddenly, as is seen in the instantaneous injection of the cheeks with blood, in the act of blushing, and of the whole head, under the influence of violent passions; in both of which instances, the local phenomena are evidently induced by nervous influence. The active congestion of certain organs—of the brain, for example—while they are in a state of excitement, is a similar pheno- menon. " If the organ which is susceptible of the increased affinity between the blood and the tissue is, at the same time, capable of considerable disten- sion, tumefaction and erection take place." It will, I believe, be readily acknowledged, that Miiller's explanation is, after all, a mere hypothesis. Is this affinity between the blood and the tissues of the body, chemical? or is it a mutual vital action? If the latter, then the vessels, they being the only tissues in contact with the blood, are active, contrary to his previous hypothesis. As to the chemical explana- tion of a blush, it surely does not merit examination. The facts referred to by Muller in the above passage, all tend to corro- borate the view I have adopted, and show that local changes of nutrition, vascularity, and circulation, may be quite independent of the heart's action. We must next turn our attention to the increase in size of some of the larger arteries. "Apply a ligature," says Dr. Hall, "to the principal artery of a limb, the circulation is then carried on by the collateral branches, which become enlarged for this very purpose, and in consequence of the obstruction." Now let us study the phenomena a little more accurately, and we shall soon see how erroneous is this explanation. In the first place, what are the physical results produced by tying one of the large arteries of a limb? The vis it tergo, or propelling power of the heart, continues just as before ; the quantity of fluid or blood within the whole system of arterial tubes is unchanged, while the forces to be over- come by the circulating power remain also the same. In fact, all the general physical conditions are unaltered after the ligature has been ap- plied, except that a portion of the blood can no longer enter the tied ar- tery. Let us now investigate what effects this non-entrance of a certain portion of the blood into its accustomed channel is likely to produce on INFLAMMATION —CAPILLARY CIRCULATION. 411 the rest of the arterial system. When the principal artery of a limb is tied, the blood circulating in the remaining arteries of the body, and the other arteries of that limb, is pressed more strongly against the arterial parietes. But as the distending force resulting from this increased pressure is not confined to any particular artery of the body, but affects all, more or less, it is obvious that a power so extensively distributed and subdivided can exert but little distending influence on any individual artery, or, in other words, can tend but little to dilate any of the arterial tubes. Now it is obvious, from the laws of hydrostatics, that this increased pressure will be more exerted in proportion on the main collateral arteries of the limb, than on the smaller; it will, in truth, be scarcely sensible in the latter, and yet these are the very arteries which enlarge first after the operation for aneu- rism. The increase in the size of the arteries commences, not where it ought to commence, if it depended merely on dilatation from increased pressure, viz. in the larger arteries, and in the collateral branches close to the ligature, but it commences in the smaller and more distant arterial ra- mifications. In addition to the fact that a proportionally less pressure is thrown on the smaller arteries, we shall recollect that the latter have pa- rietes much thicker in proportion to their calibre, than the larger branches. This is another material objection to Dr. Hall's explanation of their in- crease in size. What are the phenomena observed after applying a liga- ture to an artery of large size, where a sufficient collateral circulation may be applied? First, the sudden diminution of circulation in the parts below the ligature gives rise to coldness and paleness of the limb; but in a few hours the circulation gradually returns, the thermometrical temperature of the limb rises, and the activity of the capillary system is greater than in the natural condition of the limb. This excitement continues for some time, and then diminishes to the ordinary standard of health. In eight, twelve, or twenty-four hours after the application of a ligature to the main artery of a limb, we find the skin of the parts below the ligature pale and cool, but in a few hours afterwards its temperature rises, and it exhibits an evidently increased arterial action. Now it is difficult to conceive that the main collateral branches have been dilated in so short a space of time. The mode in which the phenomena witnessed in this instance are best explained, seems to me to be the following. When a large portion of the blood destined for the supply of a limb is cut off, all the tissues of a part so deprived receive a shock: the muscles, nerves, capillary vessels—in fact, the vital functions of the whole—are more or less affected. After some time, however, the vital depression is followed by reaction, and this commences in the smaller arteries and capillary system, its commencement being marked by uneasy sensations, increase of temperature, and arterial throbbing. The initiative of the restoration of the circulation belongs to the extreme vessels, which take on an increased action, and this is gradu- ally extended to larger arteries. These gradually augment in power, be- come enlarged and distended, and at length the circulation of the affected limb is restored to a state of efficacy, equal, if not identical with its pris- tine condition. Now, you are told that the increased activity of the capil- lary vessels, in this instance, is referable to the vis a tergo operating through the anastoraosing branches. This is a false assumption. In the first place, the influence of the heart's action, when the blood passes through small anastomosing branches, and by circuitous courses, must be less powerful than before the operation, when the main channels remained pervious. 412 CLINICAL MEDICINE. The vis a tergo is therefore lessened, and yet the capillary distension is greater than before the operation, or in the sound limb. In the next place, this argument is of more force, when it is considered that the enlargement commences in the smaller, and gradually extends to the larger vessels; and also, that in some cases the branches from the main artery through which the blood must pass, do not become perceptibly enlarged. Thus Mr. Hodgson, in the work on diseases of arteries, says—" The dilatation takes place principally in minute ramifications. The trunks, and the mouths of the vessels going off above the place of obstruction in the main artery, in several preparations, did not appear larger than in their natural state, and in a few instances only a slight dilatation was perceptible." From these facts it is obvious that the vessels least under the influence of the heart are the most dilated. But the most decisive proof is the return of the capillaries and minute arteries to their ordinary size, at the time when, the larger branches being dilated, the vis a tergo should be more operative. Hence it would appear that the power of distension resides in the arteries themselves, the irritation commencing in the capillaries, and being sympathetically propagated to the larger vessels. This is further con- firmed by the fact, that, if an inflamed part, or a vascular tumour, be supplied by several arteries, and one of them be divided, the others will enlarge. It is scarcely necessary for me to direct your attention here to the phe- nomena which occur in the erectile tissues, as the corpora cavernosa, &c. It cannot surely be maintained that the sudden increase in the afflux of blood to these parts is owing to any vis a tergo, or momentary augmentation of the propelling power of the heart. No ; tissues of this kind enjoy the power of attracting to themselves an increased quantity of blood, in virtue of the vital power resident in them, and not from any peculiar exertion of extraneousforces. In fact, the capillary vessels enjoythe property of actively dilating, and drawing the blood into them, and this appears to be one of the principal causes of the circulation. Of this there is abundant proof. It has been observed in vivisections, that after the heart has ceased to act, the capillary vessels remain distended, and appear to carry on their functions as long as any blood is supplied to them from the arteries. It has been also remarked, that the larger arterial branches become first empty, then the smaller, and finally the capillaries. Dr. Philip states, that he has observed the circulation of the mesentery to continue for several minutes after the heart had been excised. This is the true explanation of the fact, that the arteries are so frequently found quite empty after death. One of the strongest proofs we have of the power which the capillaries possess of drawing blood to themselves, is derived from the phenomena observed in vascular tumours. If scratched, or slightly wounded, these tumours frequently bleed to an alarming extent ; while the division of the arteries which lead to them, and the removal of the whole mass, is attended with a comparatively small loss of blood. This is further exemplified in the familiar operation of opening the temporal artery. If the artery be only partially divided, and its connection with the capillaries still to a certain degree maintained, it bleeds copiously ; but if it be cut across, and the connection wholly destroyed, it ceases to bleed altogether. Pro- fessor Smith, of Philadelphia,* amputated a leg below the knee,for dry gan- This fact is mentioned in a monograph which I received from America many years ago. Unluckily, I have mislaid it, and cannot call to mind the author's name. He advocated views similar to those I have here attempted to establish, and to him I am indebted for the argument derived from the placental circulation. INFLAMMATION —CAPILLARY CIRCULATION. 4J3 grene of the foot and ankle. The great arteries were found wholly altered in their structure, being, as it were, converted into tubes of bone. Although pressure was completely removed from the femoral artery, and no means whatever were used to suppress the hemorrhage, the quantity of blood lost did not amount to half a tablespoonful. At the same time the action of the heart was vigorous, and the pulse at the wrist of the ordinary strength and fulness. Now in this case some blood must have been passing through the tibial arteries before the operation, for there was some circulation in the leg down as far as the ankle, and the collateral arteries, or anastomosing branches, were not enlarged. If we refer to the phe- nomena of wounds which engage arteries, we shall find, as I have already- stated, when alluding to the operation of opening the temporal artery, that the wounded artery of an injured limb bleeds much more than the same artery of an amputated one. Hence it is that branches which would pour out a large quantity of blood, if merely wounded, sometimes do not require a ligature at all, although their divided orifices open on the surface of a stump. Another instance in which the attracting power of the capillaries may be seen, is in cases where portions of an amputated finger have again united, of which we have several examples. In this case the fluids effused by the upper cut surface are absorbed and circulated by the vessels of the amputated tip. But one of the most remarkable proofs of the position I have laid down is derived from the circulation of the blood in the placenta. In this instance the impetus which the blood possesses in the umbilical arteries has been attributed to the vis a tergo derived from the heart of the foetus. But after the detachment of the placenta, after the birth of the foetus, the pulsation in the cord ceases, first at the placenta, and then at the umbilicus of the infant. After this period a section of the cord is not folloAved by any thing like the amount of hemorrhage which might be expected from the division of vessels of such diameter, and in many instances there is no loss of blood whatever. Now why does the flow of blood cease in the umbilical arteries? The vis a tergo is as powerful after birth as before, and operates on blood in tubes free from obstruction. It cannot be attributed to cold, for the circulation continues in every part of the infant; nor to exhaustion, for the foetus loses no blood, and its circulation is now independent of the mother. Neither is it owing to the action of the lungs, which are said to divert the blood from the placenta ; for although a greater portion of blood is carried to the lungs after than before birth, yet this would not account for the total ces- sation of the circulation in vessels so large as the umbilical arteries. The explanation, therefore, commonly given is not capable of being proved. From the facts which I have brought forward, it would appear that the organic vital actions of the placenta depend upon its own life, and that when this body is detached from the uterus, it of course dies, and the functions of its capillary system cease. The suction-power of the small vessels then continues no longer to assist the vis a tergo in carrying blood through the umbilical arteries, and the circulation declines, first at the placenta, and finally in the umbilical arteries, at their junction with the abdomen of the foetus. Such are the arguments derived from experiments and pathology in favour of the capillaries having a direct influence on the circulation. Those which may be borrowed from comparative anatomy are still 414 CLINICAL MEDICINE. stronger. If we look to the vegetable kingdom, we shall find that the force with which the sap, i. e. the blood of plants, circulates in their ves- sels is very great. Hales and Dutrochet have proved this by direct expe- riment. If a vine be cut down in spring to the distance of three feet from the ground, it throws out sap with such force as to raise twenty-one feet of water. In other experiments this power was found capable of raising thirty-two and a half inches of mercury, or thirty-five feet five inches and three-quarters of water ; and thirty-eight inches of mercury, or forty-three feet three inches and one-third of water. To effect this pro- digious circulation, as it takes place in plants, the force must be very great, for we know that it is capable of raising from the ground a large quantity of water, combined with nutritious principles, to the top of the loftiest palm or forest tree—in fact, to an altitude of one hundred and fifty feet. Now in what organs does this power reside ? There is no central organ in plants, nothing like a heart—nothing like large arterial tubes. How, then, is the ascent of the nutritious fluid accomplished ? Let us study the phenomena for a moment, and we shall find sufficient evidence to satisfy ourselves that the fluid circulating in each part of the tree is brought to it chiefly by the action of the vessel of the part itself. I do not mean to deny the great power which the spongioles of the roots, acting as capillary systems, exert in driving the fluids they absorb through the tubu- lar vessels of trees ; this power is no doubt aided by the buds and leaves, whose capillaries, when acted on by a proper temperature, discharge their vital functions with activity, and are capable of drawing the sap to the extremities of the branches. Thus in the case of a vine observed by Richerand, one branch of which had crept into a smith's shop, this branch remained in leaf, or rather threw out fresh leaves in winter, while all the other branches continued quite bare. Again, cut off a branch of a living plant and place it in water, how actively does it absorb the water, and endeavour to prolong its existence. In winter this attraction of the ulti- mate ramifications of plants ceases, but returns again with the genial warmth of spring, when the buds begin to expand. Phenomena analo- gous to these are also observed in many animals. There are numerous tribes of animals possessing an active circulation, which have no heart whatever. Thus the Medusas and Echinodermata, which must enjoy an active circulation, as is proved by their rapid growth, have no heart. In the Holothurio tubulosa, Cuvier has traced vessels going to the organs of respiration (pulmonary arteries), and vessels coming from the same (pul- monary vessels), as also a system of arterial and venous tubes destined to carry on the general circulation, but no heart. There are numberless examples of this arrangement to be found in the animal kingdom. In fact, a great deal of the motion observed in the fluids of the human body is effected by other means besides the heart, and those means are the powers possessed by the capillary vessels and membranous tissues of the body, which, by virtue of an unknown law, aid materially in the circulation. You perceive, then, gentlemen, that my views are quite opposed to those who assert, that in inflammation the enlargement of the capillaries is passive. Dr. Hastings and Dr. Philip allow that the capillaries dilate during inflammation, but they attribute this effect to debility. This, however, is a mere assumption. The phrases, passive and debilitated, put one in mind of another hackneyed expression founded alike on fallacy, namely, indolent ulcers. Now there is nothing more active than what is INFLAMMATION —CAPILLARY CIRCULATION. 415 termed an indolent ulcer. It manufactures more secretion, uses more blood, and produces more pain than any equivalent portion of the same tissue throughout the body, and yet it is termed indolent! It is so with regard to the capillaries. It is said that in inflammation the capillary vessels are obstructed, and their force weakened. What is the real fact ? Take an instance of conjunctivitis. What do you observe here? The affected membrane is swollen, its nervous sensibility exalted, its thermo- metrical temperature increased, its secretion augmented. Are any of these symptoms of debility ? I think they can hardly be looked upon as such. The increase of pain, heat, and fluid secretion—the augmentation in size —all the phenomena, in fact, are opposed to the theory of debility. There is no passive dilatation or weakness ; the capillaries enlarge and dilate from increased, and not from diminished action ; red blood finds its way into vessels which before received only white ; and unusual secretions occur in the affected parts. The capillaries have the initiative ; with them commences the enlargement, which afterwards extends to the smaller arteries, and from these to the larger branches. Under ordinary circumstances, the capillary circulation continues some time after the heart has ceased to beat, for the capillaries belong to that class of tissues which possess an inferior degree of vitality ; and it has been shown by Bichat that such tissues survive those of a higher degree of organization. Hence, the capillaries continue to act for some time after the heart has ceased to beat; and as it is a law that the capillaries of the lungs will not transmit non-arterialized blood, the systemic veins become gradually distended, while the systemic arteries are emptied, so that, after death, we seldom find any blood in the latter. A very curious case, recently published by Dr. Houston, supports very strongly the views which I have put forward in this lecture.* Dr. Houston had a very remarkable case, in which the circulation had ceased in one of the lower extremities. The foot, and afterwards the leg, were attacked with dry gangrene, of which the patient died. No obstruction was found in the vessels after death, and the ordinary injection passed readily into all the arterial ramifications. The arteries were all pervious, and appa- rently natural in their texture. Now, if the circulation of the limb had depended on the arteries alone, it would not have ceased so completely. Some time ago I attended, with Mr. Cusack, a patient from the North of Ireland, a young lady of rather delicate constitution, who was attacked at a certain hour every day, in a very singular way. The circulation in one of her legs seemed almost to cease, and the limb became remarkably pale and cold. This state of the limb would last for ten or twelve hours, and then an alteration took place ; the leg became hot and painful, and its temperature became so disagreeable to the patient that she was obliged to keep the leg outside the bed-clothes, and have it constantly wetted with cold water and vinegar. During all this time the action of the heart was natural and the circulation of the rest of the body unaltered. Here we have a certain portion of a limb at one period of the day quite cold and pale, and at another extremely hot and painful. How can this be said to depend on any vis a tergo ? The true explanation of the matter is, that it depends on a periodic affection of the nerves, capillaries, and smaller arteries of the part. * The reader is referred to a note to the lectures on Fever for the details of this interesting case. 416 CLINICAL MEDICINE. Such, gentlemen, are some of the arguments in favour of the supposi- tion that the capillary vessels exercise a remarkable influence over the circulation. There are other proofs which I shall not touch on at present, as the more immediate business of the hospital prevents me from deviating any further from the path of strict clinical investigation. You may ask, perhaps, why I have entered on this subject at all, or why I have dwelt so long on matters which appear to possess only a mere theoretical interest. Because I am persuaded that much error exists with respect to the nature of the forces employed in carrying on the circulation, and because I think it of the most vital importance that you should be in possession of correct principles to guide you in the numerous emergencies attendant on the treatment of disease. The human body in its development from a lower to a higher degree of organization, loses none of its character, it ascends, retaining in its more perfect development all that it possessed in an inferior state. In the first stage of its development it possessed a diffused nervous and vascular system. It then acquired small nervous strings and capillary vessels, and finally larger arteries, larger nerves, nervous centres, and a heart. In the same way its circulation commenced, beginning in the smaller vessels and extending to the larger, aided by the vis a tergo, but independent of it in a remarkable degree. From this view of the sub- ject, it follows that, in many cases of disease, we are to look to the forces which regulate the circulation of the part affected, and not to any vis a tergo, or propelling power of the heart. The physician and surgeon must study the life of each part, in attempting to estimate its morbid conditions. It was a want of proper knowledge on this subject which led to so many errors in practice. Among these I may mention the treatment of Egyp- tian ophthalmia, in which it was thought necessary to drain the patient of blood, for the purpose of subduing a mere local inflammation. In truth, the treatment of local inflammation, whether affecting external organs, as phlegmon, carbuncle, erysipelas, or internal parts, as pleurisy, peritonitis, &c, can never be properly understood, until the old doctrine, which (by teaching that the vis a tergo was every thing in inflammation) led to a too general use of venesection, has been laid aside, and sounder opinions adopted. Postscript.—Since the preceding lecture was delivered, this subject has been handled by many physiologists, and the majority of them enter- tain the same views which 1 then, and for many years before, advocated. I shall now quote the opinions of Dr. Carpenter, the most modern and distinguished of our British physiologists ; their importance is sufficient apology for inserting them in this place. "We now come to the last head of the inquiry into the powers which convey the blood through the capillary system—that, namely, which con- cerns the agencies existing in the capillaries themselves. Many discus- sions on this subject may be found in physiological writings, and it has a bearing so immediate on one of the most important questions in pathology —the nature of inflammation—that it deserves the fullest attention. The chief question in debate is the degree in which the capillary circulation is influenced by any other agency than the contractile power of the heart and arterial system ;—some physiologists maintaining that this alone is sufficient to account for the capillary circulation ; and others asserting that it is necessary to admit some supplementary force, which may be exerted CAPILLARY CIRCULATION. 417 either to assist, retard, or regulate the flow of blood from the arteries into the veins. We shall first inquire what evidence there is of the existence of any such force: and, when led to an affirmative conclusion, we shall examine into its nature. No physiological fact is more clearly proved than the existence, in the lower classes of animals, as well as plants, of some power independent of a vis a tergo, by which the circulating fluid is caused to move through their vessels. This power seems to originate in themselves, and to be closely connected with the state of the nutritive and secretory processes, since any thing which stimulates these to increased energy accelerates the circulation, whilst any check to them occasions a corresponding stagnation. It may be convenient to designate this motor force by the name of capillary power, it being clearly understood, how- ever, that no mechanical propulsion is hence implied. On ascending the animal scale, we find the power which, in the lower organisms, is diffused through the whole system, gradually concentrated in a single part,—a new force, that of the heart, being brought into operation, and the circulation placed, in a greater or less degree, under its control. Still there is evi- dence that the movement of the blood through the capillaries is not en- tirely due to this, since it may continue after the cessation of the heart's action, may itself cease in particular organs when the heart is still acting vigorously, and is constantly being affected in amount and rapidity by causes originating in the part itself, and in no way affecting the heart. The chief proofs of these statements will now be adverted to. "The movement of the blood in the capillaries of cold-blooded animals, after complete excision of the heart, has been repeatedly witnessed. In warm-blooded animals, this cannot be satisfactorily established by experi- ment, since the shock occasioned by so severe an operation much sooner destroys the general vitality of the system; but it may be proved in other ways to take place. After most kinds of natural death, the arterial sys- tem is found, subsequently to the lapse of a few hours, almost, or com- pletely, emptied of blood; this is partly, no doubt, the effect of the tonic contraction of the tubes themselves: but the emptying is commonly more complete than could be thus accounted for, and must therefore be due to the continuance of the capillary circulation. Moreover, when death has taken place suddenly, from some cause (as, for instance, a sudden electric shock), that destroys the vitality of the whole system at once, the arterial tubes are found to contain their due proportion of blood. Further, it has been well ascertained, that a real process of secretion not unfrequently continues after general or somatic death; urine has been poured out by the ureters, sweat exuded from the skin, and other peculiar secretions formed by their glands; and these changes could not have taken place unless the capillary circulation were still continuing. In the early embry- onic condition of the highest animals, the movement of blood seems to be unquestionably due to some diffused power, independent of any central impulsion: for it may be seen to commence in the vascular area, before the development of the heart; the first movement is towards-, instead of from the centre, and even for some time after the circulation is fairly established, the walls of the heart consist merely of vesicles loosely at- tached together, and can hardly be supposed to have any great contractile power. "The last of these facts may be said not to have any direct bearing on the question, whether the capillary power has any existence in the adult 28 418 CLINICAL MEDICINE. condition; but the phenomena occasionally presented by the foetus at a later stage appear decisive. Cases are of no very unfrequent occurrence in which the heart is absent during the whole embryonic life, and yet the greater part of the organs are well developed. In most, or all of these cases, however, a perfect twin foetus exists, in which the placenta is in some degree united with that of the imperfect one; and it has been custo- mary to attribute the circulation in the latter to the influence of the heart of the former, propagated through the placental vessels. This supposition has not been disproved (however improbable it may seem) until recently; when a case of this kind occurred, which was submitted to the most care- ful examination by an accomplished anatomist." As the case alluded to, viz., that by Dr. Houston, is given in the pre- ceding lecture, I shall not again introduce it, but pass on to the conclu- sions which Dr. Carpenter deduces from it. " It is evident," he says, "that a single case of this kind, if unequivocally demonstrated, furnishes all the proof that can be needed of the existence, even in the highest animals, of a capillary power, which, though usually subordinate to the heart's action, is sufficiently strong to maintain the circulation by itself, when the power of the central organ is diminished. In this, as in many other cases, we may observe a remarkable power in the living system to adapt itself to exigencies. In the acardiac foetus, the heart is never evolved : and the capillary power supplies its place up to the period of birth, after which, of course, the circulation ceases for want of due aeration of the blood. It has occasionally been noticed that a gradual degeneration in the structure of the heart has taken place during life, to such an extent that scarcely any muscular tissue could at last be detected in it, without any such inter- ruption to the circulation as might have been anticipated." "It is equally capable of proof on the other hand, that the capillaries may, by an influence peculiar to them, afford a complete check to the cir- culation of a part, even when the heart's action is unimpaired, and no me- chanical impediment exists to the transmission of the blood. Thus, cases of spontaneous gangrene of the lowcM' extremities are of no unfrequent oc- currence, in which the death of the tissues is clearly connected with a local decline of thccirculation, and in which examination of the limb after its removal, shows that both the larger tubes and the capillaries were pervi- ous ; so that the cessation to the flow of blood could not be attributed to any impediment, except that arising from the cessation of the same power which exists in the capillaries, and is necessary for the maintenance of the current through them. The most remarkable evidence on this point, how- ever, is derived from the phenomena of asphyxia, which will be more fully explained in the following chapter. At present, it may be stated as a fact which has now been very satisfactorily ascertained, that, if admis- sion of air into the lungs be prevented, the circulation through them will be brought to a stand, as soon as the air which they contain has been, to a great degree, deprived of its oxygen, or rather has become loaded with carbonic acid; and this stagnation will, of course, be communicated to all the rest of the system. Yet, if it have not continued sufficiently long to cause the loss of vitality in the nervous centres, it may be renewed by the admission of air into the lungs. Now, although it has been asserted that the stagnation is due to a mechanical impediment, resulting from the contracted state of the lungs in such cases, this has been clearly proved not to be the fact by causing animals to breathe a gas destitute of oxygen CAPILLARY CIRCULATION. 419 so as to cause asphyxia in a different manner, the same stagnation result- ing as in the other case. " The influence of prolonged application of cold to a part, may be quoted in support of the same general proposition ; for, although the calibre of the vessel maybe diminished by this agent, yet their contraction is not sufficient to account for the complete cessation of the flow of blood through them, which is well known to terminate in the loss of their vitality. " Many of the facts which indicate the influence of the capillaries on the amount and rapidity of the circulation through them, have been already adverted to. It is a general fact, unquestioned by any physiolo- gist, that, when there is any local excitement to the processes of nutrition, secretion, &c, a determination of blood towards the part speedily takes plaee, and the motion of the blood through it is increased in rapidity ; and although it may be urged that this increased determination may not be the effect, but the cause, of the increased local action, such an opinion could not be sustained without many inconsistencies with known facts." If the phenomena which have been here brought together be considered as establishing the existence, in all classes of beings possessing a circu- lating apparatus, of a capillary power which affords a necessary condition for the movement of the nutritious fluid through those parts in which it comes into more immediate relation with the solid, the question still remains open as to its nature. That the capillaries possess a contractile power, in a far higher degree than do the large arteries, and more easily excited than that of the smaller, appears scarcely to admit of doubt ; though to what it is due, may be reasonably questioned. It has been recently asserted by Schwann, that they possess the same kind of fibrous tissue in their walls as do the large vessels ; and this cannot be regarded as improbable. It is not possible, however, that their contractility could have any influence in aiding the continuous motion of blood through them, unless it were exercised in a very different manner from that of which observation affords us evidence ; for when we are microscopically examining the capillary circulation of any part, it is at once seen that the vessels present no obvious movement, and that the stream, now rendered continuous by the elasticity of the arteries, passes through them as through unelastic tubes. The only method in which the contractility of the capillaries could produce a regular influence on the current of blood would be an alternate contraction and dilatation, or a peristaltic move- ment ; and of neither of these can the least traces be discerned. Hence we should altogether dismiss from our minds the idea of any mechanical assistance afforded by the action of the capillaries to the movement of the blood. That the contractile coat of the capillaries has for its office to regulate the calibre of the vessels, can scarcely be doubted ; but circula- tion, as is shown by the effects of stimulating injections, which, if thrown into the vessels before their vitality has been lost, will not pass through the capillaries. It would appear, therefore, to be through their action on this coat that local stimuli occasion a contraction of the capillaries; their effect, however, is different from what might have been anticipated : for, instead of the capillary circulation being retarded it is accelerated, at least, until an abnormal condition results from their continued operation. Here, again, is another evidence, that something different from mechanical power must be the agent that operates in all the foregoing cases. 420 CLINICAL MEDICINE. " The nature of this agent is at present very obscure ; and it may not be in our power for some time to unveil it. The conditions of its action, however, lie open for investigation ; and it appears from the foregoing facts, that a very simple and constant expression of these may be given. Whilst the injection of blood into the capillary vessels of every part of the system is due to the action of the heart, its rate of passage through those vessels is greatly modified by the degree of activity in the processes to which it should normally be subservient in them. The current being rendered more rapid by an increase in their activity, and being stagnated by their depression or total cessation. This is little else than a modifica- tion of the ancient aphorism—ubi stimulus, ibi fluxus. Thus it seems that ' the capillaries possess a distributive power over the blood, regulating the local circulation, independently of the central organ, in obedience to the necessities of each part. If this be true, it is evident that the dilatation or contraction of the capillaries will only have a secondary influence on the movement of the blood through them. The former condition is usually an indication of diminished vital energy ; and when it is observed, it is almost invariably accompanied by a retardation or partial stagnation of the current; on the other hand, the application of a moderate stimulus, which excites the contractility, accelerates for a time the motion of the blood, by rendering more energetic that reaction between the fluids and the surrounding tissues, which is the condition that really has the most influ- ence over the current. It is not enough to object to such a doctrine, that we know nothing of the mode in which this reaction affects the movement of the blood ; since we are equally ignorant of the modus operandi of many other causes, whose real existence is fully acknowledged, as for instance the effect of a stimulus applied to a motor nerve, in causing contraction of the muscles supplied by it."* In the Edinburgh Medical and Surgical Journal, for July, 1842, the reader will find an admirable paper by Dr. Holland, of Sheffield, on ' The Forces by which the Blood is circulated in Capillary Vessels? The author goes through all the arguments that have been advanced to prove that the circulation through these vessels is entirely due to the force of the heart, and he shows most satisfactorily how very irreconcile- able such doctrines are with facts of every-day occurrence. At the end of the paper he mentions an experiment, which I believe to be unobjec- tionable, and, if possible, even more conclusive than Dr. Houston's mon- ster ; it proves beyond doubt that the circulation through the capillaries is entirely owing to a vital property of these vessels, and independent of the influence derived from a vis a tergo. We shall allow Dr. Holland to speak for himself, " The umbilical vein conveys arterial blood from the placenta to the foetus, the umbilical arteries convey venous blood from the foetus to this organ. The origin and termination of these two classes of vessels in the placenta are involved in much obscurity. No direct con- nection is traced between them. Whatever opinions may be held con- cerning the functions of this organ, or its relations to the uterus, it will scarcely be doubted that the vein terminates in capillaries, and that the arteries originate in the same kind of vessels. It is not our intention to examine the phenomena of foetal circulation, but to allude to one striking peculiarity, viz., the circulation of blood in the umbilical vein. This fluid is transmitted from the placenta to the foetus without the aid of any * " Principles of Human Physiology, p. 417." SCARLET FEVER. 421 propulsive organ. The capillaries are, indeed, the only source of motive power shown to exist, and hence the placenta separated from the uterus, appeared capable of determining the influence of the capillaries, and the efficiency of it in urging the blood through the long capacious vein. To institute the experiment a placenta was procured, twenty minutes after separation from the uterus, and placed, wTith the exception of the cord, in a bladder, which was immersed in water at the temperature of 100° Fah- renheit. The free extremity of the cord, at the same moment, was elevated to an angle of 30°, resting on the edge of a glass, and at the distance of a foot from the placenta. At the commencement of the expe- riment no blood escaped from the vein, but in two minutes from the im- mersion, it began to flow, and continued for about twenty minutes, and at this time it was found that the glass had received above an ounce." " Here, then," continues Dr. Holland, " is an experiment, much less unexceptionable in its character than any with which we are acquainted, demonstrating the power of the capillaries to carry on the circulation, not only in their own complicated network of vessels, but in the larger ves- sels, and which ultimately terminate in a capacious vein ; and the diffi- culty to the motion of the blood was intentionally increased by the eleva- tion of the whole cord above the level of the placenta. Had this organ been immersed without the bladder, the absorption or imbibition of the water would have invalidated the experiment. The water is employed as an external stimulant for the purpose of maintaining, what may be con- ceived to be, the natural temperature of the placenta. " The flow of the blood in this experiment, in our opinion, arises entirely from the influence of the capillaries. The stimulus of the water causes the blood to excite them to contraction, and the escape of it is not opposed by any impediment. We cannot imagine that the experiment produces any important modification in the conditions of the blood. The water is not absorbed, nor is the temperature of it elevated above the heat of the body. The consideration of the circulation in this case is not complicated by circumstances acting it tergo, or in advance of the blood ; nor by the agency of respiration, or the struggles of an animal, in torture or placed in a constrained position." With the above experiment I shall conclude what I have to say on the subject of the capillary circulation. LECTURE XXXVI. SCARLET FEVER. It is my intention to-day to make a few observations on the scarlet fever which now prevails as a destructive epidemic in Dublin, and many other parts of Ireland.* The history of such epidemics is very interesting, and tends to shed much light, not only upon the changes which diseases un- dergo, but upon the fluctuations of medical opinions and treatment. In the year 1801, in the months of September, October, November, and December, scarlet fever committed great ravages in Dublin, and continued * These lectures were delivered during the session of 1834-35. 422 CLINICAL MEDICINE. its destructive progress during the spring of 1802. It ceased in summer, but returned at intervals during the years 1803-4, when the disease changed its character ; and although scarlatina epidemics recurred very frequently during the next twenty-seyen years, yet it was always in the simple or mild form, so that I have known an instance where not a single death occurred among eighty boys attacked in a public institution. The epidemic of 1801-2-3-4, on the contrary, was extremely fatal, sometimes terminating in death, as appears by the notes of Dr. Percival, kindly communicated to me, so early as the second day. It thinned many fami- lies in the middle and upper classes of society, and even left not a few parents childless. Its character seems to have answered to the definition of the scarlatina maligna of authors, for a description of which I beg leave to refer you to the Cyclopaedia of Practical Medicine, where you will find an article on the subject by Dr. Tweedie. In making this reference, however, I do not wish to be understood as expressing my unqualified approbation of the article in question, for I must in candour confess that it falls far short of what we might have expected from a physician of Dr. Tweedie's learning and experience. The long continuance of the period during which the character of scarlet fever was either so mild as to re- quire little care, or so purely inflammatory as to yield readily to the judi- cious employment of an antiphlogistic treatment, led many to believe that the fatality of the former epidemic was chiefly, if not altogether, owing to the erroneous method of cure then resorted to by the physicians of Dublin, who counted among their numbers not a few disciples of the Brunonian school ; indeed, this opinion was so prevalent, that all those whose me- dical education commenced at a much later period, were taught to believe that the diminished mortality of scarlet fever was entirely attributable to the cooling regimen, and to the timely use of the lancet and aperients, remedies interdicted by our predecessors. This was taught in the schools, and scarlet fever was every day quoted as exhibiting one of the most triumphant examples of the efficiency of the new doctrines. This I my- self learned—this I taught; how erroneously will appear from the sequel. It was argued, that had the cases which proved fatal in 1801-2 been treated by copious depletion in their very commencement, the fatal de- bility would never have set in, for we all regarded this debility as a mere consequence of previous excessive reaction. The experience derived from the present epidemic has completely refuted this reasoning, and has proved that, in spite of our boasted improvements, we have not been more successful in 1834-5 than were our predecessors in 1801-2. Before I detail more particularly the symptoms that accompany the pre- sent epidemic, I wish to enter a little at large into the subject of the changes and variations which the same disease is observed to undergo at different periods of time. Ihis is a topic which occupied some of the master minds of antiquity, and upon which the greatest of modern physi- cians, the illustrious Sydenham, bestowed considerable labour. It has been too much.neglected of late, and consequently I consider it my duty to call your attention to it, and I cannot do this better or more forcibly than by communicating to you a literal translation which I have made from the German of my friend Dr. Autenrieth's observations on this sub- ject. The task of translation is always not only difficult but irksome; but if, as in the present instance, I can by this means convey to you valuable information not before presented to my class, or to the public in English, SCARLET FEVER. 423 I never decline the labour. What I am now about to read is, indeed, most important, and well deserves the deep attention of every practical physician. The third cause, connected with time and capable of modifying diseases, is of infinite importance, both in a theoretical and practical point of view, but has seldom attracted much attention. Its existence is attested by its effects alone, for its nature remains unknown. I allude to the constitutio morborum stationaria, first noticed by Sydenham, but, since his time, nearly forgotten, or else confounded with the permanent influence of the seasons, or the accidental atmospherical changes spoken of above. All diseases, contagious and non-contagious, acute and chronic (the latter, however, seldom, except when attended with some degree of general ex- citement), have been observed to preserve a certain constitution or general character, which continues for a number of years in succession, with occa- sional interruptions, until it is displaced by another constitution of a dif- ferent character. Thus, during one period, diseases are remarkable for being frequently accompanied by a sensation of extreme weariness, sud- den sinking of the strength and vital powers, unpreceded by any evident marks of excitement, and attended by a disposition to pass into true typhus. During another period, the tongue is in general loaded with a thick white or yellowish coat, and many other symptoms of derangement in the digestive organs, such as a bitter taste, costiveness, or diarrhoea, are constantly observed. During a third period, diseases are characterized by a remarkable degree of vascular excitement, an evident tendency to local determinations, a frequent formation of morbid productions ; in a word, by all the symptoms of inflammation. It is not known whether the transition from one of these periodic con- stitutions to another takes place suddenly or gradually ; but the latter supposition appears more probable, except when the transition is accom- panied by unusually great atmospheric changes. The erysipelatous affec- tion which, both in England and Germany, succeeded the gastric and accompanied the first appearance of the inflammatory period, seems to have been an example of the gradual transition. Accurate observations are still wanting to determine whether this periodic constitution is con- fined to certain parts of the world, or extends over the whole, and whether its different species follow each other in a regular order of succession. If their order of succession should at any time be determined, it will enable the physician to foretell the character and most appropriate treatment of future diseases. The above question cannot be answered without very great labour spent in the investigation of the history of diseases in all ages and all countries, and are therefore foreign to the present work. The general indications of course vary with the nature of the prevailing constitution, and, consequently, during one period stimulating remedies, during another alvine evacuations, and during a third venesection and the antiphlogistic plan, will constitute the most effectual treatment. This very circumstance has caused much confusion in medical opinions, and has occasioned the reputation and the downfall of many an infallible system, each of which is in its turn consigned to oblivion, and perhaps again revived as a novelty at some future period. The English boast much of the astonishing improvements in science, and deride the ignorance of their predecessors, regardless of the old proverb—" Every thing has 424 CLINICAL MEDICINE. its day." Whenever, therefore, the periodic constitution undergoes an alteration, they either obstinately uphold their usual plan of treatment to the manifest injury of their patients, or else blindly embrace some system, to them new, but which really rests upon ancient and established princi- ples. In general, they do not fail to make use of so much exaggeration in support of their opinions, and thus succeed in misleading so many, that none but very well informed physicians can distinguish the fallacy of their arguments. The medical history of Great Britain affords many striking proofs of the truth of these assertions, and is replete with examples of the singular obstinacy with which the English cling to opinions once formed, a circum- stance which has materially contributed to obstruct their attaining to gene- ral views and impartial conclusions. Even to this day, a warm contest is carried on (less, however, in books than in the debates of learned socie- ties) between the senior and the junior parts of the profession, the former still inclining to Brunonianism, while the latter attribute nearly all dis- eases to inflammation. Both, indeed, appeal to experience to prove the justice of their principles, and seem entirely to forget that while the pro- priety of their practice, as applied to particular cases, remains unimpeached, the very nature of the diseases themselves may have been changed. A summary review of the character assumed by diseases during the last twenty years, both in England and other countries, will perhaps afford a solution of this question. About the end of the last, and during the three or four first years of the present century, the proportion of nervous fevers to other diseases was as one to eighteen in Plymouth (WToolcombe), as one to sixteen in London (Willan), as one to ten in Newcastle (Clarke), and in Liverpool one to five (Curry). Nor was this scourge of mankind less severely felt upon the continent, where typhus, and diseases closely allied to it, committed extensive devastations, particularly during the epi- demics of Erlangen, Jena, Kiel, Ratisbon, and Vienna. Cadiz and Se- ville were at the same period depopulated by the yellow fever, and Eu- rope in general suffered much from repeated visitations of influenza. An inclination, to a sudden sinking of the vital power, unpreceded by violent reaction, and unaccompanied by any marked symptoms of a gastric or inflammatory nature, constituted at that period the characteristic form of acute diseases, which were always preceded and attended by an unac- countable degree of debility. Stimulating and tonic medicines obtained, therefore, much celebrity, and every physician who practised during that period, attests the injurious or even fatal effects which were produced by the use of venesection, and other depletory remedies. What is still more remarkable, an epidemic typhoid pneumonia prevailed in many parts of Germany during the years 1800-1-2, in which the speedy production of an inflammatory state, by means of bark and ether, was the only method which afforded a chance of recovery. These facts must impress every impartial mind with the conviction, that the constitution of diseases has undergone much alteration since that period, and explain why physicians did not then employ copious venesection, but were obliged to content themselves with ordinary cold effusions, acids, and mercury. The reign of typhus appears to have ceased with the influenza of 1804, when a new constitution began, at first more remarkable for the disap- pearance of nervous fevers and other contagious diseases, than for any peculiar character of its own. Catarrhal and rheumatic complaints, partly NERVOUS FEVER. 425 attributable to the weather, prevailed for some time, and fevers of an intermitting type became more frequent, forming an evident transition from the purely typhus constitution to that of the vascular excitement of the following years. Some remnant of the typhus constitution was indeed still perceptible in the pectoral complaints which prevailed in London during the winter of 1804-5, and were attended with remarkable debility, requiring the greatest prudence in the use of the lancet. Venesection was indeed often entirely contraindicated, and Bateman states that it some- times even proved fatal. The constitution, however, soon developed itself more decidedly, became more universally diffused, and obliged physicians to relinquish their former plan of treatment and adopt other measures. Derangement of the alimentary canal became its prominent feature in the summer and autumn of 1804, and diarrhoea, terminating in dysentery, was often met with. This constitution suffered indeed a check from the cold of 1805, but it increased again during the following years, and afterwards became still more prevalent, manifesting itself by headache, a bitter taste in the mouth, a loaded yellow tongue, irregularity of the bowels, nausea, and anorexia. The utility of purgatives now became so obvious, that Hamilton's doctrines soon obtained as much celebrity as had been before enjoyed by the stimu- lating system. The nervous fever at Nottingham in 1807, the dysentery at London in 1808, the scarlatina at Edinburgh in 1805, and the measles at the same place in 1808, all required the purgative plan of treatment, and calomel became the favourite cathartic. The advantage then derived from the use of purgative medicines is abundantly testified by the writers of that period. This gastric constitution appeared also on the continent, but its progress was less rapid there than in England, where the inhabi- tants live in a manner calculated to augment or even to produce a ten- dency to gastric diseases. There were likewise other circumstances which impeded the formation of this constitution on the continent. Thus in Ger- many, the purely nervous constitution had scarcely yielded to catarrhal and rheumatic affections, when it was again revived in that unhappy coun- try by the political occurrences of 1805-6-7. Typhus seldom, however, assumed the character of exquisite, for the rheumatic and catarrhal affec- tions with which it was mixed partook somewhat of a gastric nature, as was proved by the great benefit derived from the exhibition of emetics and calomel. This appears in accordance with the fact that the gastric consti- tution was more fully developed wherever the ravages of war had not ex- tended, although it still required less attention in the treatment than the rheumatic symptoms, then likewise prevalent. Thus the agues which were common at Tubingen about the end of 1806, commenced in general with pain in the belly, vomiting, and irregularity of the bowels; a yellow furred tongue, headache, and tremours of the parotids, were of frequent occur- rence, and in general gastric symptoms were by no means rare. These symptoms gradually gained ground, and the reputation of ipecacuanha and cathartics increased in the same proportion. At Ratisbon the constitution was remarkably gastric in the autumn of 1809, and a nervous fever pre- vailed at Weimar in 1809-10, which was accompanied by bitter taste in the mouth, diarrhoea, nausea, and vertigo. Active catharsis was injurious in this epidemic, but much benefit resulted from the exhibition of castor- oil. The advantage derived about the same time in Berlin from the treat- ment of fevers by emetics and cooling purgatives, proved that they were there also complicated with gastric derangement. 426 CLINICAL MEDICINE. The gastric constitution had scarcely established itself, or become pretty generally diffused, when a new character, viz. the inflammatory, appeared upon the stage, and has ever since continued, sometimes combining itself with the gastric to form diseases of a mixed character, such as erysipelas, and sometimes, when favoured by the seasons or local circumstances, rais- ing itself to the rank of the chief performer. With its appearance vene- section, which had previously fallen into disrepute, became once more a favourite remedy, and in the course of a few years was pushed so far, par- ticularly in Great Britain, that Sangrado's maxim, " C'est une erreur de penser que le sang soit necessaire a la conservation de la vie, on ne peut trop saigner un malade," seems to have been the general rule of practice. The same inflammatory constitution became also general in Germany, but there it neither attained such a height, nor required such active treatment as in Great Britain, where many circumstances favoured its more perfect development; with us it generally yielded to the use of acids, cold appli- cations of mercury, but in England it called for copious blood-letting. Even in 1810, diseases had become more inflammatory at Tubingen than they had been previously; but the change was still more perceptible in 1813, when the antiphlogistic treatment required the aid of small venesec- tions, and nervous fevers were accompanied both by inflammation and derangement of the digestive organs. Erysipelatous affections were also frequent, and in many cases were of a marked inflammatory character. Erysipelas and true inflammatory fever, requiring the use of the lancet, were common at Ratisbon in 1811 ; Parrot exhibited acids, especially the acetous, with great success in the epidemic nervous fever which raged at Dorpat in 1812, and a diarrhoea of a bilious inflammatory nature prevailed at Konigsberg during the same year. This important change in the con- stitution became very evident in the nervous fever at Berlin in 1813, as well as in the formidable epidemic described by Hufeland, which ensued after the war, and raged in the north of Germany during that and the pre- ceding year. Although but a few years before the strongest stimulants had been necessary to obviate the paralysis which supervened even in the beginning of the disease, yet an opposite practice was now required, and antiphlogistic remedies were alone found capable of preventing the vascu- lar excitement from terminating in inflammation of either the head or chest. In short, the inflammatory constitution has been prevalent in Germany ever since the years 1810-11, sometimes in its pure and marked form, and sometimes complicated with gastric and rheumatic symptoms. This constitution became general at the very same period in Great Britain. Dr. Clutterbuck, of London, had indeed ascribed the origin of fever to in- flammation of the brain, so early as 1807, and about the same time Dr. Steiglitz, of Hanover, had recommended the antiphlogistic treatment of scarlet fever, in preference to the stimulating plan then in vogue. But as the inflammatory was then still subordinate to the rheumatic and gas- tric constitutions, their opinions did not gain many converts. But the in- flammatory constitution had increased so much in the autumn of 1809, and the winter of 1810, that even Dr. Bateman was obliged to prescribe venesection in fevers, a practice quite at variance with his former views. Erysipelatous inflammation became common in London, Aberdeen, and Leeds, and numerous cases of puerperal fever occurred in the latter towns, which, according to Gordon and Hey, never terminated favourably, except when bleeding and purgatives were employed with freedom. But it was NERVOUS FEVER. 427 not until 1813, when the inflammatory constitution had fully developed itself, and the bad consequences arising from violent determination of blood to the head in nervous fever could not be averted except by decisive mea- sures, that venesection came into general use in Great Britain in conse- quence of a publication by Dr. Mills, who had prescribed it with much success since 1810. In the same year that truly estimable physician, Dr. Thompson, published his admirable work upon inflammation. Blackall recommended blood-letting in several species of dropsy, and Armstrong employed the same remedy, combined with large doses of calomel, in the inflammatory puerperal fever which was prevalent at Sunderland. Vene- section became from this time as great a favourite as ever in England, not, however, to the exclusion of purgatives, which were indicated by the de- rangement of the stomach and bowels that accompanied the inflammatory constitution. Both these remedies were found extremely beneficial in the nervous fever which was epidemic in Ireland in 1813-14; its inflamma- tory character being clearly evinced by a hard and full pulse during its first stage, and a violent determination of blood to the head, by which the headache and raving are increased, while its gastric type was not less strongly marked by tenderness of the epigastrium, costiveness, or else fre- quent and unnatural alvine discharges, together with a loaded tongue and bilious vomiting. The latter symptoms were, in Dr. Grattan's opinion, of such importance, that he gave a decided preference to the purgative plan. The fever, which had previously been confined to Ireland, became gene- rally diffused over the rest of Great Britain after the famine of 1816, and continued without intermission for four years. Its inflammatory character being peculiarly favoured, both in England and Scotland, by the habits of the inhabitants and the situation of these countries, venesection attained an unexampled degree of celebrity, notwithstanding the representations of the Irish physicians, who used that remedy with more moderation. It was soon believed that there is, literally speaking, no disease whatever in which the lancet ought not to be used, and, as the human mind is ever prone to extremes, it was soon generally considered, both in England and Scotland, to be a well-founded pathological inference, " there is but one species of fever, viz. the inflammatory, and consequently venesection is the only true anti-febrile remedy. Such is the case in England at present, and it must have been so always, and in every part of the world." I flatter my- self, however, that the preceding observations and statements of facts, drawn from authentic sources, sufficiently negative these assertions, and establish the real existence of a change in the constitution of diseases, not- withstanding what Dr. Duncan once said to me, " that such changes existed only in the imagination of physicians." It is now twelve years since Dr. Autenrieth, in his Account of the State of Medicine in Great Britain, made the foregoing interesting observations ; and to me it appears that the history of the diseases which have since prevailed affords convincing proofs that the then inflammatory constitution has again subsided, and is now replaced by a typhous type: indeed, it cannot be denied that a very great difference exists not only between the present and the former scarlatina, but also between the fever of the pre- sent day and that which prevailed shortly before Dr. Autenrieth pub- lished. But this is too important a question for us to decide, without more reflection and thought than 1 have been able to bestow on it, and without more facts than I have been able to collect. The opinion I have 428 CLINICAL MEDICINE. brought forward I do not wish to be received as established ; I look upon it as probably well-founded, but as yet not proved, except so far as to merit further consideration and excite further discussion. Indeed, I have for the present been obliged, by the pressure of other engagements, to postpone a more accurate examination of this subject, and a more severe scrutiny of the facts which just now crowd into my memory; but I conclude with remarking, that the wide-spreading epi- demic influenza, which lately visited the whole of Europe, including the British Isles, was not only truly remarkable, both for the violence of the feverish symptoms and of the local congestions of the chest and heart, which accompanied its attack, but likewise for the unexpected relation which it was found to bear to all measures of active depletion. I appeal to the profession for their testimony on this matter—I ask whether all our preconceived opinions as to the a. priori indications for venesection, leech- ing, and purging, were not found to be contradicted by the effects of these remedies in the epidemic influenza of 1833. The sudden manner in which the disease came on, the great heat of skin, acceleration of the pulse, and the intolerable violence of the headache—together with the oppression of the chest, cough, and wheezing—all encouraged us to the employment of the most active modes of depletion, and yet the result was but little answerable to our expectations, for these means were found to induce an awful prostration of strength, with little or no alleviation of the symptoms. In some who were thus treated, recovery was protracted and doubtful, and the strength was not restored for several months. Indeed, nothing was more curious than the length of time which was necessary for some persons, in order to recruit their strength after an attack of this influenza, although that attack had not continued more than a few days,and had been judiciously treated, without blood-letting or unnecessarily debi- litating remedies. I have known some who lapsed into a cachectic state of long-continued debility from which they never recovered ; for, while thus reduced, they fell victims to the first acute complaint which seized them. The influenza above referred to fully confirmed the opinion I had long entertained, that in acute diseases debility and exhaustion of the vital power are by no means in every case either caused by, or propor- tioned to, a state of previous excitement. This opinion received further support from the symptoms and phenomena exhibited by the Asiatic cho- lera, in which the stage of debility and collapse commenced, and too often closed, the scene. Why do I dwell upon these occurrences, and why have I so frequently referred to the opinion above expressed ? Simply because the prevalence of the contrary opinion laid the foundation for the injudicious and exclusive application of the lancet, and of the antiphlo- gistic method generally, in Britain, and was, consequently, the cause of working excessive mischief. I have already mentioned that the disease called scarlet fever assumed a very benign type in Dublin soon after the year 1804, and continued to be seldom attended with danger until the year 1831, when we began to perceive a notable alteration in its character, and remarked that the usual undisguised and inflammatory nature of the attack was replaced by a con- cealed and insidious form of fever, attended with great debility. We now began occasionally to hear of cases which proved unexpectedly fatal, and of families in which several children were carried off; still it was not until the year 1834 that the disease spread far and wide, assuming the SCARLATINA. 429 form of a destructive epidemic. The nature of the disease did not appear in the least connected with the situation or aspect of the patient's dwell- ing, for we observed it equally malignant in Rathmines as in Dublin, on the most elevated habitations on mountains as in the valley of the Liffey. It raged with similar violence at Kingstown, and the neighbourhood of Killiney and Bray. The state of the weather seemed to exercise no in- fluence either upon its diffusion or its symptoms, which continued to ex- hibit equal virulence, no matter whether it was wet or dry, warm or cold, calm or stormy. The contagion seemed to act as a more deadly poison on the individuals of some families than upon those of others, and, con- sequently, when one member of a family had died, there was always much reason to fear for the others when attacked. At first I thought that its greater severity in such cases could be traced to a strumous habit, but subsequent experience did not confirm this suspicion, for the most scro- fulous family I ever saw went through the disease without a death, whereas in some others the mortality was great, although not a single indication of a strumous diathesis could be detected. Many parents lost three of their children, some four, and in one instance which came to my know- ledge, five very fine children were carried off. As usual in such epide- mics, the degree of intensity with which different persons were attacked varied exceedingly, some exhibiting the mildest form of scarlatina sim- plex, which required no treatment, and scarcely confinement to the room, while the majority were severely affected. When the disease was vio- lent, it assumed one or other of the following forms :— First.—It at once produced not merely fever with sore throat and head- ache, but such violent congestion of the brain, and determination to the head, as occasioned convulsions and apoplectic coma on the first or second day. This happened to a fine young woman of robust habit in Werburgh street, to whom I was called by my friend Dr. Brereton. She was at- tacked with convulsions on the second day, and died comatose on the third. In her the scarlet eruption was extremely vivid and general, af , fact I notice as a proof that the congestion of internal organs was not \ ■ caused by any retrocession of the eruption. In truth, as will appear here-1 after, the worst cases had the most general and most intense cutaneous efflorescence. When this tendency to the head took place in so violent a manner at the very onset, the patient was seldom saved ; sometimes, however, very active measures of depletion, general and local, relieved the brain, and the case then went on favourably. This happened in a young gentleman residing in Upper Baggot street, to whom I was called by the late Mr. Nugent, of Merrion row. When the scarlet fever attacked a person subject to epileptic fits, the tendency to the head was increased by the epileptic habits, and the fits of convulsions at once supervened. Thus in the case of a gentleman, aged twenty-two, who had been for several months treated by Mr. Colles and me for epilepsy, the fits com- menced on the second day of scarlatina, and continued with frightful violence until the fifth day, when they proved fatal. In a young lady residing near Black Rock, to whom I was called by Dr. Wilson, precisely the same thing occurred. She had been subject to epilepsy for many years, and when the scarlet fever commenced she was at once seized with frequently-recurring fits, which, in spite of the most active measures, ended in fatal coma on the fifth day. In the second form of the disease which I noticed, the symptoras were 430 CLINICAL MEDICINE. exceedingly violent and intense from the beginning, and the disease set in with the usual symptoms of severe exanthematous pyrexia, remarkable in the very commencement for the violence of the accompanying headache and spinal pains, and for the great irritability of the stomach and bowels. Indeed one of the very first symptoms in such persons was nausea, vomiting, and bowel complaint. Large quantities of recently secreted bile were thrown up, and the patient passed frequent, at first semi-fluid and afterwards fluid stools, curdled green or saffron yellow, and evidently composed of bile suddenly effused into the intestinal canal, with a copious and hurried secretion of mucus from the internal membrane of the bowels, and mixed with some true fecal matter. It was surprising what quanti- ties were thus thrown up, and passed from the bowels by some during the first day or two of the disorder ; neither the constant repetition of the nausea, and vomiting, nor the abundance of the discharge from the stomach and bowels, in the slightest degree mitigated either the violence of the fever or of the headache, or seemed to prevent the full formation of the eruption. It was curious to observe that this obstinate vomiting and purging was unaccompanied by the slightest epigastric or abdominal tenderness; during its continuance the belly became fallen and soft. In fact its cause was situated not in the belly, but in the brain, a fact I did not perceive until I had had an opportunity of watching the progress of five or six such cases. It depended on cerebral irritation and congestion, and was in nature very similar to the irritability of stomach and bowels which so often accompany, and too frequently mask the progress of acute hydrocephalus. As soon as I had become aware of the pathological relations of this vomiting and purging, I did not confine my endeavours to check these symptoms to measures intended to act directly on the stomach and bowels, such as effervescing draughts, chalk-mixture, stupes, leeches to the epigastrium, &c. &c. I changed my plan of treatment, and turned my attention to the state of the cerebral circulation. Having in a former lecture referred to this topic, and having explained to you the manner in which derangement of the stomach and bowels of a properly gastric origin is to be distinguished from disorder of the digestive appa- ratus, originating in a sympathetic derangement of function, itself caused by a morbid condition of the brain, and having already pointed out the importance in practice of not confounding these two states, one or other of which is so common in the commencement of violent fevers, phleg- masia, and exanthemata, I shall not at present dwell any longer on this subject. The second form of scarlatina was likewise remarkable for the violent excitement manifested from the very beginning in the circulating system, and in the production of animal heat. The pulse at once rose to above 100, it was seldom less than 120, and in many cases, particularly in young people, it ranged from 140 to 150. I have never in any other disease witnessed so many cases of excessively rapid pulse. In general the pulse in this form was regular, but in two cases it became irregular; one was that of a gentleman living in Upper Mount street, whom I attended with Sir Henry Marsh ; his pulse became intermitting and irregular on the third day, and continued to be more or less thus affected for about a week. This gentleman was attacked with subsultus, delirium, jactitation, and various nervous symptoms, at a very early period, and complained con- stantly of his throat and head. The former was violently inflamed, and his skin was covered with a bright red eruption. On the ninth day he SCARLATINA. 431 was seized with convulsive fits of great violence, and which returned very frequently during the night; his case appeared utterly hopeless, and yet he perfectly recovered. In a young lady, whose case is detailed by Dr. Nolan, great irregularity and intermission of the pulse commenced about the eighth day, and continued during the state of danger ; she also recovered. Of course irregularity of the pulse was in many not so much a symptom of disease as of approaching death, but then the state of the patient could not be mistaken, judging from all the other circumstances of the case. The acceleration of the pulse abated in all when an evident improvement in the general condition took place, but in few did the pulse become quite natural for many days after a favourable change, and in none did it fall to its usual standard in the course of twelve or twenty-four hours, as it not unfrequently does after the crisis of continued fevers ; in fact, the scarlatina never ended with a well-defined crisis. As to the tempera- ture of the body, I have already observed that in the cases I am now describing it was from the first considerable, and continued elevated until a very short period before death. Both the pulse and the heat of skin, however, were very easily reduced in energy by the use of the lancet or by the repeated application of leeches, and it was not uncommon to observe that even the judicious use of these means induced a general coldness of surface, very great sinking of the strength, and a faltering state of the pulse. This wTas remarkably the case in a young lady whom I attended along with Mr. Wilkinson, in Black Rock, and also in one of the family whose cases are related by Dr. Nolan. In both, these effects were very obstinate and alarming, for reaction was not restored until after the lapse of more than twelve hours ; both finally recovered. The pulse was sharp but not strong, and resembled the pulse of great irritation rather than that of true inflammation. The most distressing symptom at the commencement of this form of scarlatina was the sore throat ; the fauces were violently inflamed, and deglutition consequently much im- paired, while a general soreness was felt in the back of the head and neck; urgent headache was complained of by all, and from the second day the eyes became suffused ; great restlessness, anxiety, jactitation, moaning and interrupted raving soon made their appearance, and in many, sleep was banished or utterly broken by startings and delirium before three or four days had elapsed. The eruption had now arrived at its height, which it did with great rapidity, dating from the first moment of its appearance, so that the skin, everywhere covered with a scarlet eruption, resembled in appearance the hue of a boiled lobster. In these violent cases the efflorescence was perfectly continuous, and never broken into spots or patches ; the skin appeared as if evenly dyed with one uniform colour ; the surface of the tongue was likewise much affected with the same exanthematous redness, and soon became foul and after- wards dry and parched. The sudden drying of the tongue on the fifth or sixth day indicated in this form a rapid aggravation of the disease, and death in several cases was observed to follow this change in less than twenty-four hours, when it was, as in a yonng gentleman Mr. Rumley and I attended in French-street, accompanied by a sudden acceleration of the pulse and increase of the jactitation and delirium. In this form the brain and nervous system seemed to be the parts which suffered most, and many became insensible for several hours before death ; others had convulsions; when the patient survived the seventh day there was a fair 432 CLINICAL MEDICINE. chance of recovery, but many, too many, died on the fourth, fifth, or sixth day. After I had witnessed a few examples of this form of scarlatina, I con- sulted with several of my friends and colleagues, and we determined to use the most active measures of depletion in the very first instance that occurred to us. A case was not long wanting. Sir Henry Marsh and I were engaged in prescribing for some children labouring under the epi- demic, in a house in Pembroke-street, where our attention was directed to a fine boy, six years old, and hitherto perfectly healthy, who was, while we were paying our visit, attacked with the first symptoms of the com- plaint ; we immediately resolved that as soon as the stage of rigor and collapse which preceded the febrile action had passed, to visit him again and act energetically, if circumstances seemed to permit it. Accordingly we came again in the course of a few hours, and found reaction already established, attended with vomiting, purging, and headache. The sore throat, too, was much complained of, and there was great tenderness of the external fauces. We ordered relays of leeches, eight at a time, to the neck, for the purpose of relieving both the throat and brain, and we administered James's powder and calomel internally. On the next day the skin was burning in spite of a copious loss of blood from the leech- bites, the eruption vivid and already established, the pulse 140, and there had been little or no sleep. Relays of leeches were again ordered, and persevered in until considerable and lasting faintness was produced, and yet no impression seemed to be thereby made on the disease ; no abate- ment of its virulence seemed to be the result, for the raving became more incessant on the second night, and on the third day suffusion of the eye commenced, and the tongue became parched. Shaving of the head, the most industrious application of cold to the scalp, and various other reme- dies were in vain .applied ; the pulse became weaker, the breathing quicker, the strength failed rapidly, raving and delirium gave place to insensibility and subsultus, and the patient died on the fifth day. In this case depletion was applied at once and most decidedly, for we blanched and weakened the boy by loss of blood as far as it was possible to ven- ture, and yet the disease was not in the least degree checked, nor the symptoms even mitigated. A fine boy, thirteen years of age, was attacked in the county of Wick- low, where he was placed under the care of a very judicious practitioner, who did not use either venesection or leeches, but relied chiefly on the exhibition of diaphoretics, particularly antimonials. The boy died on the seventh day, having suffered much from delirium, subsultus, want of sleep, &c. His brother, who was one year older, and a very strong boy, was seized with the disease in Dublin, and placed immediately under my care. I had the advantage of Mr. Rumley's assistance, and we deter- mined to prevent the supervention of the cerebral symptoms, if it were possible to do it by means of antiphlogistic treatment: we failed, and our patient died on the sixth day. In short, in this form of the disease, where the pulse, without becoming strong, at once became extremely rapid, bore venesection badly, and required great caution even in the applica- tion of leeches ; the nervous symptoms only appeared accelerated by the system of depletion, although the heat of the skin suggested its employ- ment. The derangement of the brain and nerves in this form depended on something more than the violence of the circulation, and originated in SCARLATINA. 433 something altogether different from mere cerebral inflammation or con- gestion. What that something was I cannot even conjecture; but it was probably the result of an intense poisoning of the system by the animal miasma of the scarlet fever. Every tissue of the body seemed if I may use the expression, equally sick, equally overwhelmed, and it is'probable, that the capillary circulation in every organ was simultaneously deranged It was not gangrene of the throat which proved fatal, for in this form it never occurred; it was not inflammation of any internal viscus, for such was not found on post-mortem examination of the fatal cases ; but it was a general disease of every part. In many, another state of things, which required to be carefully distinguished from that just described, existed, and the disease was evidently attended with an inflammatory state of the constitution, requiring energetic measures. In such cases the symptoms were severe in the commencement, the throat very sore, the efflorescence, however, not quite so sudden or so perfect, and the pulse never near so quick, never excessively rapid, and always strong and distinct. Such bore bleeding and leeching well, and experienced from their use almost immediate alleviation of the sore throat, headache, and restlessness, and were not much weakened by the depletion. It must be confessed, that it was often exceedingly difficult to determine, t\ priori, whether the de- pletory system ought or ought not to be tried. Where doubt existed, my custom was to try moderate leeching, and from its effects I judged of the propriety of persevering. The disease very frequently occurred in a third form, more singular still than the two first, and much more insidious in its commencement. This form was evidently very common in the epidemic scarlet fever de- scribed by Withering, as cited by Dr. Tweedie. In this form the disease was ushered in by the usual symptoms of pyrexia, together with sore throat, slight headache, and in due time a very moderate and normal eruption. The symptoras continued moderate ; the patients, after the first few days, slept tolerably well during the night, had no raving, and were quiet during the day. About the fourth or fifth day all the febrile symp- toms had so far subsided, that a most accurate examination could detect nothing urgent, nothing in the slightest degree either alarming or calcu- lated to excite the least anxiety in the patient's condition. His skin be- came nearly of the natural standard, hvs thirst diminished, and the pulse was now scarcely accelerated ; a calm nearly complete, in fact, seemed to have followed the first onset of the disease ; and on entering the room, the physician might easily be deceived, as I myself was more&than once^ into the pleasing hope, that all danger was past, and that perfect recovery might confidently be anticipated. This hope was, in truih, founded on such circumstances as we can usually rely on ; for who would prognosti- cate danger where his little patient, sitting up in bed, and perhaps eating a dry crust with some appetite, had a placid countenance, and had enjoyed a night of tranquil sleep ? Regular alvine evacuations, diminution of thirst, sore throat, headache, and fever, together with the normal state of the cutaneous eruption, all conspired to confirm a favourable prognosis ; and so matters proceeded, the family dismissing all apprehension as to the result, and the physician most probably discontinuing his attendance about the seventh day, in the belief that all danger was over, and that his interference was no longer necessary. Matters proceeded thus until the eighth or ninth day, when a certain degree of restlessness was observed 434 CLINICAL MEDICINE. to occur, and in the morning a slight return of fever might be noticed. Then it was that a peculiar train of symptoms set in. The nostrils assumed a sore and irritated appearance about the edge of the alas, and a serous moisture began to flow from their internal cavities. Sore throat was again complained of, the skin became hot, great debility and prostration of strength came on suddenly, a painful tumefaction commenced in the region of the parotids and submaxillary glands. This tumefaction increased rapidly, becoming every day harder, more elevated, diffused, and exceed- ingly tender, but without much redness. In the course of a few days it surrounded the neck like a collar, and being attended with swelling of the face, the poor little patient's countenance was sadly disfigured. In the mean time the discharge from the nose had increased considerably, and become more viscid and fetid ; the internal membrane lining the nasal passage was affected throughout, its entire surface everywhere inflamed and tumefied, so that a snuffling sound was produced when the patient breathed through his nose : at length the discharge increased to such a degree that the nostrils became completely impervious to the air in breathing. The state of the throat generally began to alter for the worse at the very commencement of this change ; and a similar inflammation, attended with an ill-conditioned secretion of lymph and fluid, occupied the entire surface of the mouth and tongue, and at last spread deep into the pharynx. While this was going on, the fever freshly lit up, at once exhibited the most decided symptoms of the worst form of typhus and subsultus, constant muttering, raving, anxiety, want of sleep, restlessness, moaning mingled with an occasional screech, reminding one of that which is so ominous in hydrocephalus. Great difficulty was now experienced in swallowing, and the drink was frequently spirted out of the mouth after a vain attempt at deglutition. Matters now proceeded rapidly from bad to worse, and at last, after much suffering, death closed the scene, being preceded for many hours by a state of extreme restlessness, during which it was impossible to determine whether the patient was still sensible. The swelling of the neck went on increasing to the last, but seldom exhibited any tendency to point ; it continued, on the contrary, everywhere hard, or, at most, became indistinctly softened, or, to use a technical phrase, " boggy." When cut into, no matter was found ; blood, serum, and a diffused cellular slough, not separated from the living tissues, were ob- served on making the incision. I shall now read to you a letter I received on the subject of scarlatina, from Mr. O'Ferrall. His observations are extremely valuable, more espe- cially those which are made towards the termination of the letter, where he describes a most important sequela of scarlatina not hitherto mentioned by any writer. " My dear Sir,—In reply to your letter, 1 have the pleasure to send you a few brief notes of my experience of the scarlatina of last autumn and winter. " Of seventeen cases of which I possess notes, four occurred in adults, three in children under four years of age, and the remainder at different ages between the latter and fourteen or fifteen years. I seldom saw the cases in the commencement. The mode of attack was occasionally simi- lar to that of common sore throat followed by rigors; sometimes violent pyrexia and shiverings, with intolerable headache, and even delirium, SCARLATINA. 435 preceded by other signs. In some few cases, the efflorescence first at- tracted notice, the fever in these instances being throughout so mild as scarcely to demand attention. " The progress of the disease was various, but usually bore a relation to the character of the incipient fever. In general, the fever increased in intensity as the disease advanced, or as new parts became engaged; but this was not always the case. In two instances which I saw in a state of great vital depression on the third or fourth day, I was assured 4hat the early fever was very high, although it had passed rapidly into the typhoid state. " The danger sometimes appeared to arise from the condition of the entire system, sometimes from that of important parts. Of two cases which I saw when dying, one was sinking like a person in typhus fever; the other, a boy thirteen years old, was moribund in the coma, which succeeded to violent phrenitic delirium. The latter case was remarkable in this, that the phrenitic state occurred while the eruption was in its prime, the whole body retaining its deep scarlet colour until a short time before his death. The disease in this instance set in with delirium, which had been subdued, I have reason to believe, by the most active means. Death occurred in one instance from croup, the disease of the throat hav- ing passed into the trachea and bronchial tubes. In another, sloughing of the fauces, with low fever, carried off the patient on the sixth day. " In several, who ultimately recovered, life was seriously endangered by local inflammatory attacks. In one instance, a girl about seven years old, enteritic symptoms sprang up suddenly while the patient was in a very weak state, and were with difficulty subdued. In another, a boy ten years old, acute pain in the region of the heart occurred when the eruption was on the decline ; it was accompanied by short cough, palpi- tations, dyspnoea, rapid, though not irregular pulse, and sudden accession of fever. There was no perceptible frottement, but the action of the heart was violent, and there wras acute pain on pressure. It yielded to leech- ing, followed by calomel, with James's powder, till the gums were slightly touched. "Another patient, a girl twelve years old, narrowly escaped the effects of sloughing of the throat. Croup occurred in two instances, in which, notwithstanding the opinions of M. Trousseau, I could not doubt its origin in scarlatina. It happened, no doubt, in cases which had exhibited the diphtheritic patches, without much surrounding inflammation on the ton- sils, but the eruption was sufficiently marked to remove all obscurity. One child, who recovered, ejected the false membrane (which I still pre- serve) in a tubular form, and presenting a cast of the trachea a little be- yond its bifurcation. In the child before mentioned, who died, patches of false membrane were also ejected ; but she sank exhausted, and the disease was afterwards discovered to have extended far into the bronchial ramifications. " Although the treatment was generally antiphlogistic, this plan was not always applicable, even in the commencement of the disease. In all instances which I had an opportunity of observing, it was necessary to watch the effects of local bleeding. It was easy to pass the boundary of relief, and then most difficult to repair the loss, and meet the symptoms of exhaustion when they had actually set in. Wine and diffusible stimuli were often required from this cause alone, even when the cases had no- thing of the malignant or typhoid character in their nature. 436 CLINICAL MEDICINE. " Tepid sponging appeared in many instances preferable to cold, and I think the soothing effects were of longer duration. Reaction, and the distressing sense of burning heat, did not appear to recur so soon as when cold fluids were employed. Purgatives, except of the mildest kind, were not well borne, but cooling diuretics were clearly indicated, and, when persevered in, had, in many cases, the apparent effect of anticipating the sequelae of the complaint. " The ulcerations and sloughing of the throat were treated by nitrate of silver, alum, and the chlorides, according to their states. But none of these applications were to be depended on, when the colour of the fauces was intensely red, unless a few leeches had been previously applied. In one gentleman, twenty-eight years of age, free leeching, externally (to the number of forty), failed in removing the sense of suffocation or ena- bling him to swallow. A few leeches applied to the inside of the nostrils was followed by copious bleeding and immediate relief. The latter ex- pedient was indicated by the tumid state of the velum and pituitary mem- brane, the stertorous breathing, and complete occlusion of the nares. "Its mode of spreading in families was uncertain. It sometimes at- tacked children within a few days of each other ; at other times, a fort- night has elapsed before I was again requested to see a new patient. Some children escaped the disease altogether. " Among the sequelae which I had occasion to see, diarrhoea occurred in two or three instances, chronic bronchitis in one, and anasarca in four. The urine was slightly albuminous in two of the latter cases before the face and limbs began to swell ; in the other two it exhibited this charac- ter when the disease was formed, but I did not see them previously. The treatment of the anasarca was antiphlogistic and diuretic, and succeeded in restoring three to perfect health ; the fourth still remains an invalid, but not from this cause ; the apex of the right lung affords evidence of tuber- cular disease. " I have now to mention a peculiar affection of the neck, which I have not before seen in connection with scarlatina, but of which four cases have occurred during my observation of the epidemic in question. " Case 1.—About the beginning of August, 1834, I was requested by ray friend, Dr. Davy, to see a young girl, ten years old, in Upper Baggot Street. Her convalescence was tedious, some degree of fever still existing at the end of six weeks from the commencement of the attack. But her principal complaint was severe pain of the right side of the neck, close to the head, and extending as high as the vertex on the least motion of the part. She could not raise the head from the pillow without putting a hand at each side for its support, and when taken out of bed, instinctively sought a resting-place for the chin. The face was awry, its vertical diameter passing from above downwards, and from right to left. Pos- teriorly, the upper cervical vertebra? were curved, the convexity of the curve being situated a little to the left of the middle line ; there was con- siderable swelling of the soft parts covering the bones. Pressure here was intolerable, and the least attempt to rotate the head occasioned severe pain. Deglutition was now tolerably easy, but there had been con- siderable difficulty of swallowing during the early period of the complaint. There was here obviously a carious state of the articulation of the atlas and dentata, and we did not expect to remove the curvature. Perfect rest was, however, enjoined, and the usual remedies employed with a SCARLATINA. 437 view to arrest the further progress of the disease. She gradually reco- vered her health, and is now lively and well grown, but the curvature is permanent. " Case 2.—Early in August, 1834, Mary Inglesby, of Russell Place, aged 7, was sent to me by Mr. Long, of Summer Hill. She was confined to bed in scarlatina for a fortnight. At the end of this time she was taken out of bed, and then the head was observed to be turned to one side. It was now five weeks altogether from the beginning of the disease, and the parts were still in the same state. The face was awry. She complained of pain in the concavity of the curve and that side of the head, and could not bear the slightest motion or shock. Leeches were prescribed, and calomel given afterwards in doses of a grain, three times a-day, till the gums were touched. As soon as this effect was produced, the pain sub- sided, and the pain gradually acquired its natural position. Her recovery was complete. " Case 3.—A younger brother of Mary Inglesby was subsequently under the care of Mr. Long, for scarlatina. The same state of the head and neck were detected on the thirteenth day, and treated by Mr. Long, on the same plan as that adopted in the former case. The pain disappeared as soon as the mouth was made sore, and the position of the head became natural. He is now in good health. " Case 4.—I met Mr. Edgar, of Arran Quay, in February last, in the case of a young gentleman about six years old, whose convalescence from scarlatina was tedious, and in whom the difficulty of swallowing persisted after the redness of the fauces was removed. On taking him out of bed it was remarked that he was quite unable to keep the head erect. The symptoms were similar to those of the two last cases, but in a milder degree. A few leeches were applied, and evaporating lotions instantly used to the part, on account of considerable local heat. The leeching was repeated in a day or two, but as the symptoms yielded rapidly, and as he had some tendency to diarrhoea, calomel was not employed. In about a fortnight, the natural position of the head and neck was restored. " I can offer no better explanation of the occurrence of this affection, during the progress of scarlatina, than by supposing that the inflammation of the fauces and back of the pharynx was propagated to the adjoining parts. In all those cases there had been marked and prolonged difficulty of deglutition, as a symptom of the disease ; and it is to this circumstance I am desirous of calling attention, as affording an index for a careful review of the condition of the spine during the period of convalescence. Should a child be observed to lie more on one side than the other, and evince an unwillingness to be disturbed, it would be an additional reason for suspecting a tendency to this complaint. Believe me, Dear Sir, yours very truly, " JOSEPH M. O'FERRALL. " Rutland Square, West, 30th July, 1835." Since the preceding lecture was delivered, the disease has raged every winter and spring with undiminished virulence, and has resisted, as before, nearly every kind of treatment. A letter which I received from Dr. Cumming, of Armagh, stating that scarlatina had rarely been witnessed in that city since he settled there, eleven years ago, and that he had never seen the malignant form of the disease, induced me to forward a 438 CLINICAL MEDICINE. circular to the principal medical men in the provinces, to ascertain if the disease prevailed in their respective districts, and if it had assumed the fatal form we had observed in so many instances in Dublin. I shall now briefly lay before the reader the principal facts contained in the answers to1 my queries. Dr. Geoghegan, of the Kildare Infirmary, says, that during his residence there, for ten years, scarlatina never pre- vailed as an epidemic, and the sporadic cases he met with were exceed- ingly mild.* Dr. Astle, of Edenderry, relates the same. Dr. Wood- ward, of Kells, has not seen it epidemically, but isolated cases were re- markably fatal, some dying within the first twenty-four hours. Dr. Clif- ford, of Trim, mentions that it has latterly been prevalent in his district and very fatal. Dr. Clarke, of Rathdrum, states that it has been on the increase for the last three years, but has been very mild. The letter of Dr. Lloyd, of Malahide, is so important that I shall introduce it in full. " Malahide Dispensary, August 20, 1842. " Dear Sir,—In reply to your circular relative to the prevalence of scarlatina in my district, I beg to say, the year ending May, 1839, no case occurred; May, 1840, one case in an adult; May, 1841, no case ; May, 1842, thirty-two cases are registered, three of which were fatal, one 24 hours after the appearance of the eruption ; the others were a brother and sister, aged eight and six, scrofulous, and after a period of from 12 to 16 days, they died of diseased brain and abscesses in the throat. Since May, six cases have been under my care. The only cases of moment were those mentioned above as fatal, and some of the same family in which the urgent symptoms were extensive ulceration of the fauces—they recovered rapidly. During the past year, there were nu- merous instances of the disease, but so slight that the individuals were under no restraint; so that I was not applied to, save occasionally to treat some of the sequelae. " I may here allude to a curious fact. My district joins, on one side, that of Baldoyle ; on the other, Swords ; in both, epidemic diseases have frequently appeared for the last 25 years, with virulence, and after a long period commenced in Malahide district, in a mild and subdued form ; many of the poor inhabitants are aware of the circumstance. "Believe me yours, sincerely, " HANS LLOYD. " To R. J. Graves, Esq., M.D." * Since I received the above communication from Dr. Geoghegan, he has sent me the fol- lowing note:— " My dear Sin,—Since I replied to your circular, relative to scarlatina, many cases of it have occurred at Newbridge, four miles from this, on the Dublin road, and, from the number and rapidity of ihe deaths, 1 must suppose of the malignant kind. It was nearly confined to the children of the labouring class, and not having the dispensary there, I did not see them. I am, however, induced to state the condition of a boy, aged five years, I saw a day or two since, for the first time, although he then was three weeks ill. On the right temple was a large ecchymosis, about two inches in diameter; arterial blood trickling from the nose, mouth, and ears; he was greatly emaciated, and quite sensible, had diarrhcei and the hemorrhage only from the preceding day ; the cervical glands were enlarged, but had not suppurated, nor was there anasarca or dropsy ; he died the following morning. Being asked while driving past to see the child, and finding him so wretched an object, I merely told the mother I did not think he had the slightest chance of recovery. This is, I think, the only case in which I ever saw hemorrhage from the ears. Believe me, my dear Sir, yours faithfully, »W. P. GEOGHEGAN, M.D. " Infirmary, Kildare, Oct. 12, 1842." SCARLATINA. 439 Dr. Glover, of Philipstown, never saw or heard of a case of scarlatina during the four years he has resided there. Dr. Croly, of Mountmelick, states, that the disease has latterly become prevalent in that locality, and has assumed on many occasions a malignant form. Dr. Brunker, of Dun- dalk, mentions, that the disease has only presented itself in one instance within the last five years, and was very mild. Dr. Hudson, of Navan, has not met with the disease often ; and during a term of eight years has only had one fatal case ; whilst Dr. Byron of the same town states, that the disease " was very prevalent, and in several localities unusually ma- lignant during the last two years, up to a period of about two months ago, when it was observed to be on the decline. At present, there are very few cases within twelve or fifteen miles of Navan, and these are less virulent, generally speaking, than formerly," From Wexford, Dr. Boxwell writes, that there " they have had but a few scattered cases in the town for the last six years, and not one fatal." In Arklow, Dr. Wright mentions, that scarlatina has been very prevalent in that town and neighbourhood for several years past, particularly 1840-41 ; but it did not frequently prove fatal." In Athy, as appears from the letter of Dr. Clayton, it has prevailed, and some of the cases have proved fatal. Dr. Macartney, of Enniscorthy, states, that it was prevalent and fatal during 1837 and 1838, and that it was, at the time of writing, breaking out again. The following communication from Dr. Ridley, of Tullamoore, is too important to be omitted :— " Tullamoore, October 17, 1842. "Dear Sir,—Scarlatina appeared here in the latter part of November, in the last year, as an epidemic, and continued to be very prevalent until June following. During this period it prevailed most in the month of March. I saw a great number of cases in this town and the neighbour- hood, which were mostly all of the benign or simple form. Some cases occurred, in full plethoric subjects, of an inflammatory nature ; but I did not meet with a case of the malignant or typhoid disease, such as I have seen in Dublin. This epidemic raged chiefly amongst children and young people—the oldest subject I am aware of having had it was a person of forty years. It commenced with rigors, lassitude, loss of appetite (in some cases with soreness of the throat as a first symptom), and the usual symptoms of approaching fever, which continued to increase until the third or fourth day, during which time, in some instances, the fever ran high, with raving and other symptoms of cerebral disturbance. The eruption generally appeared on the second day in the form of small dis- tinct spots like flea-bites, which did not run together, and declined sud- denly on the fourth or fifth day without desquamation. In some instances the character of the eruption was an efflorescence, which remained out until the sixth or seventh day, and was always followed by desquamation, The fever was equally high in both these forms of eruption, but of greater duration in the latter. The throat was very slightly affected in the ma- jority of cases, being nothing more than a slight erythematous blush on velum and tonsils ; however, in some robust, plethoric persons, there was much inflammation, demanding active treatment. The symptoms had usually so much subsided as to enable the patient to leave the bed on the sixth or seventh day. The fatal cases which I witnessed here, were caused by congestion of ihe brain, occurring on the third day, while the eruption 440 CLINICAL MEDICINE. was well out and every thing appeared favourable, slight drowsiness set in, which was quickly followed by coma and stertor ; and in two cases death ensued in thirty hours from the commencement of those symptoms: they were all in young persons of full habit, and had no previous delirium or inflammatory affection of the brain. The sequelae were, anasarca (which was very general, and occurred after the mildest form of the disease), pneumonia, bronchitis, acute rheumatism, remittent fever, enlargement of submaxillary and parotid glands. In one instance pneumonia proved fatal in eighteen hours. It was the case of a boy of nine years old, who had been three weeks recovered from scarlatina. The treatment was that usually practised. Emetics and purgatives, diaphoretics, attending to ventilation, &c, were sufficient in the generality of cases. In the inflam- matory form, venesection, antimonials and calomel were prescribed ; when the throat was affected, the free application of nitrate of silver was found to be the best remedy. Leeches, acid gargles, application of powdered alum, blisters, &c, were also beneficial. When anasarca followed, it generally yielded to smart hydragogue purgatives; but in some cases I gave calomel and squill with advantage : as a prophylactic I was induced to try belladonna, but without success. " There was at this time a very prevalent inflammatory affection of the throat, which appeared and disappeared with the scarlatina. This dis- ease commenced with slight fever, stiffness of the neck and dysphagia, which afterwards increased to a great degree. The pharynx, tonsils, and velum, assumed a deep scarlet hue, and were in some cases covered with patches of lymph, which could be raised off with a probe, like the mem- brane of diphtherite. The tonsils became greatly enlarged ; also the parotid and submaxillary glands ; the jaw became fixed, so that the teeth could not be separated ; there was inability of swallowing, hurried breath- ing, and high fever. These symptoms increased to the fourth or fifth day, when the fever subsided with diaphoresis ; the jaw became relaxed, copious salivation came on, and the ability of swallowing was in some degree restored ; and, finally, in the course of eight or nine days from the commencement of the attack, this inflammation ended in resolution. In some few cases one or both tonsils suppurated, and in other still rarer instances, ulceration of the pharynx followed. Such are the symptoms of the most severe form of this disease ; but it was sometimes so mild, as not even to confine patients to the house. " At any other time this disease would have been looked on merely as an epidemic cynanche ; but in this instance, there was a very decided con- nection observed between it and the prevailing scarlatina. It was, in the first place, even popularly remarked, that a person who had suffered from this cynanche had not been afterwards attacked with scarlatina, and that an attack of the latter was not in any instance followed by one of the for- mer. It was likewise observed, that when one member of a family was seized with cynanche, scarlatina soon showed itself amongst some of the rest ; and in the same manner, when scarlatina appeared first, cynanche very frequently followed, so that one was considered as the forerunner of the other. The following few brief cases may serve to show this con- nection. " Case 1.—Master S. came home from school (where scarlatina had prevailed) complaining of soreness in swallowing, slight headache, and nausea. The next day the tonsils were enlarged, and he complained of SCARLATINA. 441 greater pain in swallowing ; pulse quick, skin hot; but no appearance of eruption. These symptoms remained without getting worse for three days, when they gradually subsided. Before he was perfectly well, scarlatina seized two of his sisters and his father. In the former, the eruption ap- peared as an efflorescence arid ended in desquamation ; in the latter it was in the form of distinct spots, and without any subsequent desqua- mation. " Case 2.—Master 0. came home from the same school with scarlatina. Two of his sisters and his brother were seized with it while he was ill. The eruption came out well in the spotted form. At the same time the man and maid-servant were attacked violently with cynanche, which was attended with high fever for several days. " Case 3.—Visited Mr. B. who had been suffering from severe cynanche for four days. He cannot articulate or swallow ; the jaw is so fixed as to prevent the teeth being separated to more than a quarter of an inch ; fresh tumefaction of the neck ; pulse quick ; skin hot and dry ; breathing hur- ried ; face swollen and flushed ; eyes suffused (on inquiring if any of the family had scarlatina, I found his son, who was lying in the same room, just recovering from it). After a few days, perspiration appeared over the surface of the body, the fever became less, and he was able to open his mouth and swallow a little. On first seeing the tonsils and velum, I found them coated over with a thick white membrane, which extended to the hard palate, and could be raised off easily with the probe. "Case 4.—P. N. has been complaining of headache and nausea since yesterday, feels a stiffness in his throat, and fears he is getting the scarla- tina, as three of his children are only recovering from it. The throat symptoms increased to a great degree, with a smart fever attending them. No eruption appeared, and he was well in eight days. " It is now almost generally admitted that the eruption is not a neces- sary symptom of scarlatina, which disease may occur independently of any affection of the skin. In this case the throat is supposed to be invariably affected, and the disease has received the name of 'scarlatina faucium.' But it may be a matter of some difficulty to disprove this scarlatinous af- fection of the throat from a common cynanche : the fact of scarlatina being prevalent in the neighbourhood, and the probability of the infection of it having been in some way communicated, must in such cases be taken into consideration. If it be found, however, that exposure to the infection of one disease gives rise to the other, and that one proves a preventive of the other, there are fair reasons for concluding, that it is the same disease, in the one case affecting the skin, and in the other the throat only. "I am, dear Sir, yours most truly, "JOHN RIDLEY." In Waterford, Dr. Elliott announces, that for several years it has ap- peared occasionally in an epidemic form, sometimes assuming great malig- nancy during the congestive stage, whilst its peculiar diagnostic charac- ters were as yet barely discernible. Dr. Bewley, of Moate, mentions that it has not prevailed in his district for eleven years, and that during the whole of this period he had not a fatal case. Dr. Thorpe, of Listowel, has seen very few cases of the disease, and has not had a single death. Dr. Gogerty, of Nobber (county Meath), has had many fatal cases, and 442 CLINICAL MEDICINE. the disease has been very prevalent. In Pomeroy, as appears from the statement of Dr. Harvey, the disease has been rare and mild. Dr. Con- nor, of Carlow, forwarded me the following letter, which I shall here introduce. " Carlow, Sth August, 1842. " Dear Doctor—I delayed answering your circular (received on Fri- day), until I could send you the combined opinion of some other practi- tioners, two of whom agree with me in saying, that there is annually a pretty general attack of scarlatina in this district, but nearly confined to the juvenile and infantine portion of the community, at least we do not recollect many adults affected with it, and only one fatal case amongst those, and that was the case of a lady just confined, and whose children had the disease, but recovered. As to the malignancy of the type, we can say, that whilst five children were carried off by it in one family others in same house had it slightly; and although several lost two or more chil- dren, numbers of families have been so slightly affected, that were it not that medical men recognised the disease, it would have passed away with- out any notice, requiring in some cases only the little patient to remain one day or two in bed. When many members of one family have been taken away, we have had reason to think that the constitution of the suf- ferers had more to do with the fatal result than the original type of the disease. Hoping that I have answered clearly and fully, I beg to remain yours sincerely, "SHEWBRIDGE CONNOR, M.D. " Drs. Rawson^and Porter are the persons to whom I showed your cir- cular. Any other medical statistical information you may require I shall be most happy to afford or collect. "P.S.—I have never known or heard of a case of intermittent fever in this district, though some fatal cases of typhus have had pretty regular hot and sweating stages, several in a day, perhaps the cold fit escaped obser- vation. This though not bearing on your inquiry might interest you. "R. J. Graves, Esq., M.D." Dr. Long, of Arthurstown, writes as follows— " Arthurstow of ihe inflammatory symptoms and their real sli^htness or nullity ; the actual failure 470 CLINICAL MEDICINE. Before I conclude, I shall mention the particulars of a \rery remarkable case which came recently under ray notice. I was called to visit a lady, somewhat advanced in life, but of a good constitution, and labouring under the ordinary form of influenza, with considerable dyspnoea and cough. In the course of eight or nine days her symptoms began to decline ; she got up, and seemed convalescent. As the cough and pulmonary irritation still prevailed to a certain extent, it was thought advisable not to allow her to eat meat, but she obtained leave to take some fresh haddock. After din- ner, her cough becoming more troublesome than before, she had frequent recourse to a stale and rancid cough-bottle, containing squill and ipecacu- anha. During the evening and night she felt her dinner like an undi- gested load, and her stomach turned. She vomited, and was purged and griped incessantly, until I saw her next day. On the third day, the medi- cines I had ordered moderated the purging, but the nausea and occasional vomiting continued. On the fourth day, the purging had entirely ceased, but the sickness of stomach persisted. I sought to appease this by the ordinary means, which failing, I examined her with care on the following day, and discovered a strangulated hernia. At this time the pulse had scarcely risen above the natural standard. Mr. Cusack operated that night with his usual skill, and all the symptoms depending on incarce- rated hernia ceased. But they had scarcely disappeared, when the pul- monary symptoms and the copious secretion from the bronchial tubes recurred, and she did not survive this relapse of the influenza more than a few days. This is an instructive example of an insidious combination of circum- stances very likely to mislead a practitioner; for as the vomiting was for a day or two accompanied by a looseness of the bowels, the suspicion of hernia would not strike the attention. It is plain that in this case indi- gestion produced an increased and morbid activity in the motions of the alimentary canal, which led to the incarceration of the portion of gut. Up to a certain moment the symptoms depended merely on one cause; after that period, strangulation took place—an occurrence which could not be easily diagnosed, as vomiting, one of the most striking symptoms, had pre- viously existed. When diarrhoea occurs, it is generally at the commencement of the dis- ease ; and it is remarkable that this state is frequently exchanged, rather suddenly, for one of an opposite character. Thus, when you have suc- ceeded in checking the diarrhoea with chalk-mixture and opium, a state of costiveness will frequently ensue, requiring the daily use of purgatives and enemata. I have now witnessed several cases in which the moderate use of opiates and astringents brought on constipation, requiring the use of strong purgatives and enemata, thrown up with Read's syringe. In influenza, as in many other febrile affections, the lungs become con- of bleeding in mitigating the violent and painful cough which seems most expressly to require it; and the frequent success of remedies precisely the reverse of this ; all show a speciality in the disease, to which we must refer, more or less directly, in every question of practice. What- ever the cause or precise seat of irritation, it is certain that it has rarely the character of true membranous inflammation. In truth, the same reasons which prevent or limit bleeding in hooping-cough, apply no less to the peculiar cough and irritation of the influenza. We have rarely any authority for it in the state of the pulse, which neither in strength nor frequency bears relation to these inflammatory symptoms; while the difficult or painful respiration, which often suggests the remedy, furnishes evidence against its fitness by becoming frequently more laborious than before—the effect of larger accumulation in the bronchial cells, and of diminished power."—Op. cit., page 219. INFLUENZA. 471 siderably engaged; the disease first attacks the nose and throat, then the larynx and trachea, and, finally, the ultimate ramifications of the bronchi. There are several other affections which commence in a similar way—as ordinary catarrh, bronchitis, and measles. In influenza, most persons have the nose and throat affected in the beginning ; the inflammation creeps gradually along the lining membrane of the air-passages, until it involves the greater part, or the whole, of the bronchial mucous membrane. The progress of the inflammation is extremely rapid, and in the course of twenty- four, or even twelve hours, the lungs become engaged. There is, how- ever, much difference as to the extent to which this inflammation proceeds. In many cases, it is limited to the nose and throat; the patients complain of coryza, hoarseness, and slight cough. In others, the trachea also is more or less affected, and the cough is more troublesome ; but, generally speaking, the latter as well as the former cases are unattended with fever. The patients eat and drink as usual, go about their ordinary business, and sleep tolerably well at night. This appears to be the general course of the disease when the inflammation is limited to the nose, throat, and upper part of the air-passages; when it spreads farther, and attacks the first rami- fications of the bronchi, there is some dyspnoea and tightness of chest, the cough is much more troublesome, and the appetite and digestion are some- what impaired ; but persons in this state, although resting badly and eat- ing but little, will continue to go about—constantly, however, complain- ing that they are very ill. When the smaller divisions and ultimate rami- fications of the bronchi are engaged, there is soreness of chest, remarkable dyspnoea, and constant harassing cough; the headache is also aggravated, the patient loses all inclination for food, sleeps badly at night, and is con- fined to the bed or house. First, then, you have the mucous membrane of the eyes, nose and throat affected; then the larynx and trachea; then the larger bronchi; and, finally, the smaller and more minute ramifications. When the latter state has continued for some time, more or less serous en- gorgement of the lung takes place, and this adds to the dyspnoea and cough. On applying the stethoscope over various parts of the lung, you will hear at various parts a moist crepitus, indicating the existence of serous infiltra- tion. The smaller bronchial tubes and air-vesicles are congested and filled with mucus ; the blood cannot pass freely through the lung, and conse- quently must be imperfectly aerated ; the secreting and absorbing functions of the lung are deranged, and hence arises a state in which the pulmonary capillaries become congested, and permit the more fluid part of the blood to exude into the parenchyma of the lung, giving rise to what is termed serous infiltration. Something similar to this occurs also in general bron- chitis, particularly in fever, but we very seldom have hepatization result- ing from such causes. In hepatization, the capillaries pour out, not serum, but lymph, which glues together the cells of the pulmonary tissue, and forms a dense solid mass. Hence, in influenza or bronchitis, you seldom have true pneumonic inflammation. You will have extensive and danger- ous engorgement, but when you examine the lung after death you do not find any real solidification, and you can restore the lung almost to its original permeability and buoyancy by squeezing out the infiltrated fluid. Yet I must admit that this is not always the case, and that in influenza, as well as in bronchitis, you may have true pneumonia superadded to the original affection of the lining membrane. This occurred in the case of a lady whom I attended in Capel-street, and who was attacked with influ- 472 CLINICAL MEDICINE. enza shortly before delivery. On the day of her accouchement, pneumo- nia was superadded to the bronchial inflammation, and she died with ex- tensive hepatization of the right lung. This also occurred in the case of a man of middle age, residing in Suffolk-street, who had been labouring for some days under excessive engorgement of the lung. I have also ob- served the same occurrence in a gentleman whom I attended with Mr. Colles, in Exchequer-street; and in another case which I saw in White- friar-street. One of the most singular features in the history of the present influenza, is the extraordinary degree of dyspnoea witnessed in most cases where the lung is extensively engaged, but particularly where the patients had been previously subject to pulmonary affections ; and even in many cases where the bronchial mucous membrane is but slightly engaged, the amount of dyspnoea is remarkably great. Indeed, it might be said with much truth, that the dyspnoea was by no means proportioned to the extent of pulmonary inflammation. There is at present in the hospital a woman labouring under influenza, whose chest sounds clear on percussion, and in whom every part of the lung is permeable, who presents nothing more than a few sonorous rales in the course of the larger bronchial tubes, and yet she is suffering from considerable dyspnoea, and the respirations amount to forty-six in a minute. We cannot, therefore, attribute the difficulty of breathing to mere bronchitic lesion, for it is not in proportion to this lesion. Another patient admitted into Sir P. Dun's Hospital exhibited a similar train of symptoms. He was a negro sailor, a native of New Brunswick, and wras seized with the epidemic a few days after his ship arrived in Dublin ; he was a man of Herculean form and finely developed chest, and in the prime of life. His suffering from dyspnoea was intense; his chest heaved, he tossed about in bed in a constant state of agitation and restlessness, and yet the respiratory murmur was everywhere dis- tinctly audible through the lung, and no rale could be heard, except here and there a few bronchitic wheezings. He also laboured under insomnia, and, though he had but little fever, his debility was extreme. Indeed, his pulse was so weak from the commencement, that I could not venture to treat him antiphlogistically ; and I accordingly ordered exten- sive vesication over the chest, with the use of wine, stimulants, and narcotics. This man subsequently recovered—an event which could scarcely have occurred under the plan of treatment adopted, had his dyspnoea depended on mere bronchitis. It should be also borne in mind, that in many bad cases of influenza the dyspnoea is intermittent, or at least undergoes remarkable exacerbations and remissions at certain hours of the day and night. It would appear that the respiratory derangement depends on the same general cause which produces the whole train of symp- toms, and that it might exist even where there was no bronchial inflam- mation at all. It is true, that where the bronchitis is present, it adds to the distress of respiration, but the dyspnoea appears to be chiefly attribu- table to some impression made on the vital activity of the lung. That the lungs are endowed with an inherent vitality necessary to the aeration of the blood, has been long acknowledged by the Germans, who have described a dyspnoea from paralysis of the lungs ; and this opinion is now generally adopted in Great Britain, since the results of the experiments on the eighth pair of nerves have been duly appreciated. We have abundant illustrations of this truth in asthma, in which the greatest dyspnoea is INFLUENZA. 473 often present, without any appreciable lesion of the lung. And it would be a fortunate circumstance for the patients in influenza, if this were not the case ; for we could then treat the affection of the lung as ordinary bronchitis, and should expect to find it amenable to the ordinary reme- . dies. You are aware that the mortality in cases of ordinary bronchitis is extremely small, if we except very young children and persons advanced in life. In adults, when met by prompt and appropriate treat- ment, it is generally a very manageable disease, and seldom proves fatal, unless combined with other unfavourable conditions. This, however, is not the case in influenza, nor is the pulmonary affection so easily treated, or the dyspnoea so readily controlled. I saw, some time ago, a fine young woman, servant to a gentleman in Fitzwilliam-street, for whom every thing had been done which the best and most skilful practice could devise ; but her condition, when I saw her, was desperate, and she died the following day : yet her chest sounded well on percussion, and we could hear nothing over the whole lung, except a few sonorous and sibilous rales, and the respiratory murmur seemed everywhere nearly as loud as natural. Of course, such a lesion of the nervous influence could not last long, without necessarily inducing pulmonary congestion—an inevitable consequence of imperfect aeration of blood. When the eighth pair of nerves is divided, the animal is slowly suffocated ; and, on dis- section, the lungs are found engorged, and the bronchial mucous mem- brane congested and inflamed. May not the affection of these parts in influenza be sometimes induced by lesions of nervous power in the lungs ? I am indebted to my friend, Dr. George Green, Professor of the Practice of Physic to the College of Physicians, for the following results of his very numerous post-mortem examinations in this disease, and I feel great pleasure in being able to give them—as such examinations, at least in this country, are very rare. Dr. Green observes:— " The cases which proved fatal at the House of Industry, during the late epidemic influenza, occurred principally among the aged inmates of both sexes. I had an opportunity of examining several of these cases, and the following were the principal post-mortem appearances observed. " The bronchial mucous membrane was found, in every case, more or less congested and inflamed. The colour varied considerably—being in some of a dull red, and in others of a much darker hue. The inflamma- tion, in most cases, was found to occupy both the trachea and the bron- chial tubes of both lungs ; in other instances, it was confined to one lung alone. A sanguinolent frothy mucus occupied the area of the tubes, and increased in quantity as they were traced to their minuter divisions. The parenchymatous tissue of the lung was invariably discoloured, being gene- rally of a dark or violet colour ; its specific gravity was increased, and it did not crepitate, or at least very feebly, when pressed between the fingers. The surface of its section was not rough to the touch, and when pressed in the hand, a quantity of the mucus described above was driven out. In some cases, the postero-inferior portions of one or both lungs were very dark coloured, and the finger could be passed easily through its substance. When the surface thus torn was examined, it did not appear to be granular ; it resembled more a portion of gangrenous lung, excent that there was an absence of fetor. This last appearance was found principally in very aged persons. It was rare to find any traces of the second and third stages of ordinary pneumonia in these patients ; but 474 CLINICAL MEDICINE. in the young and robust, who were received into the Hardwick Fever Hospital from the neighbouring streets, these degenerations of the structure of the lung were observed, together writh the same inflammation of the bronchial mucous membrane. " In most of the aged patients, the blood was found dark coloured and fluid in both cavities of the heart, and in every vessel where it was exa- mined. The cases in which fibrinous concretions in the cavities of the heart were found, were very few, and these invariably in the young or middle-aged. In the former class of patients, also, the lung occasionally appeared to be edematous ; and, in one or two cases, a considerable effusion of serum had taken place into the pleural cavities. The signs of recent pleuritis were very rare, but old adhesions, as might be expected in such subjects, were very commonly found between the pulmonary and costal pleurse. In one case of a lunatic, who survived the immediate attack of influenza, tubercles appeared to have been rapidly developed in both lungs. In another lunatic, two tubercular cavities were found in addition to the state of the lung and air-tubes already adverted to. " With respect to the nature and duration of the symptoms of those cases which came under my own management, I have little to say in addition to what is already so familiarly known. The physical signs afforded by percussion and auscultation were almost universally as fol- lows :— Dulness, more or less decidedly marked, in the postero-inferior portions of the lungs ; sonorous or some form of the bronchial rales through- out the chest, or, what was more common, a mixed sonorous and crepi- tating rale, or, in the latter stages, a muco-crepitating rale. The sputa were seldom rusty-coloured or tenacious, but rather resembled those of bronchitis. In many cases, the want of power to excrete them appeared to be the immediate cause of death ; but in others, the morbid cause, whatever it might be, appeared to have affected the entire respiratory and circulating systems, producing great congestion of the venous system, and a state not unlike asphyxia. The latter cases were almost all among the aged inmates of the House of Industry. " The appearances of the other viscera were not such as could in any way account for the result, so often speedily fatal; so that, so far as one could hazard a conjecture, the morbid cause appeared to have made its primary impression on the respiratory mucous surface, thereby interfering with the proper aeration of the blood, and inducing the changes in that fluid and in the structure of the lungs above detailed." Such are the appearances observed by Dr. Green in his numerous dis- sections of persons who died of influenza. They may be relied on as perfectly accurate, for no one is better acquainted with pathological phe- nomena than Dr. Green, and consequently no one better able to furnish valuable evidence with respect to the appreciable changes produced by influenza in the pulmonary and other tissues. I have already advanced the opinion, that we should not hastily assume that influenza consists essentially in the morbid changes which dissection reveals ; we should examine every side of the question, and consider whether it is not possible that the alterations in the pulmonary tissue may not be, to some extent at least, the consequences of the disease. Let us consider for a moment the method we pursue in reasoning about the pro- gress and causes of the symptoms in ordinary bronchitis. Here a patient is seized with a pectoral affection, attended by cough, dyspnoea, and more INFLUENZA. 475 . or less fever. We find certain rales, and the expectoration is altered in quality and quantity. Further, observing a number of such cases, we remark that the danger is proportioned to the degree of dyspnoea, and the dyspnoea to the extent and nature of the rales, together with the quantity and quality of the expectoration. To these the general constitutional affection, and the probable results of the disease, have certain definite relations, a knowledge of which is soon obtained by experience. But these rales, and this state of the respiration and expectoration, we have reason to believe, arise from the presence of bronchial inflammation ; and to this we refer all the symptoms observed. On this supposition, too, we proceed in our treatment, and the result most commonly justifies its cor- rectness ; and we have additional evidence of its truth furnished by post- mortem examinations. Now, in such instances, the chain of inductive evidence is complete, and we feel a conviction that our practice is founded on correct notions of the nature of the disease. But how different is the case when we assume that influenza is caused by bronchial inflammation! In influenza, the dyspnoea is not always proportioned to the bronchitic affection—nay, in some cases we have seen that difficulty of breathing was most urgent in cases where the air entered into all parts of the lung with facility, and where few and unimportant rales existed. Again, although the presence of a copious viscid secretion in the bronchial tubes was sure to aggravate dyspnoea, yet it often occurred in patients whose air-passages were very little, or not at all, obstructed in this way. The effects, too, of remedies, antiphlogistic, expectorant, and derivative, were very different from what they would have been had the disease depended on a mere bronchitis. I have already stated my conviction, that the poi- son which produced influenza acted on the nervous system in general, and on the pulmonary nerves in particular, in such a way as to produce symptoms of bronchial irritation and dyspnoea, to which bronchial conges- tion and inflammation were often superadded. In this view of the subject I am not singular, for I find that it has been advocated by Dr. Peyton Blakiston, in a short treatise on influenza, as it occurred at Birmingham. He states that his researches have led him to the conclusion, " that influenza is an affection of the nervous system, with its concomitant derangements in the organs of digestion, circulation, &c, commonly known under the name of nervous fever, accompanied through- out its whole course by irritation of the pulmonary mucous membrane, which not unfrequently amounts to congestion, and even to inflamma- tion." This distinction between influenza and feverish cold with bronchitis, is, in a practical point of view, of great importance, and should never be lost sight of in the treatment of influenza—for it prevents us from placing our sole confidence in remedies adapted to mere bronchitic inflammation. Thus, Dr. Blakiston asserts, and most physicians will agree with him in this point at least, that it was often necessary to have recourse to diffusible stimulants at the commencement, and to administer tonic medicines in an early stage of the disease. In some cases, even where great dyspnoea exists, the cough is hard and dry, and the expectoration scanty ; in others, the expectoration is copious, so as to cause constant efforts to cough it up ; and, indeed, it is melan- choly to look at the distress which patients suffer in this respect. You will hear the wheezing of the phlegm in the throat and air-passages be- 476 CLINICAL MEDICINE. fore you enter the room, and you will see the patient exhausted by suc- cessive paroxysms of cough, and ineffectual attempts to expectorate. In other cases, where the vitality of the lung is less injured and the general tone of the system less deranged, the sputa, although copious, are expec- torated writh considerable facility. The sputa bear considerable analogy to those observed in ordinary bronchitis; they consist at first of a greyish mucus, which, as the disease proceeds, exhibits a globular appearance, or assumes a puriform character, and does not coalesce ; in other cases they are extremely viscid and ropy, like solutions of gum or isinglass. A re- markable fact with respect to the sputa in influenza is, that they are very seldom mixed with air-bubbles. On mentioning this to-day to some per- sons attending my class, I was shown some sputa discharged by a patient labouring under influenza, in which there were some air-bubbles ; this, however, is extremely rare. In a lecture which was delivered here some time ago, I took occasion to allude to the secretions of the bronchial mucous membrane, and stated my conviction that this subject had not re- ceived as yet the attention which its acknowledged importance demands. There is one point, in particular, of which no adequate explanation has been as yet given—namely, why it is that in some cases of pulmonary inflammation the sputa are filled with air-bubbles, while in other in- stances, there is no appearance of air-bubbles from the beginning to the end of the disease. The presence of air-bubbles in the sputa has been explained, by supposing that air becomes incorporated with the mucus while it is driven up and down in the bronchial tubes during the acts of respiration and coughing; just as if you shake a solution of soap or any other viscid fluid in a half-empty bottle, it becomes impregnated with air- bubbles. There may be some truth in this, but I think it does not suffi- ciently explain the presence and intimate incorporation of air with the sputa in certain affections of the lung; and it appears to me that we can scarcely understand this, unless we suppose that the air and mucus are secreted together. You are awTare that air is secreted by the bronchial mucous membrane, and that in some cases this secretion is morbidly in- creased, in others morbidly diminished. Now, it is not very unreason- able to suppose that the mucous membrane may secrete air and mucus together in abnormal quantity ; and that this, rather than any mechanical agitation, may be the cause of the intimate combination of air with the expectorated fluids. I need scarcely make any observation on the cough in influenza. It is in general very troublesome, particularly at night. Many persons are not much annoyed by it during the day, but at night it becomes very harass- ing, and prevents them from sleeping. When severe, it continues both night and day; and even when persons have recovered from the fever and dyspnoea, and are able to goabout,the cough will continue extremely trouble- some: this I have observed in the majority of cases. In this state medi- cines prove of very little service, and one of the best remedies is to change to a mild country air. Cases of cough, in which I had tried every remedy without success, and which had resisted every form of treatment in the city, yielded in a few days to the salubrious influence of change of air. In influenza, the urine is generally much loaded with lithates and super- lithates, and contains a large quantity of erythric or purpuric acid. It is red when voided, deposits a good deal of sediment, and tinges the vessel in which it lies with a pink film. It bears some resemblance to the urine INFLUENZA. 477 which accompanies arthritic and gouty affections. In very bad cases, this state of the urine continues up to the period of death. You recollect what I stated with regard to the condition of the blood ; it is generally buffed, even where there is scarcely any febrile excitement in the system, and thus affords a very fallacious indication. The same observation holds good with respect to the state of the urine and the temperature of the skin. I may observe here that the heat of skin is very variable ; it is sometimes very high, sometimes natural; in fact, like the pulse, it falls and rises in a very remarkable manner, at certain times in the day. I have already spoken of the affection of the mucous membrane of the bowels. I may observe, that in some cases of influenza the morbid influ- ence is translated to the brain, and symptoms of delirium or coma super- vene. Thus, in two instances that have been communicated to me, the patients fell into a state resembling coma, during the course of the disease. In three cases witnessed by the late Mr. Swift, the attack of influenza ter- minated in a train of symptoms bearing a close analogy to delirium tre- mens, and requiring the use of blisters to the head and nucha, full doses of opium, purgative enemata, wine, and the occasional use of mercurials. The patients complained of great headache, noise in the ears, some intoler- ance of light, and more or less sleeplessness from the commencement, along with the usual pulmonary symptoms. After five or six days, they became excessively nervous, lost all sleep, had continued subsultus and tremours, and talked very incoherently, particularly at night. During the preva- lence of the cerebral symptoms, the pulmonary affection partially or wholly disappeared, but returned again in some degree after the subsidence of the delirium. All these cases terminated favourably. I believe I have already remarked, that many persons who have laboured under very severe pulmonary symptoms will struggle through the disease ; and I may mention here that I have seen persons recover, who have suf- fered from continued orthopncea for three weeks. Still the mortality, par- ticularly among the aged, is very great; and I fear that we shall shortly have but a few octogenarians to tell the occurrences of the last century. Indeed, the mortality has not been confined exclusively to the aged, for many persons in the vigour of life have sunk under the attack. There have been several deaths among the soldiers in our garrisons, notwithstand- ing the excellent state of health which our troops generally enjoy, and the skilful and judicious treatment of our present army surgeons. The results of the medical treatment and necroscopic observations in the different regi- ments in London, Dublin, and Edinburgh, will form a most valuable docu- ment, and I hope it will be made public for the benefit of the whole pro- fession. It now remains for me to say a few words concerning treatment. First, as to bleeding. A great deal was expected from general bleeding, because the disease was sudden and violent in its onset, and accompanied by symp- toms which seemed to require active measures—such as an inflammatory state of the bronchial mucous membrane, accompanied by quick pulse, hot skin, and high-coloured urine. This led persons to expect much benefit from venesection. The results, however, of its employment are, gene- rally speaking, unsatisfactory. Where venesection was employed promptly and in the beginning of the disease, and where it seemed to be strongly indicated by the buffed and cupped state of the blood, even in such cases it has failed to afford any thing like material or permanent benefit, or to 478 CLINICAL MEDICINE. produce a decided amelioration of the existing symptoms. The general impression among practitioners in Dublin at present seems to be, that bleeding is doubtful in its effects, if not altogether improper. I am much inclined to think that bleeding, unless employed within the first twelve or twenty-four hours, will be likely to do as much or more harm than good. Bleeding on the second or third day, except to relieve congestion of the lungs, seems inadmissible. The same observation holds good wTith refer- ence to other diseases. Thus, in scarlatina, if you happen to be called in when the rigor commences, and while the disease is beginning to form, you will sometimes accomplish much good by bleeding your patient; but after eighteen or twenty-four hours, when the disease is fully formed, vene- section will not do. On this point I can speak from experience. In scar- latina, the difference of a few hours renders venesection inapplicable, and even injurious. It is the same thing with respect to influenza; general bleeding is useful only in the commencement, and, where the symptoms seem to demand it, it should be employed at least within the first twenty- four hours. Where I have been fortunate enough to find the disease just commencing, I bleed to the amount of twelve or fourteen ounces, order the patient to remain in bed and take some aperient, followed by the use of nitre. In this way, by timely bleeding, aperients, sudorifics, and con- finement to bed, the attack generally passes over in two or three days. I could mention many instances of the success of this plan of treatment. In one family I treated all the individuals attacked in this way, and I have done the same thing in many cases of persons somewhat advanced in life. In the case of an old gentleman, who was very severely attacked, I suc- ceeded by these means in checking the disease at once. My experience, therefore, is, that bleeding is of service in the very commencement of the disease; but as it seldom happens that a physician is called in at this pe- riod, I would qualify my statement by saying, that, as a general measure, bleeding in influenza is seldom admissible. When you are called on to attend cases, you will most generally find that the patients have been ill for two or three days or more ; and then the only mode of abstracting blood, which you can have recourse to with safety, is by leeching. About eight or ten leeches applied over the hollow of the neck, just above the sternum, and allowed to bleed pretty freely, will prove very serviceable; and if you apply them in the evening, you will often secure to your pa- tient a good night's rest. This plan of leeching the hollow of the neck, in cases of tracheo-bronchial inflammation, is an excellent one: the leeches are applied at a spot which lies close to the trachea, and particularly to that point to which the irritation accompanying bronchitic affections is chiefly referred. By the aid of leeching, the use of aperients, if necessary, and confine- ment to bed, with sudorifics, you will frequently succeed in removing the fever and bronchial inflammation. You will derive much benefit, parti- cularly in the early stage of influenza, from tartar emetic and nitre; but I must say, that neither leeching nor tartar emetic and nitre prove as valuable and as efficacious, in influenza, as they do in ordinary bronchitis. Some of my friends, who used tartar emetic as a nauseant in the com- mencement of the disease, inform me that they have derived benefit from its use ; and others have told me that they have used tartar emetic and opium in the commencement and during the course of the disease, with advantage. I have not employed the first of these, but I have the latter, INFLUENZA. 479 and with favourable results. You may, therefore, after using antiphlo- gistics for a day or two, proceed to the use of opiates, in combination writh tartar emetic or nitre. In some cases, the camphorated tincture of opium will answer very well; in others, you will find the acetate or mu- riate of morphia better. A mixture, composed of six ounces of almond emulsion, a drachm of nitre, and half a drachm or more of the liquor muriatis raorphiae, will be found very useful. The muriate of morphia, which possesses many of the valuable properties of opium without its de- fects, will serve to tranquilize the system and produce sleep—two most important points in a disease like influenza connected with increased ner- vous irritability.* A gentleman, on whom I place much reliance, tells me that he has treated many bad cases successfully with camphor-mixture, tincture of opium, and tartar emetic. I need not mention the various remedies which have been recommended in this disease—as Mindererus's spirit, Hoffman's anodyne, ipecacuanha, alone or combined with extract of conium and blue pill, and many other remedies belonging to the class of diaphoretics or expectorants. They are all more or less serviceable, but they have all the common defect of producing less relief than they usually do in cases where the pulmonary affection is simple and idiopathic. Towards the end of the disease, you find it necessary to give stimulating expectorants and light tonics—as decoction of polygala senega, infusion of columba, &c, &c.f One word about blisters, before I conclude. They are useful in some cases, but in many of the severe ones they do little or no good, and only add to the patient's sufferings. They do not relieve the pulmonary symp- toms, and particularly the dyspnoea, in the manner you would be prepared to expect. I do not know a more remarkable circumstance, in the pre- sent disease, than the failure of blisters: and in many cases I do not em- ploy them at all. Fomenting the trachea and chest with very hot water appearsto be much more serviceable. This has proved extremely valuable in • many cases of this as well as other affections of the air-passages ; and on referring to the late American journals, I find that the plan of treating croup in its onset, by means of very hot water applied with a sponge to the throat—a plan which I recommended some time ago in the Dublin Medical Journal—has been extensively employed in America, and with the most happy results. Sponging the throat and chest with water, as hot as it can be borne, has been found, in many instances, capable of arresting all the threatening symptoms of croup at once. Several cases are mentioned in the American journals, in which the lives of the little patients were evidently saved by this application. I may state, also, that not long since a child was saved in Dublin by the same means. By the advice of Mr. Smyly, who suspected the threatened attack, the child's * I cannot agree with Dr. Holland in the following opinion concerning opium : " It seems necessary to add opium to the list of medicines, from which little certain benefit is to be had in this disorder. The restlessness at night, which is so general a symptom, would seem to require its use; but from some cause or other, it is rarely effectual in giving much relief: and, though the cough may for a while be mitigated or suppressed by this remedy, it is doubtful whether the good so obtained is an equivalent to the disadvantages in various ways incurred." — Op. cit., p. 219. f Dr. Blakiston strongly recommends the etherial tincture of lobelia, in large, doses, repeated at short intervals, in influenza where bronchitis was present. As I had not the advantage of perusing his book during the prevalence of the epidemic (it was not published till May), I had no opportunity of trying this medicine in the way he suggests. 480 CLINICAL MEDICINE. mother had every thing prepared, and by her promptitude and care arrested the disease before it had sufficient time to form. I have nothing more at present to add to the subject of influenza ; we are still much in the dark as to the best mode of giving relief—and this is the more singular, as in general the disease allows full time for the trial and operation of medical agents. LECTURE XXXVIII. Connection between diseases of different organs ; between arthritis, jaundice, and urticaria; between periostitis produced by abuse of mercury, and hypertrophy of the liver—Details of cases illustrating this connection—Its explanation—Hypertrophy of the liver produced by scrofula—Enlargement and inflammation of the liver after scarlatina—Importance of recog- nising this disease—Connection between disease of the liver and disease of the heart— Chronic hepatitis from this source, curable in young persons—Enlargement of the spleen connected with superficial ulceration of the legs—Erysipelas and gangrene, sometimes of a pseudo-inflammatory character—Treatment of this form of the disease. In order to acquire a correct and available knowledge of human pathology, and to extend the range and confirm the accuracy of diagnosis, it is of the utmost importance to observe attentively the connection between the diseases of certain organs or systems of the body. You are aware that some organs, when labouring under disease, are apt, after the disease has continued some time, to implicate other organs, giving rise to various deranged conditions, which are developed, sometimes simultaneously, but in general consecutively, and in sequence. I have already pointed out several diseased actions thus associated together, each forming a link in the morbid chain. Now it is of the greatest importance to study each link, and ascertain the nature of its connection, so as to have a distinct conception of the whole. Last session I directed the attention of my class to a train of mor- bid phenomena sometimes observed coexisting with arthritic inflammation. A person labouring under inflammation of the joints gets an attack of hepa- titis, accompanied by jaundice, and this is followed by urticaria. I have ob- served thissequence of disease in eight or nine cases. The first was in a gen- tleman residing in Lower Mount Street, whom I attended with Dr. Cheyne. This gentleman, in consequence of exposure to cold, was attacked with arthritic inflammation and fever. After he had been about ten days ill, he became suddenly jaundiced, and in a day or two afterwards a copious eruption of urticaria appeared over his body and limbs. Exactly the same train of phenomena, and in a similar order of succession, were observed in a man treated in the Meath Hospital in 1832. A short time before this, I had been attending a medical friend in Baggot Street, who had been affected in the same way ; and I mentioned to the class, as soon as I perceived the man was jaundiced, that he would most probably get urticaria. I made a similar prediction in a case which occurred recently in our wards, and it was verified by the event. Now this is not a mere fortuitous occurrence ; the various symptoms must be connected in the relation of cause and effect. It is interesting to bear this in mind, and it is besides of considerable importance to the practising physician; it enables him to predict the appearance and form of disease, and inspires his patient with confidence in his opinions and judgment. PERIOSTITIS WITH HYPERTROPHY OF THE LIVER. 481 There is another sequence of disease, not unfrequently observed, but of which the connection has not been hitherto noticed by any writer, as far as I can ascertain. About two years since, I was consulted by an English gentleman, who had been ill for a considerable time. The history of his case from the commencement was this:—Three years previously he had venereal,—used and abused mercury,—was exposed to cold, and got periostitis. He now got into a bad state of health, used mercury a second time, obtained some relief, and then relapsed again ; finally, after having used mercury three or four times, he was attacked with mercurial cachexy, became weak and emaciated ; the periostitis degenerated into ostitis, producing superficial caries and nodes of a bad character ; he had exfoliation of the bones of the cranium, and rupia, and was reduced to a most miserable state. Under our care the symptoms gradually disap- peared ; he recovered to all appearance, and even got fat. He then caught cold and relapsed again. At last his liver became engaged ; he was attacked with hypertrophy of the liver, ascites, and jaundice, and died soon afterwards. Here, then, we have venereal, abuse of mercury, periostitic inflammation, abuse of mercury followed by exacerbation of the periostitis, and the establishraent of mercurial cachexy, and the history of the case is wound up with hypertrophy of the liver. This was the first case in which I had observed this concatenation of diseases; since that period I have seen a similar train of morbid phenomena, twice in private practice and once in hospital. First we have abuse of mercury, then periostitic inflammation and mercurial cachexy, and the scene is closed by morbid enlargement of the liver. Now I do not look upon this sequence as merely fortuitous. The diseased actions are, I think, related as cause and effect, and each successive condition is consequent on the previous one. It may not be amiss to mention here some curious circum- stances observed in the case to which I have just alluded. While this gentleman's liver was enlarging, there was no tenderness of the right hypochondrium on pressure. I have observed the same absence of ten- derness in all the cases of this description which I have witnessed. The gentleman could bear pressure over the hepatic region without any incon- venience, and yet the liver was so enormously increased in size, that its inferior margin extended almost down to the pelvis. What is equally remarkable, he had no fever, and the tongue was perfectly clean and moist during the whole course of the hepatic affection. In my observations on a case in the fever ward, I remarked a few days since that some persons were too hasty in drawing inferences from the state of the tongue as to the existence of affections of the digestive organs. I shall not touch on this point, however, at present, and shall merely observe that this gentleman's tongue was perfectly clean and moist, notwithstanding the morbid con- dition and rapid growth of the liver. Another curious circumstance was, that during the hepatic affection, digestion appeared to go on very well, at least so far as the formation and due expulsion of feces are concerned. The alvine evacuations were regular, and the matter discharged presented the form and consistence of that which is passed by a person in good health. But there was a peculiarity in it to which my attention was first directed by the patient, who was an intelligent and observant person. The cylinder of fecal matter was composed of parts differing in colour and appearance : two or three inches consisted of pale clay-coloured sub- stance ; and immediately after this another portion, of about the same 32 482 CLINICAL MEDICINE. length, was observed, presenting the ordinary bilious or brown colour of natural excrement ; and then again another mass of clay-coloured matter, without any obvious trace of bile. This appearance I have now fre- quently witnessed ; and the inference to be drawn from it is this,—that in such forms of hepatic disease the functions of the liver are performed, as it were, intermittently ; it secretes bile during a certain period of the digestive process, then stops, then secretes again. This peculiarity is noticed in many diseases of the liver; and it is im- portant to remark, in attempting to explain the rationale of these hepatic affections, that in no disease of the liver is this symptom more frequently observed than in the scrofulous. Scrofulous disease of the liver is that state in which there is an increase of size in the organ, with induration and imperfect secretion, but without any remarkable tenderness. This condition in children is accompanied with irritability of the digestive organs, fretfulness, emaciation, loss of sleep, and impaired nutrition. The little patient becomes what is termed " pot-bellied," and labours under thirst, debility, and febrile excitement. This has been frequently called remittent fever, and disease of the mesenteric glands, but in my opinion unjustly. It is only a form of general cachexy connected with the scro- fulous diathesis, affecting secretion and nutrition in general, and the digestive and biliary systems in particular. It would be quite wrong to imagine, that in this form of disease the liver is the cause of the whole train of morbid phenomena ; it is merely affected in common with other organs, and forms only an individual feature in the group of symptoms. Now, in this form of scrofulous cachexy, where you have diarrhoea, emaciation, fever, thirst, and restlessness, the liver is frequently affected in the manner already described ; and in the loose stools of such a child, you will find one part bilious, another part clay-coloured ; they will be yellow to-day, and pale the next, accordingly as the liver secretes bile or suspends its functions. But in this instance, I repeat that the liver is only one of many organs affected by the same general cachexy. Could we ascertain the derangements of other secreting organs with the same facility, it is very probable we should find similar evidences of the morbid influence which pervades the whole system. This view of the question shows, that you are not to expect to succeed in removing the disease by the use of calomel or any other mercurial pre- paration. Many of those persons whose practice is little better than rou- tine, when called to treat a case of this description, first examine or in- quire as to the nature of the alvine evacuations, and fixing on the single symptom of deficiency of bile, immediately prescribe calomel, to be re- peated or continued until the secretion of the liver is established ; but they forget that this state of the biliary system depends on the general state of health, and that the absence of bile is the consequence, and not the cause of the disease. Almost all the organs of the body are affected ; and though calomel may restore the secretion of the liver for a time, it cannot bring back the organ to its natural state, or cure the disease. The malady is to be remedied in a different way: the secretions (and that of the liver among the rest) are to be improved by change of air, by an ap- propriate diet, by exercise, tepid or cold bathing, and the use of those remedies which are adapted to modify or correct that state of the system on which the general derangement depends. An observation of such-cases has led me to a train of reflection respect- HYPERTROPHY OF LIVER FROM ABUSE OF MERCURY. 483 ing the occurrence of the same order of symptoms in persons who have been injured by the abuse of mercury. Many persons who get venereal employ mercury injudiciously, and fall into what has been termed the mer- curial cachexy, in which there is a general unhealthy state of the organs. A patient who has fallen into this state very closely resembles a scrofulous person, and is apt to labour under the same emaciation, impaired nutrition, irritability, feverishness, and the same sort of cutaneous, glandular, and periostitic affections. The chronic mercurial cachexy is very like the scrofulous, and attacks very nearly the same organs and tissues. Hence the difficulty of curing affections of the liver, and other organs, when they are the result of this depraved habit. This is the key to the expla- nation of those horrible ravages which we frequently witness in cases of Venereal disease complicated with mercurial cachexy—a state of consti- tution which is closely allied to the scrofulous. You will frequently meet with this consecutive affection of the liver in cases of morbus coxse, where the patient has been labouring for years under ulceration of the joint. The growth of the rest of the body appears checked, the patient is stunted and emaciated, while the liver increases rapidly in size. It was from observing the occurrence of liver disease in persons labouring under the scrofulous cachexy, that my attention was first turned to its occurrence in persons broken down by long or injudicious courses of mercury. One word, gentlemen, as to the curability of hepatic affections of this kind. I believe that it is always an unpromising form of disease ; but persons of originally good constitution, and under the age of thirty, will generally escape, if treated judiciously, and with proper care and atten- tion. Some months ago I attended, with Sir Henry Marsh, a young gen- tleman labouring under this affection, as a consequence of the abuse of mercury. We found him greatly emaciated, and labouring under consi- derable enlargement of the liver, with commencing ascites. He had also great determination of blood to the abdomen, diarrhoea, and hemorrhoids. By strict attention to his bowels a well-regulated diet, change of air, and the use of taraxacum, conium, and hydriodate of potash, he was ultimately cured, after an illness of nearly two years, during which the liver had grown to an enormous size. I may state, that he is at present in good health, and that the liver is nearly reduced to its natural dimensions ; this gentleman's age is about four-and-twenty. I observed one circumstance in the progress of this case which is worth noting. He was suddenly attacked with a papular form of purpura, ac- companied by much tingling and itchiness, and answering to the de- scription given of Purpura urticans. This peculiar eruption was very troublesome at night, and formed several successive crops, which alto- gether lasted a month. It occupied the extremities, upper and lower, and was very abundant on the latter. The gentleman wore a bandage to relieve a varicose state of the veins of the left leg. Now the eruption never appeared in the parts subjected to the pressure of the bandage, although it was very thick immediately below and above those parts. In persons below thirty the liver may become enlarged to a very con- siderable extent, and yet return again to its natural size under proper treatment. I could point out several persons in Dublin, in whom the liver had been so much enlarged, that I thought their case hopeless, and yet they have recovered, and are at present in the enjoyment of good health. The process by which the organ returns to its natural state and 484 CLINICAL MEDICINE. dimensions is generally slow ; in two or three cases it occupied a space of time varying from one to two years. I attended a gentleman some time ago with Mr. Carmichael ; and from the history of the case, as well as the symptoms present, we were induced to look upon it as incurable ; and yet the patient has completely recovered. The late Mr. Macnamara and I attended a lady who had a very remarkable enlargement of the liver, but in the course of a year the viscus diminished so much in size, as to be very little above the normal dimensions. Within the last year (1842) Dr. Stokes and I have treated successfully an old gentleman be- tween seventy and eighty years of age, who had an enormously enlarged liver and ascites. We agreed to try a combination of blue pill and hy- driodate of potash. This he took for nearly six months, and its use was attended by a visible, almost daily, decrease in the size of the liver, and his general health gradually improved. He took the pills for a couple of months before his mouth got a little sore ; but full salivation was not pro- duced. He called on us a few weeks ago to thank us for our successful treatment, and took no small pleasure in directing attention to his altered appearance and renovated health. This is a matter of no common interest; for cases of this description have been generally looked upon as beyond the reach of medical aid. You should, therefore, be very careful in your prognosis of such cases, and not give them up at once as incurable. I may observe in conclusion, that it is entirely as the result of the ca- chectic habit that this enlargement of the liver is observed. 1 have assumed this principle as the basis of ray argument, and I think it is founded in fact and truth. It is also curious to observe, that the same cachectic state which gives rise to emaciation and decay of the body, generally occasions hypertrophy of some particular organs. What we most commonly observe in such conditions is, general wasting of the system, accompanied by increased morbid nutrition in certain organs. This appears to be the general law. You perceive that in the explanation I have given, I have supposed that enlarged liver is the result of a general cachectic state of the system, and it is of importance to recollect, that this state may be brought on by the injudicious exhibition of mercury, or by carrying mercurialization further than the constitution will bear. In this instance, we are compelled to allow, that our practice may furnish wea- pons to be turned against us by the disciples of homoeopathy. It cannot, however, be denied, that the immoderate use of mercury has been pro- ductive of liver disease. The late Mr. Hewson pointed out this to the attention of those who visited the Lock Hospital while under his care. At this period it was the custom to salivate every patient, and keep him under the full mercurial influence for a month or two ; and it frequently happened, that just as the mercurial course was finished, the patient got disease and enlargement of the liver. Were I inclined to theorise, I might, perhaps, offer some fanciful hypothesis in explanation of this oc- currence, and might trace some connection between the stimulant effects of mercury on the liver, and the subsequent hypertrophy. I shall, how- ever, content myself at present with noticing the fact, and leave the ex- planation to my juniors, who always explain matters, according to my observation, much more readily than their seniors. There are also other diseased states of the system, in which we have enlargement and morbid alteration of the liver. I can point out to you four different states of the system in which hypertrophy and disease of ENLARGEMENT OF THE LIVER FROM SCARLATINA. 485 the liver forms one of the results of the general affection of the system. The next of those to which I shall direct your attention is scarlatina. Those who have attended the wards during the past month have seen ex- amples of this. We have observed during the same week two patients labouring under scarlatina, who got disease of the liver and jaundice. One of the patients, a little boy, was attacked with the disease in an ex- tremely violent form, accompanied with high fever, and a very remarkable eruption. In afewhours after the exanthema appeared, the entire cutaneous surface was dyed of a brilliant red ; in fact, the skin looked as if it had been painted over, and there was not a single spot free. In cases of this kind the violence of the cutaneous inflammation is sufficient to kill, with- out any other unfavourable complication ; and the patient seldom lives more than three or four days. You observed in this case, that the whole epidermis peeled off. But what I wish to direct your attention to is, that this boy after two days had evident symptoms of disease and enlargement of the liver. A young man, in the same ward, had also an attack of scarlatina, but in a milder form. On the third day he likewise got inflam- mation of the liver, but was cured by general and local antiphlogistic treatment. You are aware that scarlatina is one of those diseases in which a train of unfavourable sequelse are apt to remain after the removal of the original complaint. Persons, after recovering from the exanthematous fever, will sometimes get into a bad state of health, and instead of con- valescing, become restless and feverish towards evening, have an irritable jerking pulse, hot skin, derangement of the digestive organs, diminished urinary secretion, and finally become dropsical. Now, from observing the supervention of hepatic disease in such cases, both in hospital and private practice, my attention has been directed to the liver; and I never omit making an examination of that organ when called to treat those symptoms which are looked upon as the sequelae of scarlatina. In many of these patients I have found the liver in a state of inflammation of rather a chronic character, and without any of that remarkable pain or tenderness which characterizes acute hepatitis. But still it was inflamed, as proved by the benefit derived from local antiphlogistic means; and, moreover, its condition appeared to retard and prevent convalescence. Not long since, a friend of mine, a very intelligent practitioner, who was attending a case of this description, and had tried a variety of remedies without any benefit, was very much surprised when I drew down the bed-clothes and showed him that the liver was diseased. He had not thought of the existence of any thing like an hepatic affection, and was very much surprised that his treatment had proved so ineffectual. By the use of leeches to the right hypochondrium, the employment of mer- cury, and a proper regulation of diet, the patient was soon relieved, and the fever, thirst, and anasarca, quickly disappeared. In cases of this kind, the hepatic affection is the result of the general inflammatory diathe- sis, superinduced by scarlatina. You are all aware that nothing is more common after scarlatina, than inflammation of various organs. Thus some persons are attacked with pleuritis, some with pneumonia, others with in- flammation of the liver. Many persons continue in a valetudinary state after the eruption has declined ; they do not convalesce according to our expectations ; the pulse remains rather quicker than natural; the bowels are deranged ; the appetite bad ; thirst urgent; and urine scanty. In many of these cases you will find that there is a species of chronic hepa- 486 CLINICAL MEDICINE. titis going on, which keeps up the feverishness, and retards convalescence. This is a point of great importance, to which I am the more anxious to draw your attention, because even the latest writers on scarlatina have either entirely omitted or very insufficiently noticed it. There is another organ whose morbid affections frequently implicate the liver; I allude here to the heart. I have already spoken of certain ca- chectic states, in which the liver becomes enlarged and hypertrophied as the result of the general derangement of the system. In the present case the hypertrophy and disease of the liver originate in a morbid condition of the heart; this is a very frequent cause of hepatic derangement. You have an example of it at present in the chronic ward, in the case of a poor man labouring under bronchitis of long standing, with disease of the heart, dropsy, and enlargement of the liver. In cases of this description it is a matter of some difficulty to determine in what organ the morbid sequence commences ; for where many diseases coexist, it is not easy to ascertain how they are related to each other as cause and effect. I have, however, had several opportunities of observing the progress of the dis- ease from the commencement, and the manner in which the different organs become successively implicated. Some time ago there occurred a remarkable example of this form of hepatic affection in a relative of mine, aged 14, who, in consequence of exposure to cold, was attacked with rheumatic inflammation of the joints of a very intense character. Owing to a want of proper care, the disease was allowed to go on unchecked, and metastasis to the peri- cardium took place. I happened to be out of town at the time, and he had no advice or assistance for nearly twenty-four hours. Pericarditis of a violent character became developed, and it was only by the most energetic treatment that he escaped with his life. He had pericarditis with effusion, and all the physical signs and symptoms of carditis. After the acute symptoms were removed, the signs of adhesion of the peri- cardium, hypertrophy, and partial valvular disease, continued ; and for a long time the heart's action was invariably accompanied by a long bruit de soufflet. These affections were followed by dyspnoea and increased action of the heart. But this was not all. He next got inflammation of the testicle, and finally chronic hepatitis with enlargement. The liver grew to a very considerable size ; it continued to enlarge for about seven months ; and altogether he laboured under a chronic form of hepatitis for more than a year. At last the disease yielded to treatment, and he reco- vered completely. This, you will say, was a fortunate termination ; but in young persons the powers of nature often act in a very remarkable manner in remedying or removing disease, and cures are sometimes effected in such patients which it would be quite absurd to expect in persons advanced in life. After having laboured under a long train of diseases, and having continued an invalid for nearly five years, this young gentleman at last, owing to his youth and favourable constitution, surmounted all his maladies, and is at present as strong and healthy as any person I am acquainted with. In this instance the chronic hepatitis was the result of the pericarditis, which formed the first link in the chain ; and for the space of a year this young gentleman continued to labour under an affection of the liver, the result of disease commencing in the heart. This is a morbid sequence very frequently observed. You have pericarditis, accompanied with ENLARGED LIVER FROM DISEASE OF THE HEART. 487 inflammation of the lining membrane of the heart, partial disease of the valves, hypertrophy of the muscular substance, and then enlargement and induration of the liver. This is a very common complication, and deserves your most particular attention. When you see a patient whose appearance indicates disease of the heart—who has swelling of the face, dyspnoea, lividity of the lips, and turgescence of the cutaneous vessels— in fact, that peculiar expression of countenance which at once informs the practised observer that the patient is labouring under disease of the heart, you should not neglect to inquire after the condition of the liver, for in such cases it is very frequently in a state of chronic disease. I pointed out this circumstance some time since, in the case of a late surgeon, Mr. M., and directed the attention of the medical gentlemen engaged in the treatment of the case to the liver, in which no one had suspected the existence of disease. Recollect, therefore, that in many cases of disease of the heart you will also, on examination, find disease of the liver, produced, as far as I can judge, in the majority of instances, by disease of the heart; at least, I think I have never seen any case in which the hepatic affection had the initiative, and seemed to have brought on the organic affection of the heart. In Mr. M.'s case, and several others which I had an oppor- tunity of watching from the commencement, I have no doubt that the disease of the liver was secondary, and that the morbid sequence com- menced with the heart. I am quite convinced that disease of the liver may give rise to functional derangement of the heart; for whatever impairs secretion and deranges digestion, will give rise to palpitations, tendency to syncope, and other phenomena of functional disease of the heart; but I have never seen any example of organic disease of the heart as the result of disease of the liver.* It is of some importance to be aware of this complication ; for in treating the disease of the heart you must also attend to the hepatic affection, because it has a tendency to aggravate and confirm the cardiac symptoms. This affection, however, is not to be looked upon as acute, or even sub- acute hepatitis. There is scarcely any pain of the side or tenderness present, and the patient is not always jaundiced ; it appears to be scarcely any thing more than congestion, causing hypertrophy and chronic morbid growth. I shall not, however, speak too positively on the subject, as the difference between hypertrophy and inflammation of a low and obscure character cannot be easily determined.f There is another disease in which derangement of the liver is a common * [The disease of the liver is almost a necessary consequence of im- portant disorder of the heart. It probably results directly from the diffi- culty in the circulation, which of course tends to keep this organ turgid with blood. The disease is thus frequently almost mechanical, produced directly by the difficulty in the circulation, and cannot be removed unless its cause is susceptible of cure. The symptoms of this secondary disease are not always well marked, and its very existence is often not suspected until the fatal termination of the case.—W. W. G.] f I am glad to find that this subject has been taken up by so able an observer as Dr. Bright, who, in the third number of Guy's Hospital Reports, p. 605, has made some excellent remarks on the influence of heart disease in producing congestion of the liver. In Dr. Elliotson's Human Physiology, Part I. p. 103, there are some observations which throw much light on the intimate relation existing between the circulation within the chest and liver. 488 CLINICAL MEDICINE. symptom, and I bring it forward chiefly for the purpose of rendering the subject under discussion more complete, as it is an occurrence well known to practitioners, and sufficiently dwelt on in medical books. I allude to that affection of the liver which is observed in cases of intermittent fever. Ague frequently produces a powerful determination to the internal organs, particularly the liver and spleen, and if treated badly, or unsuccessfully, is apt to bring on disease of the liver. The organ becomes congested, hypertrophied, and indurated, and presents a condition somewhat analo- gous to that which supervenes on disease of the heart, or results from the cachectic state of constitution produced by mercury or scrofula. The next form of organic derangement which I shall briefly touch on, is that of the spleen. It is of advantage to place cognate affections be- side each other, for the purpose of comparison ; by doing so, we frequently derive many instructive and useful analogies. Besides, we have had a remarkable case of enlargement of the spleen in our wards at the same time we had the cases of hepatic disease to which I have alluded. I may observe, that the circumstances under which enlargement of the spleen takes place, differ in many points from those which determine hypertrophy of the liver. We have but few examples of inflammation of the spleen, while the cases in which enlargement and congestion of that organ take place are numerous. From the peculiarities of its anatomical structure, the spleen is very apt to become suddenly enlarged. Like the liver, it may become indurated and hypertrophied from intermittent, or from some general disease affecting the system, and thus lead to a train of secondary phenomena ; the most remarkable of which is dropsy. But there is one peculiar symptom attending enlargement of the spleen, which I have fre- quently pointed out to the attention of the class, as observed at least in two-thirds of the cases, and of which we had an excellent specimen in the patient under treatment in the chronic ward. The history of this symptom is the more curious as showing a remarkable uniformity in the phenomena of a particular disease at very distant periods of time. This is seen by comparing the most recent descriptions of Indian splenitis, as given in an able analysis of Voight's work on the Spleen, published in a late number of the British and Foreign Medical Review, and the descrip- tion of enlargement and disease of the spleen given by Aretseus. The ancients, it is true, cannot be now considered as authorities to be fol- lowed either in pathology or practice ; for they were ignorant of many of the most important facts connected with the healthy and diseased states of the human body. In consequence of their inaccurate anatomical notions, they were unable to appreciate or describe many of those details which now enrich the domain of pathological anatomy ; their writings, however, are invaluable in many respects, as containing admirable de- scriptions of diseases which still continue to infest the human body, and as recording certain groups of symptoms which are still associated. A comparison of their descriptions with those of modern times, cannot fail to be extremely curious, and may even prove highly instructive ; for if we find that certain internal affections have, from the most remote anti- quity up to the present period, been generally accompanied by peculiar derangements of distant parts, we are authorized in considering this con- nection to be something more than accidental, and consequently we raay be led to discover relations between organs generally believed to be quite unconnected with each other. Thus, some years, I had three patients in ERYSIPELAS. 489 succession under my care, who laboured under chronic enlargement of the spleen, who were all affected with a similar sort of cachexy, and had all the same affection of the skin—namely, superficial ulceration of the legs. This coincidence forcibly arrested my attention, and I was still more struck with the observation, on finding that Aretseus had noticed this very circumstance in his admirable description of splenitis. " If" (says he), " the spleen does not suppurate, but becomes chronically en- larged, then the patients lose their appetite, and become cachectic, swol- len, and of an unnatural colour, while the surface of the body manifests a disposition to ulcerate, particularly on the legs : the ulcers are hollow, round, livid, sanious, and difficult to heal." This description agrees precisely with the cases to which I have already referred, and it coincides, in a very remarkable manner, with the account lately given by Dr. Voight, of chronic disease of the spleen, as it occurs in India. He observes, that the cachexy connected with the splenalgia Bengalensis frequently mani- fests itself by a tendency to ulceration ; the disposition to which is so great, that leech-bites and blisters occasionally give rise to foul or phage- denic ulcers, which, under certain circumstances, as where the patient has used mercury and is residing in a swampy district, will sometimes run on to a fatal termination. It is also curious, that the predisposing causes of the different varieties of chronic enlargement of the spleen, as given by Voight, are exactly the same as those detailed by Aretaeus ; and both writers correspond in their statements as to the age and habits of life of persons most liable to this disease, as well as the nature of the locality and the season of the year most favourable to its production. This agree- ment between authors separated from each other by so many centuries, and who describe the disease as it occurred in distinct regions, and among different races of mankind, is extremely curious, and exhibits a very remarkable example of the identity of the morbid phenomena produced by the same causes. So far of the pathological states of particular organs which arise in cer- tain conditions of the system, and most generally form a terminating link in the chain of diseased action. You will perceive that my observations are chiefly limited to a detail of the most important pathological observa- tions made in our wards during the preceding three months. After we have made a brief review of what has occurred during this period, we shall take up the consideration of the cases at present under treatment. The next disease which came under our notice so often as to deserve a separate notice, was erysipelas. There were some points of interest con- nected with the history of the erysipelas which prevailed in this hospital during the months of August, September, and October. In the space of somewhat more than two months, we had about twenty cases of this dis- ease; and, indeed, the morbific cause appears to be still lingering in our wards, though less frequently manifesting itself, for we have had only one case within the last ten days. Before, however, I proceed to notice the phenomena of the disease, as observed here, I shall make a few observa- tions connected with the treatment of this affection in general. I am anxious to direct your attention to this point, because the history of this epidemic has furnished some useful lessons, and has shown how much the treatment of any disease will depend on its epidemic character and exist- ing peculiarities. The disease was treated here in every instance, and through all its stages, with wine, quinine, and opium; and, with the ex- 490 CLINICAL MEDICINE. ception of a single case, this treatment has proved uniformly successful. Erysipelas, you are aware, is generally looked upon as an inflammatory dis- ease, and its treatment is always more or less antiphlogistic, particularly during the early stage. At this period, it is customary to treat it with general bleeding, leeching, scarifications, purgatives, mercury, and tartar emetic; and I will allow that many cases should be treated in this man- ner. But the gentlemen who have attended this hospital within the last three months, have witnessed a form of erysipelas which required from the beginning an exactly opposite line of treatment. In the management of the cases which fell under our observation, no one in his senses would think of using general or local depletion, purgatives, or tartar emetic. The moment the disease appeared, we were obliged to attack it with tonics, narcotics, and stimulants. You perceive, then, that in erysipelas there are two very distinct extremes, between which there are many intermediate shades and varieties. It is well to bear this in mind. When you are called to treat a case of erysipelas, you should recollect that it is a disease capable of exhibiting a great variety of forms, amenable to no fixed line of treatment, and requiring for its management all the sagacity and skill of an accomplished practitioner. I have seen many instances in which this affection appeared in a distinct and wTell-marked inflammatory form; and I have treated cases with venesection, leeching, purgatives, and tartar emetic, and found these means admirably well fitted to remove the disease. Here, on the contrary, wine, opium and sulphate of quinine, were the only remedies on which we could rely with any degree of confi- dence. On the other hand, you will meet with intermediate cases in which these different modes of practice should be employed, either at distinct stages of the complaint and at a considerable interval, or should succeed each other by a rapid transition. Erysipelas, I must again repeat, should not be treated from its name. Many persons have maintained, that when gangrene supervenes on inflammatory affections, and among the rest, on erysipelas, that it is the result of an excessive degree of inflammation, and that it might be successfully combated by judicious depletion. This, however, is by no means generally true; and it is of importance that, in forming proper notions of the pathology and treatment of erysipelas, you should dismiss from your minds all preconceived opinions, and be regu- lated solely by the impressions derived from correct observation and facts. What I wish to impress upon your minds is, that gangrene may and does occur in cases of erysipelas quite independently of excessive inflammatory action, and requiring a plan of practice quite different from the antiphlo- gistic. I do not assert that gangrene does not arise in many instances from the violence of erysipelatous inflammation, and that in such cases it is to be met by prompt and decided antiphlogistic treatment, but I think your views of the pathology of this disease will be both imperfect and false, if you look upon the gangrene which frequently supervenes in ery- sipelas as the result of immoderate inflammatory action. The following case, which is one of extreme interest, will, I think, bear me out in my assertion. Mrs. B., a lady of middle age, was attacked with feverish symptoms on the 24th of last March. Notwithstanding the diligent employment of anti- phlogistic treatment by Mr. Barker, the pyrexia increased; in the course of a few days her throat became sore, and shortly afterwards erysipelas appeared on the face. Her case assumed a very dangerous aspect: she ERYSIPELAS. 491 continued seriously ill for some days, and was saved with difficulty. On the 1st of April Mr. Carmichael advised the diligent application of fomen- tations, with the view of relieving the local symptoms; and her son, a young man of eighteen, of temperate habits, florid complexion, muscular frame, and who had always enjoyed a vigorous state of health, undertook the duty of applying the fomentations with much zeal and assiduity. To- wards evening, he thought, but without reason, that her case was hope- less, and fell into a violent paroxysm of grief, from which he was induced to rouse himself for the purpose of resuming his occupation of applying the fomentations. While thus engaged, he got, to use his own expres- sion, " a whiff of sickening air from the bed-clothes," and immediately felt unwell. This was on the 1st of April. On the second he was fever- ish, and complained of headache, for which he got aperient medicine, and was leeched. On the 3d there was no improvement, and he had passed the night without any sleep. On the 4th, Mr. Carmichael considered it necessary to leech the temples again, and to continue the exhibition of antiphlogistic and aperient medicines. He now began to complain of se- vere pain in the right shoulder, which at first appeared to be of a rheu- matic nature. He became more and more restless, and on the 7th of April was reported to have slept none for the three preceding nights. A very perceptible fulness was now observed under the right clavicle, extending down over the pectoral muscle; the parts were tender to the touch, but not red. Mr. Carmichael now examined the hand and arm of the same side with much attention, for the purpose of ascertaining whether any' wound or injury had existed, for the symptoms seemed to resemble closely those produced by poisoned wounds. None, however, could be detected. The restlessness now increased to an extraordinary height; during the fol- lowing night the patient changed from one bed to another at least one hun- dred times, and the servants were incessantly employed in making anil adjusting three beds, from one of which he wandered to another, impelled by an intolerable feeling of anxiety and uneasiness. During this period his bowels were free, his urine copious; and though his fever was consi- derable, it was by no means proportioned to the nervous excitement, nor was it accompanied by delirium or pain in the head. The swollen parts of the trunk were leeched freely twice, and diligently fomented, and con- tinued to present the same appearance until the 10th, when a red patch appeared near the shoulder, subsequently spreading into a vividly red ery- sipelatous blush, which occupied the skin covering the pectoral muscle, and right axillary region. I saw him for the first time on the 11th. His pulse was 120, and by no means deficient in strength; skin hot, but covered with perspiration ; he did not complain of headache, but was quite sleepless, and excessively uneasy. His muscular strength was apparently not much reduced, and, indeed, until a few hours before his death, he was able to turn in bed with ease. His tongue was dry in the centre, and furred, but moist at the edges. The erysipelas was now spreading rapidly towards the left side, and down the front of the abdomen. An attempt was made, but in vain, to arrest its progress by the application of nitrate of silver to the skin around its margin, an operation which was performed with great care by Mr. Carmichael. Mercurial ointment was next applied to the inflamed surface, and although the erysipelas continued to spread, we were led to entertain some hopes of our patient, having succeeded, by means of tartar emetic, followed by opium, in procuring for him much, and 492 CLINICAL MEDICINE. as he said, refreshing sleep. On the morning of the 13th, however, a black colour of the corium was observed in the situation of one of the bullae on his left side. This alarmed us; and in a few hours afterwards our suspi- cions were confirmed by the appearances of dark maculae in many parts of the erysipelatous surface. These livid patches spread very rapidly, and were in some places accompanied by effusion beneath the cuticle, but in others they appeared to consist in a mere change of colour in the external surface of the erysipelatous corium, without any detachment of the epider- mis. The patient took abundant nourishment, and got wine and cordials, but without any favourable effect. The scrotum now became engaged, and speedily assumed a gangrenous appearance. In some places the epi- dermis separated, and the gangrenous surface of the corium secreted sanies in large quantity, but in many parts no detachment of the cuticle took place. On the 14th, nearly the whole of the right side of the abdomen and the scrotum were superficially gangrenous, and the belly became tym- panitic. During this time Apparently healthy feces were discharged in considerable quantity; the skin was covered with perspiration; the urine was copious and natural; and we had here, what is worthy of notice, seemingly healthy secretions from the bowels, liver, skin, and kidneys, co-existing with extensive gangrene of the surface. His tongue, however, continued dry and furred ; his restlessness unabated ; and the sleep pre- viously procured by means of opium now ceased, although that medicine was repeated in the same doses. His pulse also began to sink, but he re- mained quite sensible and free from delirium until immediately before his death, which took place on the evening of the 15th. During the latter days of his illness he had sweated copiously, and there was nothing re- markable in the odour of the perspiration. I may also observe, that the pulse likewise furnished but very fallacious indications; for I can assert with truth, that six hours before bis death, though soft and compressible, it still possessed a steadiness and a volume by no means calculated to im- part a suspicion of his approaching dissolution. His strength was also such as would lead to an erroneous conception of his real danger: for, as I have before observed, he was able to turn in bed shortly before his death. This observation is borne out by other cases, in which persons with ex- tensive gangrenous erysipelas, and in imminent danger, have been known to be capable of walking about. The evidently contagious nature of the erysipelas in this instance, and the youth and previous good health of the patient, render this case suffi- ciently remarkable. It is likewise worthy of notice, as proved by the circumstances, that the gangrene did not originate in the excessive vio- lence of the cutaneous inflammation, for it did not appear in those por- tions of the skin which were primarily and most violently affected. On the contrary, we observed that the parts which became gangrenous had been paler and less tense than those which did not assume that condition, and that the portions of the skin which died, were those which had be- come engaged at the latter stage of the disease. This is of importance ; for, combined with other facts, it forms an obvious refutation of the opinion not long since maintained, that gangrene and sphacelus are in all inflammations the result of immoderate inflammatory action, and conse- quently to be averted by antiphlogistic treatment only. In many instances, this opinion, and the treatment founded on it, are, no doubt, judicious; but that there are cases in which the gangrenous tendency supervenes on GOUT —CONSTITUTIONAL INFLAMMATION. 493 inflammation, or, in other words, is superadded to the inflammatory pro- cess, but independent of its intensity, no one will deny who candidly weighs the details of the case which I have just related, and recollects that the conclusions deducible from them have of late received too fre- quent a confirmation from the rapidly fatal progress of putrid sore throat— a form of cynanche which has reappeared in Ireland, after having almost disappeared for upwards of twenty years. In both cases the disease ap- pears to be infectious, and in both the gangrene seems to be quite inde- pendent of the intensity of the inflammation. This is a question so important in a practical point of view, that I shall make no apology for detaining you, as I am anxious to impress upon the minds of my younger auditors, that there are certain forms of disease termed inflammatory, in which the ordinary treatment by depletion is quite inadmissible. LECTURE XXXIX. GOUT. On constitutional inflammation in general—on fugitive swellings and pains—Curious case of erratic gout causing transient swellings—Gout affecting the lobe of the ear—Fatly hyper- trophy of the ears—Gouty grinding of the teeth—Gouty neuralgia of the skin — Hemarks connected with Dr. Kingston's researches on consumption—On paralysis in general—On paralysis depending on affections spreading from the extremities of the nervous system to its centre—Gouty ramollissement of the spinal marrow, two remarkable cases of—History of this hitherto undescribed form of the disease—Gout may affect the spinal marrow—Combination of arthritic inflammation with bronchitis—Effects of various remedies, particularly mercury —Effects of this in chronic bronchitis—Dr. O'Beirnes's plan of rapid mercurialization in certain affections of the joints—Application of the same method to inflammation of the lungs of a scrofulous character—Cases in illustration. I take the present occasion of making a few remarks on certain varieties of gout, of which I have recently seen several singular examples, pre- mising some observations on constitutional inflammation in general. There is no proposition in pathology better established than that there exist certain constitutional affections capable of generating and modifying local inflammatory action ; and that local inflammations, depending on a constitutional cause, are subject to very different laws from those which regulate the phenomena of common inflammation. Another fact of equal importance in many points of view, is, that local inflammations depending on a constitutional cause differ remarkably from each other, and in general present specific characters easily recognized. Thus, local affections arising from scrofula are not likely to be confounded with those depending on gout or rheumatism, and the inflammations pro- duced by syphilis and other animal poisons exhibit peculiarities by which their respective origin and nature may be satisfactorily ascertained. It must, however, be admitted, that although advanced considerably in our knowledge of the phenomena of local disease depending on a constitu- tional cause, the subject still displays a wide field for investigation, and many points of much importance in pathology and practice require still further investigation. Professor Cayol, in his Lecons Orales, has made some observations on this subject well worthy of attention. Speaking of the dependence of local disease on constitutional causes, he says, " II faut 494 CLINICAL MEDICINE. necessairement conclure que les degenerations organiques nesont pas cause, mais effet. Et deslors, nous somraes fondesa vous dire, qu'au lieu d'user votre vie a chercher toujours quelles sont les degenerations organiques et les alterations de texture qui produisent les symptomes des maladies, il serait bien temps de s'inquieter un peu de savoir ce qui produit ces deg - nerations elles memes, en etudiant serieusement les caracteres, la marche, et la tendance des actes vitaux qui les preparent, et qui les produisent reelment." There is one fact connected with local inflammation depending on a constitutional cause not sufficiently noticed, namely, that certain affections of this kind are sometimes remarkably fugitive and transient. We are accustomed to regard the process of inflammation, whether common or specific, as one which generally lasts for some days ; but it occasionally happens, that a peculiar diathesis will give rise to local affections having the characters of inflammation, and which run their course and terminate in the space of a few hours. This observation, which should be borne in mind in the investigation of diseases connected with the general habit, will serve to explain some of the anomalies which strike us occasionally in the study of constitutional maladies. The first instance of this kind that came under my notice occurred in the case of a florid healthy-looking boy, aged six years, in whom, on attentive examination, I was led to suspect the existence of a scrofulous taint. At the time I saw him he was subject to a sudden and rapid formation of bumps, or tumours, on various parts of his body ; sometimes on the arms, sometimes on the legs, and occasionally on the trunk. These circumscribed tumefactions were accom- panied by a feeling of heat and tenderness, and apparently depended on local congestion, or effusion in the subcutaneous cellular tissue. But what was most remarkable in them was, they arose, ran through their course, and terminated in the space of four or five hours ; they were suddenly developed, and disappeared with equal rapidity. In the course of a month, other more permanent inflammations were set up ; scrofulous ophthalmia, glandular swellings, and ulcers supervened ; the joints be- came affected, and the boy died in about a year and a half, with all the characteristic marks of the scrofulous diathesis. I have detailed this case before, and shall not dwell on it any farther at present; but it is well worthy of notice, in consequence of the very brief duration of the first local affections. Gout is another disease which occasionally exhibits examples of its peculiar inflammation attacking various parts and tissues of the body, and that for an extremely short period of time. It is well known that persons of a gouty habit are subject to sudden pains or twitches, which last only for a few minutes, or even seconds. I shall not stop here to consider what may be the nature of these fugitive pains; I may observe, that certain facts seem to prove, that these pains are the result of a momentary con- gestion. Thus in various neuralgic affections, and in inflammatory dis- eases in which the nerves are considerably engaged, pain is suddenly produced by coughing. If a man labours under neuralgia of the frontal or facial nerves, or if he be affected with sciatica, how are his sufferings increased when he has unfortunately at the same time a cough ! Every time he coughs, the affected nerve gives notice that it feels the congestion by a sudden pain. Now the only way in which coughing can increase a local pain, is by favouring local congestion ; that it is capable of doing GOUT. 495 this is proved by the redness of the face it occasions, as also by the he- morrhage from the nose, or from recent wounds, which is so often pro- duced by a fit of coughing. As there can be no doubt, then, that a momentary congestion may pro- duce a momentary pain, we may infer that in many instances gouty twitches are owing to some cause which determines an instantaneous congestion of the affected part. Sometimes the congestion is more last- ing, and then the pain is proportionally intense and persistent. Thus Mr. Daiy, of Henry-street, knows a gentleman, the lobe of whose ear is some- times attacked suddenly by gouty congestion, accompanied by agonizing pain, but which never lasts more than a few hours. This fact brings to my mind a curious case which some years ago came under the notice of the Surgeon-General, Mr. O'Ferrall, and myself. A young gentleman of fortune perceived that the pendent lobs or tips of his ears were becoming elongated ; they increased gradually in such a man- ner that he considered himself disfigured by their unseemly length, and therefore attempted their concealment by allowing his hair to grow in long curls, so as to hide the ears. This gentleman soon afterwards be- came dropsical and died ; and, on dissection, Mr. O'Ferrall found his liver in a state of fatty degeneration. On slitting up the elongated por- tion of the ears, he discovered that their hypertrophy had been occasioned by the deposition of a large quantity of fat. The subcutaneous adipose tissue, and the omentum, were likewise much loaded with fat. This ob- servation is of some importance, as teaching us that fatty degeneration may be the consequence of a general tendency in the system to manufac- ture and deposit fat in the textures of the different organs. In this point of view the change of structure in the liver must be regarded as an effect, and not as a cause, of the general derangement of the system, and the fatal termination of the case. One of the most remarkable instances of fugitive inflammation affecting various parts of the body, which has come under my notice, occurred in the person of a gentleman lately under my care. I shall not go through the whole history of his disease, of which he has favoured me with a very minute account, but shall merely state, that he is of a gouty habit, has had an attack of gout in the stomach, and is at present subject to a gouty affection of a very extraordinary character. After labouring for some time under languor and weakness, accompanied by spasms, pain, and sense of weight in the stomach, the pain of the stomach ceases, and his face begins to swell at various points, generally commencing on the fore- head, and involving the cheek and eye, so as to close up the latter. He first feels as if a small current of air was directed on the face ; then, as it were, the fillip of a finger, or the bite of a gnat; and, on looking in the glass, he suddenly perceives a tumour rising on the forehead-, which, in the space of half an hour, becomes as large as a pigeon's egg, and, as he expresses it, moves down until it closes the eye. Sometimes it attacks his lips, and other parts of his face, but never affects his nose. These tumours have also appeared on various parts of his body ; and he observes in his letter to me, that he is sometimes led to think that they attack his stomach also. Before and during an attack of the face, which generally occurs on the left side, the discharge from the nostril of the affected side ceases. But what is chiefly remarkable in this case is, the singular cha- racter of the local affection. The tumours arise, run through their course, 496 CLINICAL MEDICINE. and disappear, in the space of a few hours; and on the following day there is no trace of their existence. Sometimes the lips, inside of the mouth, palate, and uvula, are attacked, giving rise to very considerable inconvenience. Were such tumours to occur in the neighbourhood of the glottis, 1 need not say that they would be pregnant with danger of no or- dinary character. I may observe, that this gentleman has derived great benefit from the use of hydriodate of potash, and from decoction of sar- saparilla with nitric acid, and that his health is at present much improved. His case presents a very curious example of transient local inflammation depending on the gouty diathesis. Having touched on the subject of anomalous local affections as con- nected with the gouty habit, I may be allowed to refer to a subject on which I have already published some observations. In a paper inserted in the Dublin Med. Journal for March, 1836,1 noticed the morbid habit which some individuals have of grinding the teeth, and detailed some facts in illustration of this affection. I have now seen several cases of this kind, and 1 have observed that they all occurred in persons of the gouty diathesis. The grinding of the teeth continues for years as a daily habit, and produces very remarkable changes in the conformation of these organs, affecting sometimes one side of the jaw, sometimes both ; so that in confirmed cases we frequently find the teeth ground down to the level of the gums. There is not at present the slightest doubt on my mind, that the irritable state of the dental nerves, which gives rise to this irresisti- ble tendency to grind the teeth, depends chiefly on the existence of gout in the constitution. I may observe, however, that in many persons in whom the teeth are found worn nearly to the gums, there appears to be another cause in operation. Thus, in cases of indigestion it is not unusual to find the enamel of the teeth partially or considerably worn away, long before the natural time ; and in such instances we used formerly to attribute the injury to the generation of acids in the stomach. The researches of Donne and Thomson, however, have shown that the saliva is subject to very remarkable alterations in certain forms of dyspepsia, and that when- ever the disease is accompanied by much irritation of the gastric mucous membrane, and derangement of its secreting functions, the saliva becomes extremely acid, and, of course, capable of corroding the enamel of the teeth. The following case has recently come under the notice of Mr. Pakenham, of Henry-street:— A gentleman, aged 45, slightly made, but muscular, and born of healthy parents, was attacked with shivering and loss of power of the right side after a severe wetting. He recovered under appropriate treat- ment ; but, about a year afterwards, began to observe in himself a ten- dency to grind his teeth, which gradually increased to such an extent as to prove a nuisance to himself and every one about him. Under these circumstances he consulted an eminent surgeon in Dublin, who applied the actual cautery behind one of his ears, slightly affected his system with mercury, and extracted one of his teeth,—all with considerable relief, which lasted for about six months. He then became as bad as ever, and applied to another surgeon, who tried iron in every form without success : and subsequently to a third practitioner, who used in addition leeching, blistering, pustulation with tartar emetic and various other remedies, but without any favourable result. All this time his medical attendants, so far from suspecting the presence of gout, ridiculed the idea of its existence. GOUTY NEURALGIA. 497 About three months ago, this gentleman came to Dublin, went to dine at the house of a friend, and with some others, supped late at night, and drank some whiskey punch. Next day he had vomiting, purging, and epigastric tenderness, and on the day after the ball of his great toe became swollen, hot, and exquisitely painful, leaving no doubt as to the nature of the affection. In this gentleman's case the grinding of the teeth is not constant, but it is always greatest when the stomach is most deranged. The teeth in the under jaw are all sound : three or four of the molars of the upper jaw have been extracted. The four upper incisors are ground nearly half way through to the gum on the inside, while the lower are very little worn. By pressing the tongue against the upper incisors, or by touching a certain point of one particular tooth, he can at any time arrest the tendency to grind, and can suspend it as long as pressure is continued in the manner just described. With the view of further illustrating the varieties of gout, I shall detail the following remarkable case, which came recently under my notice :— The patient, a gentleman of large fortune, is of a strong and athletic frame, about five-and-thirty years of age, and a member of a family subject to gout. He was much addicted to field sports, and accustomed, in cold weather, to frequent immersion of his feet in cold water, in pursuit of his favourite amusement, snipe-shooting. The consequence of this exposure has been, that he has been labouring for some time under a neuralgic affection of the lower extremities, which commenced in his feet and ankles, and extended gradually upwards, involving the whole of the lower extremities as far as the hips, and giving rise to sufferings of a very intense character. In a lecture formerly published, on Creeping Paralysis, I noticed, that repeated exposure of the feet to cold seems often to lay the foundation of this disease. Now in this case there is some danger that the gentleman, were proper measures neglected, may ultimately become paraplegic, or even generally paralytic. I do not bring this case forward as an example of gouty pains gradually advancing from the extremities towards the spine ; for although I strongly incline to the opinion that his complaint is of a gouty nature, and although most of his medical advisers have suspected a gouty complication, still this is by no means a decided point.* Be this as it may, his case presents a very interesting specimen of creeping neuralgia, chiefly affecting the cutaneous nerves (nerves exclusively destined to perform the function of sensation), but gradually implicating the nerves of" motion in the disease. I shall now proceed to lay before you the details of this case, which have been noted with sin- gular accuracy and ability by the gentleman himself. In a letter to me he observes:— " As you wish for a description in writing of the manner in which I am affected, I subjoin every particular I can think of which seems likely to throw any light on the subject. " It is now nearly five years since I began to suffer severely from pains in my limbs, which for the last two or three years I have looked upon as neuralgic. About a year previous to that time I had occasional pains in one foot, which increased so as to become violent on one occasion, after a long ride. I had, however, been always in the habit of riding, and * I have since seen his usual attendant, Dr. Little, of Sligo, one of the most experienced and skilful physicians in Ireland, and am much gratified by finding that Dr. Little's opinion exactly agrees with mine, as he considers the case to be gouty neuralgia. 33 498 CLINICAL MEDICINE. considered that exercise to agree particularly well with my health. In- deed, I had found hunting of great use to me, when suffering from liver complaint, having had inflammation of the liver twice in my life. It is now fourteen years since I had the last attack of liver disease, and I very seldom have pain in my side ; whenever it occurs, it is generally removed by the use of a little blue pill. " When first the pains in my limbs commenced, they were confined to my feet; then, for a long time, extended no higher than my knees; lat- terly they have ascended as far as my hips, where, and in the groin, I sometimes experience great suffering. I have had occasional twitches in my arms, and very slightly across the chest. The pain always comes on with sudden violence, which renders it very hard to bear, especially when it attacks me during sleep. I am frequently aware of its approach, from a general feeling of discomfort and depressicn ; from which, in the begin- ning of my complaint, I used to suffer very much for two or three days before an attack. These paroxysms have, for four years, shown a great tendency to periodicity, recurring generally once every week, commencing on Saturday or Sunday, sometimes on Friday, and lasting till Monday. They have twice or thrice lasted for a week together, but sometimes con- tinue only a few hours. In the commencement I have occasionally been free from them for two or three months together ; and within the last year was free from them, at two different periods, for a whole month. When in pain, I have never experienced the slightest alleviation from anything, except at times from a full meal with wine, particularly champaign. I have often been unable to remain in bed, from the violence of the pain, which is increased by the weight of the bed-clothes, or the slightest touch of any thing ; even the air blowing on the part brings on violent torture: at the same time I can bear strong pressure, or even a blow on the parts, without making me worse. The pain appears to be quite on the surface, except that sometimes it seems deeply seated, particularly in the ankle- joint and shin bone. It is unaccompanied by any redness or swelling, and flies instantaneously from one limb to the other, rarely occurring in both at the same time. It leaves behind great weakness of the affected limb, so as to oblige me to walk with a stick for some time, and occa- sionally with two. " One very unpleasant consequence of the pains in my limbs is, that I now find I cannot use exercise on horseback, if I leave it off for anytime. I have found this and walking at all times conducive to my general health. Indeed, I can still walk a good deal, even during an attack, although it is very painful, particularly when setting out. I find it necessary almost constantly to have recourse to aperient medicine—generally rhubarb pill. At times I have had giddiness of my head, and noise in my ears, to a very distressing degree ; and have had recourse to powerful purgatives, and even bleeding, to remove the symptoms, without effect. A medicine, principally nervous, in which gentian was an ingredient, relieved me at one time, after finding the above remedies ineffectual. I have already tried iron, mercury, nitro-muriatic acid, stramonium, arsenic, and the ex- ternal use of croton oil, without benefit, except that I felt rather better for a month after two of these remedies, but no longer, and the pain returned with great violence at the end of that period. The counter-irritation ap- peared to increase my sufferings. I have also tried anodyne embrocations without effect. Anxiety of mind, or annoyance, often brings on an attack. GOUT. 499 I even remarked, the other day, that it came on instantaneously, on breaking a tooth whilst eating. On the other hand, excitement, whether from a sudden necessity for exertion, as on occasion pf an accident, or any thing that gives a pleasing interest and occupation to my mind, such as travelling through an interesting country, seems to keep off, and some- times even remove an attack." In general, a regular attack of gout in the extremities is preceded by a longer or shorter period of constitutional disturbance and dyspepsia. We must not, however, in making the diagnosis between gout and rheu- matism, consider this distinction as not liable to exceptions, for I have seen more than one case of hereditary gout, in which the arthritic attacks came on suddenly, without the slightest precursory derangement of the health, or the operation of any assignable cause. I have as yet seen no instance of a similar nature in acquired gout. Another exception to the general rule is also worthy of notice. In general, a fit of the gout is preceded and accompanied by a scanty secre- tion of turbid, high-coloured urine. As the fit goes off, the urine in- creases in quantity, becomes clearer and paler, and loses its tendency to deposit the lithates and purpurates. Now, in two cases of hereditary gout, I have seen this order reversed, and the approach of the fit an- nounced by a great increase in the secretion of urine, which was quite watery and limpid, and continued so until the violence of the articular inflammation began to decline. The urine then became scanty, and de- posited the lateritious and pink sediment in great abundance. That the gouty diathesis may excite its specific inflammation in most of the tissues of our organs, is a fact generally admitted ; but I regret to state that our" knowledge concerning the effects which it produces in these various tissues, is far from being accurate or extensive. Beere, M'Kenzie, Middlemore, and others, have done much towards elucidating its effects on the eye and its appendages ; and we are tolerably well acquainted with its progress in serous, synovial, and fibrous membranes. What changes it produces in the secretions of mucous membranes, is a question which has not been studied with an attention commensurate to its im- portance. Thus, though all acknowledge the existence of gouty cough or bronchitis, the diagnosis and history of this affection are still very incom- plete. This has been acknowledged by Dr. Stokes, who has published by far the best account of bronchitis which has yet appeared.* The effects of gout on the lining membrane of the urethra and bladder are better known and studied, but I think that much still remains to be done in this as in every other class of inflammatory diseases where the inflam- mation depends upon a constitutional taint. In my published lectures I have long since expressed an opinion at variance with that generally taught concerning the bronchitis and pneu- monia which accompany pulmonary consumption, and I have brought forward strong reasons for believing that too much importance has been attached, and attention too exclusively devoted, to the tubercles in this disease. Thus authors talk of tubercular pneumonia, where it would be more correct to designate the affection as scrofulous pneumonia accom- panied by tubercles ; they speak of tubercular cavities and abscesses in * See a treatise " On the Diagnosis and Treatment of Diseases of the Chest," by W, Stokes, M.D. This work places its author among the first medical observers of the day, and has acquired for him a European fame. 500 CLINICAL MEDICINE. P the lung, in cases where scrofulous cavities and abscesses exist. In fact, I repeat it emphatically, that the essential characteristics of phthisis pul- monalis are derived from scrofula. This it is which converts what would be common into consumptive pneumonia or bronchitis ; this it is which so often renders both incurable. Tubercles and tubercular infiltration are mere results of nutrition mor- bidly modified by scrofula ; they are effects, not causes : they often exist without scrofulous inflammation, and the latter may exist without them. It gives me much pleasure to find that these opinions, which I published many years ago, have received ample confirmation from the observations of Dr. Kingston, in a paper read before the Royal Medical and Chirur- gical Society of London, and shortly noticed in the Medical Gazette, April 29, 1837. In pursuing the subject of my lecture, I shall now turn to the conside- ration of some phenomena connected with the gouty diathesis which possess a much deeper interest, and lead to views of far greater import- ance. I mentioned before, that we frequently observe flying-pains, or twitches, in various parts of the body, arising from a rheumatic or gouty cause ; that in some instances these affections appear to be limited chiefly to the nervous trunks or branches, and that we have thus what may be termed gouty or rheumatic neuralgia. We are familiar with rheumatic and gouty sciatica, and we know that Ihe history and termination of this form of disease often prove it to be inflammation of a specific character, chiefly confined to the trunk of the sciatic nerve. Now it is not unrea- sonable to suppose that this specific inflammation of a nervous trunk or branch, may, like other inflammations, extend farther, so as to involve parts of more importance to the economy. What I wish*to draw your attention to is this—that in certain cases, where gout attacks the nerves, giving rise to gouty congestion or inflammation, frequently recurring, and acquiring increased strength and deeper root as it proceeds, the morbid affection may, after years, or even months, run on until it reaches the spi- nal cord, involving a certain portion or portions of that organ, and pro- ducing loss of sensation and motion commensurate to the amount of spinal derangement. This is by no means an anomalous occurrence; it is merely an instance of disease originating in the periphery of the nervous system, passing along the trunk of the affected nerve with a retrograde motion, and finally reaching the central parts. I have already pointed out this peculiarity in many affections commencing in the periphery of the nervous system, and showed how the disease extends gradually until it reaches the spinal cord, giving rise to various forms of paralysis. It is too much the custom to look upon paralysis as depending upon original disease of the nervous centres. I have proved that, very often, disease commencing in the nerves of some particular part or organ, may be gradually propa- gated to the spine, producing all the symptoms which are referable to an original affection of the nervous centres. In my lectures on this subject, I have brought forward numerous facts in proof of the propagation of dis- ease from the circumference to the centre of the nervous system; and the pathological deductions I drew from these facts seem to me to include all the physiological discoveries made by Muller and Marshall Hall, concern- ing what the latter terms the reflex function of the spinal marrow. In these lectures I showed that enteritis, arising suddenly in two young and healthy persons, from indigestion and obstruction caused by an error in GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 501 diet, was followed in both by well-marked paraplegia. I instanced, like- wise, examples of paraplegia connected with stricture of the urethra, and which were relieved by curing the stricture ; and I detailed cases of acute and chronic affections of the uterus and kidneys, which had entailed on the patients, as a remote consequence of the original disease, loss of the power of motion in the lower extremities, sometimes partial and curable, sometimes irremediable and complete. The cases I am about to relate form a most interesting and valuable addition to those referred to, and enable me to carry the principle then advanced still farther by proving that gouty inflammation of the nerves and their neurilema, may, in process of time, extend to the spinal marrow and its investments, and give rise to derangements of the latter, terminating in ramollissement and structural degeneration. The subject of gouty degeneration of the spinal cord has not been alluded to distinctly by any author with whom I am acquainted, and is, as far as I can learn, quite new. The deductions, therefore, which are drawn from my cases, must, of course, be subject to such modifications as may be derived from future experience, and must remain to be con- firmed by further observation. It has been long known that gout may- attack the brain, and the existence of gouty paraplegia is well known by practitioners who have studied attentively the progress of arthritic affec- tions. Thus, in a case which I witnessed some time back, in consulta- tion with Mr. Kirby, he prognosed the supervention of paraplegia at a time when the indications of its approach could not have been discovered by any observer of less experience and sagacity. I have already stated that gouty affections of the brain have long been known, and I am not sure that some of the older authors raay not have alluded to gouty affec- tions of the spinal marrow ; but as our knowledge of the peculiar state of the brain and spinal cord, termed ramollissement, is comparatively recent, and not dating with any degree of accuracy earlier than the works of Abercrombie, Roston, and other modern authors, it is obvious that any observations made by the older writers concerning gouty affections of the nervous centres, can have no distinct reference to this lesion. The con- nection, therefore, of ramollissement of the spinal cord with gout, may be considered now, for the first time, distinctly pointed out. As one of the cases which I am about to detail presented an example of the most exten- sive ramollissement of the spinal marrow on record, it would, on this account alone, be especially deserving of attention ; but its interest is increased tenfold when placed in juxtaposition with the second case, so as to exhibit, in a striking point of view, the close resemblance observa- ble in the march or progress of both, as well as the identity of the lesion discovered after death. Mr. ----, residing in the Island of Anglesey, was very much addicted to field sports, and, while thus engaged, would occasionally remain for a whole day without food. He was also very fond of angling, and has been frequently known to wade up to his waist in water for many hours together, during very cold weather. His general health was good, and his habits were abstemious. In 1825, when about twenty-five years of age, he had fever, attended with inflammation of the joints, and said to be rheumatic : some pain and stiffness, and an evident enlargement of the knee-joints, remained, after the other articular affections had disappeared ; these symptoms, however, yielded, in a few months, to rest and appro- 502 CLINICAL MEDICINE. priate treatment. His health also improved greatly, and he had no com- plaint of any kind whatever until the autumn of 1828, when he had a slight attack of ordinary cholera, after returning from a shooting excursion. In the spring of 1832, he was attacked with pain in one foot, supposed to be of a gouty nature : this pain disappeared during a drive of fifteen miles in an open carriage, but a certain degree of tenderness remained, and was always felt, more or less, in the part originally affected. He had a similar attack of pain and tenderness in the same foot in the following autumn. At the time when this attack commenced he was twenty miles from home, and observed that during his journey the pain became diminished as be- fore, and in a few days subsided altogether. In August, 1833, he had a similar, but much more severe attack ; the pain was much more violent than before, and both feet were affected. This, however, did not prevent him from following field sports as usual; he went on horseback to the mountains to shoot grouse, and to this exercise, and drinking a bottle of wine, he attributed his speedy, or rather sudden, recovery from the pain in his feet. Hitherto we have seen a naturally strong constitution struggling suc- cessfully against exposure to cold, imprudent habits, and a most injudi- cious method of disturbing, or rather repelling, local inflammation depend- ing on a gouty diathesis. It is not easy to explain how it happened that driving in an open carriage, or riding over the mountains, so effectually cut short the paroxysms of gout in the feet : hut it is enough to know that the fits were suddenly and imprudently arrested, to be prepared for the consequences which ensued—viz., an irregular distribution of the gouty effort, and its determination to internal organs. In September, 1833—that is, about a month after the sudden subsidence of the last attack—he was seized with a violent colic, accompanied by obstinate constipation. The pain was very severe, but he suffered more from a gene- ral feeling of restlessness (a restlessness beyond belief, as he expressed it) than from actual pain. He was also greatly annoyed by singultus, and was jaundiced after recovering from the attack of colic. In a lecture already published, I have mentioned some cases of jaundice supervening on arthritic affections : in such instances, I am inclined to think that it depends on rheumatic or gouty hepatitis. In January, 1834, he had another attack of colic, preceded by a fit, the precise nature of which I was unable to ascertain. As these abdominal attacks frequently occurred, I shall give a description of one of them, as communicated to me by Dr. Llewelyn Jones, jun., his attending physician, a gentleman who justly enjoys a high reputation in his profession. " A dull, wearing, and fixed pain would attack the patient in the region of the colon : this pain was not increased by pressure, and was accompanied by nausea, occasionally by vomiting, and always by obstinate constipation. These symptoms were attended by a most distressing sensation of restlessness and anxiety. They lasted on one occasion for three days and nights before I could get the bowels opened, when they were immediately mitigated. The pulse was never quickened, and in general remained natural ; but if the attack was prolonged, it became weak. There never was any fever, or any well-marked indication of inflammation in the abdomen. These attacks were always preceded or followed by a gouty affection of the feet." The attacks in the stomach and bowels recurred frequently, and always with the same symptoms, until August, 1835, when a visible tremour of GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 503 the fingers became observable : during some preceding attacks he used to complain of weakness of the wrists and pains in the fingers, particularly the last joints. As the disease progressed, these pains became more in- tense and extensive, and the torture he felt in the hands and arms was beyond description. After August, 1835, he began to lose the use of his arms, the tremours increased, and he began to complain of stiffness about the neck, with great restlessness and anxiety. The abdominal attacks came on occasionally, but not so severely as before. The arms became gradually weaker, until the loss of muscular power was complete, and they were greatly emaciated ; but Dr. Jones, who had the patient under his observation until August, 1836, could not detect any evident diminu- tion, either in the upper or lower extremities, and the intellectual faculties remained perfectly unimpaired. In October, 1835, two months after the state of the upper extremities had indicated the approach of paralysis, the lower extremities became similarly engaged : they were affected with tremours and weakness, and in the following December the patient had an attack of violent pain, with swelling and increased heat in the ball of one foot, which was pronounced to be of a distinctly gouty character. After each attack of pain in the feet, as I have been informed by this gentle- man's sister, the loss of power in all his limbs increased, and if he gained a little strength in the intervals between these attacks, a recurrence of the paroxysm always made him worse than before. In February, 1836, I went to Anglesey to visit this gentleman, and saw him in consultation with Dr. Jones and Dr. Williams of Denbigh. After a minute examination of the history and symptoms of the case, I declared it to be my opinion that a gouty inflammation had attacked the nerves of the extremities, and had finally extended to the spinal cord and its sheath. I said, that at an earlier period of the disease I would have advised salivation by mercury, but as that was inadmissible under the existing circumstances, we should have recourse to other measures. I forgot to state, that from the commencement of the disease, the advice of Sir B. Brodie and other eminent practitioners in London had been ob- tained by letter. It would be useless to detail the various general and local remedies fruitlessly employed in this gentleman's case. He went to Liverpool in August, 1836, for the benefit of further advice ; but finding no relief, re- turned to Denbigh, where he died in the ensuing October. For some time before his death he was greatly emaciated, and quite paralytic in all his limbs, but retained his intellectual faculties to the last. His body was examined by Mr. Williams, whom I had met in consultation in the pre- ceding February. This gentleman informs me, that the viscera of the thorax and abdomen were healthy and normal, that no derangement or lesion of the brain could be detected, but that the spinal cord, opposite to the last cervical and first dorsal vertebra?, was softened to the consistence of thick cream ; the remainder of the cord was also softer than natural, but did not present any thing peculiar in other respects. In a letter which I have since received from Mr. Williams (to whose kindness I am much indebted, and to whose zeal and professional skill I can bear ample testimony), he expresses himself with regard to the nature of the patient's disease, in a way which confirms the views I have taken. He observes—" I once saw Mr.---- in an attack of the gout in the feet, about three years before his death. There was much pain, and a decided 504 CLINICAL MEDICINE. / gouty blush. Exposure in fishing and shooting to a very imprudent de- gree, while under the influence of these gouty attacks, I have no doubt, did much to render the disease irregular and erratic." The fact that the tremours and loss of power commenced in the arms two months before indications of paralysis of the lower extremities ap- peared, is sufficient evidence to prove that the spinal marrow was not the point from which the diseased action proceeded originally ; for had this been the case, an affection of this organ, sufficiently violent to give rise to paralysis of the upper extremities so gradual in its progress, and so well developed, must long before this period have occasioned paralysis of the legs also. There is a striking analogy between the progress of the tre- mours and paralytic symptoms in this case and in cases of painter's colic ; and the analogy likewise holds good as to the violent spasmodic affection of the bowels, and the constipation observed in both. It is further wor- thy of notice, that in painter's colic the nervous affection is accompanied by pain and weakness of the extremities, and ultimately, although long after the commencement of the disease, by spinal tenderness,—a fact which has been already noticed by Dr. Bright. Again, in painter's colic, as in the disease which I have just detailed, the affection of the spinal cord, and the consequent paralysis, are evidently subsequent to the dis- ease of the peripheral portion of the nerves. The next case, which I shall now proceed to detail, is one of equal interest and importance. A gentleman of robust frame, aged about fifty- five, and having an hereditary predisposition to gout, to which his father had been a martyr, and which had exhibited itself in one of his sons at the early age of thirteen, consulted me on the 7th of June, 1836. Being a man of extensive landed property, he resided chiefly in the country, and was in the habit of using much active employment and exercise, but in- dulged rather freely in the pleasures of the table. After suffering much annoyance from dyspeptic attacks, and various premonitory symptoms, he had a regular paroxysm of gout in the spring of 1828 ; he had a similar one in 1830, and another in 1832, each occurring, as before, during the spring season, and remarkably severe. During the year 1832, he had several slight returns of the complaint, and in January, 1833, had an alarming attack of an enteritic character, accompanied by spasms of the stomach and acute pain of the extremities. In the autumn of 1834 he suffered greatly from a nephritic affection, and got relief after passing a considerable quantity of uric acid gravel. In the spring of 1835 he had a fall from his horse, and for some time afterwards complained of pain in the small of the back and around the trunk. He recovered, however, and during the summer and autumn of that year remained pretty well; but in the last week of December caught cold, which was followed by severe cough, and pains in the chest and feet: the latter were then con- sidered to be the effects of gout. From this period, his health, though often apparently restored, was never firm : he became subject to sudden attacks of pain, particularly in the chest, which gave him much uneasi- ness. On the 3d of June he consulted a physician in his neighbourhood, to whom he described his ailment as " a slight pain in the right side, which troubled him only a short time before he got up in the morning;" this he stated he had felt occasionally for two months before. A very careful examination was made over fhe situation of the liver, the place in which he said he felt pain, but no tenderness or swelling whatever was GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 505 detected, nor was there any in the direction of the spinal cord. His pulse was at this tirae perfectly regular, his bowels natural, and no dyspeptic symptoms existed. He used, by the advice of this physician, tonic and laxative pills, and a stimulant embrocation. When he consulted me on the 7th of June, 1836,1 found him labouring under what appeared to me to be pleurodynia of an intermittent and gouty character. During the day he was perfectly free from pain, but in the evening the pain commenced, and continued with violence until morning. It is unnecessary to detail here the various local and constitutional reme- dies which I employed in this gentleman's case, but without any favour- able result. From the middle of June his symptoms became worse ; during the first part of the night his pains were very severe; towards morning he usually obtained relief by lying on his face, and carefully avoiding all motion. About the latter end of July, the pain, which had been almost constantly felt at the right side, moved to the left, imparting at one time the feeling as if a spear were passing through the diaphragm, and at ano- ther resembling the sensation as if these parts were squeezed in a vice. When he was in the horizontal position this pain was accompanied by a sense of weight; and at times the pain would shoot upwards to the clavi- cles, producing tenderness of the intercostal spaces. When the diaphragm was free from pain, it most commonly attacked the postero-inferior edges of the scapula, and the dorsal region in its vicinity. In August he tried the use of the warm bath, and found temporary relief from the first he took; he remained too long in the second, which was heated to the temperature of 100, and nearly fainted. He used the warm bath six or eight times, but found no material benefit from it, and could not bear the pain produced by the jolting of his carriage in going thither. About this time there was a visible alteration in his gait and figure: the left shoulder was elevated, his whole frame attenuated, and his face pale; he had nearly lost all power of bending the spine, and walked with a peculiar stiffness of gait, as if his arms were pinioned. On the morning of the 21st of August he stated that he had suffered great agony during the night, and on its abating, conside- rable tumefaction was observable under the right ribs. Dyspeptic symp- toms now became urgent, his urine scanty and turbid; be became melan- choly, and his mind was wholly occupied with sad presentiments. At my recommendation he came to town, in order to place himself under my more immediate observation, and to have the benefit of a consultation. About the 30th of August he got, to his great joy, an attack of gout in both feet; while this lasted, which was for about six days, he had complete relief from the agonizing pains in the diaphragm and chest. The interval of tranquillity was, however, but of brief duration; the inflammatory affection of the feet suddenly subsided, and the pain attacked the diaphragm with increased intensity. His strength, which had been rapidly failing, now gave way, and he became quite paraplegic. About the 10th of Septem- ber the abdomen became engaged, without any alleviation of the thoracic symptoms, and he began to complain of constipation, tympanitis, and ab- dominal tenderness. The mucous membrane of the bladder became next affected; he had retention of urine, with great irritation of the prostate gland, and it was necessary to draw off the water with the catheter several times in the day. This state continued from the 22d of September to the 10th of November, when the sphincter of the bladder became paralyzed, and the urine drained off as fast as it was secreted. During all this time 506 CLINICAL MEDICINE. . the urine continued to present the characteristic marks of the lithic acid diathesis in an extreme degree, and contrasted strongly with the secretion, furnished by the inflamed mucous membrane of the bladder, which con- sisted of a greyish or whitish yellow, viscid, and somewhat puriform mucus containing either a free alkali, or an alkaline carbonate. This secretion was extremely adhesive, and hung down in long ropy filaments when the vessel in which it stood was inverted. The nature of this mucus was such as to prevent any reaction from taking place between its own alkali and the acid of the urine. The coexistence of two secretions in the bladder, the one alkaline and the other acid, as observed in this case, is extremely curious. In this way the patient's sufferings went on every day increasing, and requiring the most extraordinary care to produce any alleviation, a task which was discharged with the most indefatigable humanity and attention by Mr. Richardson, of Sackville-street, to whom I am indebted for most of the details connected with the earlier history of this case. About ten days before his death, the extremities, upper as well as lower, and the trunk, became quite paralytic ; and from the cervical vertebras downwards, all power of motion and sensation was lost. His voice now became weak and inarticulate, deglutition was greatly impeded, and he finally sunk on the 27th of November, 1836. It may be necessary to state, that at the time the paraplegia was be- ginning to seize on the extremities, the patient was much annoyed by occasional involuntary jerkings of the weakened limbs. This morbid action of the voluntary muscles continued when all power of voluntary motion had completely ceased. This gentleman's body was examined twenty hours after death, by Mr. Adams. The body and limbs were greatly emaciated, and there were several sloughing sores on various parts of the body and limbs, particu- larly over the scapulas, sacrum, and ilium. The brain was perfectly healthy, with the exception of a slight effusion under the arachnoid, and into the fourth ventricle. On opening the spinal canal, which was done with extraordinary care and accuracy, the spinal marrow, from the fourth cervical vertebra down to its dorsal termination, was found converted into a morbid mass, of an ash-grey colour and pulpy consistence. The theca was quite healthy ; but on the first transverse section of it a great quantity of yellow serum flowed out, emptying at the same tirae the fluid contained in the fourth ventricle of the brain. When the medulla spi- nalis was slit from above downwards, various shades of colour were no- ticed on the surfaces of the sections. Opposite to the third dorsal vertebra a blackish colour prevailed ; and from this downwards a yellowish hue was noticed. Two little tumours, about the size of filberts, were found attached to the crura of the fourth dorsal vertebra ; these, as Mr. Adams remarked, were in all probability merely accidental formations. The bladder was very much thickened in all its coats, and was so contracted that it could not contain more than three ounces ; its internal surface was of a dark green colour approaching to black. The ureters were also thickened, the kidneys enlarged, and their lining membrane of the same dark colour as the bladder. The pelvis and infundibula of the kidneys were dilated, and contained a reddish diseased urine, with some puriform matter, the odour of which resembled that of the urine passed during the three weeks previous to his death. The other viscera did not present any thing worthy of remark. GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 507 In order to understand the nature and progress of a disease like this, which travelled in a retrograde direction along the nerves and their sheaths to the spinal marrow, it may be well to point out some of the more strik- ing phenomena by which it is characterized. In the first place, the long continuance of the pains at one side of the body only, is in itself a de- monstration that the disease was then situated in the peripheral extremities of the nerves, and not in the spinal marrow ; for it has been well observed by Ollivier, that inflammation of the spinal marrow or its sheath can never remain confined to one-half of either for more than a very limited period. Indeed, so narrow is the cavity in which these parts are contained, and so intimate is the connection of their constituent parts, that it is quite im- possible for inflammation to remain more than a few hours, or at most a day or two, confined to either side. Some facts connected with disease of the spinal vertebras, and the pains accompanying the progress of that disease, may appear to contradict this view of the subject; for in vertebral caries pains are often felt at one side, or in one limb—nay, they often cease, or seem intermittent. Now in order to explain this we have only to recollect that here the inflammation does not commence in the spinal marrow or theca, but in the bones, and that the nerves, after their exit from the spinal cord, are affected in all cases before the cord itself. The reason is obvious ; the affection of the nerves is secondary, and solely derived from their proximity to the in- flamed bone and investing tissues ; and consequently the nerves on one side may be affected, while the corresponding nerves on the other side escape for the tirae, and until the disease in the bone extends itself to their neighbourhood also. This view of the subject has not escaped the notice of German pathologists. In the case above related the pains continued in one side for months, and were then suddenly transferred to the other, an occurrence which is quite irreconcileable with the idea of their dependence on primary spinal disease. The well-marked ease the patient experienced when the gout appeared in the feet, and the perfect intermissions of pain which he fre- quently enjoyed during the earlier stages of the complaint, afford strong evidence that the pains, however violent and excruciating they might have been during the paroxysms, did not depend on an original affection of the spinal cord. Had the fall which this gentleman received, or any other injury, induced inflammation of the spinal cord, and subsequent de- » generation of structure, the order and course of his symptoms would have been very different, and long intervals of comparative ease would not have intervened between the appearance of the first pains and the subsequent paralysis. WThen paraplegia originates in disease of the spinal cord itself, retention of urine, or irritability of the bladder, often announce the approach of the disease long before the lossof power in the limbs becomes evident; whereas, in all those cases in which the paralysis creeps from the extremities along the nerves towards the spinal marrow, the bladder is affected only at a late period of the disease, as occurred in the case which I have just detailed. Finally, the remarkable similarity which exists, in various points, between this case and that of the Welch gentleman, who had never met with any accident or injury, and in whom a considerable degree of ramollissement was observed, leaves no doubt that in both instances the disease com- menced with gouty neuralgia, and inflammation of the nervous extremities 508 CLINICAL MEDICINE. and their sheaths, which gradually extended to the central portions of the nervous system, and ultimately involved the spinal cord. It is of great importance that practitioners should be aware of this ter- mination, and know that in gouty habits the sad results already noticed may be produced, particularly as a knowledge of this fact may lead them to the timely adoption of preventive measures. Having experienced the total inefficacy of colchicum, hydriodate of potash, strychnine, and all the usual remedies, in relieving or removing this form of disease, I would be strongly inclined to recommend the early insertion of issues over the spine, with prompt and decided mercurialization. Mr. Colles has recommended the use of mercury in paraplegia, and cites some cases in support of the utility of the practice. It is to be regretted that he has not given any hints as to the mode of diagnosing the cases likely to be benefitted by the mercurial treatment, from those in which mercury would be inadmissible. Hence his recommendation loses much of its value, and cannot serve as a guide to those who have to treat spinal disease connected with paralytic symptoms. It appears, however, sufficiently plain, that mercury, em- ployed at an early period of the disease, is most likely to prove servicea- ble where symptoms of paralysis arise from inflammatory affections of the nerves or their neurilema, or of the spinal cord and its sheath. So far at present on the subject of paralysis, as connected with the gouty diathesis. I hope to be able, at some future period, to bring it again be- fore you in a more complete and extended form. In the preceding observations we proved that gout often attacks the nerves of the extremities in the first instance, and then pursues a retrograde course until it reaches the spinal marrow. It is an acknowledged character of gout that it wanders from one organ to another, and that it is very un- certain as to the periods and duration of its attacks, sometimes appearing to have ceased altogether, again only to return with redoubled violence. These characters of gout are strikingly displayed in the two cases I have related, where it finally seized on the spinal marrow; and it is quite pos- sible that what took place towards the fatal terminations of these cases, may in other gouty subjects occur at a much earlier period, and without the previous occupation by the disease of the nerves of the extremities: indeed, there is no reason why gout should not attack the spinal marrow and its investing membranes in the first instance, or in consequence of me- tastasis. That rheumatism, the disease most closely allied to gout, may do so, has been proved by numerous examples, of which we owe some of the most striking to Dr. Copland and Dr. Prichard, for the result of whose researches on this subject I must refer you to the article Chorea, in Cop- land's Dictionary of Practical Medicine, where you will find that rheuma- tism not unfrequently produces both acute and chronic inflammation of the spinal membranes. These observations I make with the intention of proving that my views concerning gouty affections of the spinal cord are borne out by analogy, and the experience of others with respect to rheu- matism. The case of Coghlan, who has been for some time an inmate of our chronic ward, demands a few observations. He was adraitted for an attack of arthritis on the 10th of December, and since that period has been subjected to various modes of treatment. You will recollect that on his admission he slated that he had been attacked several times with rheumatic inflam- mation of the joints. Like most persons of his class, he has suffered greatly ARTHRITIC RHEUMATISM WITH BRONCHITIS. 509 from repeated fits of illness, brought on by exposure to the same causes. One of the greatest misfortunes that can fall upon labouring men, is a severe attack of rheumatic fever accompanied by inflammatory affections of the joints ; it not only renders them helpless and useless for a considerable time, but also in some cases leaves them cripples for life, and in addition, the nature of their employment constantly exposes them to relapses, which at length bring on incurable affections of the joints ; we have, moreover, in this young man's case, a combination not unfrequent in patients of this description, namely, the effects of cold on the chest as well as on the joints; arthritis combined with inflammation of the bronchial mucous mem- brane. Now where the arthritic affection is very severe, and accompanied by high fever, the addition of bronchitis is a great aggravation. Every tirae the patient coughs he feels like one stretched upon the rack; at every convulsive motion of the chest a severe pang is felt in every joint, and the ordinary rate of suffering is increased to positive agony. A case of this kind is often hard to be managed, even when the disease is recent and the constitution sound; but when you have to treat a severe attaek in a person who has repeatedly laboured under the disease, and whose vigour has been consequently impaired, the difficulty is greatly increased. Here much attention is required on the part of the physician. Where the com- bination is met with in a primary attack, I am generally disposed to regard both affections as of the same character, and not requiring any difference of treatment; I therefore attack the arthritis and the bronchitis with the same remedies, that is to say, venesection, leeches to the affected joints and over the chest, and large doses of nitre and tartar emetic. These re- medies, however, are only calculated for the acute stage of a primary at- tack, and where the patient's strength is unimpaired; for when the disease is chronic, and debility present, you cannot venture on the use of large doses of tartar emetic and nitre. In such cases much benefit is derived from the use of colchicum, particularly where the patient labours under more or less fever. The following is the form which I am in the habit of using, and from which I have occasionally derived much benefit— R. Misturse Amygdalarum, ^viij., Aceti Colchici, ^ss., Acetatis Morphia?, gr. i., Nitratis Potassae, gss. Sumat cochleare unum amplum omni vel secunda quaque hora. In Coghlan's case we tried this mixture with local applications to the joints and a blister to the chest, but found at the end of some days that there was no visible improvement in the patient. Now whenever a state of things of this kind occurs, no time should be lost ; for rely on it, that where colchicum .does not afford relief in a short time, and in moderate doses, there is no use in giving it a further trial. You have here to con- tend with two affections of a very serious character—one capable of ren- dering your patient a cripple for life, the other threatening him with suf- focation, from an extension of the inflammation into the minute bronchial tubes, an occurrence which is most commonly followed by dangerous congestion of the lung. Under such circumstances, the only treatment you can adopt with a hope of speedy relief and ultimate success, is to lay aside all other remedies, and trust almost exclusively to the use of mer- cury. In cases of this kind do not hesitate a moment, but mercurialize your patient at once, if his constitution be at all capable of bearing it. The treatment which was followed in the case under consideration was this:—we gave the patient ten grains of hydrargyrum cum creta, four 510 CLINICAL MEDICINE. times a-day; and with the view of relieving pain and the irritation of the bronchial mucous membrane, he took one drop of hydrocyanic acid, and ten drops of tincture of hyoscyamus, in half an ounce of almond emulsion, three times daily. Permit me here, gentlemen, to direct your attention for a moment to the influence which mercury exercises over inflammatory affections of the joints, and over certain forms of inflammation of the mucous membrane. I, in common with most practitioners, look upon mercury as a most valua- ble remedy in the treatment of arthritic inflammation, and in certain forms of bronchitis, but I do not, however, advise its indiscriminate employ- ment, or bid you mercurialize every case of bronchitis or arthritic inflam- mation ; you can cure very many cases of both without mercury, and you should only have recourse to it in emergencies, of which I shall speak afterwards, and where other remedies have failed. In treating bronchitis in general, I always try bleeding, leeching, blisters, and expectorants, before I have recourse to mercury. But where these fail, and the disease continues to wear a threatening aspect, you will often find that mercury will cure it in a very rapid and surprising manner. You had an example of this in a boy who was lately under treatment in the chronic ward. He had severe laryngitis, with an extensive inflammation of the smaller bron- chial tubes, great dyspnoea, and considerable congestion of the lung, and you perceived that the moment he came under the influence of mercury all his symptoms were ameliorated. We gave the mercury originally for the laryngeal affection, but in giving it, remarked that it would also cure the bronchitis, and such was actually the case. Observe, I do not give mercury in bronchitis as a general rule,—it is often unnecessary, and even sometimes wholly inadmissible. I will except from this that severe form of bronchitis, with congestion of the lung, in children after measles, which is best treated with calomel and ipecacuanha, as recommended by Dr. Cheyne. Many children were lost by severe attacks of this form of bron- chitis, and by hooping-cough, accompanied by congestion of the lung, until Dr. Cheyne hit upon this simple but effectual plan of treatment. But in ordinary bronchitis of an acute character, and producing a tendency to congestion of the lung, I do not prescribe mercury until other means have failed. Now I believe every practical man is aware that mercury is one of the best remedies we can employ in many cases of acute and subacute bron- chitis, but perhaps it is not generally known, that even in some cases of chronic bronchitis, that is to say, where the patient labours under chronic catarrh, with asthmatic symptoms, not only relief, but even a complete cure, is occasionally effected by the use of mercury. One of the first cases of this kind which struck me very forcibly, was under the care of Mr. Porter. The patient, who laboured under an attack of venereal laryngitis, had at the same time chronic bronchitis, with puriform expec- toration and hectic, and as the use of the stethoscope was not then well understood, was supposed to be labouring under phthisis. From the violence of the laryngeal symptoms, however, Mr. Porter was obliged to give mercury, which not only arrested the laryngeal inflammation, but also cured the chronic bronchitis. I recollect, also, the case of an elderly gentleman, treated by Surgeon Mitchell, of Harcourt-street, for an attack of very long-continued chronic bronchitis, with asthmatic symptoras, and who was subject to paroxysms of coughing and violent dyspnoea, which MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 511 sometimes lasted for twelve hours together. Now this gentleman, after the failure of various remedies, took mercury, and with the most marked and permanent relief of his pulmonary symptoms. I was, it must be con- fessed, greatly surprised by the effects of mercurialization in this case, and it was quite a novel thing to me to witness a chronic, a very chronic bron- chitis, with copious expectoration and frequently-recurring dyspnoea, ag- gravated so as to endanger life by the least cold ; it was, I say, novel to me to see a patient so affected radically cured by a mercurial salivation. Perhaps, however, nothing but the absolute refusal of the disease to yield to other remedies, could authorize the adoption of such a plan in the pre- sent state of our knowledge. This puts me in mind of a plan which I have adopted within the last six or seven years, in the treatment of certain diseases of the lungs, and on which I shall make a few observations, as it has not been spoken of by those who treat of the cure of pulmonary affections. I must here in justice confess that the idea of this plan of treatment is not solely mine, but was founded on an analogy derived from the researches and experi- ments of Dr. O'Beirne, on scrofulous inflammation of the joints. An extensive experience and deep reflection first led Dr. O'Beirne to think that the acute stage of scrofulous inflammation of the hip and knee-joint might be made amenable to active and energetic treatment ; in other words, that inflammatory affections of the joints, which terminate in some of the worst and most fatal forms of disease, viz., morbus coxae and white swelling, might be checked in limine, and before the stage of hopeless ulceration was established. He therefore proceeded boldly and at once to try whether the disease might not be arrested in the commencement by rapid mercurialization. Observe, gentlemen, this idea was completely new, it had never occurred to any other person, and was diametrically opposed to the theories of the day. The prevailing opinion on this subject was, that mercury was inadmissible, and could only produce mischief in persons of the scrofulous diathesis. Every one said, do not give mercury in such a case, it exacerbates scrofula, it even brings on scrofula in many in- stances where there had been no appearance of it previously ; you can do no good with it, and may do infinite mischief. Dr. O'Beirne, how- ever, knew the difference between the proper and improper exhibition of mercury—between mercurializing the patient at once and fully, and then stopping, and the pernicious custom of giving long and irregular courses of mercury. He tried the remedy and succeeded, and the surgeons of Europe have justly appreciated the value and importance of his dis- covery. About two or three months before Dr. O'Beirne made his discovery public, I had translated for the Dublin Medical Journal, a paper from a German author on the use of corrosive sublimate in baths, in the treatment of white swelling, and Dr. O'Beirne states that the publication of this paper gave him courage at the tirae in pursuing a plan of treatment so much at variance with the opinions of the day. I published this paper, however, at the time merely as a curiosity ; it was a novelty in practice of which I had no experience, and could not offer any explanation. This was reserved for Dr. O'Beirne. He has shown in his memoir on the subject, that if you give mercury so as to affect the system rapidly you will frequently succeed in curing the disease, particularly in the com- mencement. 512 CLINICAL MEDICINE. From this I was led by analogy to apply the same principle of treat- ment to incipient scrofulous inflammation of the lung, and I think I have often succeeded in checking at once this most formidable of human maladies. Phthisis, as every medical man knows, is capable of assuming a variety of forms, and presents at its origin much difference of aspect. In some, it arises slowdy and insidiously, and the pulmonary symptoms are so quietly and gradually developed that it would puzzle an intelligent practitioner, who had the most ample opportunities of observing his patient from the beginning, to say at what particular period distinct evidence of danger had been noticed. The reason of this is because the tubercular affection of the lung is in such patients only of secondary importance, the disease which produced it having affected the whole system before the lung was contaminated. This happens in some, but in others an opposite train of phenomena is observed, and scrofulous inflammation commences in the lung before any general contamination of the system has taken place. It is in such cases, and such only, that mercury ought to be tried, and it will avail nothing except where the commencement of the scrofulous inflammation of the lung has arisen suddenly, and in consequence of the operation of some obvious cause, as catching cold or the occurrence of haemoptysis. I think that too much stress has been laid on the affection of the lung by writers on phthisis. In some cases (I will admit even in the majority of instances), the disease commences in the lung, but in others it passes through many changes, and affects various organs before it attacks the lung. You will frequently see persons labouring under scrofulous irritation, accompanied by hectic, emaciation, loss of appetite, and excitement of pulse, long before you can find any trace of tubercular deposition in the lung. I am of opinion that many persons would die of phthisis even supposing they had no such organ as the lung. But let us suppose the case of a person of scrofulous habit who gets an attack of fever, with local inflammation, and that this inflammation fastens on the lung. Take for instance the following case: a young man of robust and vigorous frame, but evidently of the scrofulous habit, who has laboured repeatedly under scrofulous ophthalmia in his infancy, and who has lost several members of his family by consumption, gets, we will suppose, a severe cold by overheating himself in walking into Dublin from the country on a damp evening. He is attacked next day with feverish symptoms and severe catarrh, which soon becomes a formidable bronchitis ; but the young man being of a vigorous habit and fond of com- pany, continues to go out and expose himself to night air, until at length the catarrhal fever is changed into hectic, the bronchitis into organic disease of the lungs, tubercles become developed, and the disease passes into phthisis. Here, you perceive, a man gets an ordinary cold, which becomes a bronchitis ; he neglects this, and it passes into disease of the pulmonary tissue and tubercular ulceration. Now this is a very common course of diseased action in persons of a scrofulous habit, and I have in many such cases been able to trace the fatal malady to a common cold exacerbated by neglect and bad treatment. You perceive I do not use the ordinary nomenclature of writers on consumption ; I do not recognize the terms " tubercular inflammation" as connected with cases of this description ; indeed, I am inclined to think that the whole theory of inflammation being excited in the lung by the presence of tubercles is founded on erroneous views. I have repeatedly found tubercles in the MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 513 lungs of persons who died of other diseases, without any trace of inflam- mation around them, and I believe every pathologist will confirm this statement. From this and other reasons, I have been led to the conclu- sion that tubercles do not act in all cases as foreign bodies, and that the theory which attributes the origin of inflammation to their presence is wrong. In one of the-preceding lectures, I have brought forward nume- rous arguments to show that we are in possession of a much truer and more intelligible pathological explanation of the fact in question. You may have scrofulous inflammation of the bronchial mucous membrane, or you may have scrofulous inflammation of the lung singly or combined, or, what is most frequently the case, you may have either or both accompanied by tubercular development. The development of tubercles, however, in a case of scrofulous bronchitis or scrofulous pneumonia, is a coincidence, and not a cause ; and you may have either of those affections singly or combined, without any coexistent or preceding tubercular development. Most commonly scrofulous bronchitis and scrofulous pneumonia are con- joined ; the former seldom exists for any length of time without producing the latter, and the latter is usually attended by more or less derangement of the bronchial mucous membrane. But what I chiefly wish to direct your attention to on the present occa- sion (and it is a matter of the deepest importance) is, can we prevent the development of phthisis in a person of scrofulous habit who has caught cold, got a dangerous attack of bronchitis or pneumonia, and is threatened with hectic? I do not wish to enter here into any disquisition concerning the means to be adopted with the view of preventing tubercular deposi- tion, or producing absorption when tubercular matter has been deposited in the tissue of the lung. To prevent tubercular deposition you must cure the scrofulous diathesis if you can. But suppose you are called to a case of the kind I have already described, where a young man of scrofulous diathesis gets a bad bronchitis or pneumonia, exacerbates it by neglect, and is threatened with hectic, what is the best plan you can pursue ? My impression is that you should treat it as you would treat acute scrofulous inflammation of the knee or hip-joint; in other words, that you should mercurialize your patient rapidly and at once; do it suddenly and decid- edly, but without pushing the mercury too far, and you will often arrest all the symptoras of the disease as it were by a charm. I could mention many cases which have been treated successfully in this-way. I was very much struck by the case of two eminent medical practitioners who came to Dublin within this last year to place themselves under the care of Dr. Stokes and myself. One was a person of scrofulous habit, who had caught cold after taking mercury, and neglected it for three weeks. At the time we saw him he laboured under severe and harassing cough, considerable fever and emaciation, and was greatly alarmed about his condition. He had been several times leeched over the trachea by Dr. Stokes, but this, although an admirable remedy in many cases of bronchitis, failed in pro- ducing an amelioration of his symptoms, and from the persistence of his feverishness, emaciations, and harassing cough, serious apprehensions were entertained that his disease would terminate in phthisis. Having explained to our patient our views of the case, and our impression that mercury was the only remedy on which we could rely with any hopes of success, we ordered him to confine himself to his room, continue the application of leeches to the trachea, and take mercury. Now as this gentleman had 34 514 CLINICAL MEDICINE. come up to town under the impression that he was consumptive, we found some difficulty in persuading him to submit to this mode of treatment. He yielded, however, but with great reluctance. In the space of a week all his bad symptoms had nearly disappeared. As soon as he came under the influence of mercury the cough became notably diminished, and he re- covered flesh and strength with surprising rapidity. The other was a phy- sician from'the north of Ireland, who was suddenly attacked by pulmonary apoplexy, and in a few weeks came to Dublin, harassed by a constant dry cough, which prevented sleep at night, and he was visibly emaciated and anxious. In him no hereditary tendency to phthisis could be ascertained, but nevertheless Sir Henry Marsh, Dr. Stokes, and I considered the case as very unpromising, for although there was no acceleration of the pulse, the breathing was easily disturbed, and we could detect crepitus and some dulness above the right mamma, where it was evident the original seat of the hemorrhage had been. This case, too, which had resisted a mere antiphlogistic treatment, yielded in a most satisfactory manner to mercury. Bearing these facts in mind, I think, gentlemen, you will be prepared to admit that mercury is a most valuable remedy in the treatment of scro- fulous bronchitis and scrofulous pneumonia—diseases which too often re- sist the ordinary modes of treatment, and which are unfortunately so often ifollowed by fatal disease of the Jung. Where a sudden attack of cold has ^produced inflammation of the substance or lining membrane of the lung in a person of scrofulous habit—where the attack is recent, and has occurred under circumstances which preclude any suspicion of previous tubercular disease—in such a case as this you will find mercury a most admirable remedy in checking symptoms often not amenable to other plans of treat- ment, and which if neglected or maltreated would in all probability end in phthisis. I was led to the adoption of this plan by the success which has attended Dr. O'Beirnes's practice in acute scrofulous inflammation of the joints, and from observing that cases of unmanageable chronic bron- chitis had been occasionally cured perfectly where mercury had been ex- hibited for other affections; and it is a curious fact that about the time I had fallen upon this mode of treatment, it suggested itself likewise to the minds of Dr. Stokes and Sir Henry Marsh, who can testify to its utility; of course it will not succeed in all cases; and I have seen it fail in others where I had confidently expected benefit. Notwithstanding this, it is a most valuable addition to our resources in certain cases that would end iin phthisis. About a year ago I attended a young gentleman, apparently of robust ■constitution, who died of phthisis ushered in by a frequent-recurring hae- moptysis. Shortly after his death, I was called on to visit the elder bro- ther of my former patient. He had a constant hard, dry, and very distress- ing cough, which deprived him of sleep, and having continued many .weeks had produced a most formidable degree of emaciation. Consump- tion was naturally dreaded. His pulse, however, was normal, and the stethoscope did not indicate any pulmonary lesion; still, as the case had refused to yield to all the ordinary remedies, including change of air, we felt very apprehensive as to the result. I confined him to bed, applied leeches over the trachea several times, and rapidly mercurialized him, and with complete success. He has continued well ever since. MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 515 Postscript.—Since the remarks on the use of mercury in some cases of incipient phthisis were published, I have continued to employ it in the class of cases then pointed out. It has also been adopted by others, amongst whom Dr. Munk must rank foremost, for the great attention he has paid to the action of this remedy in the disease in question. This gentleman's communication first appeared in the London Medical Gazette, from which it was transferred to the pages of the Dublin Medical Journal, for March and May, 1841. I shall here introduce the principal part of his memoir, which deserves great attention, from the zeal and ability with which the author has followed up the subject:— " Cases and Observations illustrative of the Mercurial Treatment of some Forms of Incipient Phthisis Pulmonalis, by William Munk, M.D., Phy- sician to the Tower Hamlets Dispensary. " The idea of employing mercury as a curative agent in the early stage of some forms of phthisis pulmonalis, occurred, we are informed, about the same time, and without any mutual communication, to Sir Henry Marsh, Dr. Graves, and Dr. William Stokes. The two latter of these gen- tlemen have laid before the public some of their earlier experience on this interesting subject. The first communication which appeared was from Dr. Graves, and is contained in his published clinical lectures, whilst the experience of Dr. Stokes will be found detailed in his excellent treatise on the Diagnosis'and Treatment of Diseases of the Chest. The results of this practice in the hands of Sir Henry Marsh are not, so far as we know, yet before the profession. Dr. Corrigan, more recently, in a very interest- ing lecture, has pointed out the class of cases, and the stage, in which this mode of treatment is inadmissible. [Dr. Munk quotes here from the preceding lecture, which we shall omit repeating.] " The results of this practice, as hitherto published, are as follows. Dr. Graves states in general terms, that he could mention many cases which have been treated successfully on this plan, and then proceeds to particu- larize three in which its action was manifestly curative. It failed, how- ever, in two cases in which he made the trial of mercurial treatment. In two of these a permanent recovery ensued ; in two, temporary, though well-marked relief, was experienced ; in one instance it was useless ; and in another, the medicine manifestly disagreed. Dr. Corrigan narrates but one case ; yet this is decidedly in favour of the treatment; for the patient speedily recovered. Exclusive, then, of the experience of Sir Henry- Marsh, who is reported by Dr. Graves to have found this mode of treat- ment beneficial, there are for reference twelve cases. In six of these a cure resulted, in two considerable benefit, in three it was useless, and in one the medicine disagreed. " Small as is this experience when numerically considered, and insuffi- cient as to the decision of a point so completely at variance with the doc- trines of the schools, it nevertheless appears to us, that the evidence above adduced, coming as it does from persons so well qualified to form an opinion on the subject, has attracted far less of attention than its intrinsic importance legitimately demands. Out of twelve cases of a dis- ease so uniformly fatal as phthisis, there have, under a new and peculiar mode of treatraent, been six cures. This will, probably, to many persons 516 CLINICAL MEDICINE. be a startling assertion ; and I have, therefore, before making it, been careful to state distinctly from what sources the information has been derived. " On investigating the pathological condition to which the observations of the authors above quoted refer, we shall find, that conclusions as to its nature and seat must be based almost wholly on the general symptoms and general signs ; post-mortem examinations serving our purpose but little, inasmuch as few cases prove fatal at this period of its course. These circumstances combined, make necessary a large amount of observa- tions before any certain conclusions can be obtained ; and they tend, in no inconsiderable degree, to render doubtful to many members of the profession the opinions maintained by those who have given attention to the subject, whilst they no less cause the treatment pursued, and the suc- cess which is stated to have resulted therefrom, to be regarded with some degree of suspicion. This is, perhaps, but an illustration of that salutary caution which, within certain limits, should mark our conduct in reference to new views and novel modes of practice hence derived, more especially when, as in cases like the present, many of the arguments are deduced from negative, rather than from positive facts. " The form of disease now under consideration, very commonly attacks individuals in tolerable or even apparently perfect health ; although if their previous state be minutely investigated, it will, I believe, in such instances, be found that there exist more or fewer indications of deterio- ration of habit, in the shape of scrofulous cachexia—whether that be of hereditary origin, or has been acquired by error in some of the non-natu- rals. Its commencement is, in the majority of instances, sudden and well marked ; its immediate exciting cause clearly ascertainable, being in general owing to the application of some of the common causes of inflam- mation ; or it originates, as do other local inflammatory affections, during the course of fever, of the exanthemata, influenza, &c. The phenomena attending it are those which point to a lesion of the bronchial mucous membrane, pulmonary parenchyma, or, as is most frequently the case, the two combined ; that lesion being evidently inflammatory in its character, as evinced by pyrexia, and by the existence of the physical signs and general symptoms of bronchitis and pneumonia. " The disease, in its most frequent form, commences after the manner of a common catarrh. The patient having been exposed to moisture, or a low temperature, often the two combined, experiences a sensation of chill- iness, which may augment to actual rigors. These are attended by lan- guor and indisposition to bodily or mental exertion, pains about the back, and aching of the limbs ; to which succeed heat of skin, increased fre- quency and strength of pulse, thirst, and a more or less unnatural appear- ance of the tongue. The respiratory organs evidence disorder; the voice becomes somewhat altered ; irritation is perceived about the larynx, giving rise to frequent, dry, and irritative cough. As the case proceeds, sore- ness is experienced beneath the sternum, a sense of tightness across the thorax ; more frequent cough, which either then, or within a short period, is accompanied by expectoration, at first of a watery, saline, and irritating character, but which soon mellows down into a clear, tasteless, viscid fluid, scanty in quantity, and expelled with some difficulty. In other cases the expectoration presents characters different from those just men- tioned ; it is more abundant, brought up with ease, and, in lieu of being MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 517 clear and tasteless, is opaque, sweetish, and pus-like. These symptoms, individually or collectively, may be more or less severe ; they do not, in the majority of instances, arrive at such a height as to induce the indi- vidual to place himself at this period under medical care. The indispo- sition is looked upon as a common cold, perhaps more than ordinarily severe. Yet it is subjected at this time to domestic remedies alone. Should the practitioner, however, have an opportunity of examining a case at this period, he will find bronchitic rales over more or fewer parts of the chest, existing perhaps only, or at any rate greatly preponderating, in one or both lungs. After continuing for an uncertain period, these symptoms undergo modification ; some may altogether disappear; but, in general, a diminution of severity is alone experienced. The patient hence flatters himself that he is improving ; but the speedy addition to the category of symptoms of no mean import, dispel the illusion, excite fears as to the indisposition, and cause him then to seek professional advice. There is emaciation and loss of strength ; the phenomena of common pyrexia merge into, or are changed for those of hectic, among the symptoms of which, rapidity of pulse and morning perspirations will be found the most marked. There is severe and harassing cough, with or without a viscid purulent expectoration, considerable hurry of respira- tion, shooting pains about the shoulders, disturbed and sleepless nights. The stethoscopic signs at this period consist of a minute and clear mucous rhonchus, more properly, perhaps, designated by the term muco, or sub- crepitant, and existing only in the superior portions of the lung. In other cases there is heard at this part of the chest a modification of the normal respiratory sound, which, when once distinguished, can never afterwards be mistaken, but the description of which in words, as of most other sensations, is a task of difficulty. The respiratory murmur is here some- what modified, scarcely if at all diminished in intensity, yet giving the sensation of being moister, as though the bronchial tubes were lubricated with more fluid than in their healthy state ; not, however, as it would seem, in sufficient quantity to produce the subcrepitant or mucous rhonchi. " In these instances we may occasionally, by very careful and prolonged examinations, detect at long intervals, especially on a deep inspiration, a solitary and minute mucous bubble. Here we generally find that expec- toration is exceedingly slight, or altogether wanting ; whilst in the cases presenting the subcrepitant or raucous rhonchi, expectoration does exist, although rarely to any great extent. Little or no information can be ob- tained from percussion during the earlier periods of the disease, the chest then sounding perfectly well. As the case, however, advances, more or less dulness is perceived ; and when this occurs, the active auscultatory signs undergo a corresponding modification. At first there is an increase in duration and intensity of the expiratory sound, giving to the whole re- spiration a sensation of greater roughness ; this increasing, passes onwards into well-marked bronchial respiration, coincident with which there is bronchophony and bronchial cough. It were useless to trace these cases further ; tubercular matter has now been deposited in considerable quan- tity, the case is one of confirmed phthisis, and the period for the employ- ment of mercury has passed. " Such will be found the commencement and course of many of the cases of phthisis which are amenable to mercury in their earlier stages. 518 CLINICAL MEDICINE. Sometimes, however, the disease takes its origin in a severe and universal bronchitis, which at once calls for medical interference and for active treatraent. There is here great feverishness, considerable embarrassment of respiration, and intense bronchial rattles over the whole chest. Gene- ral and local blood-letting, with tartar emetic, seem to be here clearly in- dicated ; and although it be found in the sequel that these measures are not so well borne as the symptoras would have led us to expect, still from their employment the patient derives considerable relief. The activity of the disease is broken, the fever is diminished, the respiratory oppression relieved, and the bronchial rales lessened both in intensity and in extent. The stethoscope indicates, however, that the morbid action still lingers within the lung, and that the superior lobes are the parts now alone af- fected. The remedies which had proved effectual in the removal of in- flammation from the other parts are powerless over these ; and their con- tinuance serves but to debilitate the patient, and to hasten on the disease to an incurable stage. The lesion here existing may, however, be re- moved, but its removal can be accomplished in no other way than by the employment of mercury, so as to produce its specific effects upon the con- stitution. If the mineral be not had recourse to, the case goes on from bad to worse ; percussion and auscultation evidence the deposition of tubercular matter within the lung, and incurable consumption is thus in- duced. " Another and not unfrequent mode in which this disease originates remains now to be noticed. Allusion is here made to those cases the commencement of wrhich is distinctly traceable to some general disorder of the whole system, as, for instance, essential fever, the exanthemata, influenza, &c. In the course of all these there is a great liability to con- gestions, determinations of blood and inflammation. The bronchial mucous membrane and pulmonary parenchyma become frequently affected in this manner, the supervention of such morbid state being, in some in- stances, proclaimed by symptoms so well-marked, that the lesion from whence they originate cannot be overlooked. In far the greater number of instances, however, the local disease is to a greater or less degree latent, the marks of general disturbance being so numerous and severe as to cast into shade or obscure the more feeble manifestations of low mor- bid action in the lung. The former class of cases being at once recog- nised, are promptly met by appropriate treatment, the local disease is sub- dued, and the disastrous consequences to which it tends thus averted. In the latter instance, however, the local affection often goes unrecog- nised, and no measures are adopted for its removal; or, if it be discovered, its severity is frequently underrated, and means employed which prove inadequate to the end proposed. In either case the phenomena are simi- lar to those before enumerated ; they indicate a low inflammatory action of one or more tissues of the lung, existing only in the top of the organ, or, if more extensively spread, greatly preponderating in these parts. Should this condition continue, the patient presents a like succession of symptoms to those we have described above as occurring when phthisis supervenes upon catarrh, modified, however, in some measure, by the nature and usual course of the disease in whose progress they have arisen. There is an analogous mitigation and modification of the local and gene- ral symptoras, together with the addition of other phenomena dependent on the disordered state of the lung, and the disturbances in other organs MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 519 to which its sympathetic relations give rise. The patient experiences what appears to be a long, tedious, and unsatisfactory convalescence. After a time he retrogrades considerably, and the symptoms of pulmonary disease come prominently forward. The efforts of the practitioner to re- lieve the condition of general disorder are set at nought by the local dis- ease, which proves an insurmountable weight to the resiliency of the con- stitution. Emaciation progresses, the symptoms of hectic appear, and after a time the physical signs testify the deposit of tubercle in the lung. " It may probably be urged by some that the term phthisis cannot with propriety attach to the lesion of the respiratory organs above described, inasmuch as the active and passive auscultatory signs differ widely from those commonly laid down by writers as indicative of this disease, and point only to low bronchitis or pneumonia. The justice of this objection we are forced to admit, if the term phthisis be employed in a limited sense, and as expressive only of those cases in which tuberculous matter has already been deposited within the lung. But regarding the subject in a practical point of view, we come to an opposite conclusion : for abundant experience testifies that the transition from the state above de- scribed to that of confirmed phthisis is gradual and progressive ; that in point of fact the condition now under consideration is neither more nor less than that which determines scrofulous deposition to the lung, whilst it is, at the same time, the very action by which this deposit is effected. 11 In the three cases above described, phthisis, from neglected though mild bronchitis—as the sequel of severe bronchial inflammation ineffi- ciently treated, or as ensuing upon bronchial or parenchymatous inflam- mation occurring during the course of other and general disease—there is found only a sibilant, clear, mucous, crepitant, or muco-crepitant rhon- chus ; these persist for a long period, and are, during the early stage, unaccompanied by other signs. The sonorous rhonchus is rarely heard ; the mucous exists in a diminutive form, approximating in character to the crepitant; the expectoration but rarely undergoes the same rapid succes- sion of changes observed in pure ordinary bronchitis, but remains clear, tenacious, spumous, observing more the habitudes of peripneumonic or of bronchopneumonic disease. This combination of symptoms points there- fore more to the minute bronchial tubes as the seat of disease, than to either the larger tubes or the parenchyma. It presents much resemblance to that form of disease termed capillary bronchitis, but is attended by less expectoration than is usually found in this disease, when occurring in its more usual site, the lower portions of the lung. " Now if it be asked, says Dr. Stokes,* what gives these signs of bron- chitis their value as diagnostics of incipient tubercle, the answer is, that it is not by their mere characters (for these do not differ from ordinary bronchitis), but it is from their situation,! localization, and combination, with comparative dulness of sound, that they derive their value: The " " Treatise on the Diagnosis and Treatment of Diseases of the Chest, p. 392. f " Louis, says Dr. Cowan, has invariably found that the sibilant, mucous, and submucous rales resulting from simple catarrh, originate in the lower part of the chest, while bronchitis complicated with pulmonary tubercles is always situated in the upper lobes. Simple bronchitis usually attacks both sides of the chest, while rhonchus from tubercles is at first almost con- stantly confined to the upper lobe of one side. Of the immense importance of this law there can only be one opinion, and, in many instances, attention to the seat of bronchitis would dissipate much doubt and anxiety, and early indicate the real nature of an affection which, without the knowledge of this fact, would frequently be confounded with simple catarrh, and thus frustrate the hopes both of the patient and practitioner. 520 CLINICAL MEDICINE. same phenomena scattered over, or even existing intensely throughout the lung, but being equable, and unaccompanied by dulness, would not only have no value in the diagnosis of phthisis, but would render the existence of tubercle improbable. Simple bronchitis is seldom circumscribed, while that of the consumptive is commonly so : the latter begins in the upper portion of the lung, remains obstinately fixed in the air-tubes, gradually spreads downwards, and while in its first stages in the lower lobe is com- bined with tuberculous ulceration in the upper : it may be intense in the upper lobe while the lower is altogether free, or engage the whole of one lung while the other is scarcely affected. These are not the characters of ordinary bronchitis. " A new aspect has been given to the pathology of tubercular disease by the investigations of Sir James Clark,* Dr. Carswell,f and the late Dr. T. J. Todd,! wh° nave proved that, for its production, a previous mor- bid condition of the system must exist: in other words that a necessary element in the causation of scrofula is a certain cachexia or abnormal state of the fluids of the body. In what this consists has been most clearly shown by Dr. Carswell, whilst the circumstances leading thereto have no less satisfactorily been elucidated by Sir James Clark and Dr. Todd. From the united labours of these gentlemen have resulted the important pathological law, that tuberculous matter exists as a morbid constituent of the blood, is eliminated from it by a process analogous to, if not identical with, secretion, and is thus deposited, in a visible form, in different organs or parts. " The contamination of the blood exists in some cases for a long period, and proceeds to a great extent before the deposition of tubercle com- mences. It seems not improbable that in such instances the sanguineous fluid becomes so thoroughly saturated (if the phrase be allowable) that an attempt at relief is then commenced, and nature sets about the work by eliminating the morbid product in conjunction with the secretions. Dr. Carswell is of opinion that the surfaces of mucous and serous tissues are those upon which tubercular matter is chiefly deposited ; that as regards relative frequency the former very far exceeds the latter : for here, he says, ' as into the great emunctory of the system, it appears to be sepa- rated from the blood, and becomes visible to us under a variety of forms.' Dr. Carswell is at issue with most pathologists as to its deposition in the molecular structure of organs. In no one instance has he witnessed it so situated. Our own observations tend to an opposite conclusion, although we doubt not that the most frequent sites of tubercle are those pointed out by Dr. Carswell. We believe with most pathologists, that tubercular matter has no peculiar site ; that it may, under certain circumstances, appear in any organ or part of the body, making its appearance thereby a lesion of nutrition, whereby such matter is secreted in place of, or in union with, those molecules of the blood, which, appropriated to the organ itself, become an integral portion of its structure, and thus repair the losses it is ever undergoing. " This deposition is frequently a silent process ; it commences and proceeds to a certain point, unaccompanied by any known pathological * "Treatise on Pulmonary Consumption, Lond., 1835. f " Art. Tubercle, Cyclop, of Practical Medicine, and Illustrations of the Elementary Forms of Disease. Fascic. Tubercle. * " Art. Indigestion, Cyclop, of Practical Medicine, and in Sir James Clark's work on the Influence of Climate, and Change of Air, &c. MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 521 state, or, if phenomena of disorder do occur, they are to be regarded as effects or coincidences rather than as causes. It will probably be found that this relation obtains only in those cases where scrofulous cachexia, and the contamination of the blood, which is its essence, has proceeded to a considerable degree, and where the local deposit is the result of the overcharged condition of the blood, rendering relief by the elimination of some portion of the morbid constituent, indispensable. " In other, and, perhaps, the majority of instances, tubercle is deposited long ere the cachectic state has arrived at the degree above supposed. In these, such an event is determined by irritation or inflammation, under the influence of which there is a large afflux of blood to the part, and coin- cident with it an increase and modification of secretion. In lieu of the results of common inflammation, as occurring in a healthy subject, there is here deposited tubercle, or coagulable lymph variously modified, the modification consisting in the approximation of that product, more or less closely in character to tubercle. The analogy which exists between these two morbid products, and the mode in which one may pass into or give origin to the other, has been clearly shown by Dr. C. J. B. Williams. Its further consideration here would extend these remarks to an inconve- nient length ; I shall, therefore, content myself with referring those who may wish to enter fully on the subject to the third volume of the Library of Medicine, p. 166, et seq. " The close connection existing between irritation or inflammation in one or other of the tissues of the lung and tubercle, as cause and effect, has been particularly dwelt upon by Andral,* who enumerate the following as the principal morbid alterations accompanying the development of tubercle : first, hyperaemia of the bronchia of a certain size; second, hyperaemia of the air-cells and ultimate ramifications of the bronchia without obliteration of their cavities; third, hyperaemia of .the same parts with considerable thickening of their parietes, and obliteration of their cavities ; fourth, an effusion of blood into the tissue of the lung; the blood thus effused coag- ulates, becomes a living part, and secretes tubercle.f In reference to these pathological conditions he states that, in certain cases, and those not the least numerous, the morbid alterations of the lung were evidently prior to the formation of the tubercles, and contributed to produce them. In the Clinique Medicale there is a passage explanatory, in some respects, of that just quoted. In it the author alludes to the influence of bronchial inflammation as giving rise to tubercle ; but the explanation will, mutatis mutandis, apply with equal force to the same pathological condition else- where situated. ' What ought never to be lost sight of,' says he, ' is this—that, in order that inflammation of the mucous membrane of the air-passages shall be followed by the production of pulmonary tubercles, it is necessary to admit a predisposition. This being admitted, we can easily conceive how, in one individual, very slight bronchitis is sufficient to produce tubercles, whilst others do not become phthisical from the most severe and long-continued pulmonary catarrh.' Sir James Clark also expresses his belief that inflammation in a tuberculous constitution may give rise to the deposition of tuberculous matter in place of coagu- lable lymph, which, in healthy subjects, is its natural product, and thus inflammation may be one of the immediate causes of tuberculous disease.! * Pathological Anatomy, translated by Drs. Townsend and West, vol. ii., p. 553. f This opfnion of the secretion of tubercle by the blood itself, M. Andral has since eschewed. i Op. ctat., p. 46. 522 i CLINICAL MEDICINE. " I have quoted these authorities at length, because I conceive that the recognition and just appreciation of the facts and opinions therein con- tained will have a most important bearing upon practice, and because each day's experience leads me to the opinion that cases like to these are far more numerous than is now generally admitted. The existence, in one class of cases, of inflammation within the lung, to be succeeded by the deposition of tubercle as cause and effect, is widely different from those in which an inverse relation obtains—where tubercular matter is first laid down, and inflammation follows either as consequence or coin- cidence. The causes determining tuberculous disease towards the lung are, in these instances, widely different; in one it is well known, and within the reach of medicine ; in the other it is unknown, and the means at our command are comparatively inoperative. One class of cases are curable, though, from circumstances, not always cured; the other are incurable, as regards medicine, though nature's efforts are, in a few rare instances, more successful. " As inflammatory action is in these cases the distinguishing character- istic, and throughout performs so important a part, it is but natural that, to its consideration, much attention should be given, and that its removal should be held as a canon of the first importance in our treatment. Blood- letting, either general or local, counter-irritants, emetics, digitalis, &c, the means which experience testifies to have been the most efficient in the treatment of phthisis, act principally by the removal or diminution of in- flammation, determination of blood, congestion, and the disordered move- ments in the system to which their existence gives rise. These measures are, however, rarely sufficient for the perfect cure of the pathological con- ditions above-mentioned, more particularly of the variety termed scrofu- lous, or the modification impressed upon inflammation by its occurrence in a scrofulous constitution. Highly important as auxiliaries, they must in no case be neglected, but as controllers of the disordered action of the capillaries, which constitutes inflammation, they are, in the majority of instances, inoperative. A medicine was wanting more potent in its effects, one whose action was evidenced not so much upon the central organs of the circulation as are blood-letting and digitalis, but on the periphery of the system, the capillaries. " Iodine and its numerous preparations have been recommended to public confidence, as a medicine calculated in some degree to meet this want. The action of iodine is manifested principally as a stimulant of the capillaries ; by giving tone to these vessels it expedites the circulation through them, obviates and removes congestion, and frees the secretions. It exercises little, if any control, upon the peculiar action, whatever it be that constitutes inflammation ; but after the removal of this state a degree of congestion commonly remains, and here iodine is most effectual. Re- liance must not, therefore, be placed on iodine in the class of cases and stage above described, although it comes in, as we shall show, with ex- cellent effects, at a somewhat later period of the treatment.* " It has, by abundant experience, satisfactorily been proved, that in the * There are peculiarities in the action of the analogous substance, bromide, which seem to point it out as peculiarly adapted to certain forms of scrofulous disease, especially phthisis. I am at this time making comparative trials with the bromide and iodide of potassium, the results of which, I hope, at a future period, to lay before the profession. Of its superiority in some forms of cardiac disease, I am already pretty fully convinced. MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 523 treatment of common inflammation there are no means at our comiriand which, in point of efficacy, will bear comparison with mercury. How- ever much pathologists may differ as to the proximate cause of this state, or writers on the effects of medicines to the mode of action of this mineral, they one and all agree in the truth of the above assertion. The know- ledge of this fact suggested to the mind of Dr. O'Beirne the employment of mercury in scrofulous affections of the joints. He regarded the inflam- matory action attending these cases as a point of primary importance, and to its immediate removal directed all his attention. The results of the practice he was thus led to adopt proved the correctness of his ideas, no less than the value of the measures upon which he relied, whilst the adap- tation of a like practice to those forms of phthisis during the earlier periods, of which inflammatory action is the predominant and all-important local condition, led to scarcely less successful results in the hands of Drs. Graves, Stokes, and Corrigan. " Mercury has heretofore been frequently proposed by distinguished authorities as a remedy in consumptive cases. It has never, however, acquired any great celebrity in the treatment of this disease ; the pro- posals and recommendations for its employment, whensoever or from whomsoever originating, appearing to have passed unheeded by the bulk of the profession, or if attended to or followed to have fallen short of the expectations which its too sanguine advocates had raised, and thus to have dropped again into disuse. Among those who have recommended mercury we may mention Dr. Rush, and other physicians, his contempo- raries in Philadelphia. A perusal of their writings will clearly substan- tiate the charge of what to us must appear indiscriminate practice—a fault less justly perhaps to be attributed to them than to the imperfect state of our science at that period. Upon no point in practical medicine were our predecessors more likely to run into error. The absence, until a very short period, of any correct information as to the precise nature and pro- duction of tubercle, the limited period during which mercury is in truth available, and the difficulty which existed, previous to the introduction of the new methods of diagnosis, of distinguishing the proper cases and their stage, were circumstances which one and all tended to render some- what indiscriminate the application of mercury. Here, as in all other in- stances of indiscriminate practice, the evil results must have far exceeded the beneficial. Under such circumstances it cannot be matter for wonder that careful practitioners should have opposed the practice, or that teach- ers should have laid it down to students as an axiom in practical medi- cine—that the employment of mercury in scrofulous diseases, but espe- cially in phthisis, was fraught with danger, and could be productive of no good. " The injurious effects now alluded to as ensuing from the employ- ment of mercury in phthisis, are less attributable to the existence of pul- monary disease than to that of general disordered action of the whole system, of which the former is the consequence, and a certain indication. Our best writers agree in the belief that the full action of mercury in the scrofulous cachexia is singularly injurious ; that the depression which the medicine thus given produces is more effectual than any other in increas- ing the cachectic state, and, should tubercle exist, in hurrying it through its various changes. It has, moreover, been asserted, and probably with some justice, that the mercurial fever once excited has a great tendency 524 CLINICAL MEDICINE. to increase hectic, and even in cases where this last condition has never appeared, to pass gradually into and terminate in it. Hence will appear the justice of the view entertained by Dr. Stokes, when he terms the remedy a two-edged sword, and expresses his conviction that its exhibi- tion must not be lightly attempted. " In coming to a conclusion as to the employment of mercury in any particular case, we have to decide on the propriety of employing means which are calculated to remove local disease, but do so at the expense of, and with some detriment to, the general constitution. In a word, our conclusion hinges on this, whether the local or the general disease be at this time the most important. Dr. Stokes writes as follows:*—'As to the general employment of mercury in incipient phthisis, I am any thing but sanguine, yet that by its assistance in removing irritation from the mucous membrane and parenchyma we may occasionally arrest the development and progress of tubercle, seems more than probable, for there can be little doubt that in the scrofulous habit there is more danger from the persistence of irritation of the lung, than from the action of mer- cury on the system.' " The existence, then, of such irritation or inflammation, whether mem- branous, parenchymatous, or, as is most frequently the case, the two combined, is that which calls for immediate attention to the lung, even at a temporary disregard to the constitution. Dr. Corrigan says,f that the use of mercury is in removing that degree of low local inflammation, which, allowed to remain unchecked or improperly treated, would termi- nate in tubercular deposition and consequent phthisis. And Dr. Graves,! after mentioning those cases of consumption which arise gradually and insidiously, whose commencement it is impossible accurately to determine, goes on to say, ' the reason of this is because the tubercular affection of the lung is in such patients only of secondary importance, the disease which produced it having affected the whole system before the lung was con- taminated. This happens in some, but in others an opposite train of phenomena is observed, and scrofulous inflammation commences in the lung before any general contamination of the system has taken place. It is in such cases, and such only, that mercury ought to be tried, and it will avail nothing except where the commencement of the scrofulous inflammation of the lung has arisen suddenly, and in consequence of the operation of some obvious cause, as catching cold, or the occurrence of haemoptysis.' " It may then, in general terms, be stated, that the absence of pre- existing tubercular deposit from every organ of the body is the circum- stance justifying our neglect of the contra-indication which scrofulous cachexia presents to the employment of mercury. The word ' pre-existing' has been here introduced, because it seems likely from the physical signs that, in some cases terminating favourably, tubercular matter has been present in the lung before the mercurial treatment was commenced. In them, however, such deposit was trifling in amount, and secondary to, and dependent upon, the bronchial or parenchymatous inflammation, for the cure of which mercury had been employed. " An interesting and most important object of inquiry is, how far such * Op. citat., p. 450. f London Medical Gazette, 2d Series, vol. iv., p. 74. $ Loc. citat. MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 525 tuberculization raay proceed, and the case nevertheless be amenable to mercury. Facts are wanting to decide this point. In one of Dr. Stokes's favourable cases, ' the antero-superior portion of the left side sounded comparatively dull.' In another, ' the right clavicle and scapular ridge sounded slightly, but decidedly dull.' In one of ray cases (No. 4), there was slight dulness of the left scapular ridge ;' in another (No. 6), the same phenomenon, in an exceedingly slight degree, was perceptible upon percussing the left scapular ridge, the clavicle, and the two superior ribs. I must, nevertheless, in the face of these cases, express my conviction, that the presence of dulness diminishes greatly our chance of success ; and did the previous history and general symptoms leave me in much doubt as to the propriety of employing mercury in any particular case, the existence of a very moderate amount of dulness would induce me at once to omit its use. I agree, indeed, with Dr. Hughes in thinking, * that appreciable dulness on percussion is very far from being an early physical sign of phthisis, and that when it is clearly distinguishable below one or both clavicles, or in the acromial regions, the complaint has generally- advanced too far to be effectively treated.' It must, notwithstanding, be borne in mind, that dulness on percussion may even in cases of undoubted phthisis arise from other causes than the deposition of tubercle, and may either spontaneously, or from the effects of treatment, be considerably diminished, and even altogether removed from certain portions of the lung. The cause of dulness in such cases is either inflammation or con- gestion, and it is to intercurrent attacks of this nature, and their subsequent removal, that we are to attribute the alteration of the phenomena above mentioned. Many writers are of opinion, that the dulness occurring very early in consumptive cases is more owing to congestion or inflammation of the lung, than to the presence of tubercle. That such is the correct explanation of the cases above referred to, where dulness has been reco- vered from, seems more than probable. Every one at least must admit, that such an explanation is more consonant with our knowledge of the habitudes of tubercle, and the effects of medicine, than that which would attribute it to the absorption of tubercle itself. Admitting the occasional absorption of tubercular matter to be a well-established fact, it yet remains to be proved, that such a process is favoured by the action of mercury upon the system. Without, however, denying that such may be the case, and allowing that analogy is in favour of the supposition, it must be con- fessed, that the present state of our science by no means warrants us in receiving this effect of mercury as more than probable. "The period, however, which may elapse between the commencement of the indisposition and the deposit of such a quantity of tubercle as to pro- duce dulness, varies much in different cases. It may be stated, perhaps, as ranging between three weeks and three months. I have known the lung so far solidified within the former period, as to put the use of mercury quite out of question. The attack supervened in this instance upon mea- sles. In the course of three weeks the superior portions of each lung gave a perfectly dead sound upon percussion, and there was an entire absence of respiratory murmur in the same parts. The patient, aged 18, died within nine weeks from the commencement of his illness, and upon exa- mination, cavities were found in the apex of each lung; the surrounding parts being completely solidified. That the condition above described may continue for eleven weeks, and so small an amount of tubercle be de- 526 CLINICAL MEDICINE. posited, as but slightly to impair the sonoriety of the lung, is proved by the case of Thomas Smith (No. 6), below detailed. My experience has not been sufficiently extensive to enable me to say whether or not it may last longer without giving rise to marked dulness. Two cases I have wit- nessed, the histories of which were so perfect, as to leave little or no doubt as to their nature, where a period little exceeding three months sufficed to induce well-marked dulness, and render the use of mercury inadmissi- ble. One of these cases came under my observation fourteen, the other fifteen weeks from the commencement of the illness. That the usual course and tendency of scrofulous bronchitis or pneumonia are not represented by these extremes is sufficiently probable. The rapidity of progress observed in one instance, and its protracted duration in another, must be looked upon as exceptions to a general rule. The average duration of this pri- mary stage will, I think, be found in a period about intermediate between the extremes above mentioned. Although speaking doubtfully on this point, I am at least certain that the rapidity of progress within a given period increases in a direct ratio with the duration of the disease. Thus, for instance, if we compare two patients, one of whom has been suffering five weeks, the other eight, and whose symptoms at the time of our com- parison are as nearly alike as possible, we shall find that after a given time, say a week or a fortnight, a much greater progress has been made in the latter than the former. It is thus only we can explain a circumstance con- stantly noticed by such patients, that their symptoms were at the commence- ment comparatively stationary, or at most made but slight progress; that sub- sequently they became more and more rapid in their course, and latterly each day has sufficed to induce a well-marked increase in every symptom. We deduce from this fact an important practical precept—to lose no time in put- ting the patient under the specific influence of mercury, and this more espe- cially when the case has been at all protracted. The delay of a few days early in its course may be without ill effects, and will probably, in many in- stances, be advantageous, by giving time for the employment of important preparatory or auxiliary means; but where such symptoms have persisted for a much longer period, any considerable delay is likely to be followed by serious consequences; for the disease may thus advance to such a de- gree, as to place it out of reach of medical assistance. " Admitting the injurious influence of mercury upon the general consti- tution, yet having determined upon its employment for the removal of local disease, an object of no slight importance is to administer the medi- cine in such a manner as to obtain to the utmost the beneficial effects it is capable of producing upon the lung, whilst we avoid, as far as possible, the damage it may do to the constitution. The more immediate of the injurious consequences of mercury are fever, great nervous irritability or disorder of the alimentary canal, whilst the more remote, though not less important, morbid states are, in a great measure, dependent upon, and originate in, one or other of the three conditions just enumerated. To ob- viate, then, or diminish these as far as practicable, is our only chance for good. Much may be done in the way of prevention, by the employment of preparatory treatment—a point too much neglected in the present day, but to which the attention of the profession has recently been directed in a forcible manner by Dr. Colles. Fever, in the proper sense of the word, is a rare result of mercury in the scrofulous diathesis. It does, however, sometimes occur, and chiefly in those individuals who present more or fewer MERCURY IN SCROFULOUS AFFECTIONS OF THE LUNG. 527 of the indications of plethora—who have a firm, unyielding pulse, and other indications of the phlogistic habit. These, it must be confessed, are rare concomitants of the scrofulous diathesis: they frequently occur, however, in the form of pyrexia, as symptomatic of local inflammatory action ; but whether primary or secondary, their existence predisposes strongly to the occurrence of mercurial fever. In a primary or idiopathic state we rely chiefly on aperient medicines, saline diaphoretics, quiet, and low diet. These means, pursued for a few days, are usually sufficient to reduce all inflammatory disposition, and to pave the way for the mercurial course. But when originating in local inflammation, other measures, as blood-let- ting, either local or general, may be required in addition. This feverish condition, despite all preparation, will commonly occur in a greater or less degree immediately preceding the establishment of mercurial action on the gums. It is evidenced by the usual phenomena of pyrexia, and by an aggravation of the local symptoms, for the cure of which mercury has been employed. The application of a small number of leeches, and the admi- nistration of saline diaphoretics, will suffice to control these symptoms, which, however, either spontaneously diminish or subside on the establish- ment of ptyalism. As the more frequent consequence of mercury, wre no- tice nervous irritability, which, in the scrofulous habit, it is next to impos- sible wholly to avoid. A clear state of the intestinal canal, and a healthy aspect of the evacuations, are the conditions best calculated to ward off such a state. If not already existing, they should, therefore, be obtained by medicine ere the use of mercury is commenced. Notwithstanding this preparatory treatment, it will usually be advisable to combine either seda- tives or narcotics with the mercurial. A light bitter infusion may, in some cases, be advantageously substituted for or combined with the sedative. This practice is called for more particularly where, in addition to great debility, there is a clean, moist tongue, healthy condition of the excreta, and copious perspirations. Sarsaparilla often acts kindly as a soother of the irritable state of the nervous system, producing a greater tranquillity during the day, and more comfortable nights, than will any selection or combination of narcotics. To this end the infusion of Dr. O'Beirne, pre- pared with lime-water, seems peculiarly adapted. Disordered condition of the alimentary canal is a frequent accompaniment and cause of the ner- vous irritation above mentioned. It may, however, occur, per se, but whether alone, or in combination, its removal is a point of the first impor- tance in our treatment. Where there is reason to apprehend the superven- tion of this condition, the exhibition of mercury should be preceded by a mild, yet efficient laxative. Rhubarb with soda and a few drops of tinc- ture of hyoscyamus in an aromatic water, will here be found highly bene- ficial. Any irritation or uneasiness remaining after the free evacuation of the bowels, will commonly subside in a short time under the use of alka- lies with hyoscyamus and mucilage. Mercury, in its mildest form, should then be entered on, and its action may be guarded by combination with an alkali, as chalk, or with this and Dover's powder. "During the mercurial course attention to diet and regimen must be rigidly enforced. The patient should be placed on the farinacea, or milk; animal food, fruit, vegetables, fermented, vinous, and spirituous liquors, being altogether proscribed. He should inhabit a large, airy, well-venti- lated apartment, constantly maintained at one temperature, and, in addi- tion, should wear next the skin a fine flannel garment, enveloping the 528 CLINICAL MEDICINE. whole body from neck to foot. With the preparatory and concomitant measures now recommended, mercury will generally be well borne, and its use, wrhen once commenced, must be regularly continued until the gums become affected. From an irregular and indecisive administration of this medicine, ill effects will almost invariably result. Should it, there- fore, manifestly disagree, its exhibition must be immediately and finally desisted from. In other instances, where but slight phenomena of dis- order occur, it becomes a question, to be decided only by the circum- stances of the individual case, whether, despite of these, to continue its employment or withdraw the medicine and attempt to remove the cause upon which its injurious effects appear to have depended. In the latter instance we may, perhaps, be justified in once more resorting to its use; but if it again disappears, the medicine must be at once withdrawn, never more to be employed. " I have usually combined in one formula, with the mercurial, ipeca- cuanha and a sedative ; the frequent irritative and distressing cough com- monly attending this disease, proving, as it does, a constant source of dis- quietude through fhe day, and of restless nights, with the results of broken rest, are indications sufficiently clear (independent of those derived from the general habit) for the administration of sedatives. Hyoscyamus, or conium, are those which I principally employ ; but where these fail of producing the desired effect, recourse may be had to hydrocyanic acid, belladonna, the salts of morphia, &c. Ipecacuanha acts beneficially in freeing the expectoration, and I am inclined to think, determines the action of mercury more particularly to the bronchial mucous membrane. " However beneficially these measures may operate, it must not be for- gotten that the employment of mercury is but preparatory to other and more strictly curative treatment. After the removal or suspension of local disease by mercury, an equally or even more difficult task remains of cor- recting the cachectic condition upon which has mainly depended the local lesion. The patient, no less than the practitioner, should remember that from extreme and immediate danger he has only been snatched by severe and almost equally dangerous means ; that the same liability to local dis- ease exists as before, ready again to start into existence upon the applica- tion of the slightest exciting cause. One great object in administering mercury is to gain time for the employment of measures to restore the general health, by removing a local action which, allowed to continue, would give rise to such disorganization as quickly to place the patient out of the pale of cure, and long ere means calculated to work a salutary influ- ence on the constitution could take effect. Unless this truth can be fully admitted, and the practice to which it leads rigidly enforced, mer- cury should upon no account be administered. It does not fall within the purport of this paper to discuss the treatraent best adapted to the cure of scrofulous cachexia. This has, indeed, been so fully done by Sir James Clark, in his thirteenth chapter, as to leave nothing to be desired.* " WTith these prefatory remarks, I proceed to detail the nine cases * " Pilcarne, as quoted by Allen, Synop. Univ. Med., ed. v.. p. 159, Lond., pursued a prac- tice not unlike that herein recommended :—• Quamdiu tabes est in primo gradu et probahile est sanguinem 11011 esse extravasatum ulcusve nondum factum debet ante usam decoct: ex lignis et dum purgantibus utimur adhibcri mereuiius dulcis non quicem cum purgantibus simul eodem die sed sine purgantibus post aliquot dies.' PERIOSTITIS. 529 which I have subjected to the mercurial mode of treatment. Five of them have recovered ; one was temporarily relieved, but died subsequently of phthisis; three experienced little or no benefit from the treatment adopted. These, with the cases of the Dublin physicians, are twenty-one in num- ber, of which eleven were cured, three considerably benefited, six expe- rienced no relief, and in one, the medicine disagreeing, could not obtain a fair trial." I regret exceedingly that space will not admit of the insertion of the notes of Dr. Munk's nine cases of this disease treated by mercury. LECTURE XL. PERIOSTITIS. Gentlemen,—Before I enter on the subject of our intended lecture, I have to remark, that there are some cases in the hospital possessing considera- ble interest. Those to which I would particularly direct your attention, are three cases of pneumonia, in which the stethoscopic phenomena are palpably and distinctly marked. I am anxious that junior students should examine these patients, and with the*m commence the investigation of chest diseases, because the indications in the cases alluded to are so ex- tremely plain and obvious. Much of the discouragement which students experience in endeavouring to become stethoscopists, arises from the obscure and doubtful nature of the cases which are too often presented to them in the very commencement of this study. I would recommend beginners to examine, at first, the peculiarities of healthy respiration in boys, and then in adults, and never to apply the stethoscope to a diseased chest until they have been first informed, by some competent person, of the presence of well-marked phenomena. In one of the cases above stairs, the rale crepitant is exceedingly distinct; and having once heard it, you will always be able to recognise it with facility. There is also a man affected with phthisis, in whom the gargou- illement is so audible, that the merest beginner, on applying the stetho- scope under the clavicle, would say he heard the gurgling of air entering a cavity containing fluid. I point your attention particularly to this case, because its self-evident nature renders it highly valuable. We have also a well-marked case of haemoptysis, or spitting of blood, a term which I prefer to that of pulmonary apoplexy. This man had laboured under this affection for some time, and two days since spat, during the course of the night, about three pints of blood. There are many cases of cerebral dis- ease, vertigo, epilepsy, and paralysis arising from apoplexy, or following painter's colic ; so that those willing to instruct themselves will find the field for observation sufficiently ample. I shall now proceed to make some remarks on the general pathology and treatment of periostitis. I regret to state that the articles on this sub- ject in Cooper's Surgical Dictionary and other works are deficient in a practical point of view. It is a disease which has been known as long as syphilis ; but its true pathological nature was not pointed out until Sir Philip Crampton described it in the first volume of the Dublin Hospital 35 530 CLINICAL MEDICINE. Reports. We have frequently heard tenderness of the skin, with increase of size, termed swelling, or diseased growth of the bone ; but you will find that, in most of these cases, the swelling and other symptoms are owing to the peculiar state of the periosteum alone. Periostitis is a dis- ease of considerable importance, because its symptoms are produced by scrofula and other cachectic states of the constitution, as well as by the abuse of mercury and other remedies. You will have occasion to observe instances of this disease superinduced by cold, or by giving mercury un- der unfavourable circumstances, and in the latter case frequently con- founded with syphilis. This is an important fact, and you should hold it in memory. Another great mistake is, confounding it with neuralgia, or where it attacks the head, with hemicrania, because one side of the head only may be affected, and the pain may be increased at a stated hour, generally towards night. I have seen the carbonate of iron given in large doses by a medical gentleman of considerable eminence, to cure a pain in the side of the head, which arose from inflammation of the periosteum. Another instance of a similar kind has lately come under my observation in private practice, and once I committed the same mistake myself. Before I enter into the further consideration of this subject, I must state to you that an opinion was formerly entertained, that membrane or peri- osteum was the repairer of bone, where its regeneration was necessary. But in this process, the vessels of,the bone itself are as much concerned, and membrane contributes nothing to the formation of bone, except so far as its vessels are engaged. The formation of callus in fractures, the devel- opment of healthy bone in necrosis, the organization of node and exostosis, depend not on any membrane, but on the vascular part of the periosteum, and on the vessels of the bone itself. It is true, however, that where other vascular channels are cut off, the periosteum will, to a certain degree, supply their place, thus becoming the sole means of establishing vascular communication. It is to Scarpa we owe our information on the true nature of the reparation of bone. You will find, on this sub- ject, a great number of experiments detailed in Cooper's Surgical Dic- tionary. With respect to the periosteum, it is, like other parts of the system, lia- ble to inflammation ; but you are not to suppose that its liability is greater than that of other tissues. This would contradict the arrangements of nature ; for it is with this membrane she has clothed many parts of the body which lie close to the surface, as the shins, head, ribs, elbow, and other joints, which, besides the periosteum, have, for the most part, only a thin covering of integuments. You all know how frequently the peri- osteum is exposed to injury in the foot-ball matches at schools, and at our Irish fairs, and with how much impunity. I may observe here, that the term I shall employ in speaking of the affections of this membrane, peri- ostitis, is a name introduced by Sir Philip Crampton. Now, according to the view which I have taken of the formation of bone, it will appear that the subjacent bone is often as much diseased as the periosteum, and, indeed, sometimes the disease commences in the bone, and afterwards extends to the periosteum. With this exception, the definition given by Sir Philip Crampton is good. I beg leave to mention, en passant, that Mr. Howship's papers on the Formation and Diseases of Bone are deserv- ing of your perusal. He has examined and given delineations of the various structures of diseased bone ; but I do not consider his account of PERIOSTITIS. 531 the structure of bone to be sufficiently established to enable us to deduce important pathological facts. There are numerous interesting preparations, illustrative of this subject, in the Museum of the Dublin College of Surgeons ; and there is none who can do more towards improving our notions on the structure of bone than its late scientific curator, Dr. Houston. He has formed a classified cata- logue, in which a minute account is given of the pathological circum- stances of each case, and the attendant symptoms during life. I need not say this is a valuable acquisition to our stock of knowledge. In the course of our inquiry I shall communicate to you several useful hints on perios- titis, which I received from Dr. Houston. You will observe, gentlemen, that, in inflammation of the periosteum, the peculiar texture of this membrane modifies the symptoms of the dis- ease. The periosteum is fibrous, and, though not thick, is remarkably strong and unyielding, lacerated withjdifficulty, and does not accommodate itself, except to that which it was intended by nature to cover ; hence, if a part increases in size, the periosteum over it is stretched and tightened, and this is one of the principal causes of the severe pain usually felt. You are aware of the swelling which attends the common forms of inflam- mation of cellular substance, where the parts can extend themselves on every side, must be differently circumstanced from that which arises from abscess, under fascia, or lying close to a bone, and that there must be a corresponding difference in the pain. You will find, in various surgical works, that, in periostitis, the pain is sometimes great where very slight changes have taken place, and that little pain is felt in some cases where there is considerable alteration of structure. It is a remarkable fact, that, in many instances of periostitis, exactly corresponding parts of the bones of different extremities, on different sides of the mesial line, will be found simultaneously or successively attacked. Thus, if a certain spot on the bones of one fore-arm, or one acromion, or any other part of the scapula, be attacked by inflammation, similar ap- pearances will manifest themselves in the other, either at the same time, or in a few days after. If it seizes on one clavicle, you soon observe it in the other. You will have occasion to treat this disease in perhaps most of the human bones, but particularly in the head, tibia, femur, ster- num, and scapula. In the sternum it sometimes leads to a carious de- struction, forming a large hole in the bone, as happened in a young man, formerly in this hospital ; in his case, each stroke of the heart caused matter, mixed with air, to bubble out, presenting a very curious and frightful appearance. Periostitis, occurring in the neighbourhood of joints, often spreads to the joint itself, giving rise to periostitic arthritis. Thus, from the tibia, it frequently spreads to the knee, or ankle, and from the humerus, or scapula, to the shoulder-joint. The sternal articulation of the clavicle is a favourite seat of periostitis. In the ribs, it much more frequently attacks them in their anterior portion, not far from the sternum, or from their cartilages, and occasionally gives rise to costal caries, for which Cittadini has recommended a particular operation. I would re- commend you to hold in memory, that when the disease affects the thigh- bone, it is almost invariably about the junction of the middle and lower thirds, and generally on its anterior or inner surface ; this is a practical observation which I have not seen noticed in books.* There is also, in * Mr. Colles has, since this lecture was delivered, alluded to the occurrence of nodes in 532 CLINICAL MEDICINE. this form of periostitis, one peculiarity that, besides the very great severity ( of the pain which attends it, we find that it yields with the greatest pos- sible difficulty to medicine, and that the means of curing it are a deside- ratum we have still to discover. The next species, most remarkable for its painful symptoras, and one which deserves to be explained more fully, is periostitis of the head. There are three subdivisions of this species. The first kind is very easily recognised, for you will find the affected spots sore, slightly swelled, and hardened, with marked tenderness on pressure, and the headache, which accompanies them, radiating from these spots as from so many centres. In the second form you will find the pain obscure and not confined to a certain spot, but the swelling and thickening of the scalp are evident, and give certain indications of the nature of the disease. You may also observe cases where the inflammation is diffused over one side of the cranium, and not fixed to a small distinct spot, and these are attended with severe pain. With respect to these varieties, you will not find much difficulty in ascertaining their nature : but there is another kind in which the diagnosis is much more obscure. A patient, for instance, complains of severe headache, at first attended with intermissions, gene- rally increased towards night, and accompanied with a sense of weight in the head ; his eyes look watery afid heavy, and lose their usual animation, and his spirits are depressed ? Ask him in what part of his head he feels the pain, and he cannot tell you exactly. Sometimes he refers it to the fore- head, sometimes to the side of his head. There is no point of the scalp in which you can detect any soreness or swelling. Matters go on in this way for some time, he begins to lose his rest, the intermissions become shorter and not so perfect, and the pain increases. During the day it is tolerable, but, towards evening, it is excruciating, and does not allow him to enjoy one hour's rest in the twenty-four. The largest doses of opium, and other strong narcotics, are useless. Rest in bed, stupes, cold lotions, narcotic liniments, even bleeding and leeches, give but very small relief. After exerting all your ingenuity, you still have the mortification of finding that there is something wrong going on, which eludes your skill. On your first visit, from the appearance of the patient and the detail of his symp- toms, you are led to suspect that the brain is the part diseased. You employ your antiphlogistic remedies, but find no improvement, and begin to doubt the correctness of the diagnosis. Moreover, in cases of this kind (where you will find a tenderness in the integuments on close examina- tion, and pain limited to one side of the head), there is, occasionally, a partial ptosis of one eyelid, which creates alarm, and leads you to imagine that it is the brain itself which is affected. Ptosis, or falling down of the upper eyelid, is a very frequent symptom of cerebral disease ; and, con- sequently, in determinations to the head, in fever, and other complaints, it is a bad sign when one eye, in consequence of some degree of ptosis, appears smaller than the other. There is certainly some degree of para- lysis in this case, but it is only secondary, and not depending on the brain, but on the inflammation, affecting the nerves themselves. I men- tion this because it is not generally known or described, and because it is liable to excite alarm. Now, why is this disease not easily recognised, this situation, in his work on the Venereal Disease. He points out the many symptoms gene- rally supposed to characterize morbus coxce, which attend this affection, and particularizes the diagnostic features of the two diseases.— Vide Colles on Venereal. PERIOSTITIS. 533 or why is the bone so often devoid of tenderness to the touch ? It is because the internal surface of the bone is the part first engaged, and the disease cannot become evident until after some tirae. After your usual treatraent has been continued for a week or ten days with little improve- ment, a certain spot on the head will be found tender on pressure, and it is only then that the true nature of the case will appear. For this disease there is no cure but mercury iodine. However useful depletion may be to prepare the system, nothing but the seremedies in large doses will re- lieve the disease. Give a scruple, or half a drachm of calomel, in the course of the day, and bring the system thoroughly under its influence. You will do well to combine different proportions of this remedy, as there are some constitutions which are more quickly affected by one preparation than by another, and then combination is always valuable. It is very remarkable, that though you have made the month sore, relief is not im- mediately obtained ; you must go on and affect the system, very decidedly, and when you have accomplished this, the pain and other symptoms will disappear. Of this we have an instance in the chronic ward. A perios- titic patient had his mouth sensibly affected for several days, but with very little relief of pain. What did we do ? We doubled the dose of calomel, and in a few days the pains had altogether disappeared. You may have perceived analogous instances in cases of iritis, where the dis- ease begins to diminish on the mouth being made sore, and even may appear to have entirely subsided. Encouraged by this, the practitioner decreases the dose of mercury ; the mouth continues sore, but in a few days, although the small doses of calomel are continued, and although the mouth is still affected, the characteristic symptoms of iritis again recur, and go on increasing, if you continue to trust to the diminished doses of calomel. Under such circumstances, a beginner might be discouraged, and lose confidence in mercury, because the iritis had returned while the mouth was still sore, and before the remedy was discontinued. What is to be done ? Instantly resume the large doses of calomel, with a more decided mercurial action, and the iritis disappears.* In the mercurial treatment of periostitis, arthritis, peritonitis, and pleurisy, a similar me- thod of managing this remedy is occasionally required, and it is of vital importance that you should know this. With respect to that species of periostitis which affects the femur you must recollect, that this bone lies so deep, that it is sometimes not very easy to detect the periostitic swelling. Generally it is the part of the bone before mentioned which is attacked, and in the cases I have seen, the inflammation was on the inner side of the bone. From its situation, this species is very apt to be mistaken for various diseases, particularly neu- ralgia, sciatica, abscess in the shaft of the bone, morbus coxae, &c. After some time, a certain degree of tumefaction may be distinctly felt, but not until the patient has suffered excruciating agony and distressing want of sleep ; indeed in one case the poor sufferer scarcely slept at all for twenty nights in succession. One of these cases was relieved by corrosive sub- limate, but two others were not in the least improved by mercury pushed to the utmost. Narcotics totally failed, but a seton over the affected part seemed to do some good. But, to return to periostitis affecting the cranium; it occasionally assumes the chronic form, attacking both sur- * These are the kind of cases that have since been found to yield rapidly to the influence of spirit of turpentine, as first recommended by Mr. Hugh Carmichael. 534 CLINICAL MEDICINE. faces of the bone, in a slow insidious manner. The following instructive example of this affection fell lately under my observation :— A young man, of good constitution, previously healthy, becarae subject to epilepsy, very frequent and violent. Some time previously he had complained of headache, chiefly referred to the left side of bis forehead. The convulsions on the right side were stronger than on the left. He continued in this state for many months, and becarae incapable of pur- suing his usual occupation. The convulsions became more frequent, recur- ring at different times in the day ; and some of his medical friends thought they observed a prominence in the frontal part of the skull, and were anxious to have him trephined in that spot. On looking at him in front, you could not at once perceive any unnatural elevation in the forehead ; but, by examining it from above downwards, according to the norma verticalis of Blumenbach, there was a perceptible swelling, as if the whole bone had been pushed forward in that situation. After seven months' illness, he was seen by Dr. Colles, Sir Philip Crampton, and myself. We objected to his friends' proposal to trephine, because we could not be certain that there was any projecting growth of bone pressing on the brain in this place, and because it had a certain degree of tenderness on pressure. WTe were afraid, also, that there was an intimate union between the internal periosteum and the dura mater, as well as between the latter and the surface of the brain ; consequently there was danger that the operation might induce inflammation in all these parts. Considering it to be a case of internal periostitis, in which the inner table of the bone and corresponding part of the dura mater were affected, we agreed to try the effect of mercury. We employed frictions for this purpose, as the internal exhibition of mercury produced sickness and vomiting; and at the end of eight or ten days, when the mouth became affected, we had another consultation. We were told there was no improvement; the fits still continued ; his friends exclaimed that mercury was useless, and called for the application of the trephine : we were almost in despair. On closer inquiry, however, we found that though the fits had displayed the same violence, there was some slight diminution in their frequency, and on this slender hope we urged the continuance of the same remedy. As soon as his system was completely affected, the disease began to decline percepti- bly, and he became free from pain, and the convulsions ceased. When the vertebrae become the seat of periostitis from syphilis, scrofula, or abuse of mercury, it will be generally found in the bodies of the verte- brae. When brought on by syphilis alone, I believe, it seldom attacks the bodies, such cases arising chiefly from the abuse of mercury or scrofula. In persons of broken constitution from combined venereal and improper mercurialization, it is not an uncommon occurrence to find the neck pre- senting the symptoms of subacute crick, or collum obstipatum, which, if treated in the common mode, the disease becomes confirmed ; and of this I have seen an instance in a gentleman, whose neck became permanently stiff for want of skill in his medical attendants. It will be obvious that inflammation of this kind, affecting the vertebrae, may be readily com- municated to their ligaments and the adjoining tendons, and in this way produce the deformity. I have treated some such cases, and would turn your attention to it, because you will not find it mentioned in books. You will be able to know it by careful examination, by pressure, and find that its cause was disease of the periosteum of one, two, or three of the PERIOSTITIS. 535 vertebrae ; and you will employ, in treating it, leeches, repeated blistering, and compound decoction of sarsaparilla, with hydriodate of potash. If this does not do, mercury, and, except the disease has continued too long, you will cure it. Other vertebrae, as those of the back and loins, raay become the seat of periostitis, and it may be mistaken in those cases for Pott's disease, or for Teale's spinal neuralgia, from which it is sometimes difficult to distinguish it. Periostitis sometimes attacks the sacrum and os coccygis, and is then peculiarly painful, as is now exemplified in the male ward. In females, I have been twice consulted within the last year for a pain in these same parts, which was at times excruciating, and always considerable ; it was increased to an intolerable degree by sitting down, and hence they were obliged to avoid society. It appeared to be a variety of hysterical neuralgia, and yielded to nervous medicines com- bined with tonics, together with the local application of stupes, narcotic liniments, &c, &c. I know not whether authors have mentioned this peculiar neuralgia. When periostitis attacks the sternum, it is very liable to be mistaken for disease of the chest. I remember a young gentleman, some time ago, who had a severe pain in his chest, which gave his father such alarm, lest it might be consumption, that he brought him with him to London for the benefit of change of air and to have medical advice. On his way thither he caught a cold, and in this condition waited on a medical gen- tleman, who prescribed medicines for him adapted to the cure of pulmo- nary disease. On his return to Dublin (his pain still continuing) I was called in to treat him for a complaint in the chest. On placing the steth- oscope over the spot where he complained of pain, he winced, and, after a minute examination, I discovered that the disease was entirely con- fined to the periosteum. It is possible, however, that in such cases, the disease may ultimately reach the chest, for the sternum is a very porous and spongy bone, and a complete perforation of its substance may be the result of periostitis long continued. Another way in which it may be confounded with rheumatism of the intercostal muscles, or pleurisy, is where periostitis attacks the ribs. This is a very common source of pain, tenderness, and stitch of the side. There is a form of periostitis which extends from the bones of the foot to the plantar aponeurosis; it is found chiefly in labouring men; and the predisposition to it seems to arise from the use of the spade in digging. I do not know that this form has been mentioned by any author I am ac- quainted with. The following symptoras are generally present. The pa- tient complains of excessive pain in the sole of the foot, extending into one or both malleoli whenever he attempts to lay the plantar surface flat on the ground, and in order to save himself, he walks either on the heel or outer edge of the affected foot, the toes of which are strongly contracted, so as to relieve the tense condition of the plantar fascia. The pain is much in- creased wThen pressure is made in the centre of the sole or on one of the malleoli, these latter processes being generally enlarged, and accompanied with swelling of the adjacent parts. Besides the pain produced by pres- sure on the plantar surface, the patient generally suffers from lancinating pain through the ankle-joint. This disease is one of frequent occurrence, and many cases of it are admitted every winter into the Meath Hospital, where it is familiarly known by the name I have given to it, viz., " Plantar Rheu- matism." The most severely painful instance of all the varieties of peri- 536 CLINICAL MEDICINE. ostitis is, perhaps, the paronychia periostei, or bone-whitlow, to which, as it belongs to surgery, and its treatment is well known, I shall merely allude. I shall now enter into the consideration of the special pathology of pe- riostitis. This disease may be divided into two kinds, the diffused and the circumscribed. With the former we have nothing to do, it is never found in the medical wards, and comes properly under the care of the sur- geon. It may, however, be well to mention its chief characteristics. By diffused periostitis I mean that form which occupies a large portion of the periosteum, which arises from cold, accident, and other similar causes, which has no connection with, or dependence on particular states of con- stitution, or specific diseases, and which frequently terminates in necrosis. The other species, which comes more immediately under the care of the physician, I have termed circumscribed, from its comparatively small ex- tent. Circumscribed periostitis may arise from cold, but, in the majority of instances, its origin may be traced to some specific cause, as mercury, syphilis, or scrofula. It is a much more frequent disease than the former, and presents several varieties. In the first place, it may exist without detachment of the periosteum from the subjacent bone. Here the perios- teum becomes inflamed and thickened, while the bone beneath assumes a greater degree of vascularity and consequent increase of size. By this process, which is always comparatively slow, the connection between these parts is increased, and the tendency of the augmented vascular action is to form depositions. Hence, the thickening of the periosteum is some- times very great, and, in process of time, forms a very considerable cir- cumscribed tumour, which to the touch feels so solid, that it is often mis- taken for bone. In this stage of the inflammation, pain and tenderness are complained of in the affected part, and we sometimes find the integuments swollen and discoloured. Matters, however, after some time, assume a more chronic form, and the intensity of the symptoms diminishes, there is little or no tendency to grow larger, and the pain and tenderness undergo a change for the better, though they do not cease altogether. It is at this period that the periosteum, previously thickened, becomes more dense in its structure, and in some cases seems to be almost converted into a fibro- cartilaginous tissue. When this change has been effected, it is doubtful whether the diseased mass is ever again absorbed, though it must be con- fessed, that swellings, whose history and physical characters strongly in- dicate their having undergone this change, occasionally disappear altoge- ther in the course of a few months. Many instances will occur in the prac- tice of medicine, where cartilage, or even bone are absorbed under other circumstances, evincing the value of proper treatment, or the efficacy of unaided nature. To recapitulate: inflammation of the periosteum, attended by deposition and thickening, without effusion of fluid, by increased vas- cularity of the subjacent bone, and adhesion between it and the perios- teum, after remaining for some time, will be found to decrease in the vio- lence of its symptoras, and to assume a fibro-cartilaginous hardness, and in this state it may be absorbed or not. That it may be absorbed, we are led to expect from analogy; for we see frequent instances of the absorp- tion of cartilage and bone ; but it will be often found to continue for life, and in some instances, to be converted into a true body node. It is worth your while to consider how the latter process takes place. Ossification commences in the thickened periosteum, and bone is formed, constituting PERIOSTITIS. 537 in general a circumscribed bony node which rises from the external sur- face of subjacent bone. In process of time the external lamina of the true bone becomes absorbed, and at the same time, a cancellated structure is developed in the node, which becomes continuous with the cancelli of the bone beneath, and thus there is formed on it a kind of bony arch. We are not able to ascertain at what period this takes place; but you will find instances of this formation in a state of progress in Mr. Howship's account of some specimens in Mr. Heaviside's museum, in which he discovered that the external surface of the old bone was not quite absorbed, and that no cancelli were as yet formed. A considerable disfigurement is frequently the consequence, where this affection attacks various parts of the same limb; and you may have observed a man in the chronic wards, in whom the shape of the tibia is lost from this cause. A recurrence of those attacks gives rise to several irregular and partial elevations on the bone, which blunt its edges, and fill up its natural concavities, so as to leave scarcely a vestige of its original symmetry, a circumstance which may be frequently observed in the deformed tibiae of prostitutes. You observe, gentlemen, in the first stage of this disease, the thickened periosteum presents a uni- form density, but in process of time a cancellated structure makes its ap- pearance in their deep-seated portion, while, as in the natural shafts of long bones, a layer of firm osseous structure constitutes their surface. It is obvious, therefore, that in the first stage there is a distinct line of demar- cation between the new and the original structure; while, in the second stage, no such distinct boundary exists, the cancellated portion of both being perfectly identified. The next form of periostitis is that which is attended with detachment from the subjacent bone, of which there are several varieties. In the first kind, you find that, in a space varying from twenty-four hours to eight or ten days, an elevation appears on some part of a bone, with pain and tenderness on pressure, and forming a hard tumour, giving to the touch the feeling of a solid substance. This error may be detected by a more accurate examination, and there will be some elasticity discovered in the swelling. * The cause of its seeming to be a solid tumour arises from the manner in which the periosteum is tensely stretched over the effused fluid. In the second stage of this variety, there is a gradual diminution of the pain and swelling ; the fluid, which was effused under the perios- teum, is absorbed, and the subjacent bone and periosteum become again united. This process generally occupies some time ; but there are instances where its accomplishment is more speedy. Of this nature are the tumours which arise and disappear with such rapidity on the scalp and elsewhere, which yield quickly to leeches and blistering, and after exist- ing for some weeks, or perhaps even days, vanish, and leave no sensible trace behind. The pathological distinction of these tumours consists in this: that the surface of the subjacent bone does not die, and, conse- quently, the process of reparation is short ; for when the effused matter is absorbed, there is nothing to prevent the adhesion of the bone and peri- osteum. The variety just described is not attended necessarily with ulceration of the skin ; but there is another kind, in which effusion, as just described, takes place, accompanied by increased vascularity on the surface of the bone beneath. The matter effused at length escapes through an opening, made by ulceration in the integuments, and nature effects a cure by means 538 CLINICAL MEDICINE. of granulations, arising from the vascular surface of the bone, which, uniting with granulations from the periosteum and integuments, repairs the breach of substance, and produces consolidation of the separated parts. In the next variety, matter is effused beneath the periosteum, and the bone of the affected portion becomes vascular at a little depth, while the surface is white and dead, consisting of a thin, worm-eaten, cribriform lamina, which, after some time, separates and opens for itself a passage through the integuments. This exfoliation is followed by a growth of granulations from the vascular bone beneath, and the process of healing is perfected in the manner before described. In some instances, the dead lamina is not thrown off at once, but undergoes a very curious process, being perforated, and as if worm-eaten, and thus allowing the granulations thrown out by the healthy bone to pass through its structure until the whole of the disorganised plate is removed. Such are the chief varieties of periostitis, exclusive of that species which is observed in scrofula, and which, from the disease simultaneously affecting the bones and perios- teum, can scarcely be called periostitis. In some vitiated and cachectic constitutions, the periosteum becomes affected, in consequence of ulcera- tion commencing in the skin from rupia, boils, or ecthyma ; this, how- ever, I shall not enter into at present. With respect to the derangement which takes place in the skin, it always bears proportion to the internal ulceration, and in the first species mentioned there is scarcely any. In the other kinds, it is of great use at the commencement to cut down to the bone through the integuments and periosteum, as recommended by Sir P. Crampton ; for this practice, by lessening the inflammation, limits the quantity of bone which is about to die, and consequently the extent of integument likely to be removed by ulceration. When we come to consider periostitis, and investigate its causes, we find that it frequently arises from specific poisons, as scrofula, mercury, or syphilis. You have many opportunities, in the surgical wards, of be- coming acquainted with the characteristic marks of that form which owes its existence to scrofula ; it is generally milder in its symptoms ; there is less pain and tenderness ; the swelling is less ; and it is most commonly observed in young persons, in whom we cannot suspect the operation of syphilitic or mercurial causes. I do not, however, mean to say, that you will not find the latter causes combined with scrofula, even in very young persons ; but such an occurrence is rare. But where this disease occurs at later periods of life, you are sometimes puzzled to decide whether it is a consequence of syphilis, or whether it is superinduced by mercury. When called to a case of this kind, inquire accurately into its history, and if you find that the person has taken mercury for the cure of primary or secondary symptoms, that it cured the disease, and the cure was de- cided ; that in a week, a fortnight, or a month after this the patient was exposed to cold ; that a great number of spots are simultaneously affected, and in corresponding parts of the limb,—you will be led to conclude that the disease is mercurial periostitis. About a week ago, a young gentle- man called on me with several periostitic swellings on his bones. I said to him, " You were taking mercury within the last six weeks." He said he was. " You then went out and got cold." He said he had ; and in this way I extracted from him the history of his complaint, and guessed it with such accuracy, that he stared at me as if I had a hundred heads. PERIOSTITIS. 539 Such a case as this, gentlemen, arises from cold affecting the constitution, while under the influence of mercury. But there is still a more perplex- ing one ; you may have mercurial periostitis mixed up with venereal symptoms. This is no uncommon thing among persons advanced in life, who have had frequent attacks of venereal, and undergone repeated courses of mercury. You have the two diseases blended in a very com- plicated form, and then indeed are we placed between Scylla and Cha- rybdis, mercurial action producing a cachectic state of constitution, and venereal a diseased state of certain parts. Moreover, you are all aware every thing that impairs the constitution has a tendency to bring on scro- fula. Now, take a person who is suffering from syphilis ; deprive him, as you often must (from the confinement a mercurial course requires), of pure open air, keep him on low diet, and what is the consequence ? To the syphilis and mercurial cachexy, you have scrofula frequently super- added, and that hideous combination of disease which we sometimes meet with at the present day, but fortunately not so often as formerly. Some years ago, all such cases were mercurialized—often to death. .In the wards of the Lock Hospital in this city, the progress of the patient towards cure was calculated in proportion to the number of pints he spat during the day. In the skulls of persons who lived during the last century, pre- served at Leyden, the destruction of the bony tissue is extraordinary : indeed, a phrenologist would be often puzzled by the havoc made by disease among the organs of our forefathers. An old writer, I think it is Herodotus or Zenophon, says, that the skulls of the Egyptians, lying on a field of battle, could be recognised by their hardness. Those of the last century, it seems, we can distinguish by their softness. This is no longer the case ; longevity, in the present century, is remarkably increased; and I think there are some countries which will be considerably raised in the scale of population from the improvements introduced in the treatment of venereal ; for this we are chiefly indebted to English surgeons and phy- sicians. Much credit is due to Sir Thomas Moriarty, Mr. Mathias, Mr. Carmichael, and other surgeons, who were the first in pointing out the baneful effects of excessive courses of mercury. Dr. Thomson, of Edin- burgh, has also done a great deal in promoting our knowledge on this point. It is but justice to mention, while speaking on this subject, the valuable and important services of our fellow townsman, Mr. Carmichael. WThen he first published his observations on the treatment of venereal disease, his opinions were looked upon as merely theoretical by most of the surgical profession here, and his practice industriously decried. I do not go so far as to admit all that Mr. Carmichael has advanced ; but it is from him we first received abundant proofs, that the majority of the cases of syphilis can be cured without mercury, and this is highly important. To the knowledge of this fact, to the more judicious employment of mer- cury, to the introduction of vaccination by Jenner, at the beginning of the last century, and to the general improvement, not only in diet, but also in medical and surgical treatment, we are to attribute the increased lon- gevity of the present period. Human life had almost doubled, and we began to hope that in 1900, it might be quadrupled. The mortality in London decreased in the proportion of 15 per cent., and the profits of Insurance Companies declined. In Dr. Hawkin's book, which was pub- lished in 1829, you will find that he strongly expressed his gratification and delight at the cheering prospect which lay before us ; and we were 540 CLINICAL MEDICINE. all ready to sympathize in his anticipations, when, unfortunately, the cho- lera came, and brought us back to our original position. But to return to our subject. It is unnecessary for me to bring proofs in support of the opinion, that mercury alone brings on diseases of the bones. You are aware of the case of a man named William Byrne, in this Hospital, who got mercury for disease of the liver, and returned in a fortnight after he was discharged with periostitis. Dr. Lendrick had a case of poisoning by corrosive sublimate some time ago. The stomach pump, and white of egg, succeeded in saving the man's life, but he got a severe attack of periostitis. I shall now detain you for a short time in speaking of the treatment of periostitis. As to the local means, you will find much good from leeching, and blisters dressed with mercurial ointment, particularly when the disease is recent, and the inflammation circumscribed. I have also found the greatest benefit from mercurial inunction over the affected part. If the blisters produce but little effect, try the tartar-emetic ointment; I have found it useful where blistering failed. In obstinate cases, Sir P. Cramp- ton's plan of cutting down to the bone may be had recourse to. When a periosteal node breaks and matter is discharged, and you observe the bottom of the sore covered with pale unhealthy granulations, or a piece of diseased bone lying in it which ought to be detached, introduce a stick of nitrate of silver, and touch, not the whole, but some given part of the surface every day, and you will produce a rapid improvement in its ap- pearance. This treatment was introduced by Mr. Nichol, and you will find a detail of it in the Edinburgh Med. and Surg. Journal deserving your atten- tive perusal. As to the general treatment of periostitis, where the constitu- tion is strong, and there is no objection to the use of mercury, this remedy, in the form of corrosive sublimate, affords a very certain and speedy relief, having premised venesection and leeching. Even when the disease arises after a course of mercury, or in consequence of syphilis, where its symptoms are violent and the constitution is strong, the rapid introduction of mer- cury is the best treatment you can adopt. This is particularly suited to that painful species of cranial periostitis which I have described, and which scarcely yields to any other remedy, and also to those cases where the disease attacks the shaft of the femur. In both of these affections the mercurialization, to be effectual, must be carried to decided salivation, and must be continued for three or four days after the mouth becomes sore, though you will meet some cases which yield before salivation. This, however, is an uncommon occurrence. Where the symptoms are less violent we may content ourselves with Plumraer's pill or blue pill, in alterative doses. In persons of delicate habit, who are much worn out by disease, and where all other means fail, corrosive sublimate sometimes succeeds, or De Velno's vegetable syrup. The latter acts on the constitu- tion in a mild and beneficial manner, and I have seen many persons restored to health by its agency. W"e must never forget, however, that there is a material objection to the use of mercury in hospitals among the poor; for, on returning home, they are almost invariably exposed to fatigue and cold, have consequently a strong liability to relapses, and are then of course worse than before. This unfortunate occurrence may be generally avoided among the wealthy, and to them the mercurial cure is therefore more applicable. Besides mercury, the most effectual remedies are colchicum and tartar emetic, but particularly hydriodate of potash. You PLEURO-PNEUMONIA. 541 will find, that after bleeding or leeching, by employing colchicum with narcotics,as, for instance, the wine or tincture of the seeds of colchicum with Battley's sedative liquor, or black drop, combined with magnesia, you will produce a very powerful effect. You are aware of the power which colchicum produces in subduing inflammatory affections of the heart, and also of the joints, and it must be looked on as a very valuable remedy. You have, in addition to this, the different antimonial prepara- tions. The antimonial wine and James's powder will be particularly serviceable. You cannot combine colchicum with antimonials, in conse- quence of their effect on the stomach, but you can combine either of them with narcotics. During the whole course of the disease you must employ narcotics ; they relieve pain, and are to be used plentifully, but with dis- crimination. When the disease becomes chronic, give sarsaparilla with nitric acid. The latter enhances the value of the sarsaparilla, though we are unacquainted with its modus operandi. You have, therefore, gen- tlemen, four modes of treatment, first the mercurial, which, where it is admissible, is the most speedy and effectual ; next, the antiphlogistic, consisting of bleeding, leeches, colchicum, antimonials, and narcotics ; thirdly, the chronic treatment, which comprises sarsaparilla and nitric acid with narcotics, change of air, and time, and fourthly, that by hydrio- date of potash, either by itself, or what is better, combination with sar- saparilla. Postscript.—When these lectures were delivered in 1832-3, I was not so well acquainted with the great utility of hydriodate of potash, in periostitis, but I have since made most ample trial of it and am convinced that it possesses greater power over this, than almost any other disease. It is of extreme service in all forms of periostitis, whether arising spon- taneously, or as a symptom of syphilis, rheumatism, or abuse of mercury. The same rule should be observed, which was before laid down, namely, to increase the dose gradually, until a decided impression is made on the disease. I shall refer briefly to some points connected with the case of an old man in the chronic ward, who died lately of inflammation of the lung. At the period of his admission, he had been ill for some time ; both sides of the chest, but particularly the left, sounded dull on percussion ; he had extensive bronchial respiration and crachet rouille, in fact, it was a very bad case of double pneumonia, a disease which at his time of life is very seldom cured. WTe did all we could to arrest the progress of the disease ; we cupped him over the left side, gave him mercury so as to affect his system, and applied blisters to both sides of the chest, anteriorly and posteriorly. These were the only active measures which remained for us to employ ; from the man's age, the weakness of his pulse, and the duration of the disease, we could not venture on general bleeding; we could only attack the disease with local depletion, mercury, and counter- irritation. All these remedies were applied with great diligence, but unfortunately proved incapable of checking the disease. His cough con- tinued, respiration became more difficult, and though his mouth became affected, the dulness on percussion increased day after day ; and though the patient was removed into a warmer room, and every attention paid to his comfort, it was evident that he was getting gradually worse. About 542 CLINICAL MEDICINE. a fortnight after his adraission, his expectoration assumed the purulent character, and it was obvious that the lung had passed from the stage of hepatization into that of interstitial suppuration. He took the decoction of polygala, with Iceland moss and syrup of white poppies, but without any relief to his symptoms ; the disease increased, and he died on the nineteenth, sixteen days from the date of his admission. On examining the lung, the ordinary phenomena of pneumonic inflam- mation were discovered ; parts of the lung were in the state of grey he- patization, others were infiltrated with pus, and broke down easily under the finger. We found, too, that he had not only pneumonia, but also extensive pleuritis and pericarditis. The pleurisy had probably com- menced about eight or nine days before his death ; the pericarditis was of an origin somewhat more recent. You may ask why I did not recognise these affections before death. The reason is twofold. The man was in a very weak and hopeless con- dition, and both sides of his chest were sore from the blisters ; these are circumstances under which I have strong objections to torment a patient with examinations, and therefore I made none in this case. The other reason is, that in a patient who has been greatly reduced by some acute disease, new inflammations are apt to spring up with great rapidity, and with still greater latency. I remember a very remarkable case of the same description which occurred at the Meath Hospital, where the patient had a very extensive inflammation of the pleura with exudation of lymph and effusion of a considerable quantity of fluid, and yet not one of these symptoms was recognised during life. This man, you will recollect, never complained of pain in the side, nor had he orthopnoea, irregularity of pulse, lividity of countenance, or any of those symptoras which are looked upon as indicative of pericardial inflammation, yet on dissection we find the pleura extensively engaged, lymph exuded on its surface, and a small quantity of sero-purulent effusion in its cavity ; and on ex- amining the heart, we find the pericardium covered internally with an extensive gelatinous layer, consisting of lymph and puriform fluid inti- mately mixed together. You perceive, then, in this case, a confirmation of what I have so often insisted on, that pleuritis may occasionally run through its course, unaccompanied by pain in the side, and that inflam- mation of the pericardium may exist without orthopnoea, irregularity of pulse, lividity of countenance, or fainting, symptoms formerly believed to be more or less manifest in every case of pericarditis. The pathology of pericarditis has been investigated but lately with the care it deserves: the labours of our French brethren have been mainly instrumental in pro- ducing its present degree of advancement. In England some valuable observations have been contributed by Dr. Elliotson and others, but they have been more than rivaled by the contributions to the diagnosis of this disease, which have appeared in the Dublin Medical Journal. To return to our subject. Pericarditis is a disease of quite as frequent occurrence as pleurisy, and often, as in the present instance, associated with the latter ; on the whole, I do not consider pericarditis as more dan- gerous or more difficult to cure than pleuritic inflammation, neither does its existence seem less easily ascertained. Some cases, it is true, are extremely insidious in their nature, but the same may be said of cerebri- tis, pneumonia, and all other phlegmasiae ; usually, however, a careful and attentive physician will at once detect the existence of pericardial in- PLEURO-PNEUMONIA. 543 flammation. When he finds that a patient has been exposed to causes capable of exciting fever, that he has been liable to gout or rheumatism, or has been actually attacked writh either, then will his attention be directed to the heart; if he perceives that its action is either unusually violent or irregular, or if he observes that uneasiness and oppression of chest are complained of to a degree not to be accounted for by any pul- monary lesions present; if he finds that his patient has the appearance of a person labouring under some serious disease, and that none such exists in the lungs themselves, then will he be called on to examine the region of the heart with the greatest accuracy. One of the most common symp- , torus of pericarditis is tenderness in the intercostal spaces over or near the heart. This is not perceived in many cases until pressure is made with the fingers. Tenderness occurs in many who do not complain of pain or stitch in this portion of the chest; when the latter coexists with ten- derness, the presumption in favour of the presence of pericarditis is still greater. The pain and uneasiness about the heart, are, as Dr. Elliotson remarks, generally increased by pressing in the left hypochondrium, up- wards towards the diaphragm. I must refer you to Dr. Stokes's and Dr. Mayne's papers for any analysis of the physical signs derived from per- cussion and auscultation, and also for an explanation of the reasons why the general symptoms are subject to' such striking variations in this dis- ease. In some you have, soon after its commencement, lividity, ortho- pnoea, and tendency to fainting, combined with irregularity of pulse ; in others the disease runs its whole course, whether it terminates fatally or in health, without any of these symptoms ; in fact, no disease is more inconstant in its characters, and none more requires the aid of investiga- tion by means of physical signs, which, if well-conducted, seldom fails to clear up all doubts. Of one thing I am certain, that inflammation of the pericardium in a person of tolerably good constitution may be generally arrested in its progress by bleeding, frequent leeching, and scruple doses of calomel. It is mere trifling on such occasions to have recourse to tar- tar emetic, digitalis, or the common antiphlogistic remedies. Instantly use every effort to produce the full action of mercury on the system. Apply the ointment to the axillae; smear it over the inside of the thighs ; make your patient respire the vapour of hydrargyrum cum creta as often in the day as he can bear the process, and be assured that you are pursu- ing the proper course. Well has it been observed by Dr. Elliotson, when speaking of a fatal case of pericarditis,—" The only chance I had to save the life of this person would have been to have pushed the mercury fur- ther. I am quite sure that more lives are saved in inflammatory diseases by carrying mercury to a great extent, than by merely having recourse to it for the simple production of ptyalism." It is the want of decision in the practice of the French physicians—it is to their want of confidence in mercury, that we must attribute the greater mortality of pericarditis in Paris than in Dublin ; for most of our patients recover, most of theirs die. Of course, gentlemen, the most unfavourable of all cases is where peri- carditis attacks a person debilitated by previous sickness, such as fever, dropsy, &c. Here the disease runs a very rapid, and too often a fatal course, and cannot be controlled. One practical remark, and I have done. Before effusion takes place into the pericardial sac never apply a blister ; after it has occurred, repeated and severe blistering over and about the region of the heart is one of our best remedies. 544 CLINICAL MEDICINE. Two years ago I had an opportunity of studying a case which subse- quently proved to be an example of inflammation of the muscular sub- stance of the ventricles, ending in suppuration and the formation of a large abscess in the ventricular parietes. This is a very rare occurrence, for the simple reason, that inflammation of the substance of the heart generally proves fatal before pus is formed. A very robust gentleman, aged fifty- five, from the neighbourhood of Wicklow, came to Dublin for the benefit of advice. He had complained of cough for many months, together with dyspnoea and palpitation of the heart ; latterly he had become anasarcous, and suffered much from distress and pain referred to the region of the heart. This pain formed the chief subject of his complaint, and darted over the chest. On examination, I immediately detected hypertrophy and dilatation of both ventricles, and I announced the existence of val- vular disease, inasmuch as a loud and extensive bruit de soufflet existed, together with a remarkable fremissement cataire, and a very irregular pulse. This opinion w7as delivered in the presence of Dr. Sherwood and Mr. Hetherington. Our patient returned to the country, where he con- tinued to complain of pain in the heart that was at times excruciating. He died suddenly at the end of a few weeks. The results of the post- mortem examination were kindly communicated to me by Dr. Sherwood. Considerable dropsical effusion into both pleural cavities ; heart exceed- ingly enlarged. " On slitting open the pericardium, I found (says Dr. Sherwood) that the heart adhered to its entire surface by means of bands of coagulable lymph, which were easily broken down except at the apex of the heart, where they were very strong and firm. In attempting to break them, more than two ounces of purulent matter escaped into the cavity of the pericardium, which caused me to institute a very close ex- amination of the parts, in order to discover whence the pus came. I found a small rent in the apex of the heart, immediately below the floor of the left ventricle, exactly in the situation of the firm adhesions before spoken of. On enlarging this opening, Idiscovered a cavity in the sub- stance of the heart, with a regularly-defined wall, capable of containing more than two ounces of fluid. The walls of both ventricles were enor- mously thickened ; all the valves were more or less affected ; but the chief disease lay in the semi-lunar valves of the aorta, which were nearly altogether ossified." This case was extremely remarkable, and exhibits an example not merely of the dropsy and dyspnoea which so usually attend hypertrophy and valvular disease of the heart, but also of a combination of chronic pericarditis and chronic inflammation of the muscular substance of the ventricles, ending in the very rare termination,—abscess. Having made these observations, I shall next call your attention to the disease of Francis Thorpe, which is important both in itself and from the circumstance of such cases being frequently met with. This lad, who was much exposed to the weather, being an outside servant, was attacked about six months ago with cold, followed by hoarseness and sore throat, with cough, then slight, but at present rather troublesome. A certain degree of rawness about the fauces was observed soon after the attack, and latterly the sub-maxillary glands have become slightly enlarged. On looking into the throat, the velum and fauces appear redder than natural, the amygdalae are swollen, and the mucous membrane covering the back and sides of the pharynx is dry, and covered with irregular superficial CHRONIC LARYNGITIS. 545 excoriations. The hoarseness still continues, and he can only speak in whispers. His general health, however, does not seem in any degree impaired ; he has no fever, his appetite is good, and his sleep natural. This case, however, is one which demands particular attention. A boy is attacked with cold ; he gets slight local inflammation of the fauces and larynx ; this produces cough and hoarseness, which go on for months rather increasing than diminishing, and his symptoms finally assume a chronic and intractable character. Still he does not fall away in flesh, has no symptom of hectic, and, on examining his chest, you cannot find any evidence of the existence of tubercles. In making the prognosis in such a case, you should always act with great caution. Though an ex- amination of the chest should detect no distinct sign of tubercles, and a review of the state of the constitution should satisfy you that there was no fever, night-sweats, or wasting of flesh, yet the obstinacy and persist- ence of the inflammatory condition of the larynx and fauces would seem to show that the affection, though not decidedly of the scrofulous charac- ter, was still very analogous to it, and might end in phthisis. You should not be so sanguine as to anticipate a certain cure, because the cough and laryngeal symptoms are unaccompanied by fever, or by stethoscopic phe- nomena, indicating the approach of phthisis. The disease, by fixing itself in the larynx, and keeping up a constant irritation in the neighbourhood of the lungs, would probably, after some time (if exacerbated by fresh colds, and confirmed by neglect), give rise to tubercular development. Allow me to allude here briefly to a form of chronic laryngeal inflam- mation which has been described under the name of phthisis laryngea. Of this disease there are two varieties. In one case the hoarseness and sore throat follow the development of tubercles in the lung ; in the other they precede it. Consumptive persons very frequently get, shortly after the occurrence of scrofulous inflammation of the lungs, sore throat, hoarse- ness, and laryngeal cough. But this is different from the hoarseness and cough which precede phthisis. In the former, the laryngeal symptoms are secondary, and form only a part of the general disease ; in the latter, they constitute the first link in the chain of morbid action. The former take place only in a constitution decidedly scrofulous ; the latter occur most commonly in constitulions which have been impaired by various debilitating causes, and thereby rendered analogous to, or identical with, the scrofulous. One disease, however, explains the other; for it is clear that if a certain state of the constitution is capable of occasioning scrofu- lous inflammation of the lungs and tubercular development in the pulmo- nary tissue, in the first instance, and laryngeal disease in the second, it is clear, I say, that the order of succession may be very easily inverted, and, that in such a constitution, the accidental circumstance of a cold falling on the larynx, may determine the appearance of disease in that part long before the lungs become engaged. Hence, whenever you are called on to treat a case of chronic laryngitis, where the disease has lasted for any length of time, and where the patient's system has been impaired by any debilitating cause, or where you have any reason to suspect that he is of a strumous diathesis, your prognosis should be always guarded. You should not, however, give up the case at once ; particularly if an examination of the chest assures you that there is no scrofulous deposition going on in the lung. In the first place, endeavour to remove the inflam- mation of the throat, if possible ; by doing this, you will accomplish a 36 546 CLINICAL MEDICINE. vast deal: and in the next, you should direct all your efforts towards im- proving the state of the constitution ; for in this way you raakethe greatest progress in checking the tendency of the individual to scrofula. If there be much tenderness of the larynx on pressure, as you can easily ascertaiu by placing your finger and thumb on each side of the thyroid cartilage, pressing the larynx backwards, and moving it from side to side, you should commence with the local detraction of blood. A small number of leeches should be applied to the throat every second or third night, and this should be continued for a week or fortnight. If there be no tender- ness of any amount, and the patient can bear pressure freely, there is no necessity for applying leeches. Your means must then be confined to those remedies which act immediately on the diseased mucous surface, and for this purpose, one of the best applications is a solution of nitrate of silver, ten grains to the ounce, or a solution of the sulphate of copper, in the same proportions. The best mode of applying it is to take a pro- bang, or a small piece of sponge, fastened to the end of a quill, dip it in the solution, and having slightly squeezed it to prevent the fluid from dropping, touch the excoriated and red parts of the fauces as far as you can conveniently go, rather by pressing the sponge gently against the inflamed mucous membrane than by rubbing. It will be essentially neces- sary to touch every portion of the diseased surface of the pharynx; for if any part be omitted, it will have the effect of keeping up the disease. You perceive the object here is to change the action of the mucous mem- brane. By acting powerfully in this way on the mucous membrane cover- ing the pharynx, fauces, and entrance of the larynx, you will often suc- ceed in bringing on a healthy action, which spreads to the parts in the vicinity. Of this we have an illustration, afforded by the results of treat- ment in chronic diseases of the skin, where local applications to a par- ticular part not only cure that part, but also extend their influence to a considerable distance on every side. It is the same with respect to irri- tation or inflammation of the lower part of the digestive tube ; the use of astringent injections, which can only affect the lower part of the rectum, is often found of essential service in relieving dysenteric affections of the colon. In addition to the use of the nitrate of silver, we have employed a remedy in this boy's case, which has been found beneficial in several instances where no sign of pulmonary irritation is present—I allude to the use of iodine inhalations. This was also intended to make a still further change in the condition of the diseased mucous membrane. It is made by putting from five to ten drops of the tincture of iodine with half a drachm of tincture of conium, and four ounces of hot water into an inhaler, and making the patient draw the vapour into his throat for about ten minutes, every night and morning. This form of inhalation proved extremely serviceable in the case of a gentleman who has attended my lectures this winter. About the commencement of November, while in a delicate state of health, he was attacked with cold, and got sore throat, followed by slight huskiness of voice, and hard, incessant, laryngeal cough. These symptoras continued during December and the greater part of January, and were not completely removed until the beginning of February. He had considerable rawness of the back and sides of the fauces and larynx ; we observed that the mucous membranes of those parts had a strong tendency to become excoriated ; for whenever an exa- CHRONIC LARYNGITIS. 547 cerbation of his symptoras occurred, and that his cough in the morning was harder than usual, small portions of the detached pellicles of lymph, exuded by the mucous membrane, came away at each fit of coughing, and his sputa were tinged with blood. There was another symptom in this case, which you will very frequently meet with in similar instances, namely, a remarkable feeling of chilliness in the integuments of the fore part of the neck and external fauces. This he was in the habit of remark- ing, and could always foretell the occurrence of an exacerbation of his laryngeal symptoms, by the increased feeling of cold in the cutaneous surface over the diseased parts. In this case a great deal of good was effected by the inhalation of iodine with conium. The mode in which this gentleman employed it was by dissolving from six to nine grains of the extract of conium in hot water, and then adding the tincture of iodine. Instead of the common inhaler, which contains but a small quantity of fluid, and in which the inhalation becomes cold in a very short time, he employed for the purpose a high old-fashioned teapot, which contained a large quantity of fluid, and could be used for a much longer period. Under the use of this, with counter-irritation, and the internal use of iodine with sarsaparilla, the laryngitis disappeared. It returned, however, about a month afterwards on fresh exposure ; but was speedily removed by the use of the nitrate of silver solution. Another thing which we have prescribed for this boy, and which proves an excellent adjuvant in the treatment of such cases, is counter-irritation by croton-oil frictions. To an ounce of compound camphor liniment, we add twenty or thirty drops of croton oil; and of this lotion about one or two drachms are to be rubbed over the parts, night and morning, until the eruption appears. Two rubbings are generally sufficient to produce a copious eruption of papulae, about the size of a pin's head, and having exactly the appearance of a disease at present very rare—the eczema mer- curiale. We have not, however, been able to effect any remarkable improvement in this boy's symptoms, by the means to which I have just now alluded; and the question is, what other remedies have we left from which we could hope to derive any advantage? The boy has no fever or emacia- tion; his appetite is good, his sleep regular, and the stethoscope informs us that there are no symptoms of tubercular development; we are, there- fore, I think, authorised in attempting to arrest the disease by the only means of which we have a choice under such circumstances. It is my in- tention to attempt its removal by mercury, and I have therefore ordered him to take, three times a-day, half a grain of calomel, three grains of blue pill, with a grain of the extract of conium; and instead of iodine, we have directed him to inhale the vapour of hydrargyrum cum creta twice or three times daily. If, however, we find that this does not produce speedy im- provement of his symptoms, we shall stop it immediately, as the use of mercury in such cases is generally a perilous experiment. I shall also take care to pay attention to the general state of his health, as this is a matter of great importance in cases of chronic diseases. I had almost forgotten to observe, that in such cases the use of the decoction of sarsaparilla with nitric acid has been found extremely beneficial. There is one point in the treatment of chronic laryngitis which you should never forget—and that is, to make the patients refrain as much as possible from speaking. Unless they do this, you will find it very difficult to effect a cure. A per- 548 CLINICAL MEDICINE. son with an inflamed larynx, who exercises his voice as usual, acts as foolishly as a man who reads with inflamed eyes, or walks with a sprained ankle. The only thing I have to add with respect to the treatment of this disease is, that the patient should be kept as much as possible in an equal temperature, and hence it will be necessary, in many instances, to confine him to the house, or at least to prevent him from exposing himself to a cold and damp atmosphere. When he recovers, he should use cold gar- gles and cold lotions to the throat, in order to render the parts less suscep- tible of cold. Allow me now to direct your attention to two cases of prurigo which have been recently adraitted. The first is that of Jane Cassady, a woman advanced in life, but of tolerably good constitution, considering her age, station, and circumstances. About three months before admission, a rash appeared over her arms, legs, and body, which was preceded and accom- panied by pain of the stomach, head, and limbs, with recurring rigors. As far as we can learn from her description, this appears to have been urticaria ; of this, however, we cannot by any means be certain; and be- sides, it is of little consequence, as prurigo raay come on without it. She is at present labouring under prurigo senilis, not thickly disseminated, but still a source of constant annoyance to her from the intolerable itching it produces. Several of the papulae have formed dark red crusts, but this is in consequence of their bleeding from being scratched. This affection has been so well described by writers on cutaneous dis- eases, and is so easily recognised, that I shall not take up your time in detailing its characters: a few circumstances connected with treatment, however, should be mentioned as deserving your notice. In the first place, I may observe that prurigo is a most harassing complaint, and, if not checked, has a tendency to undermine the constitution by disturbing the patient's rest. The warmth of the bed-clothes, by increasing the vascu- larity of the skin, occasions an aggravation of the symptoms ; the patient passes a miserable and restless night, and rises in the morning quite un- refreshed. This, in process of time, gives rise to a kind of febrile condi- tion of the system; the mouth and fauces become dry; the appetite is im- paired; the secretions deranged, and debility and emaciation gradually produced. It is a disease which has broken many a constitution, which, previous to its accession, was to all appearance unimpaired and healthy. Prurigo has been confounded with common itch, but if you examine the parts it occupies, you will easily distinguish them. It is most likely to be confounded with the small vesicular itch, where the vesicular papulae (this is the most expressive terra I can think of) are extremely minute. There is a papular itch, and there is also one which is intermediate between the vesicular and the papular ; it is with the latter that prurigo is most apt to be confounded. The difference between them, however, may be recognised by observing the parts of the body on which they appear. Itch generally attacks the extremities, and particularly the inside of the joints and the spaces between the fingers. Prurigo, however, does not occupy the same situations. If you examine this woman, you will not be able to find any trace of the eruption about the joints or between the fingers—and this circumstance is of itself sufficient to make the dis- tinction, for itch would not have lasted for three months without attacking these parts. I may also observe, that prurigo senilis is generally accom- panied by derangement of some of the important secretions of the body, PRURIGO. 549 but particularly of the urine. Its appearance is in many instances pre- ceded by a scanty flow of urine, and it is frequently accompanied by the deposition of a copious whitish sediment, which is the lithate of ammonia. This observation is worthy of attention, because it furnishes us with a hint towards the treatment, of which we may sometimes avail ourselves with great benefit to the patient. You will, in such cases, often effect a great deal by the use of diuretic medicines—as cream of tartar with decoction of juniper berries and squill ; or with the more stimulant diuretics—as turpentine and cantharides. It will be also good to vary these remedies according to the circumstances of the case, and they should be always given in combination with medicines calculated to act beneficially on the digestive organs. In this case, we have given decoction of sarsaparilla with nitric acid for the last two days ; before this we gave cream of tartar with powdered bark. These are some of the best medicines which can be used internally in the treatment of prurigo senilis. It is, however, a very obstinate disease, and you will be often obliged to try many internal and external remedies before you can hit on one that will prove service- able. Cooling diuretic aperients, aperients combined with tonics, and the decoction of sarsaparilla with nitric acid,—these are the chief internal remedies ; as to external ones, they are extremely numerous. In the present case we have, in the first place, directed the patient's body to be washed with a lather of soap and warm water every night and morning. The water for this purpose should be used as hot as the patient can bear it, and a very soft brush or sponge should be employed. In prurigo, a vast deal of good has been done by merely washing the itchy parts with soap and warm water; how it acts I cannot say, but I have seen a great deal of advantage derived from a long-continued perseverance in its use. After this you may have recourse to more powerful applications—such, for instance, as sponging the parts at bed-time with hot whiskey and laudanum, a pint of the former to a drachm of the latter. Here you have the stimulant effect of the whiskey, the narcotic of the laudanum, and the peculiar action of heat on the skin, all combined, and calculated therefore to make a very decided impression. How this effect of heat is produced I cannot tell, but we all know that, whether applied in a moist or dry form, it exercises a powerful influence over the vascularity and nervous vitality of the skin. Neither can I tell you what description of cases are most likely to benefit by it; some cases of prurigo senilis are much relieved by warm applications, others are not; you should, however, always make a trial. There was one application used in this woman's case, to which I shall briefly call your attention. A drachm of acetate of lead was dissolved in two ounces of wine vinegar mixed with the same quantity of water, and this was rubbed up with olive oil so as to form a liniment. Mr. Nalty, who mixed up the ingredients, says that three ounces of olive oil were absorbed. You are aware that oil conducts itself, with respect to the metallic oxides, as it does with the alkalies. This formed a liniment, which, when allowed to stand, separates; but its ingredients are at once miscible by shaking the bottle. From its use the woman has derived great relief, and I can recommend it to you as one of the best applications in prurigo. Before I conclude this lecture I shall allude briefly to the very inte- resting case of Sarah O'Neil. This young woman was admitted on the 550 CLINICAL MEDICINE. 17th of February, having been attacked, on the 10th, with fever of the ordinary type. On the day after her admission, she complained of want of sleep, and pain of the forehead and temples ; but she had no raving, tinnitis aurium, intolerance of light, or other symptoras of inflammation of the brain. She had been confined about a fortnight before she came in, and complained that her breasts were very troublesome to her. Her belly was soft and fallen, quite free from tenderness or soreness, and she stated that her bowels were free. Her tongue was furred, her pulse 130, the lochia suppressed for the last two days. Things went on tolerably well for four or five days, when her belly became tympanitic, and she began to complain of pain on pressure. The action of the heart now became more violent; her pulse rose to 140, and blood began to appear in her stools. On the 24th of February—that is to say, about the four- teenth day of her illness—her pulse was 150 ; she passed a large quantity of blood from the bowels, and the tympanitis subsided. In cases of fever accompanied by tympanitis and signs of intestinal congestion, hemorrhage from the bowels, particularly when it occurs on one of the critical days, should not be interfered with. It is in this way that nature very frequently brings about relief of the congestion and irri- tation of the gastro-intestinal mucous membrane, just as she relieves con- gestion of the head by bleeding from the nose. In the case of a lady whom I attended along with Mr. Palmer, some time ago, at Drumcondra, the occurrence of intestinal hemorrhage was followed by the most marked effects; her belly became soft, the tympanitis disappeared, and all her febrile symptoms were speedily removed. The appearance of blood, therefore, at such periods and under such circumstances, is to be looked on as a favourable occurrence ; nor should it be interfered with in any way until, from its continuance or its quantity, it appears likely to produce debilitating effects. In the present case, however, this hemorrhage will require to be very carefully watched. The woman's system is that which is favourable to profuse fluxes of blcod, for it is not long since her ac- couchement, and she has had suppression of the lochia. She has had but little fever for the last two or three days, but the action of the heart still continues extremely violent, and her pulse is still rising. Respiration, too, has been considerably accelerated ; and, where this occurs, you have always reason to apprehend danger. I have accordingly endeavoured to moderate the hemorrhage by the use of acetate of lead and opium. A draught composed of two grains of acetate of lead, eight minims of tinc- ture of opium, and fifteen minims of wine vinegar in six drachms of water, has been prescribed to be taken as occasion requires. A large blister has been applied, so as to cover the epigastrium and sternum, and she has been allowed port wine and chicken-broth. Where a patient, debilitated by previous fever, has been attacked with hemorrhage, you should be careful in supporting the system by small quantities of wine, and light nutritious food ; for there is always more or less danger to be apprehended of a sinking of the powers of life. In cases of this kind the cautious use of acetate of lead, with opium and wine, are the only means on which we can rely with any confidence. A man was admitted into the ehronic ward a few days ago who cannot separate the lower from the upper jaw to the distance of more than two lines. What are the cases in which we find this immobility of the lower jaw ? Most comraonly in tetanus or locked-jaw ; but here this cannot be PRURIGO. 551 the case, for the man has no sign indicative of a tetanic affection, no rigi- dity of the muscles of the neck ; his countenance is very different from that of a tetanic patient, and he has not been exposed to any of the ordi- nary exciting causes of that disease. But leaving all consideration of the nature of the disease out of the question, what is it that prevents him from moving his lower jaw? It must depend on one of two causes ; either the muscles which perform the motions of the lower jaw are stiff, rigid, and incapable of motion, or else there is some disease of the articulation which obstructs the motion of the bone. This proposition is universally true of all articulations, that when they become impeded or completely obstructed in their motions, the derangement arises frora some abnormal condition of the muscles, or of the bones and ligaments which form the joint. In this case we find, that, in addition to being unable to perform the proper motions of the lower jaw, the patient has intense pain, darting from the angle of the jaw towards the temple, the ear, and the side of the neck. This pain is of an extremely violent character, so as to re- semble tic douloureux, and the resemblance is still farther increased by its being more or less intermittent. Now, on inquiry into the history of this case, we find that the patient had some time ago laboured under toothache, for which he got the last molar tooth but one of the upper jaw extracted, and that immediately afterwards he was seized with violent pain in the part, and found that he could no longer move his lower jaw as usual. I have seen many cases of this kind, in which a painful or carious tooth, or an injury done to the gum or jaw, has been followed by violent darting pain in the nerves of the face, simulating in many parti- culars tic douloureux. I remember being sent for to Middleton, near Cork, some time since, to see a young lady of delicate constitution, whose health was materially deranged from what was said to be an attack of tic douloureux. She had been under the care of many practitioners, and had used very large doses of the carbonate of iron and sulphate of quinine, and at the time I visited her was taking arsenic. The first thing I did on my arrival was to examine her teeth. On close inspection I observed that on the crown of one of the upper molar teeth there was a spot which appeared to be decayed, and found on inquiry that she had frequently suffered from pain in this spot when she drank any cold liquid. I had the tooth drawn and soon afterwards the pain completely ceased. Yet in this case the pain was not only of an intense character, preventing sleep and wearing out her strength, but it had its intermissions, and was aggravated at particular hours of the day. Another instance of the same kind came under my notice about twelve months ago. A young lady was brought to me by a medical friend of her's to have my advice for an attack of tic douloureux. She had been attended by this gentleman with great care, and no mode of relief left untried, for her sufferings were in- tense, and she had constant exacerbations of pain. I asked him, were her teeth sound, or had she any disease of the gum or jaw ? He said not, and that he was sure of this, for he had examined her teeth over and over again. On opening her mouth, however, I thought I saw some appear- ance of unsoundness in one of her teeth, and recommended her to go to Mr. M'Clean and get it drawn. She did so, and the pain quickly dis- appeared. I could also give many cases in which an injury done to some of the branches of the dental nerve has given rise to symptoms closely resembling those of the tic douloureux. One of the most curious circum- 552 CLINICAL MEDICINE. stances connected with such cases is, that the pain is always of a more or less intermittent character. The same thing is observed in that form of headache which arises frora irritation of the brain, produced by spiculae of bone growing from the internal table of the skull. In a case which occurred some time back at the Meath Hospital, where several spiculae, some of them more than a quarter of an inch in length, were pressing on the brain, the headache was of a distinctly intermittent character. This remarkable periodicity of exacerbation, in cases where the operation of the exciting cause continues still the same, seems to be peculiar to the nervous system. In many cases considerable derangement of the facial nerves is found to follow an injury done to some branch of the dental nerve in drawing a tooth. When the bone has been injured by the force used in extracting the tooth, it frequently happens that, if the injury be not quickly repaired, and the parts healed up, symptoms resembling those of tic douloureux or rheumatic neuralgia will supervene, and give the patient a great deal of annoyance. Such was the origin of the mischief in the case before us; the man received an injury of the upper jaw in drawing a tooth which is not as yet healed, as you may perceive by introducing a probe between the separated portions of gum, when you will find it grate against the rough surface of the bone. In addition to this, there is considerable ten- derness of the gum and swelling of the neighbouring parts, which have extended to the muscles, their sheaths, and finally to the articulation of the lower jaw. You can satisfy yourselves of this by examining the parts and striking the lower jaw, so as to press it suddenly upwards and back- wards into the glenoid cavity, just in the same way as you press the thigh bone against the acetabulum when you wish to ascertain whether there is inflammation of the hip-joint. The motion of the lower jaw is here pre- vented by inflammation, extending from the upper jaw so as to involve its ligaments and the neighbouring muscular sheaths. There are other causes, also, which may be attended with the same diminution of motion in the joint. Thus a man may get an attack of rheumatism in the scalp, which may extend to the temporal muscles and prevent him from being able to depress his lower jaw, and I have known cases in which this con- dition of the temporal muscle has given rise to suspicions of the existence of trismus. When you examine the articulation you find nothing amiss, but when you come to press on the temporal muscle above the zygoma, the patient complains of pain and tenderness. The irritation produced by rheumatic inflammation gives rise to a fixed rigid state of the muscle, and hence the patient cannot open his mouth. This form of disease I have described long since, in a paper published in the Dublin Hospital Reports. It can be relieved with great ease by applying leeches to the temple, and ordering the patient to rub over the part a small portion of mercurial ointment with extract of belladonna, two or three times a-day. The same state of the temporal muscle is sometimes observed as resulting from an extension of inflammation, in case of a wound of the scalp in its vicinity. In the case before us, almost every thing will depend on the process which nature may adopt with respect to the injury of the maxillary bone. If ihe bone throws up healthy granulations, and the inflammatory process ceases, the affection of the nerves, as well as of the muscles and joint, will quickly subside. All we can do under the circumstances is to apply JAUNDICE WITH ARTHRITIS AND URTICARIA. 553 leeches over the side of the face, and order the man to rub in mercurial ointment; every thing, however, will depend on the turn the disease of the bone may take. I wish to make a few observations on a case of jaundice in the small chronic ward. I do not intend to enter into any particular inquiry con- cerning the causes of this disease ; you are aware that it may depend upon many causes, upon affections of the mind, gastro-duodenitis, inflammation or abscess of the liver, the presence of gall-stones, diseases of the head of the pancreas, aneurism of the hepatic artery, and, what is more remark- able, in some cases may arise without any assignable cause whatever. In the present instance it seems to have been the result of acute hepatitis. The man was attacked with symptoms of inflammation of the liver, and about a fortnight afterwards became jaundiced. It is unnecessary for me to draw your attention to the history of the case, or the present state of the patient ; all I shall do at present is to make a few remarks on some points of treatment. In the first place, the jaundice is, as you perceive, of an intense cha- racter : the man is as yellow as he could be. Now this I look upon as a favourable sign ; the deeper the colour is in recent cases the greater is the chance of effecting a cure. There are no cases so intractable as those in which the tinge of yellowness is so faint that you would be likely to overlook it, as in the case of a man in the chronic ward, in whom the colouring is so slight, that it requires some attention to ascertain whether he is jaundiced or not. Such a case as this is always of a chronic, intrac- table character, and this is too frequently connected with a scirrhous state of the liver. Again, in this man's case we cannot detect any appearance of bile in the evacuations ; this is another good sign. When jaundice coexists with bilious stools, the prognosis is, generally speaking, bad. A but slight tinge of yellowness of skin, and the continued presence of bile in the stools, are two circumstances which I always look upon as indica- tive of an unmanageable and frequently incurable affection. It generally depends on a scirrhous state of the liver, or some organic derangement beyond the power of medical treatment. Again, another good sign in jaundice is, that as long as the bile is absent in the stools it should be present in the urine. If a patient labouring under jaundice has clay- coloured stools, and you find on examination that his urine becomes heavily laden with it, it is a very favourable circumstance, for it shows that, although the usual channel for the exit of bile from the system is stopped up, nature has provided a remedy for the evil by establishing an- other emunctory. You can understand then the reason of the anxiety I felt at finding that this patient's urine was becoming paler and diminish- ing in quantity, at a time when bile was not present in the stools. In acute cases of jaundice, you should always bear in mind that patients will sometimes have a complete suppression of the biliary discharge, fol- lowed by coma, without any symptoms of disease of the brain. Why this occurs in some and not in all cases we cannot understand, but, from whatever cause it may arise, we find that in some instances jaundiced patients become stupid and lethargic, and die in a state of confirmed coma. In such cases there is always very great danger, and where coma has appeared as a prominent symptom of jaundice, you should always give an unfavourable prognosis. I have never seen but one patient re- cover under such circumstances. On the other hand, it is equally curious 554 CLINICAL MEDICINE. that derangement of the urinary system is one of the most common symp- toms of disease of the brain. You will therefore understand the cause of my alarm, when I observed a diminution of the urinary secretion in this patient. As soon as I perceived this symptom, though the patient had been taking mercury, and was improving at the time, I immediately ad- ministered a diuretic, and this fortunately succeeded in producing a co- pious flow of urine. We prescribed the following diuretic, which had not been taken for many hours when it produced a decided determination to the kidneys:— R. Mistura? amygdalarum, ^viij. IS'itrat. potassae, ^'j- Tinct. digitalis, gtt. xv. Spiritus setheris nitrosi, ^ij. of which a tablespoonful was to be taken every second hour. There is one practical remark to be made on this and other similar cases. As soon as the symptoms of jaundice begin to decline, and bile makes its appearance in the stools, you should attend carefully to the state of the patient, and note any symptom which may occur of an anomalous character. Now, in this patient's case, we observed that a degree of restlessness was present, which terminated in a complete want of sleep. About the time when he began to manifest a degree of improvement, he became quite sleepless without any evident cause, and continued so for two or three nights ; and I have already stated in a former lecture that, no matter when this symptom occurs, whether in fever or towards the termination of some acute disease, it always requires your attention. I therefore immediately took proper steps to restore sleep ; and accordingly we find, on inquiring this morning, that he has rested well and feels much better. The man had been taking mercury, and his bowels were free ; but, not content with this, I gave him a purgative, consisting of infusion of senna with electuary of scammony. This he was directed to take early in the morning, so as to secure its operation before night; and about nine or ten in the evening, after his bowels had been freely opened, he took a full opiate, which produced a long and refreshing sleep. Before I conclude, allow me again to communicate a few detached observations on the connection which exists between jaundice and some other diseases—as, for example, inflammation of the joints. It is now many years since Dr. Cheyne and I attended a gentleman in Lower Mount-street, who, in consequence of exposure to cold, was attacked with inflammation of the joints, accompanied by considerable general fever ; almost every joint was attacked in succession, and his sufferings were excessive. The disease bore the form I have so often described under the name of acute sweating arthritis—a form very obstinate and difficult to treat, and accom- panied after some time with great constitutional debility. When this gentleman had been about ten days confined to bed under treatment, he suddenly became jaundiced, and it was now evident that acute, but not violent, hepatitis was superadded to the original disease. In a day or two afterwards, a copious eruption of nettle-rash—urticaria —appeared over his body and extremities. Exactly the same diseases appeared, and in a similar order of succession, in a man treated in the Meath Hospital, in June, 1832—an occurrence which at the time excited some interest among the students ; for when I observed that jaundice had supervened on arthritis, I mentioned to the class that it was not at all URTICARIA. 555 unlikely that the jaundice would be soon attended by urticaria. I was induced at the time to make this prediction, as my mind was full of the subject, having been engaged, along with Mr. Porter, in attending a medical friend residing in Baggot-street, in whom jaundice was soon fol- lowed by urticaria. Since my attention has been drawn to the connection between these three diseases, I have seen and heard of several other instances in which they appeared thus associated together. A circumstance so remarkable deserves to be studied with more than ordinary interest. Let us, therefore, consider what facts are supplied by physiology and pathology capable of throwing some light upon this hitherto unobserved and uncul- tivated subject. In the first place, nothing has been longer recognised by physicians, as an established fact, than the intimate sympathy which exists, both in health and disease, between the digestive organs and the skin. Now, acute hepatitis always produces more or less derangement of the stomach and alimentary canal, and we may therefore consider its connec- tion with urticaria in the same way that we are in the habit of viewing the cases, so frequently observed, in which certain sorts of fish have produced serious symptoms of indigestion followed by nettle-rash. The association between these two diseases is rendered more remarkable by the fact, that, when fish taken as food exerts a poisonous effect on the system, it frequently produces not merely violent stomach and bowel complaint, but also inflammation of the joints and rheumatic pains. If I can establish this, you will allow that the connection between arthritis, disease of the digestive organs, and urticaria, can no longer be considered as fortuitous and depending on the accidental concurrence of causes haying no deter- minate relation, but must be looked on as owing to and arising from the operation of some fixed law which regulates and originates this develop- ment of morbid actions in, if not a frequent, at least a uniform mode of succession. The Otaheitan eel (puhhe pirre rowte) produces, when eaten, a most copious scarlet eruption of the skin—most probably urticaria—and occa- sions sudden tumefaction of the abdomen, together with swelling of the extremities, hands, and feet, the pain felt in the limbs is so excruciating that the patient becomes quite frantic. I may remark here that this and many other species of fish which act as poisons on the system, give rise very speedily to paralysis of the extremities. You will find in the Edin- burgh Medical and Surgical Journal, vol. iv., p. 396, in an excellent review of Dr. Chisholm's work on the poison of fish, an account of the effects produced by eating the murcena conger, the following passage : " In the course of the following night, they were all seized with violent griping and cholera, together with a peculiar sensation of the lower extre- mities, attended with violent convulsive twitches, faintings, &c. They all perceived a brassy taste in the mouth, and a rawness of the oesophagus, as if it had been excoriated. These symptoms continued to afflict the negroes for a fortnight, and then terminated in paralysis of the lower extre- mities. After suffering for several months, they recovered with difficulty." Are we not here forcibly reminded of what I said in a former lecture concerning the connection between enteric disease and paraplegia■? Werlhoff, as cited by my friend Dr. Autenrieth in a book* of extraor- dinary ability and research, gave a case where the gadus aeglesinus asellus produced a violent affection of the stomach and bowels, together with * Ueber das Gilt der Fische. Tubingen, 1833. 556 CLINICAL MEDICINE. urticaria. Chisholm relates the same of the flesh of the dolphin. Urtica- ria, diarrhoea, dysentery, paraplegia, are said, by the same author, to be frequently observed in consequence of eating the flesh of the grey snapper. Forster relates a similar train of accidents produced by eating the sparus pargus (porgee). In short, I could bring forward citation after citation in proof of the truth above advanced ; but I have done, for enough has been already said to establish the point in question. Having established the fact that disease of the digestive organs is often intimately associated with urticaria, it remains to prove that a similar con- nection exists between hepatitis—the cause of the derangement in the diges- tive organs (in the case before us)—and arthritis. Every one has observed how frequently inflammation of the joints becomes in its course compli- cated with inflammatory affections of internal viscera. In general, those viscera whose component tissues are most similar to the articular are the organs affected. Hence the heart and pericardium are so often attacked in the course of rheumatic fevers. It sometimes happens, however, although less frequently, that the internal organ attacked has little analogy in point of tissue with the joints. Thus, in rheumatism and in gout, the stomach, the bowels, the lungs, or the liver, may become engaged ; and of these none, perhaps, so frequently as the liver. We need not be sur- prised at this, when we consider how intimately the digestive function is connected with arthritic inflammation, which is indeed generally preceded or accompanied by well-marked symptoms of hepatic and stomach com- plaints. Indeed, almost all medicines that afford relief in arthritis are attended with well-marked symptoms of their having acted upon the secretions of the alimentary canal and liver. Thus, colchicum seldom diminishes the pain and inflammation of the joints, until it produces copious bilious evacuations. LECTURE XLI. Case of secondary symptoms which made their appearance soon after a mercurial course; method of treatment—Case of syphilitic eruption—Mouth suddenly affected by a small quantity of mercury—Effects of this on the progress of the cure—Earache preceded by rigors coming on during this course of fever; danger of; treatment—External tenderness; value of, as a symptom in inflammation of brain, lungs, abdomen &c, &c.—Vomiting considered as a symptom in fever; its treatment—Chronic rheumatism ; successful treatment of—Ob- stinate case of arthritis ; cure of, by local applications—Observations on the effects of mer- cury applied locally—(vase of syphilitic iritis; action of belladonna in. You have observed that we have two cases of syphilis under treatment— one in the female, the other in the male chronic ward. They possess no pe- culiar interest beyond the ordinary run of syphilitic affections, still they deserve a share of your attention; for it is on your experience of indivi- dual cases, much more than on the knowledge derived from books, that your treatment of this obscure and protean malady will depend. It is now more than a year since the female patient received the syphi- litic poison into her constitution. What the nature of the primary sore was we cannot ascertain, but, from the account she has given, it seems to have been true chancre. Some time after this occurred, she got sore throat, articular pains, and an eruption, for which she was treated in this hospital SECONDARY SYPHILIS. 557 about ten months since, and dismissed apparently cured. The disease, however, returned in a few weeks, and she has been labouring under its effects up to the present moment. Three circumstances in this case demand our attention: first, the re-appearance of syphilis after a mercurial course —for she was mercurialized here soon after her first admission; secondly, she exhibits a degree of syphilitic cachexy, being rather pale and emacia- ted; and, thirdly, the slow progress which the disease has made in her system, being limited to a few blotches on the skin, some periostitic swel- ling of the bones of the leg, pains, and slight arthritis. In treating this case I intend to give mercury, so as to affect her sys- tem ; and, having accomplished this, I shall keep her under its influence for some time. I shall also, should it appear necessary, order her a free allowance of the decoction of sarsaparilla. Under this treatment you will find that the eruption will soon disappear, the periostitic pains and swel- ling be removed, and the constitution begin to improve. She has been ordered three grains of blue pill, and half a grain of calomel, three times a-day—a quantity which you will generally find sufficient to bring on mer- curial action in females. I have no doubt but that the disease will, in this case, yield to mercury in a very short time, and that her health will be completely restored. The failure of mercury in producing a permanent cure, on a former occasion, is no argument against its employment here; if there were no syphilitic taint in question, I do not know any remedy by which the cutaneous affection and the periostitis could be more effectually relieved. On another occasion I shall speak more at large upon this im- portant subject, and shall bring forward facts in proof of the assertion, that mercury may fail to eradicate the effects of the venereal poison at a certain period of the disease, and may nevertheless be capable of curing the dis- ease effectually at a future time. This may appear paradoxical, but it is not the less true. The other patient, John Kelly, presents an eruption of red scaly blotches, extensively diffused over the trunk and extremities, and closely resem- bling psoriasis. This man, like many others, denies the occurrence of a recent syphilitic taint, and gravely states that it is some years since he ex- posed himself to infection. Instances of this kind are to be met with every day; patients will not tell the truth about these matters, and false state- ments tend to throw a darker shadow over a disease in itself sufficiently obscure. However, in this case, the poison seems to have confined its effects to the cutaneous surface; there is no affection of the throat, perios- teum, or joints. The eruption covers almost every portion of his body; it made its appearance two months before admission, and was preceded by feverish symptoms and pains in the larger articulations. In undertaking the treatment of this case, there is one practical point to be held in view. The man's general health is good, his strength undi- minished, and his circulation active. I therefore ordered him to be blooded, and have kept him for eight or nine days on antimonials and low diet. By preparing him in this way, I knew that the mercury which I intended to give him would act more rapidly on his system; and such was the case —for on the second day after he commenced using it his mouth became affected. But here a difficulty arose, which, in cases of this description, is apt to embarrass our treatment; the mercurial influence appeared much sooner than I expected or wished. He had been ordered three grains of blue pill, and half a grain of calomel, three times a-day; and on the second 558 CLINICAL MEDICINE. day, before he had taken six pills, salivation commenced. Now, in all cases where mercury affects the mouth sooner than you desire, and as it were in spite of you, it will not do as much good as where its action pro- ceeds regularly and in accordance with your purpose. It is a general rule that most benefit is to be expected from mercury where its action is regu- larly progressive, or where the quantity taken is in proportion to the effect produced on the system. Hence we look upon it as an unfavourable oc- currence, when a small quantity of raercury occasions sudden and copious salivation; such an event deranges our calculations, and tends to embar- rass our practice. Now, in this case the patient, after taking five pills, became salivated on the second day. We found we had been going on too fast; it was necessary therefore to pause, but not desist. We accord- ingly reduced the quantity of mercury to three grains of blue pill, and half a grain of calomel, to be taken every second night. By these means we kept up a slight discharge of saliva, and the man's symptoms began to improve. The eruption is now disappearing rapidly, and it is to this point I wish to call your attention. What are the marks which indicate the subsidence of an eruption of this kind, and by what criterion are you ena- bled to judge of the progress of the cure? When the parts are about to return to their healthy condition, three circumstances occur: first, the vivid red or copper colour of the eruption begins to fade ; secondly, the heat of the affected parts becomes reduced; thirdly, the excessive secretion of morbid cuticle is arrested, and the quantity of minute scales covering the blotches diminished. In such cases, the affected parts of the skin are highly vascular, and the secretion of cuticle is morbidly excessive in quan- tity; hence the continued desquamation from the surface of the blotches. You should, therefore, attend not merely to the colour of the eruption, but also to the quantity of minute scales on each blotch, when you wish to ascertain whether an eruption is fading or not. You can judge of this by your eye, or you can tell it by passing your finger over the diseased sur- faces. The fading of the colour of the eruption, the decrease of the ele- vation and roughness in the blotches, and the gradual disappearance of the minute scales—these are the circumstances by which you can ascertain the subsidence of a syphilitic eruption. As the cure progresses, you find the parts assuming a more natural appearance: the same quantity of morbid cuticle is no longer thrown out by the affected spots of corium ; the blotches become smooth and lose their elevation, and, finally, the red colour of the skin disappears. Of all the symptoms, discoloration of skin is the last to recede, and it generally happens that enough has been done in the way,of treatraent long before the skin resumes its natural complexion. If you were to continue the administration of mercury until the natural colour returned, you would very often push it to a useless and even dangerous extent. In such cases, a faded brownish or dirty tinge remains long after the re-establishment of healthy action. There is a case in the female fever ward which requires a passing observation. A young woman, previously in the enjoyment of good health, was seized with symptoms of fever after exposure to cold ; she got rigors, followed by headache, hot skin, thirst, nausea, and accelera- tion of pulse. It is unnecessary for me to detail the symptoms which attended her illness during the past week ; I shall content myself with pointing out the symptoms which particularly attracted my attention to her case on Saturday morning. At that time her fever had increased ; EAR-ACHE PRECEDED BY RIGORS IN FEVER. 559 she complained of severe headache and restlessness ; had foul tongue, thirst, and symptoms of gastro-intestinal irritation. Such matters, how- ever, demand no very particular consideration ; what chiefly fixed my attention was the occurrence of slight and transient rigors during my exa- mination : I observed her shuddering three or four times in the space of a few minutes. On questioning her respecting these brief rigors, she informed me that they had occurred with more or less frequency for the last three days. Now, whenever you meet with a symptom of this de- scription in fever, be on your guard ; watch the case with anxious, unre- mitting attention, and never omit making a careful examination. It is in this way that one of the worst complications of fever—treacherous and fatal disease of the brain—very often commences. On examining this girl, we found that she had not only headache, but also acute pain refer- red to the left ear, the external meatus of which was observed to be hot and tender to the touch. In addition to this we were informed by the nurse that she had been seized with a sudden fit of vomiting shortly after we left the ward on the day before. Here was an array of threatening symptoms calculated to awaken attention in any, even the most heedless observer. A patient, after exposure to cold, is attacked with symptoms of fever ; she has headache and restlessness ; she then begins to complain of acute pain in the ear, darting inwardly towards the brain ; and, finally, is seized with sudden vomiting. Under these circumstances, it is not dif- ficult to form a diagnosis, and there can be little doubt but that the phe- nomena here present were indicative of incipient inflammation of the membranes of the brain. It is not easy to say whether in such cases the inflammatory affection of the membranes precedes the external otitis, or whether the inflammation commences in the external ear and spreads inwards, though I am inclined to adopt the latter supposition, and the circumstance of the fever and earache arising from cold seems to give an additional degree of probability to this view of the question. Be this as it may, there could be no doubt but that this girl was, on Saturday, labouring under incipient inflammation of the membranes of the brain, as denoted by headache, rigors, acute pain in the ear, and vomiting. Here let me observe, gentlemen, that in cases of this description, I look on the occurrence of external tenderness, not merely as an indication of internal disease, but also as a favourable symptom. I have remarked that in all cases where this happens, the physician becomes more speedily and sensibly aware of the existence of internal disease, and the remedial means employed act with a more decidedly beneficial effect. I would prefer having to deal with an inflammatory affection of the brain or bowels, ac- companied by external tenderness, and would feel much more certain as to the result, than if this symptom were but faintly marked, or totally absent. This observation is founded on experience. In treating this case, you have seen that I have ordered relays of leeches to be applied in the vicinity of the affected ear until the earache has ceased. I have long followed this practice of applying a number of leeches in succession for the relief of local inflammation, and I can state with confidence that the result has been, in the majority of cases, highly satisfactory. Some prefer the application of a great many leeches at once ; but my experience speaks strongly in favour of the practice of applying a small number, repeated at short intervals, until the violence of the local inflammation is subdued. Relays of six or eight leeches will 550 CLINICAL MEDICINE. s iffiee in the majority of cases of pectoral, cerebral or abdominal inflam- mation. In some, however, when the attack is violent, fifteen or twenty must be applied at once ; each succeeding relay may consist of a smaller number than that which preceded it. In this manner I have maintained a constant oozing of blood from the integuments over an inflamed organ for twenty-four, or even thirty-six hours. In addition to this, I determined to bring her system rapidly under the influence of mercury, and, with this intent, administered calomel to the amount of a scruple in the twenty-four hours. These means have acted favourably, and she feels much better to-day. (This patient perfectly recovered.) Allow me to make one observation more which this case suggests. This young woman, you recollect, had, on her admission, some epigastric tenderness, which we removed by leeching, and she remained free from any symptoms of gastric irritation until last Saturday, when she got a sud- den attack of vomiting. Now, in all feverish complaints, where, during the course of the disease, the stomach becomes irritable without any obvious cause, and where vomiting occurs without any epigastric tenderness, you may expect congestion, or incipient inflammation of the brain or its mem- branes. If called to a case of scarlatina, where there is severe vomiting, and perhaps diarrhoea, unaccompanied by thirst or epigastric tenderness, what should your practice be ? Are you to direct your attention to the alimentary canal, and endeavour to arrest these symptoms? No. The vomiting here depends on active congestion of the head, and such cases are very apt to end in coma, convulsions, or death, from disease of the brain. You are all aware, that in cases of injuries of the head, followed by congestion of the brain, vomiting is one of the most prominent symp- toms. The same thing occurs in febrile affections, attended with deter- mination to the head. You are not to conclude that a fever is gastric, because it commences with nausea and vomiting: this is a serious, and very often a fatal mistake ; yet I am sorry to say it has been committed by many practitioners, and I have been guilty of it myself. In such cases, you should not waste time in attempting to relieve gastric irrita- tion by cold drinks, and leeches to the epigastrium, or to check diarrhoea by chalk-mixture and opiates ; you should direct your attention at once to the seat and origin of the mischief, and employ prompt and effectual means to relieve the cerebral congestion. Where the disease sets in with severe vomiting, unaccompanied by-distinct evidences of gastric inflam- mation, whether it be common fever, or scarlatina, or measles, or small- pox, I commence the treatment by applying leeches to the head, convinced that in this way I shall be most likely to prevent an approaching danger- ous congestion of the brain. I am anxious to impress this observation on your minds, because I am fully sensible of its importance, and feel certain that you will derive much advantage from bearing it in recollection dur- ing the course of your future practice. The next affection to which I shall draw your attention is chronic rheu- matism, of which we have a well-marked instance in the man who lies in the chronic ward immediately under the window. He complains of pain, weakness, and numbness of the lower extremities, for which he used the decoction of sarsaparilla and minute doses of corrosive sublimate, for a fortnight, without any obvious improvement in his symptoms. His com- plaint is of considerable duration, it being now fifteen weeks since he was first attacked. This, I need not tell you, is a very unpromising feature CHRONIC RHEUMATISM. 561 in his case. When rheumatism has continued for three or four months, it becomes a very intractable disease ; indeed, there is scarcely any affec- tion which tasks the ingenuity, and tries the patience, of a medical man more than chronic rheumatism. In this case, however, we have been so fortunate as to hit on a remedy suited to the complaint ; the man has been rapidly improving within the last fortnight, and is now nearly well. You will recollect that, when I undertook the treatment of this case, the patient was free from fever, his general health but little impaired, his pulse tran- quil, his appetite good, no remarkable tenderness or redness of the joints —in fact, nothing to indicate the existence of acute local inflammation ; consequently, it would have been useless to have recourse to leeches or blood-letting, or to administer antimonials, nitre, or colchicum. In such cases as this a different line of practice must be followed ; you must have recourse to stimulant diaphoretics—remedies which will increase the secre- tion from the skin, at the same time that they exercise a stimulating action on the nervous and capillary systems. Accordingly we prescribed for this man the following electuary, of which he Was to take a teaspoonful three times a-day:—Powdered bark gj., powdered guaiacum ^j., cream of tartar ^j., flower of sulphur ^ss., powdered ginger ^j. ; to be made into an electuary with the common syrup used in hospitals. The guaiacum not only acts on the nerves, tending to remove chronic pains, but also acts on the skin ; you will find these, and other properties possessed by it, detailed at large in your works on Materia Medica. Whether given in the form of powder or tincture, it often proves an extremely useful re- medy in cases of chronic rheumatism, where no symptoms of active local inflammation or general fever exist ; where either of these are present it is inadmissible. Ginger has also a stimulant effect, although its action is much more limited. It is a favourite domestic remedy, and is very fre- quently prescribed by our rival candidates for therapeutic celebrity—old ladies—in cases of chronic, or, as they term it, cold rheumatism; and I must confess that I have seen some benefit derived from their specific— ginger tea. With these we combined sulphur, which exerts a peculiar stimulant operation on the skin and alimentary canal. Sulphur is an ex- tremely active remedy, and singularly penetrating in its nature, finding its way into many of the secretions and most of the tissues of the body. You will find it in the urine in the form of sulphates, and it is exhaled from the skin and mucous membrane of the bowels in the form of sulphu- retted hydrogen. Having said so much respecting sulphur, you will per- haps inquire why I prescribed the bark? It is not easy to give a satis- factory explanation of this ; but we know, from experience, that in cases of rheumatism, after fever and local inflammation are removed, bark and other tonics have been found extremely valuable. The cream of tartar is given with the view of tempering the other stimulant remedies, it being known to possess cooling and aperient properties. The whole form a combination which is similar in its composition to a well-known popular remedy for rheumatism—the Chelsea Pensioner. Having thus explained the general tendency of these medicines, and mentioned that they are to be made up into an electuary, it only remains to speak of the effect produced, and the dose or quantity to be given. I have stated that the ordinary dose is a teaspoonful three times a-day ; this, however, will be too much for some, and too little for others. The object in every case should be to keep up a mild but steady action on the 37 562 CLINICAL MEDICINE. bowels, and to procure a full alvine discharge at least once a-day. If the dose mentioned already does not answer this purpose, it must be increased ; if the bowels are too free, it must be diminished. You should never omit making regular inquiries after the state of the bowels, while the patient is using this electuary ; for, if these matters are neglected, the patient will not obtain the full benefit to be derived from it. Besides opening the bowels this electuary acts on the skin, and frequently causes a rapid disappearance of the disease. I need not say that, in addition to this, I ordered warm baths ; they coincide in effect with the electuary, acting on the skin, and tending to relieve the rheumatic pains. There is another very remarkable case bearing some affinity to the pre- ceding, on which it may be necessary to offer a few remarks ; I allude to the patient with sweating arthritis, to whom I drew your attention this morning. This poor man, who is somewhat advanced in life, has been labouring for several months under inflammation of the joints of a rheu- matic character, manifesting itself by pain, stiffness, swelling, and pro- bably some slight effusion into the synovial membranes. These symptoms were accompanied by profuse and constant perspirations, with a tendency to diarrhoea—circumstances which caused a manifest deterioration of his health and strength ; he became pale, cachectic, and emaciated. His case had been very tedious and intractable ; he had been a long time in the hospital, and had used all the most appropriate remedies, but without an/ appreciable improvement; his joints remained stiff, painful, and almost useless; he was greatly reduced in strength, and entirely con- fined to his bed. In addition to this, his pulse continued unreduced in frequency, and this is always a bad sign ; cases of rheumatic arthritis, attended by prolonged excitement of the circulation and copious sweat- ing, are generally found to exhibit an intractable chronicity, and too often terminate in rendering the unfortunate patient a cripple for life. Now in this case many remedies had been tried without effect, and the state of the man's constitution, combined with the circumstance of his having a tendency to bowel complaint, contributed to reduce still further the scanty list of our remedial agents. Alterative remedies, to affect the general system, were almost entirely out of the question, and a vast number of local applications had proved unsuccessful. It occurred to me here, that some benefit might be derived from mercurial ointment, gently rubbed over the affected parts, assisting its action by the use of rollers applied around the joints. Fortunately, the experiment proved successful; in the course of a week or ten days, the swelling diminished considerably, the pain is nearly gone, and the power of motion is returning. His mouth has become affected, but the rebel experienced appears to be proportioned, not to the influence of mercury on the general system, but to its effect on each individual joint. As a proof of this, I may state that the man has been mercurialized before, but without any favourable result. Here, gentlemen, is an important point for consideration. A patient •labours under a certain number of local inflammations, for which mercury is given internally, so as to affect the mouth, but without any manifest improvement of symptoms ; we afterwards try the same remedy in another form ; we apply it locally, in the shape of ointment, rubbed into the skin over the diseased parts, and we succeed in giving relief. This is a fact deserving of attention. You will perhaps ask me to explain this—I cannot do it; but I can bring forward many other analogous examples. If you GREAT UTILITY OF LOCAL APPLICATION OF MERCURY. 563 refer to the late Mr. M'Dowel's valuable paper on Erysipelas, published in an early number of the Dublin Medical Journal, you will find that many cases of this affection derived great benefit from the use of mercurial ointment; in fact, much more than they could by giving mercury inter- nally. In the next place, I have met with many cases of enteritis and peritonitis, where the disease continued after the system became affectetl by mercury ; and I have observed that these cases yielded rapidly to blistering the abdomen, and dressing the raw surfaces with mercurial ointment. Sir H. Marsh and I attended a young gentleman lately, who had low fever, accompanied by a quick but feeble pulse, and great rest- lessness. About the tenth day, his belly became tender anil exquisitely painful; he had thirst, diarrhoea, and other symptoms of enteric and peri- toneal inflammation.. Before his illness, he had been of rather delicate habit, and had further impaired his health by close study. He was there- fore unfit for depletion, and of this we were convinced by the debility which followed the application of a few leeches. Under these circum- stances, we ordered a large blister to be applied to the abdomen, and the vesicated surface to be dressed with mercurial ointment. This proved eminently successful ; the peritonitis, enteric irritation, and fever, soon disappeared, and the young gentleman recovered completely. The same thing is seen in many cases of pleuritis ; the constitutional effect of mer- cury will fail in removing the affection of the pleura until it is applied locally. I might also refer to instances of common inflammation of the testicle, in which mercurial ointment, smeared over the part, has been found decidedly beneficial. It is unnecessary for me, however, to mul- tiply examples ; what 1 have stated give ample proof of the utility of raercury applied locally. When I was a student, it was the fashion to scout the doctrine that any distinct effect could be produced by the local application of mercury ; our teachers laid it down as an axiom, that, to produce any sensible effect, it was necessary that it should first enter the system through the lymphatics. Thus, when you rub mercurial ointment over the liver to remove hepatic derangement, they said, before it could exert any influence on the liver it had to pass along the thoracic duct, become mixed with the circulation, and manifest its peculiar action on the whole economy. Hence, in a case of hepatitis or testitis, it was deemed useless to apply mercurial ointment over the liver or testicle, since it had, as they expressed it, to go its round through the whole system, before it could affect either of these organs. This reasoning has an appearance of plausibility, but it is contradicted by facts. Numerous examples might be cited to prove that the greatest advantage may be derived from the local application of mercury, independent of any effect produced by it on the general system. How often do we see an incipient bubo dispersed by mercurial frictions, before any constitutional effects occur? How frequently do we see laryngeal and hepatic inflammation relieved by the use of mercurial ointment without salivation? Do the beneficial effects, which we so often observe from the emplastrum ammo- niaci cum hydrargyro, depend necessarily upon the mouth being affected ? Is the relief which follows the use of mercurial ointment in erysipelas or testitis, unattainable unless preceded by mercurial action in the whole system ? Indeed, any person who reviews this subject dispassion- ately, will see that the doctrine of a preliminary constitutional affection being absolutely necessary, in order to obtain the specific action of mer- 564 CLINICAL MEDICINE. cury on any particular organ, is wholly untenable ; while, on the other hand, there is a host of evidence to prove that, locally applied, it pro- duces a primary and distinct effect, totally independent of its action on the general economy. The last case to which I shall direct your attention, is one of syphilitic iritis. A young man has been admitted this morning, presenting symp- toms of secondary syphilis in a well-marked form, but simple and uncom- plicated by any previous treatment. He took no medicine for the primary or secondary symptoms, except two pills, which he got at the dispensary about two months ago, and which were not followed by any sensible effect. The secondary symptoms came on with pains and feverishness, and are at present extensively diffused over his body in the form of ele- vated blotches, of a character intermediate between the papular and squa- mous. About four or five days back, he was advised to take a warm bath for his pains, but having to walk a considerable distance afterwards, the day also happening to be chilly and sharp, he got cold in returning home, and soon after experienced pain in the left eye, with lachrymation, and diminution of the power of vision. Had he been exposed in the same way while in health, he would probably get slight conjunctivitis, or sore throat, or bronchitis ; but the case was altogether different with a man labouring under a constitutional affection, having a tendency to manifest itself in almost every tissue of the body, and prepared to modify every form of inflammation to which accident might give rise. Again, if the man's constitution was in a sound state, his feverish cold, or conjunctivitis, or sore throat, could be removed by very simple means, such as bathing the feet, taking a little warm whey on going to bed, and some opening medicine the next morning. But here the state of the constitution occa- sions the substitution of syphilitic iritis for simple conjunctival inflamma- tion, and demands a peculiar plan of treatment. You are all aware, that persons who have taken mercury for syphilis, without being entirely cured, are very liable to get iritis on slight exposures. Some persons attribute this entirely to the mercury ; but mercury, in such cases, merely acts by rendering the patient more liable to cold, so that when iritis occurs in a patient who has been under a mercurial course, it is not in conse- quence of the direct operation of mercury, but by its increasing his lia- bility to be affected by impression from cold. For the same reason, the circumstance of his having taken raercury before, is not, as some persons maintain, any argument against his using it a second tirae. On examining this man, we found that he had some pain referred to the eyebrow ; the eye is also more vascular than natural, and presents that appearance which is so characteristic of iritis; there is some alteration in the colour of the iris along its free margin, but no irregularity of pupil. Along with these symptoms, there is dimness of vision, and objects ap- pear as if seen through a veil. This arises not from any opacity of the cornea, or opalescence of the aqueous or vitreous humours, but from inflammation affecting the iris, ciliary zone, and, probably, the coats of the retina. In such cases, where the inflammation spreads from the iris to the ciliary zone, it would appear that the ciliary nerves and retina partake in the mischief, for vision becomes affected before we can discover any appearance of derangement in the optical instrument. The peculiar ap- pearance of the eye in this man, the change of colour in the free margin of the iris, and the diminution of the power of vision co-existing with an SYPHILITIC IRITIS. 565 eruption of the skin, point out the nature of the disease, and show that the affection of the eye, though proceeding frora a common cold, has been modified by the syphilitic taint in the constitution. We next come to consider the plan of treatment to be pursued. In order to prepare his system for mercury, I have ordered him to be blooded, purged, and put on the use of antimonials for two or three days. Vene- section, purging, and tartar emetic, may be of some use in relieving oi arresting the symptoms of iritis, but I do not place any great reliance on them for removing the disease; I merely employ them as auxiliaries, de- pending on mercury for the cure. Here it may be necessary to observe, that there is considerable variety in cases of iritis. Some are extremely mild ; there is no palpable sign of acute inflammation present, and the chief symptom is diminution of the power of vision. Such attacks are sometimes not perceived by the patient until some accident informs him that the sight of one eye is nearly gone. In other cases, after reaching a certain point, it begins to decline, and frequently terminates spontaneously. Others pre- sent symptoms of a more decided character, but still are free from danger. Every attack, however, where the inflammation is at all of an intense cha- racter, will go on to destroy vision, unless met by prompt and efficacious treatment. In this man's case the symptoms are not very acute, and hence there is no necessity for having recourse to mercury at once; the disease might certainly terminate in disorganization of the eye, but it would be some weeks before this would be accomplished. On the other hand, there are cases which, if neglected, would destroy vision irremediably in the space of three or four days. Such cases require extremely prompt and ener- getic measures. But where iritis is not of a violent kind, you need not depart from the plan of treatment you would have laid down for the cure of syphilitic affections where no iritis existed. Here you bleed, purge, give antimonials and raercury, and you find that the syphilitic eruption and iritis disappear together. But where the symptoms of iritis are so severe as to threaten rapid disorganization of the eye, you disregard the syphilitic affection, and direct your entire attention to the preservation of the eye. Here you bleed, leech, apply belladonna to the eye, and give calomel, in doses of ten grains or a scruple, every third or fourth hour, so as to bring the system as rapidly as possible under the influence of mercury. With respect to belladonna, I believe you are all aware of its value in iritis. Some think that its action is merely mechanical, that it dilates the pupil and no more; but I am firmly convinced that its influence is not limited to mere dilatation of the pupil. I believe that it acts on the vita- lity of the eye, and that when employed externally or internally, it pos- sesses the property of diminishing the irritability of that organ, and thus tends indirectly to remove local inflammation. In scrofulous ophthalmia, where the eye is exquisitely sensible, where the slightest exposure to light causes intense pain and copious lachrymation, one of the best remedies I ' am acquainted with is belladonna, given internally. Thus you perceive that belladonna has not only a mechanical action, producing dilatation of the pupil, and tending to prevent adhesions, but also, by its influence on the retina and ciliary nerves, diminishes the irritability of the eye, and aids materially in effecting the removal of local inflammation. I have spoken on a former occasion of the utility of mercury in certain cases of rheumatic fever, where the inflammation of the joints will not yield 566 CLINICAL MEDICINE. to other means: I have now to add, that for the last seven or eight years the hydriodate of potash has been found to be a most useful adjunct to mercury, and well calculated for following up and completing the benefi- cial effects produced by that remedy. In fact, in treating arthritic or rheu- matic fever, when I have reduced the violence of the fever and of the in- flammatory affection of the joints by means of bleeding and leeching, fol- lowed by tartar emetic or nitre, or both combined ; or when after the anti- phlogistic treatment, both local and general, I have produced a marked alleviation of the patient's sufferings, either by the use of colchicum or by the use of mercury combined with opiates—then, I say, we can employ the hydriodate of potash with the greatest possible advantage, as it quickly dissipates the remaining pain and swelling of the joints, and contributes powerfully to bring the disease to a speedy termination, while at the same time it greatly diminishes the danger of a relapse. I have experienced much comfort and feel much confidence in the treatment of rheumatic fever since I adopted this practice ; and it now never happens to me to meet with cases which, in spite of all my efforts, become chronic, and confine the unfortunate sufferers to bed for months. You have observed, that in most cases of acute rheumatism affecting the joints, no matter what mode of treatment I adopt in the commencement and during the acme of the dis- ease, I generally complete the cure with the hydriodate of potash, begin- ning with doses often grains, which are quickly augmented to twenty or thirty grains, three times a-day. It is generally given in decoction of sarsaparilla, to which some preparation of morphia forms a useful addi- tion. Iodine and hydriodate of potash exert a very powerful influence over scrofulous inflammation: but their influence, as has been proved by recent experience, extends likewise to inflammations connected with olher states of the constitution, and they are frequently exhibited now with the best effects in certain varieties of syphilis, pseudo-syphilis, gout, mercurial cachexy, and rheumatism. The power of iodine in moderating mercurial salivation and the severe ulceration of the mouth which frequently accom- panies it, has been asserted by some and denied by others. Be this as it may, it certainly is an excellent adjuvant to our usual means for diminish- ing the pain and inflammation which attend periostitic affections, and many of the troublesome sequelae of syphilis. I may observe also, that the hy- driodate of potash has been found to prove a most valuable auxiliary in the treatment of chronic anasarca and the ascites that follows scarlatina. In another place I have spoken more fully of the utility of hydriodate of potash in arthritic rheumatism, lumbago, and sciatica; and Dr. Osbrey has likewise directed the attention of the profession to its powers in these af- fections, in an extremely valuable practical paper on the combinations of iodine, published in a late number of the Dublin Medical Journal, to which I feel pleasure in referring the reader. I have been told likewise by some excellent practitioners, that they have derived much advantage from the ioduret of iron in rheumatic affec-* tions of the joints, after the acute stage has subsided. My own experience of the effects of this remedy is too limited to allow me to express any opinion on its merits. Having spoken of mercurial salivation, it occurs to me this moment, that the remarkable fact of the difficulty of salivating infants and very old persons must depend, in some measure, on the undeveloped state of the CLEAR SOUND OF SOLIDIFIED LUNG. 567 parotid glands of the former, and their shrunken and atrophied condition in the latter. The apparatus connected with the insalivation of the food is comparatively but little required before the teeth appear in infancy, or after they have fallen in advanced age. I wish now to make a few observations on the use of decoction of sar- saparilla and nitric acid in certain cases of chronic cough. The utility of this combination has been long recognised in cachectic states of the sys- tem and affections of the skin, whether syphilitic or mercurial; and it has also proved itself very efficacious in various species of sore throat, chronic pains, and other textural derangements of a slow and tedious character. The marked effects which the decoction of sarsaparilla and nitric acid produce in these diseases of the general habit, skin, and mucous mem- brane of the throat, led me to infer, that the same combination might be employed with advantage in cases of chronic cough, attended with red- ness and relaxation of the mucous membrane of the fauces, elongation of the uvula, and some degree of general debility. I have observed that such cases are almost invariably accompanied by more or less derangement of the digestive organs and an irritable state of the general system ; and from their analogy to other states of the constitution, in which nitric acid and sarsaparilla have proved extremely beneficial, I was induced to give this combination a trial; and I can now state, that it has not disappointed my expectations. Decoction of sarsaparilla, given in doses of a pint daily, with a drachm or more of nitric acid, has proved a most useful and valua- ble remedy in the treatment of cases of this description. It is scarcely necessary to observe, that in addition to the use of this remedy, change of air, moderate exercise and recreation, and a nutritious but not heating diet, are required. In some of these cases it will be also necessary to apply lotions of the nitrate of silver or sulphate of copper to the fauces and tonsils ; and where the uvula is greatly relaxed, it will require to be frequently touched with the nitrate of silver, or even to be shortened by an operation. Guided by the same principles, I have frequently exhibited decoction of sarsaparilla with nitric acid in cases of persons of a reduced and relaxed habit, who are troubled with a slight but frequently-recurring cough or hem, and the expectoration of a few bronchial sputa, occasion- ally mixed with blood, which appears to come, not from the lungs, but from the eroded mucous membrane at the top of the pharynx and larynx. In such cases I have observed, that the cough and expectoration took place chiefly in the morning after awaking, and in some had continued for weeks without any dyspnoea, pain in the chest, or fever. I may also remark, that the same combination may be often given with advantage to patients whose mouths have been recently made sore by mercury admi- nistered for the cure of bronchitis or pneumonia, and will occasionally be found useful in removing the still lingering remnant of pulmonary disease, at a time when mercury could not be pushed farther with safety. Speaking of pulmonary affections leads me to notice a collateral subject of very great importance : I allude to percussion as a means of arriving at a true diagnosis in cases where solidification of the lung has taken place. It is generalfy believed, that in cases where the actual quantity of air in the lungs is morbidly increased or diminished, percussion furnishes us with means of information adapted to every variety of case, and capable of unlimited application. This, however, is not the fact. It is true that when percussion furnishes positive evidence of increased pulmonary soli- 568 CLINICAL MEDICINE. dity, we may be pretty sure that solidification exists ; but such evidence is not furnished by percussion in every case of the kind indiscriminately; for it now and then happens, that percussion elicits a very clear sound frora the parietes of the chest, corresponding to considerable solidification of the lungs within. Of this I have now witnessed several instances. You will ask, how then are to explain this apparent contradiction between the results afforded by percussion ? This is a question of much import- ance, and I hope the solution which I am about to offer will be found adequate and satisfactory. An old man named Foy died lately at Sir P. Dun's Hospital, of hepa- tization of the inferior lobe of the right lung, with numerous tubercular depositions in the upper lobes of both lungs. During his illness, I pointed out the existence of extensive hepatization of the lower lobe of the right lung, in which perfect and decided dulness marked out accurately the space occupied internally by the solidified pulmonary tissue. But ante- riorly and above, the parietes of the chest returned a clear sound on per- cussion, nor could a vestige of dulness be anywhere detected. Yet the whole of the upper lobes of this patient's lungs were occupied to such an extent by crude tubercles, that no portion of the upper lobes could be selected, equal to half the size of a fist, which would not sink in water. This was owing to tubercular matter, which occupied the pulmonary tis- sue in detached infiltrated masses, or in single crude tubercles. How, then, did it happen that such extensive solidification of the upper lobes existed without any corresponding dulness on percussion ? A careful examination of the pathological condition of these lobes satisfactorily ex- plained the anomaly. On accurate inspection, we found that although the solidified masses of the pulmonary tissue were extremely numerous, and predominated over the parts which still retained their natural vesicu- lar texture, so that an extensive portion of the upper lobes seemed to be quite solid, yet the solidified portions were insulated and divided from each other, throughout the interior of the lobe, by intervening laminae of healthy pulmonary tissue, and on their surface were, for the most part, covered by a stratum of healthy vesicular lung, from a quarter to half an inch in thickness. Indeed, although the solidified masses (to use a geo- logical expression) sometimes cropped up, and came to the surface, yet this was comparatively a rare occurrence ; and by far the greater portion of that surface was composed of a thin stratum of pervious vesicular tis- sue. To this was owing the clear sound elicited by percussion. You will recollect, therefore, that in certain (I will admit rare) cases of tubercular deposition in the lungs, the tubercular development may have proceeded to the extent of rendering the greater portion of the upper lobes impervious to the air, and may have solidified those lobes considerably, and yet the solidified portions maybe so divided from each other by laminae of healthy lung, and may be so covered by a stratum of vesicular tissue, that the general result of percussion is to elicit a clear sound over the whole of the parietes of the chest corresponding to the affected lobes. CHRONIC DIARRHCEA. 569 LECTURE XLII. Persesquinitrate of iron in chronic diarrhoea—Newlv observed affection of the thyroid gland in females—Its connection with palpitation ; with fits of hysteria—Erysipelas—Remarks on the formation of acidity of the stomach in indigestion—Psoriasis—Treatment by arsenic. Having lately used, with very considerable success, a preparation intro- duced by Dr. Christison, namely, the persesquinitrate of iron, I shall make a few observations here on its properties and use. The combination of iron with nitric acid forms a remedy possessing tonic, and, at the same time, astringent powers, and hence peculiarly well adapted for the treatment of certain forms of chronic diarrhoea and dysen- tery. You will be consulted by females of a delicate and weakly habit, who frequently exhibit symptoms of nervous derangement, such as palpi- tations, sleeplessness, and headache, who are easily excited or alarmed, have a tendency to emaciation and paleness, and have little or no appe- tite. Combined with these general symptoms, you find that they have been labouring under diarrhoea for weeks, and even months, and that this, with the other causes of debility, has rendered their condition exceedingly uncomfortable. You will also be informed by the patient, that she has tried many remedies without benefit, and that she is extremely anxious to have something done to give relief; and hence it is a matter of import- ance to be acquainted with any remedy which may be likely to prove serviceable in such emergencies. It would appear that this form of diarrhoea does not depend on an inflam- matory condition of the stomach and intestinal canal, for the indications of inflammation are absent, such as pain, tenderness on pressure, thirst, redness of tongue, and severe Or continued griping. It would rather seem to be connected with congestion of the mucous membrane of the digestive tube of a passive nature, and resembling the scrofulous ; it is also of an unmanageable character, and very seldom amenable to the ordinary modes of treatment. The common astringent remedies totally fail ; chalk-mixture, kino, rhatany root, and catechu, are useless, and in such cases it has been observed that opium is generally injurious. If you prescribe opium it certainly checks the disease for a time, but this tem- porary relief is accompanied by debility, malaise, restlessness, and many other uneasy symptoms, and the diarrhoea soon returns, and is as bad as ever. The medicine which I have found most effectual in such cases, is the persesquinitrate of iron, in the form recommended by Dr. Christison. With it I have succeeded in curing many cases which had been exceed- ingly obstinate and of very considerable duration, the disease having in one case resisted all the efforts of medical skill for seven months, and in the other for two years. Seven or eight drops of the liq. ferri persesqui- nitratis, increased gradually to twelve or fifteen in the course of the day, was the' quantity prescribed in both cases. In the course of four days a slight diminution of the diarrhoea was perceived, in a fortnight the patient felt much better, and in a month or five weeks it had disappeared alto- gether. This took place without being followed by any bad effects ; there was no swelling of the stomach, no tympanitis, no tormina, no restless- 570 CLINICAL MEDICINE. ness or nervous derangement ; the patients recovered their health and strength, and the cure was at once safe and permanent. The effect of this remedy admits of an explanation on either of two grounds. You are aware that nitric acid exercises a very powerful influ- ence over many morbid discharges. In chronic diarrhoea or dysentery, and in a certain form of diabetes, it is one of the most efficient and appro- priate medicines which can be prescribed. We can therefore understand its peculiar adaptation to the case of which I have spoken. The nature of the complaint requires a tonic as well as an astringent; and you all know that nitric acid is used as a tonic in many cases attended with debility and emaciation. With respect to iron, its mode of action is equally intelligible. Many of the salts of iron exert a very remarkable influence on the conditions of mucous membranes. The sulphate, tartrate, and many other preparations are prescribed with great advantage in chronic fluxes from mucous membrane ; hence the benefit so frequently derived from the use of Griffiths' myrrh mixture in the treatment of chronic bron- chitis characterized by a supersecretion from the bronchial membrane, unaccompanied by fever. You perceive, then, both the medicines which enter into the composition of persesquinitrate of iron are well calculated to check morbid discharges and strengthen the tone of the system. The only objection to this remedy is, that it is apt to spoil: if kept longer than a week it is decomposed, and hence you should always take care to have it quite fresh when you prescribe it, in order to secure its full operation. I have lately had occasion to observe the good effects resulting from a combination of nitric acid, with vegetable astringents, in a little girl three years of age, in whose case I was consulted by Mr. Wallace, of Town- send-street. She was of a strumous habit; her appearance was that of a delicate but not very sickly child, and, in spite of the long continuance of the complaint, she was active and lively, although her appetite was small. Four or five times during the day, and six or seven during the night, she was seized with a slight griping pain, and a sudden desire to evacuate the bowels. Each evacuation was scanty, and consisting of muco-fecal matter. A great variety of the usual remedies had been tried —alterative doses of mercury, purgatives, astringents, opiates, &c. I pre- scribed the following mixture, which had the happiest effect, and per- formed a speedy cure : $. Decocti hsematoxyli (P.D.),5iv. Vini rubri Lusitanici, §j. Acidi nitrici dilut., gtt. x. Tinclurse opii, gtt. v. M. sumat coch. j. medium, quarter in die. You will recollect that nitric acid, when given in large doses, often pro- duces diarrhoea, as in the common combination of one drachm of dilute acid with a pint of decoction of sarsaparilla. I have lately seen three cases of violent and long-continued palpitations in females, in each of which the same peculiarity presented itself—viz., enlargement of the thyroid gland ; the size of this gland, at all times con- siderably greater than natural, was subject to remarkable variations in every one of these patients. When the palpitations were violent, the gland used notably to swell and become distended, having all the appear- AFFECTION OF THE THYROID GLAND. 571 ance of being increased in size, in consequence of an interstitial and sudden effusion of fluid into its substance. The swelling immediately began to subside as the violence of the paroxysm of palpitation decreased, and during the intervals the size of the gland remained stationary. Its increase of size, and the variations to which it was liable, had attracted forcibly the attention both of the patients and of their friends. There was not the slightest evidence of any thing like inflammation of the gland. One of these ladies, residing in the neighbourhood of Black Rock, was seen by Dr. Harvey and Dr. Stokes; another of them, the wife of a clergyman in the county of Wicklow, was seen by Sir Henry Marsh ; and the third lives in Grafton Street. The palpitations have in all lasted considerably more than a year, and with such violence as to be at *times exceedingly distressing ; and yet there seems no certain grounds for concluding that organic disease of the heart exists. In one, the beating of the heart could be heard during the paroxysm at some distance from the bed—a pheno- menon I had never before witnessed, and which strongly excited my attention and curiosity. She herself, her friends, and Dr. Harvey, all testified the frequency of this occurrence, and said that the sound was at times much louder than when I examined the patient, and yet I could distinctly hear the heart beating when my ear was distant at least four feet from her chest! It was the first or dull sound which was thus audible. The sudden manner in which the thyroid, in the above three females, used to increase and again diminish in size, and the connection of this with the state of the heart's action, are circumstances which may be con- sidered as indicating that the thyroid is slightly analogous in structure to the tissues properly called erectile. It is well known that no part of the body is so subject to increase in size as the thyroid gland, and not unfre- quently this increase has been observed to be remarkably rapid, consti- tuting the different varieties of bronchocele or goitre. The enlargement of the thyroid, of which I am now speaking, seems to be essentially dif- ferent from goitre in not attaining a size at all equal to that observed in the latter disease. Indeed, this enlargement deserves rather the name of hypertrophy, and is at once distinguishable from bronchocele by its becoming stationary, just at that period of its development when the growth of the latter usually begins to be accelerated. In fact, although the tumour is very observable when the attention is directed to it, yet it never amounts to actual deformity. The well-known connection which exists between the uterine functions of the female and the development of the thyroid observed at puberty, renders this affection worthy of atten- tion, particularly when we find it is so closely related by sympathy to those palpitations of the heart which are of so frequent occurrence in hysterical and nervous females. Another fact well worthy of notice is, that females liable to attacks of palpitation almost invariably complain of a sense of fulness, referred to the throat, and exactly corresponding to the situation of the thyroid. This sensation only continues while the paroxysm of palpitation lasts, and fre- quently is so urgent as forcibly to attract the patient's notice, who now complains of its inducing a sense of suffocation. Here the interesting question occurs, whether this feeling of something that impedes the respi- ration at the bottom of the throat, during the hysterical fit, and which has been included under the general term globus hystericus—the question arises, I say, whether this feeling is always of purely nervous origin. To me it 572 CLINICAL MEDICINE. appears probable that it is often induced by the pressure arising from a sud- den enlargement of the thyroid, which enlargement subsides as soon as the fit is over. Of this I am certain, that the lump in the throat, of which such females complain, is often exactly referred to the situation of the thy- roid; and, indeed, I have been told by other practitioners, upon the accu- racy of whose observations I can rely, that this swelling in the throat of females during the hysteric paroxysm has more than once excited their wonder. It is obvious that if palpitations depending on functional disease of the heart are capable of exciting this swollen state of the thyroid, we may expect to observe the tumefaction of this gland also where the palpi- tation depends on organic disease of the heart, as in the following case detailed to me by a friend. A lady, aged twenty, became affected with some symptoms which were supposed to be hysterical. This occurred more than two years ago; her health previously had been good. After she had been in this nervous state about three months, it wras observed that her pulse had become singularly rapid. This rapidity existed without any apparent cause, and was con- stant, the pulse being never under 120, and often much higher. She next complained of weakness on exertion, and began to look pale and thin. Thus she continued for a year, but during this time she manifestly lost ground on the whole, the rapidity of the heart's action having never ceased. It was now observed that the eyes assumed a singular appearance, for the eyeballs were apparently enlarged, so that when she slept, or tried to shut her eyes, the lids were incapable of closing. When the eyes were open, the white sclerotic could be seen, to a breadth of several lines, all round the cornea. In a few months, the action of the heart continuing with un- ceasing violence, a tumour, of a horseshoe shape, appeared on the front of the throat and exactly in the situation of the thyroid gland. This was at first soft, but soon attained a greater hardness, though still elastic. From the time it was first observed, it has increased little, if at all, in size, and is now about thrice the natural bulk of the fully developed gland in a fe- male after the age of puberty. It is somewhat larger on the right side than on the left. A circumstance well worthy of notice has been observed in this young lady's case, and which may serve to throw some light on the nature of this thyroid tumefaction. The circumstance I allude to is, that from an early period of the disease a remarkable disproportion was found to exist between the beats of the radial and of the carotid arteries, the pul- sations of the former being comparatively feeble, while those of the latter were violent, causing a most evident throbbing of the neck, and accom- panied by a loud rustling sound. In about fourteen months the heart pre- sented all the signs of Laennec's passive aneurism; the tumour in the neck is subject to remarkable variations in size, sometimes diminishing nearly one-half. None of her family have had goitres, nor was she ever in any of the usual localities of the disease. Some time ago, you will recollect, we had a case of erysipelas in a young woman, which came on towards the termination of fever; a similar occur- rence has taken place in a patient in the male fever ward. A man who has been for some time labouring under fever, got, about two days since, an attack of erysipelas of the scalp, spreading downwards over the neck and shoulders. The man had been ill of fever of a nervous type, and un- accompanied by any decided marks of visceral congestion; his condition was to a certain extent modified by previous habits of intemperance, but ERYSIPELAS—DYSPEPSIA. 573 still his strength was not much prostrated, nor did he appear to be in a very dangerous state. About the fourth week of his illness he gets an attack of erysipelas of the scalp, which runs downwards over the neck and shoulders, and threatens very dangerous if not fatal consequences. How were we to treat this case? The man's constitution, habits, and the pe- riod of his fever, contra-indicated depletion in any form, and the only thing which we could expect benefit from, was the use of sulphate of qui- nine, which we had prescribed in two former cases of this kind with good effects. We gave it here, also, in the form of an enema, for the state of the man's stomach was such as to preclude the possibility of giving it by the mouth without hazard. An enema composed of five grains of quinine, five drops of laudanum, and two or three ounces of mucilage of starch, was injected three times a-day. I cannot as yet state what the result of this case may be, but the disease is certainly not progressing, and the man says he feels better to-day, so that there are grounds to hope for a favoura- ble termination. Internally I have given the man magnesia with camphor-mixture, on an empirical principle. It has been stated by some of the older writers, that when erysipelas occurs in a weak habit, or supervenes on other diseases, that there is an acescent condition of the stomach, and that it is on this condition the erysipelatous tendency chiefly depends. I have with this view been induced to try the exhibition of small doses of magnesia ; I have ordered a mixture composed of six ounces of camphor-mixture with a drachm of magnesia, of which the patient is to take an ounce every second hour. I may take this opportunity of observing, that since I published some remarks in the Dublin Medical Journal, upon the occasional symmetrical march of erysipelas at both sides of the median line, I have seen other examples of this symmetry. One occurred very lately in Sir P. Dun's Hospital, in a woman in whom the point of departure for the disease was the face. From this the erysipelas spread over the scalp, and then advanced downwards over the neck and shoulders. During its daily progress I pointed out to the students how precisely its outline at one side of the median line corresponded with that at the other. This coin- cidence was the more singular, for the boundary of the advancing ery- sipelas was at each side very irregular in form. I think, therefore, that more accurate observations on this subject will cause a change of opinion in the minds of some who at first opposed my views. There is another case in which I gave magnesia to a man labouring under a particular species of indigestion. He had been for a long time suffering from chronic rheumatism, and this was combined with dyspepsia, characterized by a tendency to supersecretion of acid in the stomach, with gastrodynia and sour eructations. In addition to anti-rheumatic medicines, and enemata to keep the bowels open, we prescribed the subnitrate of bismuth with magnesia, for the purpose of relieving pain and acidity. In gastrodynia, with increased secretion of acid from the stomach, one of the best remedies we possess is the subnitrate of bismuth, with which I am in the habit of combining morphia, or, as in the present case, magnesia. I ordered ten grains of magnesia, twenty of powdered gum arabic, and six of the subnitrate of bismuth, to be taken two or three times a-day, according to circumstances ; this powder was to be fol- lowed by a tablespoonful of water, containing one sixteenth of a grain of 574 CLINICAL MEDICINE. muriate of morphia. In such cases, if milk does not disagree with the patient, you may pour the powder into a quantity of boiled milk; allow it to cool, and then stir it with a spoon, and make the patient swallow it. The gum arabic is used for its demulcent properties, and because it enables Ihe patient to swallow the powder with more facility ; and the fluid in which you mix the powder, whether it be water or milk, is to be used warm in order to dissolve the gum more speedily. This is a very good combination, and I have seen many cases of dyspepsia, with acid eructations, which had resisted bismuth, prussic acid, or morphia, given singly, yield to it. I need not state to you the reasons why magnesia and other antacid remedies are given in such cases; but it may be necessary to mention briefly the principle on which opiates are prescribed. Dr. Elliotson has shown, that many of the morbid states of the stomach depend on deranged nervous energy, that in such cases, the most efficient means we can use are narcotics. As to the subnitrate of bismuth, its mode of action is not very obvious ; but we know that the metallic salts possess great influence over various nervous diseases, as well as over morbid secretions. Witness the effects of carbonate of iron, oxide of zinc, the preparations of arsenic and antimony, and several others. On this account we prescribed the sub- nitrate, hoping to derive some benefit from its use, as well with respect to checking the sour eructations, as to relieving the gastrodynia. It may be well to make a few observations in explanation of the manner in which tonics and narcotics act in diseases of the stomach. Formerly physiolo- gists were of opinion, that in weakly stomachs the act of digestion was accompanied by the formation of acid and flatulence, because the food being imperfectly acted on, was allowed to undergo the process of fer- mentation, a process which gave rise to the acid and the wind in the stomach. In compliance with this view, physicians endeavoured to pro- cure relief in these cases by prescribing a regimen little likely to undergo a fermentation capable of causing a production of either air or acid ; and they endeavoured to neutralise the bad effects of these, when produced by means of the administration of alkaline medicines. They used, how- ever, to be astonished at observing that many articles of food, which outside the body never formed any acid during the fermentation (or more properly putrefaction), occasioned, nevertheless, wThen eaten, as much acidity in the stomach as any other aliments. It was remarked also by practical men, that although present relief was obtained by means of alkalies, yet their constant exhibition seemed rather to increase than diminish the tendency of the formation of acid in the stomach. This fact could not be explained in the then state of physio- logy. In the year 1821, I read an essay on this subject before the Asso- ciation of the King and Queen's College of Physicians, in whose transac- tions it was subsequently published. In this essay I pointed out the true source of the acidity and flatulence observed in dyspepsia, and proved, contrary to the received opinions, that it was the result of a morbid se- cretion. In fact, I showed that the stomach has the power, when in health, of secreting acids and air, both essentially necessary for the solu- tion of the alimentary mass; and I proved, that in dyspepsia this power is morbidly deranged in such a manner as to give rise to a supersecretion of acids and air. This view of the subject was soon recognised to be correct, and in consequence, new' methods of treating dyspepsia were pro- PSORIASIS. 575 posed. Among the proposals for obviating acidity, that of Dr. Elliotson, who recommended prussic acids and other narcotics capable of acting upon the nerves of the stomach (through the influence of which secretion is effected), was found to be the most successful, and has been sanctioned by the most extensive experience. Before I conclude I shall call your attention to the case of Ellen Far- row, who has been for a considerable time labouring under extensively diffused psoriasis. She was admitted about the beginning of last Novem- ber, and we are now come to the 10th of December; so that she has been a patient here for nearly six weeks. Her disease is of better than two years' standing, and the eruption covered almost every part of the surface of the upper and lower extremities, the trunk remaining unaffected. The patient, you perceive, is a fine healthy country girl ; and though the com- plaint has lasted so long, her system does not seem to be in the slightest degree impaired—appetite, digestion, and sleep are perfectly good. Now, on examining her soon after her admission, you will recollect that I told you that the duration of the disease, the absence of constitutional irrita- tion, and of irritation in the parts affected by psoriasis,-all contra-indicated a mode of treatment which frequently proves highly useful, namely, the antiphlogistic. If called to a case in which the disease was recent, and attended with heat of skin, redness, and itching, I would bleed, leech the affected parts, and put the patient on a spare diet. Even in some cases of a chronic character, this treatment may be employed with great advan- tage. Here, however, the state of the patient was such as not to require antiphlogistics, and accordingly we put her on the use of Fowler's arse- nical solution. By the way, when you give this remedy in private prac- tice, where patients or their friends are very curious in scanning your prescription, you may, in order to prevent alarm, or have the action of the medicine interfered with, write on your prescription—" Liquor mine- ralis Fowleri." I mention this case of Farrow's chiefly for the purpose of showing the extent to which the arsenical solution may be carried. Bear in mind, I do not mean to boast of the quantities of medicine my patients swallow. Some persons appear to think, that there is something very brilliant in prescribing enormous doses : I should, however, be very sorry to make such experiments. Arsenic is a very powerful remedy, and its effect on diseases of the skin can be amply secured by moderate doses ; where these fail, it is very often from not continuing the use of the remedy for a sufficient length of time. Latterly this girl has taken ten drops of Prow- ler's solution three times a-day ; and, as she is getting well, I do not in- tend to increase the dose. We began with three drops three times a-day ; after a few days this was increased to five, and then to seven drops three times daily. She then began to take ten drops three times a-day ; but after a few days having got an attack of ,>hivering, followed by symptoms of feverish excitement and herpes labialis, we stopped the arsenic for five days, and then began to give it again in small doses, which were gradu- ally increased until we came to the quantity she is taking at present. Whenever you have a patient under the use of arsenic, you must never omit making daily inquiries as to the state of the head and stomach ; if the patient complains of gastrodynia or nausea, if there be pain or giddi- ness of head, or if, these being absent, a state of feverishness or general nervous excitement supervene, it is a proof that the remedy has been 576 CLINICAL MEDICINE. pushed sufficiently far, and under such circumstances you should suspend or give up its employment. In this case, being unwilling to give up the use of arsenic, as it appeared to be curing the patient, I merely suspended it for a few days, and then had recourse to it again. In order, however, to prevent it from acting unfavourably on the stomach, I have latterly prescribed it in the following form :— R. Liq. arsenicalis, M. x. Aqua? distillatae, 5J. Tinct. opii, M. x. Spirit, lavandulae, compos. ^ss-—ft* haust. This appears to agree very well with the stomach ; and as she is improv- ing very rapidly, I intend to continue it for some time without increasing the dose. The only other point worthy of remark in the case is, that we observed in it a phenomenon connected with the state of the skin, such as usually occurs when a patient is using sulphur or sulphureous waters for the cure of chronic cutaneous affections. After they have been taking these reme- dies for some time, they experience a slight exacerbation of symptoms, and complain that the eruption is growing worse. This, however, should never induce you to give up the remedy without further trial; for this tem- porary aggravation generally precedes the disappearance of the disease. W7e dismissed a case of dysentery lately from our wards, concerning which I promised to make a few observations. During the months of August and September last, we had in Dublin several cases bearing a de- cided analogy to the dysentery of Cullen. There were fever, griping, tenesmus, a constant inclination to go to stool without being able to pass any thing but a little mucus and blood, and occasionally scybalae. In this form of disease, some authors are inclined to attribute all the bad symp- toms to the presence of these scybalae, which are small hard lumps of fecal matter, evidently formed in the sacculi of the great intestine. You will find others asserting that this cannot be the case; for in many dysenteries there are no scybalae at all, and that even when they do occur, they have no connection with the disease. The latter take no account of scybalae, while the former state that the diseased condition of the intestine depends upon the irritation produced by them, and that you never can expect to cure the disease without getting rid of them by active purgatives. For my part, I believe that there are certain dysenteric states of the great in- testine, in which the main cause of the disease arises from the lodgment of quantities of hard, unhealthy, and long-retained fecal matter; but in cases of epidemic dysentery, I do not think that scybalae have any thing to do with the formation of the disease, or the aggravation of its symptoms. In the present case, the affection appears to have been pure rectal dy- sentery, depending almost exclusively on inflammation of the rectum, not extending to the sigmoid flexure of the colon, and certainly never as far as its arch. The symptoms present were fever, increased heat of skin and quickness of pulse, with a feeling of heat and pain in the situation of the rectum ; for the first day the discharges consisted of mucus and blood, com- bined with fecal matter, but after this the mucus and blood were voided alone with great griping and tenesmus, and the patient was obliged to get up to the night chair thirty times in the course of twenty-four hours. There was, however, no symptom indicating that any portion of the intes- PLEURO-PNEUMONIA. 577 tine beyond the rectum was affected. Now, what was the consequence of this state of things? The inilammation of the rectum gave rise to con- stant spasm of that organ ; the colon partook more or less in its spasmodic action, and hence every attempt to pass the stools was resisted. Here, however, the feces lay in a portion of the intestine free from inflammation; they could not produce any aggravation of the symptoms, and the scybalae were to be looked on as the consequence and not the cau>e of the disease. Now, whether purgatives were given by injection, or by the mouth, they would have done no good in such a case as this; we might have copious fecal discharges, but without the slightest diminution of the local symp- toms. I do not mean to say that there are not dysenteries in which pur- gatives are highly useful; but in the case before us, where the disease was limited to the rectum, I did not think that any benefit could be derived from them. I confined my attention, therefore, entirely to local means directed to the part inflamed, applied leeches to the anus, gave narcotic and emollient enemata, and after I had in this way relieved pain and irri- tation, t combined with the enemata, first, a small quantity of the acetate of lead, with the view of restoring the tone of the relaxed mucous mem- brane, and afterwards changed it for the sulphate of zinc. Under this treatment the case went on very favourably, and we have been able to dis- miss the man in a very short space of time. LECTURE XLI1I. Pleuro-pneumonia—(Jases of latent pleurisy; of pneumonia—Phthisis; latent ulceration of the bowels in—Diarrhoea of phthisis—Jusei valious on the stammering of paralytic persons —Its explanation—Very remarkable case of stuttering cured by chronic laryngitis—Treat- ment of hoarseness—Velpeau's method of treating sore throat. Let me now direct your attention to another topic. You have seen that a principal feature in the character of the present pneumonia is its compli- cation with pleuritis ; we have had several cases of inflammation of the lungs, combined with inflammation of their investing membranes, but I do not recollect that we have had a single case of pure pleuritis, or pure pneu- monia. In the patient who lies at present in the chronic ward, labouring under pleuro-pneumonia, the inflammation occupied the superior part of the right lung in the first instance, and this is rather remarkable, as pneu- monia generally commences in the lower part of the lung. Hare, however, the pneumonia and pleuritis were located above, each being in point of extent nearly of the same dimensions, the portion of inflamed lung corre- sponding in its area to the portion of pieura engaged in the disease. Soon after his admission we found that the inflammation was making further progress, but its spreading was attended with this remarkable peculiarity, that while the pleuritic inilammation in the superior part of the right side of the chest became limited and ceased to extend itself, the pneumonic inflammation commenced travelling downwards and backwards, so that after two or three days we had pleuro-pneumonia in the upper part of the lung, and further down in the lower and back part of the lung it was merely pneumonia unaccompanied by pleuritis. This is an occurrence which I have frequently witnessed, that when pleuritis and pneumonia co- 38 578 CLINICAL MEDICINE. exist, the latter will spread, often in spite of all our efforts, while the former remains stationary. 1 wish to impress this fact on your minds, that pleu- ritis never exhibits such a tendency to extend itself gradually, day after day, as pneumonia; if the pleura becomes inflamed, the extent to which it is likely to be engaged will be determined in twenty-four hours; whereas, in cases of pneumonia, the disease, though limited at the commencement to one or two small insulated spots, will frequently begin to extend in every direction from these points, until in the course of a few days it involves a large portion of the lung. In other cases, many days are required before the spreading of pneumonia ceases. This case is of considerable interest to the stethoscopic student, as ex- hibiting in a very satisfactory manner all the physical signs of pneumonia, as well in its pure state as where it is complicated with pleuritis. It is unnecessary for me to enter into any detail of the symptoms or of the physical signs, but I invite you to study them as well worthy of your attention. A patient has recently died, who came into hospital labouring under a disease which generally proves fatal, namely, double pleuro-pneumonia. He had violent pleuritis and pneumonia in both sides of the chest under these peculiar circumstances; that in the left side the pneumonia was situated above and anteriorly, in the right side below and posteriorly ; so that the lungs were affected nearly at the opposite ends of their transverse diameters. On his adraission, he appeared extremely low and weak, and it was obvious that the case must terminate fatally. His respiration was extremely quick and laboured ; he had great oppression about the chest, constant anxiety, incessant harassing cough, quick weak pulse, and a countenance expressive of intense suffering. On examining the chest with the stethoscope, we found that both lungs were extensively solidified ; and this, combined with his age, and the manifest sinking of the powers of life, prevented us from indulging in any hope of being able to arrest, much less to remove, his complaint. He was a poor creature, moving in the very lowest class of life, ill fed, without sufficient clothing, most wretchedly lodged, and constantly exposed to cold and hardships. He had been employed in breaking stones on a road at fourpence per day, and out of this miserable pittance endeavoured to maintain a family. From repeated exposure to inclement weather, he got a violent attack of pleuro-pneumonia, which, being neglected at the commencement, assumed an intractable character, and when he came into hospital, the disease had been of several weeks' standing, his system reduced to the lowest state, and no sign whatever of reaction. In estimating the danger of a patient labouring under pneumonia, I have tohi you that it is not so much in proportion to the extent of lung engaged, as to the quickness of respiration, and the presence or absence of symp- toms of asphyxia. You will see one man in pneumonia, having nearly the whole right or left lung inflamed and solidified, breathing easily with the other lung and apparently suffering but little inconvenience; while you will find others, with a smaller amount of disease, exhibiting symp- toms of distress bordering on asphyxia. I attended a young gentleman eighteen months ago, who had complete carnification of the left lung, and pleuritic effusion on the same side, pushing the heart so far out of its place, that it could be felt pulsating under the right mamma. His illness lasted for nearly four months ; yet the fluid was afterwards completely PHTHISIS SENILIS. 579 absorbed, the lung gradually assumed its natural condition, and he reco- vered perfectly. About six months after, I was again called to see him, and found that after exposure to cold he had got a violent attack of pneu- monia in the right lung, which had run on to hepatization, and on exam- ining him by the stethoscope and percussion, I found that almost the whole of the lung was solidified. In this case, there never was any thing like an approach to asphyxia ; indeed, the distress of breathing was extremely slight, and he recovered completely in two months. This was rather a singular case ; the patient one year getting violent pleuritis, followed by extensive effusion, forcibly compressing the lung so as to render it quite useless, and pushing the heart out of its place ; and the next year getting an attack of pneumonia in the other lung, ending in solidification of nearly the whole organ, and yet recovering completely from both. I need not say that there could have been no scrofulous taint in this gentleman's constitution, for if there had, the chances were that he would have sunk under either of these attacks. He lives at Crumlin ; and in both instances his attending physician was Dr. Adams, of Stephen's Green. • In such a case as this, the utility of the stethoscope was obvious ; by its means we not only learned the nature and extent of the disease we had to combat, but also the exact situation where topical applications, such as leeches, blisters, setons, &c, should be applied with greatest ad- vantage. I had lately an opportunity of witnessing an extremely inte- resting case of perfectly latent pleurisy. It was seen in the first instance by my friend and former pupil, Mr. B. Guinness. A fine young gentle- man, catching cold, contracted some slight fever apparently catarrhal, which altogether subsided in five or six days, but he remained very weak. I saw him on the tenth day ; a very slight cough remained, his breathing was regular, and he felt no want of breath ; he had had no pain in the side from the commencement; he was weak and rather sleepless ; other- wise he could specify no complaint. I do not know what induced me to percuss his chest—perhaps it was the force of habit; be this as it may, percussion led me to the discovery of extensive pleuritic effusion on the right side. He recovered perfectly under the use of proper remedies. Let me now direct your attention for a few moments to the case of M. Murphy, who died on Saturday last. This man, aged sixty, was admitted on the'first of November. He had been ill for nine months before his admission, and stated that his illness originated in exposure to cold. It commenced with cough, oppression of chest, dyspnoea, and haemoptysis. During the first month, the haemoptysis recurred frequently, and, as he thought, generally with more or less relief; but during the latter period of his illness, it was entirely absent. On his admission, he had well- marked hectic fever, with copious puriform expectoration, and appeared very much emaciated. The right clavicle sounded pretty clear, but under the left clavicle there was well-marked dulness, with a full mucous rale approaching to gargouillement and pectoriloquy. The two latter symptoms became much more decided in about a week after his adrais- sion, and I accordingly marked on his card " Phthisis Senilis." The only other circumstance connected with the history of his case which deserves attention, was, that he laboured under constant costiveness, which continued up to the period of his death, his bowels never yielding except when he used purgative medicines. It is unnecessary for me to enter into a detail of the remedies employed 580 CLINICAL MEDICINE. to alleviate his symptoras—the only duty which remains for the physician under such circumstances ; I shall therefore content myself with noticing the phenomena observed on dissection, with one or two particulars which seem to demand a brief observation. You will recollect that this man exhibited, for several weeks before his death, unequivocal signs of a large cavity in the left lung, and that latterly the right lung also had become dull on percussion, and that the stethoscopic phenomena indicated the formation of a new cavity at its upper portion. Here are the lungs; the left, you perceive, is larger than the right, and exhibits a marked depres- sion at its upper portion, where the phthisical cavity is situated. You perceive also, that the pleura investing it is very much thickened, and very rough on its surface ; this appearance was in consequence of its intimate and universal adhesion to the corresponding pleura costalis, from which it was separated with considerable difficulty. You perceive that the right lung is rather smaller than the left ; the left, being rendered more extensively solid by disease, has become incapable of collapsing after death to the same extent. We shall now make a section of the lung, to show the extent of the cavity. Here is the cavity; you perceive that it is nearly large enough to contain a small orange, and that its walls are lined with a firm semi-cartilaginous membrane. At the upper and internal part there is a small opening, which seems to be the commencement of a fistulous passage, a very common occurrence in cases of phthisis senilis ; I shall introduce a probe and lay it open. Here is the track of this fistu- lous opening, and you perceive it terminates in one of the large ramifica- tions of the left bronchus. You may perceive, also, that the section I have made displays masses of small granular tubercles in the upper and anterior portion of the lung, quite different in size and appearance from the large tubercles seen in the child and adult. I shall now make a section of the right lung. It is much more natural in its feel and appear- ance than the left, but still in all chronic cases of phthisis we seldom have the disease limited to a single lung. Here you perceive are a few patches of granular tubercles, looking as if they were infiltrated into the substance of the lung, and not surrounded as the large tubercles of the adult and child are, by vascular condensed pulmonary tissue. Here, you see, I have cut into a small cavity ; from its contents and appearance, you can judge that it is of comparatively recent formation ; it has no semi-carti- laginous lining, and is of very inconsiderable size. You perceive, also, that it communicates freely with a pretty large sized bronchial tube, and contains a quantity of muco-purulent secretion. With respect to the state of the viscera of the abdomen, I may observe, that with the exception of some portions of the intestinal tube, which I am about to show you, they presented nothing very remarkable. The liver and kidneys were found to be of the natural size, somewhat indu- rated, and very friable, and the spleen exhibited several small tubercular spots on its surface. Here are the stomach and the duodenum, which you perceive retain their normal appearance ; and the same remark is to be made .of the colon and rectum. In the caecum, however, which you see here, and here also in the ileum, there are several ulcerated patches of an oval form, and corresponding to the situation of the glands of Peyer. In some places you perceive the ulcers have destroyed not only the mucous membrane, but also the muscular coat of the intestine, and have very nearly produced perforation. LATENT ULCERATION OF THE INTESTINES. 581 A most important inference may be drawn from this fact. Here we have several ulcers destroying the mucous coat of the intestine, and ealing their way through its muscular tissue, so that the only barrier left to prevent an effusion of the intestinal contents into the cavity of the peri- toneum, is a thin layer of serous membrane. Yet, during the whole time he remained in the hospital, his bowels were so obstinately costive, that we were obliged to give him purgative medicine every second or third day, to procure an evacuation. You would suppose, a priori, that a man, in whom ulceration of the bowels existed, would suffer considerably from pain, griping, and tympanitis, and that he would labour under the diar- rhoea so frequently observed in the advanced stage of phthisis. Our pre- decessors entertained a notion that the diarrhoea of phthisis is a species of interna] sweating ; they observed, that when the patient ceased perspiring frora the skin, he was generally attacked with a watery diarrhoea, and hence they termed the diarrhoea, colliquative. Afterwards it was found, on numerous examinations, that where this diarrhoea had existed, there was in most cases ulceration of the bowels ; hence pathologists began to believe that this ulceration had a great deal to do with the intestinal symptoms observed towards the termination of phthisis, referring to it the abdominal pain and tenderness, the unmanageable character of the diar- rhoea, and the aggravation of the hectic symptoms. Now it strikes me that this mode of accounting for these symptoms was, perhaps, too hastily adopted. No doubt ulceration of the bowels may produce all the symptoms detailed ; but, on the other hand, it raay exist to a very remarkable extent, and yet produce no symptoms by which it could be recognised. Here was a patient who never had the slightest tendency to diarrhoea, who never complained of pain, griping, flatulence, or abdominal tenderness ; on the contrary, his bowels were not merely slow, but even confirmedly costive, and he always felt more or less relief from the use of purgative medicine. None of us ever suspected that any thing like ulceration existed ; we gave him a full dose of castor oil every second day, which produced one rather scanty evacuation, and yet when we come to examine his intestines, we find numerous patches of ulcera- tion. This case is calcalated to make a deep impression on every reflect- ing mind ; in a practical point of view, it is of great importance. If the scrofulous disease had in this case been entirely limited to the bowels, and had not touched the lung, the great probability is that it would have been almost wholly latent; that the man would have taken no notice of it, would have thought himself well, and eaten, drunk, and worked as usual; that the disease would have gone on stealthily committing its ravages, and that one of the first symptoms of danger would have been the occurrence of perforation, followed by universal and fatal peritonitis. The question would then be as to the cause of death. The pathologist would open the body, and find at once that the cause of the whole mis- chief was ulceration of the intestines; but he would be mortified to think that the work of destruction had gone on silently and unobserved, and that it could not be recognised until a new disease appeared, under which the patient sank. I have read of more than one case in which a person killed by accident was found to have large ulcerated patches in the ileum, and yet had not been known during life to complain of any intestinal symptoms. In one case, a strong and apparently healthy Lascar, who had eaten heartily an hour before he was killed, and whose digestion was, 582 CLINICAL MEDICINE. according to his friends' account, unaffected by any morbid derangement, presented, on examination, a number of deep ulcers in the ileum, which would in all probability have ended in perforation and peritonitis in the course of a few days. At the conclusion of this lecture I intend to speak of hoarseness and chronic laryngitis, and shall most probably return to this interesting topic again. At present I shall detain you for a few moments with a brief out- line of a case of total loss of voice, which I have recently witnessed, and which is in itself so singular, that I make no apology for giving it. Before I mention this case, allow me to observe that loss of speech arises sometimes from lesions of apparently a very trifling character. A person may totally lose his speech without any previously existing or pre- monitory symptoms indicative of nervous lesion—without having expe- rienced any sensation of pain or vertigo, any noise in the ears, any indi- cations of determination to the head—in fact, without any thing to show that the aphonia was connected with any particular state of the brain. Thus, a barrister, whom I attended with Dr. Beatty, was walking up and down the hall of the Four Courts, waiting for a case to come on, and chatting with one friend and another; as the hall was rather crowded and hot, he went out into the area of the courts for the sake of the air, and had not remained there more than ten minutes when an old friend from the country came up and spoke to him. He was pleased to see his friend, and wished to inquire about his family, when he found, to his great sur- prise, that he could not utter a single audible sound ; he had completely lost his voice. He recovered the use of his tongue in about three weeks, but not completely, for some slowness of speech remained. When the loss of speech was first perceived, his friend brought him home in a carriage; and during the day he had several attacks of vertigo, and afterwards he- miplegia. For several hours, however, before distortion of the face or any of the usual symptoms of paralysis had commenced, the only existing symptom was loss of speech. This gentleman died of apoplexy in about two months. In many cases of paralysis you will find that, although the patients have lost the power of utterance, yet the motions of the tongue appear to be nowise deranged. In the majority of cases it can be shortened, elongated, raised, depressed, or moved from side to side, with as much apparent facility as in a state of health ; and yet the voice is in some instances very much impaired—in others, totally lost. In such cases it would ap- pear that the defect lies in the glottis, which forms and modulates the voice, and not in the tongue or lips, which divide and articulate it. In- deed, this is evident to any one who observes the interrupted and spas- modic efforts which paralytic persons make when speaking ; they are, in fact, all stutterers. But to return to the ca.'e to which I have alluded. A young gentleman of delicate constitution, and who is now about sixteen years of age, con- tinued to enjoy tolerably good health up to his sixth year. When about six years of age, he went to bed one night in health and without any un- usual symptom, but on getting up in the morning it was observed that he had lost his speech, and was unable to articulate a single word. His family became alarmed, and sent for a physician immediately; the boy got some internal medicine and a stimulant gargle, and recovered his speech in a few days, without the occurrence of any symptom of laryngeal HOARSENESS AND LOSS OF VOICE. 583 inflammation or cerebral disease. But what was remarkable in the case was this: the boy, who up to this period had spoken well and distinctly, now got a terrible stutter. This resisted all kinds of treatment, and for ten years he continued to stammer in the most distressing way, and was so annoyed by it himself that, when a boy, he used to stamp on the ground with vexation whenever he failed in uttering what he wished to express. In the month of May last, he got an attack of chronic laryngitis of a scro- fulous character, and evidently the precursor of phthisis. Indeed, he is at present labouring under phthisis; Dr. Stokes and I have examined * him, and we feel convinced that tubercular deposition is going on in the lungs. But what is most curious in the case is this: after he got the laryngitis, a very peculiar change took place ; the laryngeal inflammation modified the tone of his voice so as to make it a little husky, but the stammering has completely ceased. You are aware that stammering has been explained as depending on spasm of the muscles which are employed in modifying the column of air as it rushes through the narrow aperture of the glottis. At certain times, and under a variety of circumstances, those fine muscular organs become spasmodically affected, the vocal chords no longer undergo the same steady and exact tension and relaxation, and speech becomes interrupted in con- sequence of frequently-recurring closure of the glottis. With respect to this disease, I would beg leave to refer you to a very excellent chapter in Dr. Arnott's work on the Elements of Physics, vol. i. p. 644. In the case to which I have referred, inflammation taking place in the mucous membrane covering these delicate muscular fibres, you can con- ceive that either the thickening of the mucous membrane, or the alteration in the state of its vitality, may have so modified the disposition of the parts, that they become incapable or indisposed to undergo those rapid contractions necessary to produce stammering, by inducing closure of the glottis at the moment that its aperture ought to remain open. The case itself, however, is an extremely curious one, and I do not believe that there is any similar one on record. Everything which bears on the cure of so important a disease as stammering, even though it be accidental, and not the result of medical care and ingenuity, is of great value, inas- much as it tends to place the causes of the disease in a clearer light. In this point of view I look upon the case as one of very great interest. I shall conclude this lecture with a few detached observations on hoarse- ness, or loss of voice, from sore throat or slight laryngeal inflammation—a form of disease which is now very prevalent. A form of hoarseness is frequently observed in growing boys or girls, which assumes a very chronic character, and often resists for a long time almost every form of treatment. A boy gets cold, followed by sore throat and feverish symptoms, which may last for a few days, and then disappear under the use of aperient medicines, or perhaps without any interference on the part of the parents or the physicians. The feverishness and sore- ness of throat subside, but the hoarseness remains, and the boy can speak only in whispers. This condition may last for weeks, and even months, without any other symptoms whatever; the patient has no cough or diffi- culty of breathing; his appetite is good, sleep and digestion natural, and there is no appearance of emaciation. The only thing amiss with him is the impairment of voice, and this continues so long that it gives rise to a considerable degree of anxiety on the part of his parents. When you exa- 584 CLINICAL MEDICINE. mine the fauces, you find no appearance of inflammation in the mucous membrane, and there is no superficial or deep-seated tenderness in the re- gion of the larynx. How are you to treat this form of disease? It de- pends on a relaxed and weakened state of the chordae vocales, and perhaps the muscles of the larynx—the result of inflammation of an exceedingly chronic character—and will not be benefitted by leeches, or antiphlogis- tics, or low diet. The best thing you can do in such a case is to have re- course to the use of strong stimulant gargles. You begin with a drachm of the tincture of capsicum in six ounces of decoction of bark, which is to be used five or six times a-day. After some time you can increase the quantity of tincture of capsicum, but you never need go farther than half an ounce in a six-ounce mixture. In the next place, you will have re- course to frictions over the region of the larynx and external fauces with croton oil, which is much better adapted for such cases than tartar-emetic ointment. The eruption produced by tartar-emetic ointment is productive of a great deal of annoyance, and when the pustules break they prevent the boy from wearing his neckcloth. All the purposes of a counter-irri- tant are quite as well fulfilled by croton oil, and with much less inconve- nience. The best form for using it is the following:— U. Liniment: camphors comp., §j. Olei crotonis tiglii, M. xx. Of this mixture a small quantity, say a couple of drachms, should be poured into a saucer, and rubbed over the fore part of the neck night and morn- ing, until a full crop of pimples appears. When these have dried up and desquamated, it should be again applied, and in this way a mild and man- ageable, but very effectual, degree of counter-irritation can be kept up for any length of time. In addition to these measures (should the disease con- tinue), I would strongly recommend small doses of iodine, and change of air. I have been induced to give iodine in such cases from observing that inflammation of a chronic character seems to have many points of re- semblance to that which arises from scrofula. The last thing which I have to observe on this form of hoarseness is, that you should, particularly in the beginning, insist on the observance of strict silence—a point which is said to be exceedingly hard to be attained where the patient happens to be a female. In some cases all ihese means fail, and then something more energetii- must be attempted, 'fhe inhalation of the vapour arising from tincture of iodine and tincture of conium, added to hot water in a proper apparatus, has proved useful to some; but in all obstinate cases the sheet- anchor is mercury exhibited internally, and by means of inhaling the fumes of hydrargyrum cum cretti. In general, it is necessary to continue the mercurials until the mouth is slightly touched, when the hoarseness will be found to yield. It is obvious that, before we employ mercury in a case of chronic hoarseness, we must feel well assured that we have not to deal with a hoarseness arising from a phthisical tendency, for in this case mercury would prove injurious to the constitution. In such cases the stethoscope and percussion often afford valuable assistance, by showing that although ihe patient has had a hoarseness and cough for weeks, or even months, yet there are no symptoms of tubercular development in the lungs. The cough is only the result of laryngeal inflammation or irritation; the sub- maxillary glands and the amygdala? are often slightly enlarged, the fauces are red, and the back of the pharynx is covered with irregular superficial AMAUROSIS. 585 excoriations. Connected with the subject of sore throat is the discovery, lately announced by Velpeau, of the use of alum in powder in acute cy- nanche tonsillaris. He states that this powder, applied by means of the finger to the fauces and mflamed parts, exercises a wonderful effect. The symptoms, says Velpeau, are stopped as if by enchantment, the fever dimi- nishes, the redness and tumefaction of the inflamed parts subside, the ap- petite returns, and convalescence is speedily established. This applica- tion is successful at any period before suppuration has been established. Alum has long since been applied in substance to the throat, in cases of angina maligna, and in chronic sore throat; but, before Velpeau, no prac- titioner ever dreamed of making use of alum as a local application during the first stages of acute cynanche tonsillaris. By the way, this use of alum is calculated to throw some light on the good effects which this substance exerts, when taken in large doses, in cases of violent pain in the stomach arising from indigestion, recommended by Dr. Griffin, of Limerick. LECTURE XLIV. Amauhosis—Acetate of lead in Asiatic cholera—Remarkable mobility of sternum. There is at present in the hospital, a man whose case has been marked imperfect or (to use a better phrase) incomplete amaurosis. He has been complaining at different times during the past year, and for the last six months his vision has been very weak, with the exception of occasional intermissions. He can perceive objects tolerably well with the right eye, but scarcely at all with the left, and in both vision is more or less dim and imperfect. On examining this man's eyes, you cannot discover in either of them the slightest perceptible defect as an optical instrument. The deficiency of vision, therefore, does not depend on opacity of the cornea, on disease of the lens or its capsule, or on any affection of the aqueous or vitreous humours ; it is simply an impairment of the vitality of the organ, con- nected with functional disease of the retina. Having thus satisfied our- selves as to the seat and nature of the disease, we come next to inquire into its cause and origin. From a careful examination-of the man's state of health, wTe can have no doubt on our minds as to whether the amaurosis in this case has been produced by derangement of the stomach or not. You are all aware that the celebrated Richter has long since shown, that functional disease of the retina is often connected with a deranged state of the alimentary canal, and that it may be treated successfully with emetics and purgatives. Here, however, we have no evidence of the existence of congestion or derangement of the stomach and bowels. The man's appetite is good, his bowels regular, and his health robust. But when we come to examine the head, we find evidence of cerebral con- gestion sufficient to account for the functional lesion of the optic nerve. Our patient has been a long time complaining, at different periods, of a sense of fulness in the head, and is subject to attacks of vertigo while walking, causing him to stumble occasionally, and labour under frequent apprehensions of falling down in the street. He prefers walking along 586 CLINICAL MEDICINE. the middle of the street to either side, and says that he is always worse when he attempts to walk along the flagway. This is an ordinary symptom observed among persons who have a tendency to vertigo ; they are fre- quently made worse by the operation of causes in themselves apparently inconsequential, and the nature of which we cannot well understand. You are aware that, in many persons, the act of looking for any length of time at objects moving rapidly in a straight line, and still more in a circle, has a tendency to produce giddiness. Thus, looking out of the window of a steam-carriage on the objects apparently moving backwards with great velocity, or looking over a bridge at the current of a rapid river, or gazing at a person whirled round in a gyrating swing, is very apt to give rise to vertigo. Again, persons labouring under a morbid sensibility of the brain, very often become giddy from looking at a succession of objects moving with much less rapidity. Hence you will find such persons made giddy by walking through a crowded city, and having a number of persons pass by them on the flagway, and they seek for an opportunity of getting into the middle of the street, to avoid meeting so many objects. I knew a person who could never pass by a line of railing with any degree of comfort; if he happened to look at them as he moved by, he becarae almost immediately vertiginous. Giddiness is also generally produced by looking down from a great height, in a vertical direction, or by looking upwards, provided the object be immediately overhead, and at a great distance. Under these circumstances, most persons experience a feeling of vertigo, no matter what their position may be at the time. There seems to be little doubt that the sensation of giddiness does not depend merely on the distance or position of the object looked at. It would appear that, in general, some continuous communication must exist between that object and the spectator. Thus we feel giddy when we look down from a precipice at something below7, or when standing beneath the dome of St. Peter's or St. Paul's we regard with attention the vaulted structure above ; but we do not feel giddy when we look down from a balloon, or look upwards at the moon or stars near the zenith. It has not been sufficiently remarked by writers, that persons subject to vertigo are often almost as much affected by looking upwards as by looking down- wards. Persons who are inclined to vertigo, will also become giddy by directing fhe eye with a fixed attention for any length of time to the one object,—such as continuing to look in a straight line, or endeavouring to direct the course of their movements along a plank of narrow pathway. These circumstances are all very difficult to explain, and I bring them forward merely as illustrating the fact of this man's preference for walking in the middle of the street. In this man, as you may have perceived, we had several circumstances calculated to direct our attention to the state of the brain as connected with the impairment of vision ; besides vertigo, and a tendency to stumble in walking, he had flashes of light before his eyes, and other luminous hallucinations, with tinnitus aurium on one side. With respect to the flashes of light before the eyes, I may observe, that they may b^ produced by the operation of various causes ; a blow or pressure on the eye will cause them ; they may arise also from a particular state of the arteries which supply the optic nerve, and thus at each pulsation of the heart a flash of light is seen. This morbid sensibility of the retina, which, under such circumstances, appears to be itself the source of light, is very often a AMAUROSIS. 587 symptom which ushers in the extinction of the visual power. It is a very general remark, that hypersensibility of an organ is but too often the pre- lude to total loss of its functions. Thus we frequently have a morbidly sensitive state of the eye before it becomes incurably amaurotic, a morbid sensibility of the ear, ushering in loss of hearing, and unnatural excite- ment of the sense of touch preceding paralysis. But in this case we have not only an irritable condition of the retina, but also an affection of the pupil ; the iris is sluggish in its motions, and this symptom occurring at this particular period, combined with the vertigo, luminous hallucinations, and gradual but steady progress of the disease, give us some reasons to apprehend that it will end in complete amaurosis. Seeing, however, that the symptoms have originated in a congested state of the brain, it is our duty, as far as possible, to check its progress. This is to be done by cupping over the nape of the neck, leeching the temples and behind the ears, and acting on the bowels by brisk purgatives. With the same view I intend to insert a seton in the nape of his neck, and to administer the nitrate of silver internally, combined with a small quantity of aloes, a remedy which is possessed of some valuable properties in the treatment of chronic congestion of the brain, whether tending to produce amaurosis or headache. With respect to the causes of amaurosis, I may observe, that they depend either on disease of the brain, as congestion, inflammation, the presence of tumours of various kinds, or on injuries of the retina itself, or of the supra and infra orbital branches of the fifth nerve, or on affections of the alimentary canal. All these matters, however, have been so well detailed in different articles on amaurosis, to which I refer you, that I shall pass over them at present, and close ray notice of this case with a few desultory remarks. I believe I mentioned in a former lecture, that I had seen a very curious case of amaurosis, in which the cause of the disease seemed to be connected with an impression made by cold on the facial branches of the fifth nerve. I have already taught the class, that paralysis of any part of the body may arise from an oppression made not only on its own nerves, but also on the peripheral extremities of the nerves of another and even a distant part. I have also remarked that the fifth nerve is connected with the nerves of all the senses, but in particular with the optic, and hence we can explain why injuries of its supra and infra-orbital branches may bring on amaurosis. In the case to which I refer, the patient was exposed, while travelling outside on a stage-coach, to a .keen north- easterly wind, and, when he arrived in Dublin, his lips were very much chopped, and the skin of his face bore evident marks of the cold, and drying powers of the wind. Soon afterwards, he began to complain of dimness of vision, and a thin gauze veil seemed to be extended between him and every object he looked at. After five or six days, when he applied to me, I found a considerable degree of amaurosis present, and at the distance of a few feet he was unable to recognise the countenance of a friend. He had no headache, vertigo, or tinnitus aurium ; in fact, nothing to indicate cerebral congestion, and his appetite was good, sleep undisturbed, bowels regular. He had never thought himself, nor did a medical gentleman, to whom he had applied, ever suspect, that the impression of cold on the face had produced the amaurosis, and he said that he had been advised to get himself leeched and cupped over the back of the neck. On examining into the cause of his disease, and having 588 CLINICAL MEDICINE. found that he had been exposed to severe cold, it occurred to me that the amaurosis might be connected with the impression made by cold on the superficial branches of the fifth nerve, and, on more accurate investigation, I found that there were some grounds for this opinion. I was further confirmed in this view of the subject by the details of a case communi- cated to me by my friend, Dr. Montgomery, in which the patient evi- dently got paralysis of the portio dura from exposure of one side of the face to cold. Of course this paralysis was attended with distortion of countenance, in consequence of many of the muscles of the face depending on the portio dura for their supply of nervous energy. But what was particularly remarkable in this case, was, that vision on the affected side of the face became dim and indistinct. Now, can this be explained? Yes, very easily. You all know that the branches of the portio dura have an extensive comraunication with the supra and infra orbital branches of the fifth. Now, the paralysis which commenced in the portio dura grad- ually extended to the branches of the fifth, and through them to the optic nerve, with which the fifth is intimately connected, and hence it was the retina became finally deranged in its function, and dimness was produced. There is one circumstance more to which, as I am on the subject of amaurosis, I shall briefly call your attention. You will recollect the case of a boy whom we have had very recently under treatment for amaurosis, and may perhaps remember that one of the remarkable points in his case was this :—when he looked straight forward he did not see any thing in the direction to which his eyes were turned, but he could see the objects that were considerably below, or to either side of, the axis of vision. There are two or three circumstances under which a person cannot see an object by looking directly at it, and I wish to state these circumstances. In the first place, it may happen that an opaque spot may be situated on the centre of the cornea and directly in the axis of vision, as we some- times see in cases of scrofulous ulceration, followed by permanent opacity of the cornea. Now, in this case it is plain that the person cannot see objects placed directly before him and in the axis of vision. The second case is one where the patient cannot see objects directly before him, but can distinguish them tolerably well at a certain angle of obliquity, the cornea being perfectly clear and uninjured in its texture. Now, this may arise from an opacity of the lens, limited to its centre, and not generally diffused through its substance, 'fhe lens is a compound body, the struc- ture of which was, until very lately, but little known. When the lens or its capsule is affected with opacity, this opacity is not always equally diffused, but sometimes occupies the central portions of these organs, while the circumferential portions retain their transparency. Hence, when a person under such circumstances wishes to see an object, it is necessary that the rays of light should fall obliquely in order to reach the retina. A third case is, where, although the cornea and crystalline lens are in the natural state, still the patient sees objects a little removed from the axis of vision much better than those which are in it, as in the case to which I have just alluded, where the patient could scarcely distinguish any ob- ject placed directly before him, but could see tolerably well objects at either side of, or below, the direct line. The reason of this appears to be, that when a person so circumstanced looks directly at an object, the picture of the object falls on a part of the retina not obedient to the sti- AMAUROSIS. 589 raulus of light. In the process of ordinary vision the parts around the axis, and corresponding to the field of vision, have ihe picture of the ob- ject looked at, painted on them, and vividly and strongly illuminated. The central portion of the retina bears on it the picture of the object which the mind attends to, for it is surprising how indistinct and how- little attended to, any object seen obliquely is. Now, where disease has rendered this central portion of the retina insensible to light, then the at- tention is immediately turned, with a greater degree of intensity, to the sensations derived from the surrounding portions, and the patient is ena- bled, so long as this portion retains its sensibility, to enjoy the sight of objects placed obliquely and not in the axis of vision. Even in healthy eyes the non-central portions of the retina may be rendered available in particular cases. This has been proved by Brewster, Herschel, and others. In looking, for instance, at a star of the smallest magnitude, it vanishes from the sight and is lost when looked at directly, l§ut, if you turn a little from it, it will still catch the eye and be visible, because the image of the star will now fall on a part of the retina which is generally in darkness, and which is more sensible from being unaccustomed to the glare of light. Hence in many cases of amaurosis it is not unusual to find that the patient retains the power of vision so far as regards objects placed at an oblique angle with the axis of the eye after direct vision has been all but extin- guished. This is all I have to say at present with respect to amaurosis. As there is no other case presenting peculiarities to which I might call your attention, I shall beg leave to occupy your time for the remaining part of our lecture hour with a detail of the circumstances under which I have been led to employ the acetate of lead in Asiatic cholera, and to communicate briefly the mode of its administration and the results which attended its use. You are aware that during this epidemic, which com- menced its fearful career in Dublin in the spring of 1832, the modes of treatment principally relied on were, bleeding in violent spasmodic cases, emetics of ipecacuanha and mustard, the application of heat externally, and internally stimulants, but above all, calomel, not in small but in large and frequently-repeated doses, either alone or combined with opium. I need not tell you that the mercurial treatment came to us sanctioned by high authority : it was a remedy to which the experience of Indian prac- titioners had given a high character, but in our hands, I must say, it proved of very little value. Be this as it raay, I must say that I had rea- son to be dissatisfied with this mode of treatment ; I had tried it myself, and had seen it tried in every way which ingenuity or experience could suggest, but I had seen it fail almost in every instance. About the middle of last summer the epidemic, began to spread fearfully among those who had hitherto been exempt from its attacks; many per- sons in respectable life were seized, and my private practice afforded numerous opportunities of becoming practically acquainted with the dis- ease. In several cases to which I was called in, the malady had not ad- vanced to the stage of collapse, the symptoms of cholera, properly so called, had merely commenced, the intensity of the disease was still far- away, and a fair chance was afforded for the operation of theiapeutic agents. In most instances, I tried calomel and all the ordinary remedies with profitless results ; my treatment proved too often ineffectual ; and some persons, whose lives I highly valued, perished in spite of all my efforts, leaving me grieved for their loss, and mortified by my own want 590 CLINICAL MEDICINE. of success. I found that I could no longer place any confidence in calo- mel, and determined, in my own mind, to give up a remedy which had so signally failed ; it was, however, a question of deep anxiety to me what I should select instead, or to what article in the Materia Medica I should have recourse, where so many had proved utterly valueless. About this period I happened to be called on to attend a case of obsti- nate diarrhoea with ray friend Dr. Hunt. The case was an extremely harassing one, and had resisted all the ordinary remedies. I advised the use of acetate of lead and opium in full doses ; this was given, and I had the satisfaction of finding that the diarrhoea soon yielded. Before this period I had received a letter from that able practitioner and excellent man, Dr. Bardsley, of Manchester, directing ray attention to the use of acetate of lead in large doses in that form of diarrhoea which occurs to- wards the termination of long fevers, that is to say, the diarrhoea which precedes and accomj#mies inflammation of the glands of the small intes- tines. I had subsequently, at Sir P. Dun's Hospital, several opportunities of witnessing the truth of Dr. Bardsley's remarks. I saw that, in many cases during the course of fever, where the patient was low and pros- trated, symptoms of intestinal congestion came on, followed by diarrhoea, which many persons thought would end in ulceration of the glands of Peyer; and I found that in such cases the acetate of lead was the only remedy that could be relied on. I observed, too, that, contrary to the prevailing opinion on the subject, it could be given in large doses with perfect safety. You are aware that Dr. Bardsley has shown that it may be given to children in very considerable doses without any bad effects, and that in adults he has pushed this remedy to the extent of twenty or thirty grains in the day, without any unfavourable consequences. With these impressions I came to the resolution of trying the acetate of lead in the next case of cholera which offered a chance of deriving benefit frora. any kind of treatraent. It is known that there are some cases in which the disease at once assumes so frightful a malignity, that the patient is lost from the very moment of his seizure. This hopeless and intrac- table malignity is not peculiar to cholera ; it is seen in fever, scarlatina, croup, measles, and hydrocephalus; in fact, there are certain forms of all diseases in which the best-directed efforts of medical skill not only fail in curing the disease, but even in retarding its progress. But there are cases of cholera where the patient is not struck down at once, where the disease is not developed at once in all its awful intensity, and where tirae, brief though the space may be, is allowed for the play of therapeutic agencies. It is in such cases the acetate of lead may be given with some prospect of success, and it is by such cases alone, and not by those which are necessarily fatal ab initio, that its value is to be tested. Before we proceed further, I may observe, that the principle on which the calomel treatment was employed in cholera arose from almost constantly observing that there was a total deficiency of bile in the stools. Soon after the supervention of an attack, the alvine discharges were observed to be white and without the slightest tinge of bile ; and on this very re- markable symptom practitioners dwell almost exclusively, thinking that the patient's only chance lay in restoring the secretion of the liver. Now it is obvious that the absence of bile in the stools is no more a cause of the disease than is the deficiency of urea in the kidneys or of serum in the blood. Viewing the disease in this light, it would be just as reasonable ACETATE OF LEAD AND OPIUM IN CHOLERA. 591 to give a diuretic to restore the secretion of the kidneys, as to give calo- mel to produce a flow of bile. The liver ceases to secrete, not only in consequence of the injury done to its vitality by the proximate cause of cholera, whatever that may be, but also frora a mechanical cause, namely, from a diminution in its supply of blood. It may appear strange that when the same given number of vessels go to the liver and come from it at all times, that the quantity of blood circulating in it should be greater at one tirae than another. I have not time at present to enter fully into this subject; but it is a fact admitting of sufficient proof, that the quan- tity of blood circulating in any organ is very much modified by the state of its capillaries. The quantity of blood also which goes to a gland varies according to the peculiar state of that gland, being greater during its period of active secretion than when it is at rest. But in a case of cho- lera, where the capillary vessels of the intestinal canal from the stomach and the rectum are actively engaged in taking up the serum from the whole mass of blood, and pouring it into the cavity of the digestive tube, there is an enormous drainage from the system, and there must be, con- sequently, a deficiency of blood somewhere. Now it would appear that a quantity of blood, sufficient for the purposes of secretion, is abstracted, not only from the biliary, but also from the urinary system ; and hence it appears just as reasonable to give diuretics to restore the urinary secre- tion, as to give calomel to excite the secretion of the liver. It would be, a priori, as original a mode of treatment, and be equally as successful. I have therefore no hesitation in saying, that the calomel treatment has no claim to merit on the ground of theory, and, as far as I have observed of it in this country, it seems to be of no practical value in the treatment of cholera. With regard to the quantity of acetate of lead which may be given in this disease, and the mode of administering it, a few words are neces- sary. I have already stated, that when I first tried it, I prescribed it in large doses, fortified by the authority of Dr. Bardsley, and by my own experience of its utility in many cases of diarrhoea. It appears, that before I recommended the acetate of lead, it had been used at the Cho- lera Hospital in Grangegorman-lane. Of this I was not aware, until a book was subsequently published by Dr. Cranfield, which I afterwards reviewed in the Dublin Medical Journal, and I feel that on that occasion I did fair and impartial justice to its merits. I certainly did not know that the acetate of lead had been given at the Grangegorraan Hospital; for, in the very able report of cholera, as observed at that institution, published by one of its officers, Mr. M'Coy, the treatment relied upon appears to have been the mercurial, and not a word was said of acetate of lead. It had certainly been used there by one physician ; but it was given in smaller doses, insufficient to produce decided effects, and no stress had been laid on its value as a remedy in cholera by the practi- tioners attached to the hospital. Be this as it may, acetate of lead was not known to the medical men of Dublin, and to the practising apotheca- ries, before I recommended it. It had been frequently employed in the form of injection by them ; but no one had given it in large doses by the mouth, or introduced it to the particular notice of the profession. I be- lieve I can fairly claim the merit, such as it is, of being the first to give it in large and effectual doses. The mode in which I prescribed was this :__a scruple of the acetate of lead, combined with a grain of opium, was divided into twelve pills, and of these, one was given every half- 592 CLINICAL MEDICINE. hour, until the rice-water discharges from the stomach and rectum began to diminish. In all cases where medicine promised any chance of relief, this remedy was attended with the very best effects. It gradually checked the serous discharges from the bowels, and stopped the vomiting. I need not say of what importance this is: as long as these exhausting discharges continue, as long as the serum of the entire body continues to be drained off by the intestinal exhalants, what hope can we entertain ? What benefit can be expected from calomel and stimulants, when every function of the digestive mucous membrane seems to be totally extinguished, except that of exhalation, and while profuse discharges, occurring every five or ten minutes, are reducing the patient to a state of alarming prostration? Knowing the inevitable fatality of all cases where these discharges went on unchecked, 1 was happy in having discovered a remedy which seemed to possess more power jn arresting them than any yet devised, and this impression was confirmed by the results of subsequent experience. That the acetate of lead will succeed where all other astringents fail, was proved by the case of Mr. Parr, of this hospital. Having got an attack of threatening diarrhoea, at a time when cholera wras prevailing in Dublin, this gentleman used various kinds of astringents, and took so large a quantity of opiates, that he became quite narcotized, but without any relief to his symptoms. When I saw him he was as bad as ever, and was be- ginning to exhibit appearances of collapse. I advised the use of pills, composed of acetate of lead and opium, in the proportions already men- tioned, and had the satisfaction of finding that before night the diarrhrjea had ceased. The pills are to be used one every half-hour while the diar- rhoea remains unchecked, but as it begins to diminish, the intervals be- tween each pill may be prolonged, and in this way the patient raay be gradually prepared for leaving off the remedy altogether. I have fre- quently given in this way as much as forty grains of acetate of lead in twenty-four hours, with great advantage to the patient, and without any bad consequences ensuing. It is unnecessary for me to say any more on this subject ; if I chose to mention names, I could bring forward the names of many medical men in Dublin, whose lives, I am happy to state, were saved by the use of this remedy. I may, however, observe, that this mode of treatment has now become universal here, and that it has almost completely superseded the use of calomel and opium. I will confess that this fact is a source of high gratification to me, and I point also with pleasure to the fact, that since it became extensively known (as it did during the last invasion of the epidemic), the profession has gained more credit than before, and the number of cures has been proportionally greater. I have referred to this subject also for another reason. I feel it a duty which I owe myself, to defend myself against a series of attacks which were made on me, and to vindicate my claims, not to having been the first to administer acetate of lead, for it had been given previously by Dupuytren, and at the Grangegorman Cholera Hospital, but to having been the first to prescribe it in large and sufficient doses, to render it an available and useful remedy, and to introduce it to the general notice of the profession. The credit to which I lay claim, rests solely on the:>e grounds. 1 have been attacked on more than one occasion in the public papers, and gentlemen signing themselves Honestas, Candidus, and Verax {per antiphrasin, I suppose, for they have shown neither honesty, candour, REMARKABLE MOBILITY OF THE STERNUM. 593 nor truth), have attempted to rob me of the merit of what they sneerincjly called the lead treatment. I have thought it necessary to say so much in the way of explanation, lest any of ray friends or pupils should misinter- pret my silence.* The following case of remarkable mobility of the sternum was observed by Dr. Stokes and myself. A medical student, nineteen years of age, and of a sanguineous temperament, who had often been attacked by violent pectoral inflammation, particularly a few years ago, but who had since become comparatively healthy and robust, applied to me for advice con- cerning a pain in his chest. This happened after lecture in Sir P. Dun's Hospital, in the presence of several of the students and Dr. Law, who saw with astonishment this young man open his shirt, and with his hand push the sternum deep inwards towards the spine, so as to convert the anterior part of the chest into an extensive and by no means shallow cavity, at the bottom of which was the sternum. The rapidity with which this was ef- fected, and the unnatural appearance the chest then presented, excited a most disagreeable feeling of alarm in the minds of the spectators ; for we could not avoid dreading that he was inflicting on himself some serious injury. The portion of the chest which yielded in this singular manner to pres- sure, comprised the sternum from within two inches of its superior edge, and seemed below this point to be limited laterally by the lines answering to the junctions of the cartilaginous with the osseous portions of the ribs, so that the whole space capable of being pressed inwards was nearly trian- gular in shape, and was very extensive. The sternum was so tender to the touch, that in applying the pressure, he was obliged to press at some distance at each side of this bone. When the pressure was carried to ;che farthest point, the sternum was pushed in, as nearly as we could guess, about two inches, and the action of the heart, as well as that of the subja- cent lung, appeared to be notably diminished, and, in consequence of this, the pulse was weakened. This young man was subject not only to con- stant pain in the sternum, but likewise to frequently-recurring violent pal- pitations of the heart. His chest was sufficiently ample and well formed, but he had lately become round-shouldered, in consequence of his seeking relief from pain by stooping forward. No other portion of his osseous sys- tem exhibited the least trace of softening. The only affection which I can call to mind the least resembling this, is the softening which some- times affects the female pelvis, giving rise to great distortion, and which softening is accompanied, during the months or even years of its forma- tion, by severe pelvic pains. * While these pages were passing through the press, I received the following gratifying note from my friend Surgeon Auchinleck, of Dominick Street, which I have much pleasure in laying before the reader: — " Dominick Street, September 6, 1842. " Dear Grates,—I have received lately a letter from my brother (Dr. Claudius Auchin- leck), at present quartered at French Rocks, rteringapatam, in which ho mentions that cholera had broken out among the native troops quartered there, and that he had recourse to the use of calomel and opium in large doses, to arrest its frightful progress, but that he found it totally inadequate. He therefore laid it aside, and adopted in its place the administration of the acetate of lead and opium, as recommended by you, and was much gratified by the favourable results, the mortality being greatly reduced, and finally, on the change of the monsoon, the disease itself disappearing. He requested that I should mention this fact to you, which I do with much pleasure. Very truly yours, r « WM. AUCHINLECK. " Doctor Graves, Merrion Square." 39 594 CLINICAL MEDICINE. LECTURE XLV. Case of phlebitis—Remarks on the symptoms and treatment of this disease—Pathology of phlegmasia dolens—Its treatment—Case of cancrum oris—Fatal termination—Remedies employed—Case of ague cake—Observations on the different varieties of ague—True ague, or intermitting fever—Ague produced by inflammation of internal organs—Nervous ague— Hysterical ague—Treatment of ague cake. Among the cases at present under treatment in our wards, that of Mary M'Quade particularly demands your attention. This poor woman was ad- mitted a few days since labouring under an attack of fever, accompanied by considerable prostration, anxiety, and restlessness; in addition to these symptoms, she has a local affection of a very important nature: the right leg, as far as the knee, is swelled to twice its natural size, and a large ery- sipelatous blotch occupies the fore part of the foot, extending over the ankles on each side. The thigh also is increased in size as far as its upper third, so that the tumefaction embraces more than two-thirds of the whole extremity. There is a considerable degree of tension present, and the limb, particularly along the internal surface as the leg, is extremely tender, the soreness being so great over the course of the veins and lymphatics, that she could not bear the slightest touch. Here we had a swelling of the lower extremity depending on an inflam- matory condition of the part, and the question is, in what tissue did it com- mence, and what are its characteristic features? Before we discuss this question, it may be proper to observe here that the disease had its origin frora cold. When a patient is exposed to cold under unfavourable cir- cumstances, local inflammation is generally the consequence, an'd it de- pends on a variety of causes of what description the inflammation will be, and on what particular part it will fall. Where the lower extremities are the parts chiefly exposed, inflammation of the cellular membrane of the leg is apt to ensue, or it may attack the veins, as in the case before us, constituting phlebitis, or the lymphatics may be primarily and almost ex- clusively engaged. In a few cases inflammation attacks the arteries of the limb, as in a case which has been published by Dr. Stokes and myself in the Dublin Hospital Report, where a person, after exposure of the lower extremities to cold, got an attack of arteritis, terminating in mortification of the limb and death. Exposure of the lower extremities to cold, gives rise to phlebitis much oftener than to arteritis. Dr. Stokes and I have published a striking case where inflammation of the veins of the leg was produced by this cause. You will find this case referred to by Dr. Lee, in the excellent article, Phlegmasia Dolens, in the Cyclopaedia of Practical Medicine. You perceive, then, that painful swelling of the lower extre- mities originating in cold, may consist either in the whole cellular mem- brane being engaged, or it may arise from inflammation of the lymphatics of the veins, or of the arteries. Now when inflammation attacks in the first instance the subcutaneous tissue of the lower extremities, it frequently in its progress involves the lymphatic and venous tissues, the arterial very seldom, for the arteries lie deep, and have no connection with the subcu- taneous cellular membrane. There is, however, nothing more common than that inflammation commencing in this way should terminate in phle- PHLEBITIS —PHLEGMASIA DOLENS. 595 bitis, and disease of the lymphatics. This appears to be the nature of phlegmasia dolens, that peculiar inflammation which generally attacks one, and seldom both, of the lower extremities, which is most commonly ob- served in females, and which is characterized by swelling not pitting on pressure, by excessive cutaneous tenderness, and by a remarkable white- ness of the skin of the affected limb, accompanied by increased heat, and more or less lesion of the locomotive function. These are the principal symptoms which characterize phlegmasia dolens. The inflammatory con- dition of the limb causes an exudation of fluid into the cellular membrane, consisting partly of serum and partly of lymph; this produces swelling which is of a firm and rather unyielding character, not pitting on pressure like that which results from anasarca. After some time the inflammation extends to the neighbouring tissues, and attacks the veins and lymphatics, a circumstance which has led many persons, among others Dr. Lee, to believe that phlegmasia dolens arises primarily from phlebitis. This, how- ever, is not borne out by the fact, nor is it true that it consists in inflam- mation of the lymphatics, as others have suggested; it may engage both the lymphatic and venous tissues, but it differs in many points from pure phlebitis, or true inflammation of the lymphatics. In the case before us it would appear that the inflammation commenced primarily in the veins, and by a careful examination you will be able to discover some essential points of difference between the disease and phlegmasia dolens. There is a good deal of soreness present in this case, but the exquisite neuralgic tenderness of phlegmasia dolens is wanting. Again, the shining appearance of phlegmasia dolens is absent, and the co- lour differs greatly from the dead whiteness observed in that disease. The tenderness also is here more localized, being chiefly complained of on the inside of the limb, and along the course of the veins and lymphatics. On the other hand, it may be observed that these affections have many symp- toms in common, and you may have remarked that here, as in phlegmasia dolens, the locomotive power of the limb is considerably diminished. This, however, has been remedied, to a certain extent, by the curative means employed, and the patient is now able to raise up the whole limb, and bend the leg on the thigh. Now, whence arises this loss of power so often witnessed in cases of phlegmasia dolens, and phlebitis, and in- flammation of the subcutaneous cellular tissue of the lower extremities ? I am inclined to think it depends on a morbid impression made on the ultimate ramifications of the sentient nerves, which is propagated along the larger trunk to the spinal cord, and from thence by a reflex course is brought to bear and react on the muscular nerves of the limb. In my remarks on paraplegia, I have spoken of this matter at large, and given several instances of loss of power in a limb, produced by impressions made on the extremities of its cutaneous nerves ; and such appears to be the lesion of the locomotive power observed so frequently in cases of phlebitis and phlegmasia dolens. In many cases of paralysis, we find the first stage of the disease attended with an increased sensibility of the nerves of the part affected, tending to show that the primary source of the disease consists in an impression made on the sentient extremities of the nerves ; and there is nothing more common in such cases than to find the loss of the motor power accompanied by deranged sensation. In phlegmasia dolens and phlebitis, we have great cutaneous tenderness, and this is very rapidly followed by more or less diminution of the muscular power of the limb. 596 CLINICAL MEDICINE. I shall now refer briefly to the curative means employed in this case, observing that it has this in common with many cases of phlegmasia dolens, viz., the inflammation has engaged in succession the cellular membrane, veins, and lymphatics. When the lymphatics are attacked with inflammation, they become swelled, and have a knotty cord-like feel, and this condition is most commonly attended with the appearance of erysipelatous patches on various parts of the limb, over the place where a number of lymphatics are simultaneously engaged. This appears to be the case in the present instance, and it explains the occurrence of the erysipelatous blush which covers the instep and ankle. I need not tell you that the appearance of erysipelas over any part of a limb so cir- cumstanced, strongly demands our attention, as it might be an indication of the seat of an injury which may have given rise to the disease. In this case, however, it was the product of the disease, and had no connection with its origin. The treatment of a case of this description cannot be conducted on strict antiphlogistic principles. The fever which accompa- nies venous inflammation is of a low typhoid character, and prostration sets in at a very early period. The intimate connection of the venous system with the whole economy, the peculiar character of the inflamma- tion affecting the venous tissue, and the rapid prostration of strength which ensues, are all circumstances which contra-indicate general deple- tion. On the other hand, the best effects have been obtained by active local bleeding, and this appears to be so much the more necessary in cases of phlebitis, as the inflammation is apt to run very quickly into the suppurative stage. I therefore ordered forty leeches to be applied along the inside of the affected limb, directing the nurse to encourage the bleed- ing by warm fomentations. In addition to this, two ounces of mercurial ointment, combined with two drachms of the extract of belladonna, were spread on large pieces of lint, and applied over the limb after the leech- bites had ceased to bleed. That mercurial ointment thus applied has a tendency to subdue inflammation of a low erysipelatous character, has been shown by Mr. M'Dowel in an excellent paper published in an early number of the Dublin Medical Journal. To this we added the extract of belladonna, because the local inflammation was attended with hypersensi- bility of the limb, a condition over which belladonna is known to possess a remarkable influence. Dr. Lee, I should observe, does not appear aware of the great utility of narcotics in the painful swelling of the extre- mities after fever, or in true phlegmasia dolens. In both these diseases, together with active local depletion by means of the frequent application of leeches, we should employ anodyne ointments, and, above all, large doses of opium internally. Some patients in phlegmasia dolens, if the bowels be regulated, will bear and derive benefit from four, five, or even six grains of opium in the day ; I speak of the second stage of the disease. The same observation applies with regard to wine, and to sul- phate of quinine. It is obvious that phlegmasia dolens consists of some- thing besides mere inflammation ; the pain is altogether different from that attending ordinary phlegmasia ; it resembles more a general neuralgia of the extremities of the subcutaneous nerves. The internal treatraent consisted in giving a few grains of hydrarg. cum creta three times a-day, to keep up a free state of the bowels, and with a view of gently affecting the system. These means are very likely to be attended with success. The woman at present is much better, and the inflammation is sensibly CANCRUM ORIS. 597 declining. I shall not, however, anticipate the result, and for the present shall only call your attention to the case. You raay perhaps ask me to account for the great tumefaction of the limb observed in this case. It has been supposed by some persons that the whole swelling depends on the obstruction of the veins ; but if inflam- mation was entirely limited to the veins, the swelling could not be so extensive. It is true that if you produce artificial obstruction of any of the great veins, by placing a ligature on it, you cause, for the time, very considerable edema of the limb. The obstruction to the passage of blood through an inflamed vein will necessarily give rise to a certain de- gree of swelling, but I am inclined to think that this is not the only source of the tumefaction ; it would appear that in addition to phlebitis we have the inflammatory process communicated to the neighbouring parts ; the cellular tissue and probably the lymphatics become engaged, there is a copious effusion of serum and lymph, and to this the general increase in size of the limb is to be chiefly attributed. With respect to the termination of phlebitis, I may remark that it gene- rally ends in adhesion of the sides of the vein, and obliteration of its cavity, so that when the patient recovers, the affected vein feels like a piece of whip-cord lying under the skin. We had some patients here who had obliteration of this kind, and in one of them who died after- wards of fever, I found some of the smaller subcutaneous veins had be- come totally impervious through their whole extent, and resembled hard cords. This is all I have at present to say with respect to phlebitis, ob- serving that the diseases which are most analogous to it are phlegmasia dolens, and a particular morbid enlargement Of the lower extremity, which has been described by Dr. 'fweedie, and by Dr. Stokes and myself, in the Meath Hospital Reports. A child about four or five years old, who has been for some time in the fever ward, has been recently attacked with a very formidable disease, cancrura oris. Like most patients labouring under this malady, she had been previously debilitated by the occurrence of fever, for a child in good health seldom, indeed I may say never, gets an attack of this kind. A preceding febrile condition of the system, and a depraved habit of body, must have existed in every case where cancrum oris occurs. The disease itself is nothing more than mere local inflammation setting in under unfa- vourable circumstances, and during a morbid state of the system, and hence the local inflammation rapidly assumes the gangrenous character. In children, many forms of general disease are apt to bring on a state of the system in which inflammation of any part has a strong tendency to run into gangrene, and this is to be borne in mind with reference to the present case, for cancrum oris has nothing peculiar in it except its situation. It is not my intention at present to enter into any particular description of this disease. It has been well described by many surgical writers, and you will find a very valuable essay on the subject published by Dr. Curaing in the fourth volume of the Dublin Hospital Reports. There is also a very excellent article on cancrum oris in Forbes's Cyclopaedia of Practical Medicine, to which I beg leave to refer you. It may, however, be necessary to allude briefly to some points connected with its treatment. In the first place, I may observe, with reference to the general principles of treatment, that you should not be misled by the name of the disease, 598 CLINICAL MEDICINE. or think that because there is a gangrenous condition present, you should rely exclusively on detergent and antiseptic remedies. This is a common but pernicious error—it is the error of prescribing for names and not diseases, the easy but dangerous practice of unreflecting empiricism, by which the reputation of medicine has been so often damaged. He who commences the treatment of cancrum oris with the internal and externa] use of antiseptics, is acting on false principles ; his practice may have the sanction of time, but it has not the support of observation and experience. In the early stage of the disease, when the cheek is of a deep red colour, tense, prominent, and shining, I do not know of any means which tend so directly to diminish the amount of inflammation, and check the progress of gangrene, as the application of leeches, few in number, but frequently repeated. This is the mode of treatment which I have found to be most effectual, and which, from my experience of the disease, I can recommend as the most likely to prove beneficial, when, unfortunately, the ordinary resources of medicine are too often ineffectual. With respect to internal remedies, Dr. Cuming lays great stress on the utility and value of purgative medicines. They may be certainly neces- sary, and as the little patients very often swallow the sanious discharge from the ulcer, more or less derangement of the intestinal canal must accompany the disease. But along with purgatives I would strongly recommend the use of sulphate of quinine, either in the form of enema, or, if the child can be got to swallow it, made up into a syrup, and its solution favoured by the addition of a little sulphuric acid. With regard to the external applications, you have a choice of many remedies, each of which you will find recommended by authors, but none of which can be exclusively relied on in any case. The balsam of Peru with castor oil forms a good application, or you may blend it with honey, as we did in this case—one ounce of the balsam to two ounces of honey. You raay also employ washes composed of solutions of nitric or muriatic acids, or of the chlorides of soda or lime. In the present instance the sore has, in spite of all our efforts, eat its way from the internal to the external surface of the cheek. On Saturday, the centre of the cheek was characterized by the appearance of a bluish- black spot, indicating the occurrence of sphacelus. In the meantime it was curious to observe how little constitutional disturbance was yet produced ; the child, notwithstanding the manifest existence of extensive sphacela- tion of the cheek, continued for several days to have a tolerable appetite, and to sleep well, being nearly free from fever, and complaining but little ; as the mortification progressed, destroying rapidly the external parts of the cheek, &c, matters soon altered, and the poor little patient sunk exhausted and suffering. Let us now direct your attention to the case of a sailor who has recently been discharged. This boy was one of the crew of a vessel which re- turned lately from the West Indies, and was exposed to great hardship during his voyage. Boys in his situation suffer a great deal of fatigue and rough treatment; they are the drudges of all on board, and it is impos- sible to conceive w7hat privations they endure. When the vessels arrive in unhealthy climates they are generally the first who fall victims to the pre- vailing malady, and such was the case of this lad, wrho got yellow fever immediately after his arrival at the West Indies. From this he recovered, but on his way home he was attacked with irregular intermittent, which AGUE CAKE. 599 lasted for a considerable tirae. He had no treatment, and the disease subsided spontaneously, leaving him extremely weak and emaciated. He was, however, obliged to work as usual on his passage, and he arrived in Dublin about three weeks since, debilitated, thin, and with a counte- nance expressive of long-continued suffering. He had on his admission that peculiar hue of skin which often follows tedious intermittents, and which those who have once seen will always recognise with facility. This colour is to be distinguished from the hue of light jaundice—it is what has been termed clay colour. In the present instance it was mixed with a faint tinge of jaundice, and on examining the stools we found that they contained scarcely any bile. He had no fever; his pulse was rather slow and regular; he complained of lassitude; his urine was• deeply tinged with bile ; and his belly tumefied. On examining him, we found that the abdominal tumefaction did not depend on the presence of fluid in the peritoneum : it was produced by enlargement of the liver and spleen, intestinal congestion, and tympanitis. Here was a case of what has been vulgarly termed ague cake ; that species of congestion and enlargement of the liver and spleen which is apt to accompany the paroxysms of an intermittent, and in some cases to remain after the disease has subsided. You are aware that some persons, during the paroxysm of an intermittent, will complain of pain in the right hypochondrium, but more frequently in the left, and on examination the liver or spleen is found increased in size. If you take the trouble of reading the experiments which have been made with the view of illus- trating the functions of the liver and spleen, you will have a good idea of the facility with which enlargement of these organs, but particularly of the latter, may take place. The spleen undergoes very remarkable changes, even in its natural state, during the process of digestion, and there is a great difference between its size when an animal is fasting, and its size when an animal has taken food. Indeed, it is surprising how rapidly it will become filled with blood, and how quick the transition is from a state of collapse to a state of congestion. It is easy, therefore, to conceive how the spleen may, during the paroxysms of an intermittent, particularly in the cold or congestive stage, become manifestly enlarged. The increase of size, however, never occurs to such an extent in the liver; unlike the spleen, its magnitude remains nearly the same, and its volume does not vary like that of the spleen with the time of day or the period of digestion. It is obvious, therefore, it priori, that the spleen should be more frequently the seat of congestion than the liver, and that its enlargement should be more distinct and palpable. But it is not in the liver or spleen alone that congestion occurs during an aguish paroxysm, it may take place in any organ ; and this, in a practical point of view, is worthy of being borne in mind. Thus, in a case which I attended, the patient got intermittent of a tertian type ; during each paroxysm he had some distress about the chest and slight cough, but these symptoras dis- appeared during the intervals. As the disease, however, went on, the fits of coughing and dyspnoea increased, and the sulphate of quinine failed in arresting the paroxysms. The pulmonary congestion became gradually more marked and permanent, and no longer disappeared during the intervals ; finally, inflammation of the lung took place, and the patient died with extensive hepatization. This happened about twelve years ago, when the old notion of connecting the cold stage of ague with debility 600 CLINICAL MEDICINE. was universally prevalent, and before the practice of bleeding for the relief of visceral engorgement had been introduced. Subsequently, the practice of bleeding in the cold stage, as introduced by Dr. Mackintosh, was tried on an extensive scale in the Meath Hospital, and it is a practice which I can strongly recommend in those cases where there is recurring inflammation of some internal organ. It is not a mode of treatment appli- cable to all cases, and in mild cases unaccompanied by excessive con- gestion of any viscus, it is totally unnecessary ; but where an important organ is threatened, it is a valuable remedy, and has on some occasions cut short the paroxysms altogether, or rendered them much milder and more manageable. Sometimes ague is accompanied by symptoras of congestion and in- flammation of some internal organ during the paroxysms; and yet, by giving sulphate of quinine, you will succeed in arresting the intermittent and the visceral disease at the same time. I recollect the case of a boy who was under treatment here for ague, and who, during the paroxysms, had severe bronchitis with dyspnoea. The cough did not leave him even during the intervals, but it was much milder; I was, however, doubtful whether the case would admit of the exhibition of sulphate of quinine, from the violence of the pulmonary symptoras during the fits. I deter- mined, after some time, to try the quinine, and I found that it stopped both the intermittent and the bronchitis. It is to be observed, however, that in this case the bronchitis was of a chronic character; and I believe that in all cases of ague accompanied by visceral derangement, where quinine succeeds in curing the disease, the inflammation is either of a trifling description, or is one of a chronic nature. Where the visceral derangement is great, quinine will not succeed, and hence it is of great importance, in the treatment of ague, that you should carefully attend to the state of the internal organs. There are several forms of disease which simulate intermittent in a very remarkable manner; and, as this may lead to very dangerous errors, it is necessary on all occasions to make a strict inquiry into the origin and his- tory of the complaint. Some forms of hectic assume the intermittent cha- racter, and have been frequently mistaken for ordinary ague. Of this I had lately a very striking instance in the case of a lady, who came from the county of Limerick to consult me for what was stated to be an attack of irregular intermittent. She had been confined in August; had been feverish after her accouchement—the consequence, she believed, of ex- posure to cold—and got a slight cough. This continued, but without any expectoration, for two or three weeks, and then she was attacked with fever of an intermittent character, and exhibiting a well-marked ter- tian type. She began to take quinine, but this aggravated the cough very much without having any effect on the paroxysms. Various other reme- dies were also tried, but their only effect was to render the paroxysms more frequent and irregular. The moment I saw her I was convinced that she was labouring under some visceral disease. I examined her chest, and found dulness under the right clavicle with tubercular crepitus. Her cough had been dry until she came to Dublin, but now it became suddenly moist, and a distinct gargouillement could be heard. The ap- parent intermittent was nothing more than phthisical hectic ; and Dr. Stokes, who was also called in, came to the sarae conclusion. I recollect having observed something of the same kind in a case which I attended HYSTERICAL AGUE — TREATMENT OF AGUE CAKE. 601 some time ago with Sir Henry Marsh. The patient had well-marked in- termittent, and we treated him for it ; but the sulphate of quinine, and the other remedies which we employed, had only the effect of converting the fever into remittent. On a sudden, the gentleman, without having made any complaint of pain in the side, or any thing indicative of de- rangement of the liver, became suddenly jaundiced, and sank rapidly. On dissection, we found seventeen or eighteen small circumscribed ab- scesses in the substance of the liver. The intermittent hectic here de- pended on interstitial inflammation of the liver—a disease which is gene- rally of a latent and incurable character. I need not refer here to certain forms of fever which accompany disease of the brain and of the urinary system, and which are remarkable for their intermittent character. There is, however, one form of anomalous inter- mittent, of which it may be necessary to say something : I allude to that species of ague which seems to be exclusively confined to females of a nervous habit—at least I have never met with it in any others. Persons of this description, after an accouchement or some acute disease, or in consequence of violent mental emotions, will sometimes get into a pecu- liar state of health, in which they are liable to recurring periodic attacks of fever. Some time since, Dr. Stokes called me to see a lady who, shortly after her confinement, had got an attack of well-marked tertian. She had, at the regular time, severe rigors, followed by acceleration of pulse, heat of skin, and profuse sweating. When the paroxysm was over, she felt tolerably well, but still there was much excitement of pulse, and the intermissions were any thing but perfect. Sulphate of quinine had been tried by the accoucheur in attendance, but had failed. On exam- ining the case, I found that the lady was of a decidedly nervous and hys- teric habit, and advised the use of nervous and antispasmodic medicines. A mixture containing musk, camphor, and ammoniated tincture of vale- rian, was prescribed, and the intermittent symptoms rapidly disappeared. But to return to the case of this boy. How are we to treat this ague cake ? The disease has not as yet proceeded so far as to produce ascites ; but if permitted to run on, it would soon cause effusion into the peritoneal cavity. In a case of this kind a great deal will depend on whether there is any fever present or not. If there is no remarkable excitement of pulse or heat of skin, general antiphlogistic means will be unnecessary, for any local tenderness or irritation can be relieved by local bleeding. In the case before us, there was a slight degree of tenderness, and we applied leeches once with benefit; but we did not apply them over the abdomen —they were applied to the anus, because it is well known that leeches applied in this situation have a remarkably good effect in removing intes- tinal congestion, and consequently in relieving hepatic engorgement. Those who have remarked the relief which a flow of blood from piles gives in cases of hepatic engorgement with dyspepsia, will recognise the value of depletion of this kind, and will imitate the natural mode of relief, by art. Hence the use of leeches applied to the anus in cases of intesti- nal congestion and hepatic or splenic engorgement. There is no neces- sity here for applying a great number of leeches—three or four every second day will be quite sufficient, and we have found this number answer every necessary purpose. In addition to local bleeding and attention to diet, I ordered this lad to take a few grains of blue pill once a-day, not with the intention of affecting his system, but merely with the view of 602 CLINICAL MEDICINE. keeping up the free action of the bowels. I continued the mercury only as long as the tenderness of the liver remained ; for experience has shown, that in those cases of ague cake where there is merely enlargement of the liver without tenderness, mercury is a bad remedy. In cases of this kind, wdiere the stage of active congestion is past— where there is no fever—where the tenderness is removed, and nothing but the increased size of the liver remains—how are you to accomplish a cure ? First, by inserting one or two setons over the liver; and secondly, by the use of iodine and tonics. The use of setons in cases of this de- scription is well known, and needs no comment. I recollect the case of a lady, who, after several attacks of jaundice, got chronic enlargement of the liver. The right lobe of the liver, which was the portion chiefly affected, extended down towards the crest of the ilium, and was exces- sively indurated. This state had occurred after the patient had used mercury and had been copiously salivated. Two setons were inserted over the region of the liver, and these produced rapid diminution of the enlargement, and a perfect cure. With respect to tonics, I may observe, that they prove extremely useful in chronic enlargements of the liver and spleen. We are in the habit of using, in this hospital, a combination somewhat similar to the celebrated Bengal spleen powder ; it consists of vegetable and mineral tonics, com- bined with a vegetable purgative—as, for instance, aloes—and we have seen the best results from its use. With respect to iodine, it is a valuable adjuvant in such cases, particularly where the system has been much de- ranged, and where mercury would be likely to run down the patient. Here iodine gives vigour to the constitution, and tends in a very remark- able manner to promote the absorption of the morbid products, on which the enlargement chiefly depends. Let me now refer you briefly to the case of Catherine M'Donnel. This girl is labouring under an attack of chorea of considerable standing, and is at present about fourteen years of age. I mention this because it is not improbable that the appearance of the catamenia, which frequently come on about this period, may have some influence on the future progress of her complaint. She states that her disease commenced about seven years ago, and that ever since she has been subject to its attacks at various times. Her health is somewhat impaired, but not, however, to such a degree as to prevent her from following her usual avocations. Her pre- sent attack commenced about three weeks ago. It is unnecessary for me to enter into any description of the convulsive motions of the limbs, and other symptoms which characterize chorea ; neither is it my intention to enter into the general history of the disease : you will find an admirable account of its symptoms, pathology, and treat- ment, in Copland's Dictionary. I shall merely remark, with reference to this case, that there is no headache, and an accurate examination has failed in detecting any symptoms of determination to the head. Neither have we derangement of muscular motion during sleep ; the girl's sleep is tranquil and regular. There is no evidence of gastric derangement present. She relishes her food, and, what is rather singular, her appetite is better during the attacks than during the intervals. Her tongue is clean and moist, but her bowels are inclined to constipation. It is of import- ance to bear in mind here, that her symptoms do not appear to have any connection with cerebral or gastric derangement. She has no headache, + CHOREA. 603 flushing of the face, noise in the ears, or throbbing of the temporal arte- ries, and there is nothing but constipation to show that the digestive organs are out of order. I dwell on these two circumstances particularly, because some persons have attributed chorea to cerebral irritation, and others to indigestion and gastric derangement exclusively. I am quite ready to grant that it may be produced occasionally by either of these two causes, and that the presence of either will tend to aggravate it, but am inclined to look on chorea as chiefly a nervous disease, and to be cured chiefly by nervous medicines. Dr. Copland's remarks upon this question are excellent, and deserve to be attentively studied. For my own part, I think that in this, as in many chronic diseases where indi- gestion exists, it is often a consequence, not a cause, and is produced by debility of the vital powers of the stomach and intestines, organs which are affected by causes acting on the whole organization. Thus a too rapid growth, premature or unnatural sexual indulgence, confinement, want of exercise, of rest, care and anxiety, &c. &c, may each occasion a weak state of every organ of the body, including debility of the sto- mach. In a girl of this age, who labours under constipation, it is always proper to commence with the use of purgatives, and I have accordingly ordered her some pills, composed of aloes and capsicum ; but I would not persevere in the purgative plan any longer than was necessary for removing constipation. What I mainly depend on for removing the dis- ease is tonics, one of the best of which is carbonate of iron, in doses of half a drachm four times a-day. There was a controversy between Dr. Billing and Dr. Johnson, with respect to the doses of carbonate of iron to be employed in this disease ; and it is asserted, that in cases where doses of half a drachm, three or four times a-day, will not succeed, a cure may be effected by giving three, four, or even five drachms, frequently in the day. With regard to this subject, I must confess that I am for moderate doses ; and I think, in general, as much good may be accomplished by half a drachm or a drachm, three or four times a-day, as by much larger doses. I have accordingly ordered this girl to take half a drachm four times a-day, and will persevere in the use of the remedy until we have given it a fair trial. The carbonate of iron tends, in general, rather to produce a relaxed than a constipated state of the bowels, and consequently is peculiarly well adapted to chronic cases of debility. The mistura ferri aromatica, in moderate doses, is another excellent formula. When we have to deal with constitutional weakness, which has arisen gradually, and continued long, we must trust more to the operation of general physi- cal influences than to medicine ; and in graduating the doses of tonics, we must remember that it is impossible in such cases suddenly to strengthen ; we must therefore rely upon the gradual operation of tonics, given for a long continuance, and in moderate doses. This rule should never be lost sight of in the treatment of chronic diseases ; important as it is, most practitioners seera little influenced by it, or perhaps they are altogether ignorant of it, otherwise we should not see them using concen- trated and powerful tonics in such large and repeated doses in chorea. Another general rule as to the use of tonics in chronic diseases—usually you will be more successful with mild and diluted than with powerful and concentrated medicines. Thus, for example, cinchona in powder is often preferable to sulphate of quinine in chronic diseases. There is a very curious case of paralysis agitans at present in the female 604 CLINICAL MEDICINE. chronic ward, which claims a few remarks. You must have all remarked the patient, Ellen Davis—a young woman about twenty-five years of age. She has a most peculiar expression of countenance, and, as her disease is rather a rare one, I beg that any gentleman who has not seen it, will take the opportunity of paying her a visit. According to the account which she gives of herself, the disease appears to have originated in a sudden and violent mental emotion. The poor girl, like most of the lower class of country people, happened to be a firm believer in the existence of ghosts and such like nonentities, and this superstition has formed the source or exciting cause of the disease in question. She was, unfortunately for her- self, located in a very uncomfortable situation, her house being close to a road between two churchyards, a complete thoroughfare for ghosts, and where figures of a very questionable description had been frequently seen by many of her neighbours. Some of her acquaintances, who were aware of the frightful notions she entertained about personages of this kind, resolved to amuse themselves at her expense, and played off a practical joke of a very cruel nature. A churn-dash was procured, to which a sheet was appended, so as to form no unapt representation of a sheeted head- less corpse, and this was dandled between two trees by means of a rope. The poor girl, who happened to be going to bed at the time, was utterly appalled by the sight of what she conceived to be one of these ghosts sweeping through the air, and immediately dropped down in a state of total insensibility. The fright deranged her nervous functions in an extra- ordinary degree, she became vertiginous, lost the use of her limbs on one side, and took to bed, from which she states she did not get up for three months. The history of this case is of course extremely uncertain. In chronic cases, and among patients in her class of life, you can seldom expect to get an accurate or satisfactory account. It is quite clear that she had he- miplegia, but whether it arose from the fright or not we cannot exactly say. The symptoms of hemiplegia after some time began to decline, and she gradually regained the power of walking. This, however, is but feeble, and though it is now seven years since the occurrence of the attack, the muscular power of the limbs is very slight. She had also during the progress of her complaint an attack of amaurosis, which she says deprived her entirely of sight for nearly a year, and that after this period she re- covered the use of one eye completely, but the other still remains amau- rotic, and she can distinguish objects with it very imperfectly. At present she affords a very remarkable specimen of paralysis agitans. She cannot walk slowly, and when she has commenced walking she cannot stop with- out considerable difficulty. The muscles of the extremities, face, and tongue are very little under her control, and are in a state of almost per- petual motion. The muscles of the eyelids and eyeballs are also similarly affected, and this gives to her countenance a strange and peculiar expres- sion. You will find an excellent description of this disease in Dr. Elliot- son's lectures; a very interesting case is also detailed in Dr. William Stokes's lectures, published in Renshaw's London Medical and Surgical Journal. It would appear that in this disease the muscles are not by any means beyond the control of the will, but they are so influenced by the operation of some other unknown cause, that their motions are more or less irapefect and inadequate. She can walk quickly with tolerable ease, for in walk- PARALYSIS AGITANS. 605 ing quickly the muscles are contracted more rapidly, and the will more strongly exercised, so that the obstacles to regular motion are in a great measure overcome, but when she walks slowly, time is given for the cause which produces the anomalous motions to come into play, a spasmodic state is established, and the muscles cease to obey the will so implicitly. I knew a gentleman who had a very curious form of this paralysis agitans. When about to walk, he was obliged to have himself balanced, and set off by some other person, just like a piece of machinery. When once set a-going, and on a smooth road, he went on very well for a considerable tirae, but if interrupted by a hill, or by the unevenness of the ground, he was compelled to run backwards in a right line until stopped by some one, and so little control of his motions had he at this time, that if a pond or precipice lay behind him, he could not prevent himself from tumbling over it. I have occasionally seen him under such circumstances, and the ap- pearance he makes is singular and ludicrous. He goes backwards until he meets with a wall or some other object which resists his further pro- gress. This is a very curious circumstance as connected with the nature of the disease. I do not intend at present to enter into any inquiry respecting the nature and treatment of paralysis agitans. The prognosis of the disease appears to be, a priori, unfavourable, from the total want of any exciting cause which might be discovered and removed. If the disease consisted in con- gestion of the head or spine, or if there was any apparent lesion by the removal of which we could hope to effect some good, we might entertain a more favourable opinion with respect to its termination, but it unfortu- nately happens that in too many cases we can do nothing more than ob- serve the curious phenomena which it presents. Let me now direct your attention to the case of a man named Murphy in the chronic ward, who came in with bronchitis accompanied by ana- sarca. He had old bronchitic cough, copious expectoration, and ortho- pnoea; but he had no symptom of disease of the heart; his pulse was regu- lar and rather slow, he had also albuminous and scanty urine, but without any fever, thirst, or nausea. The recent origin and sudden appearance of the disease induced me to look upon it as a case of acute dropsy, and I commenced the treatment by antiphlogistic measures, which, as you may have perceived, have been followed by remarkable benefit. What I wish to call your attention to particularly in this case, is the state of the patient's urine. On his admission, we found that his urine was highly albumi- nous; when submitted to the action of heat at the temperature of 170° it coagulated rapidly, and showed distinct traces of the presence of a large quantity of albumen. Yet under the use of opium in moderate doses this man's urine became in two or three days perfectly free from every trace of albumen, and has continued so ever since. Now this case alone would be a sufficient refutation of the opinions of those who look upon albuminous urine as a pathognomonic sign of disease of the kidneys, as described by Dr. Bright, and who are in the habit of marking such cases in the hospital as cases of "Bright's Kidney." It ap- pears rather strange, as in our case, that a man should have "Bright's Kidney" to-day, and not have it the next day. We have had a great many instances of this kind, and in various cases which came under treat- ment in this hospital, I have shown that this state of the urine may depend on mere functional disease of the kidney. Indeed, nothing is more com- 606 CLINICAL MEDICINE. mon than to meet albuminous urine in the dropsy which succeeds scarla- tina, and yet most of the patients perfectly recover. I had lately an op- portunity of examining the kidneys of a boy named William Young, who was admitted into Sir Patrick Dun's Hospital on the sixth day from the commencement of anasarca after scarlatina. This boy's urine had a spe- cific gravity as high as 1027, and contained an enormous proportion of albumen. He died suddenly of convulsions the fourth day after his ad- mission. His kidneys were in every respect healthy. One word with respect to the diuretic remedies, which in this case I have employed with remarkable success. Having removed the acute symptoms by antiphlogistic treatment, I prescribed the following decoc- tion :— R. Decocti hordei, lb. j. Sacchari albi, ^j. Niitratis potassse, ^'j- Acidi nitrici diluti, 3J. Spiritus aetheris nitrosi, ^j. Two tablespoonfuls to be taken every second hour. This is an excellent mixture, and well suited to the stage intermediate between the acute and chronic form of dropsy, where you wish to excite the action of the kidneys, and are afraid of stimulating the system gene- rally. It has acted very favourably in the case before us, having increased the urinary discharge very considerably without producing any constitu- tional excitement. LECTURE XLVI. Glanders and button-farcy in the human subject—Particulars of a case of glanders, with the post-mortem appearances—Remarks on the variety of skin diseases produced by the intro- duction of an animal poison into the system—Case of button-farcy—Analogous appearances, where, as in typhus, an animal poison is sometimes generated in the body—Furuncular inflammation, or carbuncle, generated by animal poison ; also tubercles—Sometimes a pre- ternatural whiteness precedes the purple hue of mortification—Remarks on phlegmasia dolens—Phlegmasia dolens of the eye. In pursuance of my intention, as announced in a former lecture, I shall proceed to-day to the consideration of two affections resulting from ani- mal poison, one of which has been but recently introduced to the notice of the medical profession ; of the other, I am not aware that there are any published cases in existence. I allude here to glanders and button-farcy in the human subject. The profession is chiefly indebted to the researches of Dr. Elliotson for the first accurate account of glanders in the human subject—a disease which has now excited a very large share of attention here and on the continent. Many other observations, published since Dr. Elliotson un- dertook the illustration of this disease, have established the fact, that the morbid matter secreted by horses labouring under glanders may commu- nicate the infection to the human subject, and thus give rise to a loath- some, painful, and generally fatal disease. From the notices which I have been able to collect, it appears that glanders in man is of very fre- quent occurrence in Ireland—so frequent, indeed, that I think the legis- GLANDERS. 607 lature is called on to imitate the wise example of the Prussian govern- ment in placing glandered horses under the surveillance of the police. Like many other animal poisons, that of glanders does not seem capable of affecting every individual indiscriminately; indeed the average sus- ceptibility must be small, for grooms and veterinary surgeons take few or no precautions in examining the diseased animals ; and yet the propor- tion infected, compared with the number exposed, is by no means consi- derable. That such persons exhibit great carelessness in examining glan- dered horses appears from the directions given in books on farriery, " that the finger should be introduced into the nostrils for the purpose of ascer- taining whether certain spots suspected to be ulcers are so or not." Now, when the viscid gluey nature of the discharge from the nostril is taken into account, we cannot but conclude that this operation of introducing the finger into such a mass of vitiated and poisonous secretion would more frequently prove the means of infection, were the human constitution very susceptible of the poison—for we are to recollect that the fingers of such persons are seldom free from scratches and abrasions. I shall now read the following case of glanders in the human subject. It is one of extreme interest, and has been most faithfully and graphically detailed. It occurred in the Richmond Hospital, and has been commu- nicated to me by Dr. M'Donnel, one of the surgeons of that institution. You will find in it many points of resemblance to a series of cases trans- lated from a German journal, and published in the Medico-Chirurgical Review:— " Patrick Wallace, a healthy muscular man, aged twenty, was admit- ted into the Richmond Surgical Hospital on the 6th of October, 1836. It is stated that he had been in care of a glandered horse—driving, clean- ing, &c.—and that he had been in the habit of drinking out of the vessel from which the horse drank. It appeared, also, that he had had an abra- sion on one of his ears. On admission, he had much the appearance of a person labouring under cynanche tonsillaris: he could only open his mouth to the extent of half an inch ; this was the only uneasiness com- plained of. The left tonsil was very much enlarged, red, hard, and pro- jecting towards the middle line ; no fluctuation could be felt; there was a general fulness about the angle of the jaw, extending upwards nearly as far as the zygoma. The submaxillary gland on the same side was also enlarged and indurated. These symptoms had been ushered in by fever- ishness, a few days previous to admission. He was ordered to have eight leeches to the throat, to be followed by a poultice, and a bolus composed of calomel and jalap. " Next day the external swelling was found to be increased ; greater difficulty of opening the mouth; the tonsil still hard and swollen. Twelve leeches were applied to the fauces, and the patient took the tartar-emetic mixture of the hospital, with sulphate of magnesia. " On the 15th of October, the disease is reported to be on the increase. Tonsil still hard, but no fluctuation ; left side of the face greatly swollen ; eye of the same side nearly closed, from tumefaction of the lids; general inflammatory appearance over the cheeks, and great hardness of the tis- sues about the angle of the jaw of the same side, extending towards the chin ; several circumscribed spots of redness, varying in extent from the size of a sixpence to that of a halfpenny, with irregular margins, scat- tered over different parts of the body ; two pustules observable on the left leg. 608 CLINICAL MEDICINE. " 16th.—A vesicle containing a yellowish serum observable on the left tonsil ; the same inability of opening the mouth continues ; increase of swelling over the left side of the face ; a small abscess has formed on the posterior part of the left fore-arm ; some delirium during the night; three evacuations from the bowels. The tonsil to be brushed over with a solu- tion of nitrate of silver; a blister to the fauces ; the tartar-emetic mixture to be continued. " 17th.—Some sleep during the night, interrupted by delirium of a low muttering character. Patient appears willing to answer questions, but cannot, from obstruction in the mouth. This, however, lasts but for a moment, and he then lapses into a state of incoherency. Mouth open to the extent of half an inch ; left eye closed ; considerable swelling of the left side of the face, which is indurated, hot, tense, and shining ; all the glands on both sides of the jaw, but particularly on the left, are swollen and hard ; same state of tonsil; nares dilated ; breathing stertorous, somewhat hurried, about 28 in the minute, and interrupted by frequent sighs. Pulse very small, rapid, intermitted, and cannot be counted ; skin hot, tongue furred, teeth covered with sordes. He complains of great thirst, but says he feels no pain ; it is evident, however, that he feels great uneasiness in the joints and limbs when moved. There is, how- ever, no swelling or redness of the joints ; there is no discharge frora the nostrils, nor is there any perceptible ulceration of the mucous membrane of the nose. No apparent affection of the absorbent glands in any other part of the body. " During this period, vesicles and pustules of various sizes, and at va- rious stages of growth, had made their appearance on different parts of the body, particularly on the back. They varied in size from the head cf a pin to the section of an almond. In the first stage they resembled very minute vesicles, scarcely surrounded by any inflammatory border, and containing a limpid serum. In the second stage, the serum was re- placed by pus ; there was a considerable blush of redness around each pustule, which at this period became greatly increased in size. When one of the vesicles was punctured, the serum appeared to come from a single cavity under the cuticle : this operation did not produce any subsi- dence of the tumour, a considerable hardness still remaining in the cutis or beneath it, with a cavity in the centre in which the serum was con- tained. A number of achores existed in various parts, congregated to- gether, and not much larger than the head of a pin. These clusters wrere surrounded by white raised margins, having much the appearance of wheals, and about a line and a half or two lines in breadth ; between these margins and the achores there existed a line of redness. The whole taken together are rather of an oval shape. There also existed numerous inflammatory spots on the right shoulder, left arm, and other parts of the body. These were of a dark brown, approaching to a livid colour; when pressure is made on them the colour disappears, but returns immediately when it is removed. On running the finger over them, a small hard tumour was felt in the centre ; the margins of these spots were irregular. " On the 17th, the character of the disease became more plainly devel- oped : at three o'clock, p.m., pus in considerable quantity was observed to issue from both nostrils. The patient was ordered to take the solution of chloride of soda internally, in drachm doses, three times a-day ; and also a mixture composed of carbonate of ammonia, liquor setheris oleosus, GLANDERS. 609 and camphor-mixture. At five o'clock, p.m., he was found half out of bed, his head resting on the pillow ; still able to express his wants; pulse not to be counted ; legs and feet cold ; breathing stertorous; numerous stigmata scattered over the surface of the body. The purulent discharge from the nostrils has ceased, but there is a discharge of mucus from the mouth, with considerable fetor of breath. " Eight o'clock, p.m.—A copious perspiration has broken out over the body ; face red, tense, shining, and very much swelled ; swelling has now extended to the right side of the face ; right eye nearly closed ; can open the left better; a few pustules have made their appearance at the inner canthus of the eye. Pulse, tongue, and skin, as in last report; delirium and muttering continue. " Died at 4 o'clock, a.m., October 18th. " On examining the body ten hours after death the redness was found to have disappeared from the face ; the glands about the left angle of the lower jaw as before mentioned : they were found matted to the surround- ing parts- The cellular tissue covering the submaxillary and parotid glands was infiltrated with serum, and indurated ; numerous depositions of pus were found in the tissue of the sub-maxillary and parotid glands. The brain was firm, but its ventricles contained a considerable quantity of fluid; the arachnoid membrane was opaque in many places; several patches of vascularity were observed on the pia mater. The lungs pre- sented a congested appearance ; numerous pustules were scattered over their surface—some separate, yellow in the centre, and surrounded by an ecchymosed border; others existing in clusters. They resembled, in every respect, those found on the surface of the body. The lining mem- brane of the larynx was very much inflamed, especially about its upper part and about the epiglottis. The inflamed parts in this situation were of a livid hue. There was some appearance of vesicles in the trachea, but this could not be satisfactorily ascertained. The bronchial tubes were filled with mucus; the stomach contained a quantity of yellowish green mucus—its lining membrane presented an ecchymosed and inflamed appear- ance. The liver was somewhat enlarged, and adhered by its inferior margin to a few folds of intestine. The periosteum did not exhibit any appreciable deviation from the normal state." One of the chief things to be noticed in the foregoing case is the variety of inflammatory affections observed in the skin, as the result of the intro- duction of an animal poison into the system. There was, in the first place, the general diffused redness of the face, then superficial inflammatory spots on the shoulders and arms, resembling erythema nodosum; in the next place, scattered pustules of various sizes, commencing in the form of a vesicle, which afterwards became a pustule surrounded by an inflam- matory zone; and lastly, achores congregated together and surrounded by an elevated white margin, within which there existed an inflammatory ring of a red colour. Another point worthy of notice is the state of the lungs and bronchial mucous membrane. The lining membrane of the larynx, particularly in the vicinity of the epiglottis, was inflamed and of a livid colour, and there was an indistinct appearance of vesicles in the trachea. But what was particularly deserving of note in the lungs, was the existence of pustules on their surface, bearing the closest resemblance to those found on the surface of the body. It is not stated whether there was any appearance of vesicles or pustules in the nose, pharynx, or 40 610 CLINICAL MEDICINE. oesophagus; but we are told that the stomach was ecchymosed and inflamed. The following case was witnessed by myself and Dr. Halahan, and seems more nearly allied to the variety of glanders termed button-farcy. I regret that want of time has prevented me from arranging its details in a form more worthy of your attention ; and were not the disease one of comparatively rare occurrence, I should not have ventured to lay the case before you in its present imperfect state. The subject of this case was a gentleman residing in Rathmines, an extensive proprietor of horses, and who, having originally graduated as a surgeon, exhibited much skill in the veterinary art. About the time of his illness he had some horses in his establishment labouring under glanders and button-farcy, to which he paid particular attention. After having la- boured for some days under considerable lassitude and derangement of the stomach and bowels, he was attacked on the 8th of July with rigors, fol- lowed by great thirst, excessive heat of skin, and pains in his limbs. 'fhe moment he felt himself attacked in this way, he said he was sure that he had got some dangerous infection from the horses, and would never recover. He took some blue pill and colocynth, which produced a few dark and very fetid evacuations. On the 9th, his pulse was 94, his urine very high-coloured, his thirst and feverish symptoras rather increased, and he suffered greatly frora constant nausea and vomiting. A tumour now began to appear about three inches above the inner ankle of the right foot. He applied a poultice over it, but was obliged to remove it in a short time, in consequence of the pain occasioned by its weight. The tumour was about the size of half a walnut, of a dull red colour, tense, shining, and exquisitely painful; Its external aspect was peculiar, and might be compared to something intermediate between a boil and a spot of erythema nodosum. On the 10th, another tumour of the same character appeared near the outer ankle of the same leg ; and in this way the disease went on, tumour after tumour appearing on dif- ferent parts of the body, with an increase of the feverish symptoras, until the 20th of July, when he was first seen by Dr. Halahan. At this time several tumours had appeared on different parts of his body ; there was one of an extremely painful character on his head, and he complained of great tenderness and pain along the right clavicle. His thirst was still urgent, his restlessness excessive, the slightest motion gave him exquisite pain, and sleep had completely abandoned him. He had endeavoured to regulate his bowels by purgative medicines, and had applied leeches to the tumours and to the clavicle at various times, but without any decided benefit. There were eight or nine tumours on different parts of the body, of the character before mentioned, without any tendency to suppuration, and so exquisitely painful that he could only bear a single sheet over him. The inflammation about the clavicle, which was of a diffuse character, had extended up the neck and over the right shoulder; there was not much swelling, except about the clavicle ; the colour of the affected parts was a peculiar dusky red. Immediately over the clavicle two vesicles were observable, filled with a transparent fluid. Three dozen of leeches were ordered to be applied over the clavicle and shoulder, and the patient was directed to use chicken-broth, beef-tea, and other light nutritious articles. On the 21st, all symptoms are stated to be on the increase. His fever, BUTTON-FARCY. 611 thirst, and sleeplessness, are undiminished ; his tongue furred and dry; his teeth covered with sordes ; his pulse small, weak, and rapid ; his nausea and vomiting not so troublesome. He had received no benefit from the application of the leeches ; the swelling and stiffness of his neck was increased, and he had now some difficulty of swallowing. The erysipelatous surface of the neck, clavicle, and shoulder, were lightly brushed over with lunar caustic, which gave the patient an agreeable sensation, and from which he stated that he derived much relief. This was repeated the next day at his own request, and with equal benefit; the difficulty of deglutition diminished, and for two days he went on pretty well. On the 25th, there was an evident increase of fever: the tumours over the body and limbs were increasing in size and number ; and his anxiety, restlessness, and sufferings unabated. He had taken alterative doses of calomel and James's powder, and his bowels had been regulated by mild aperients and enemata. I saw him for the first time on the 28th. His pulse was then 98, small and easily compressed ; his thirst excessive ; his restlessness and agony such as would strongly excite the pity of persons most conversant with scenes of human suffering. He had several tumours over different parts of his body, all exquisitely painful, and in their aspect something between boil and erythema nodosum. Some of them were hard to the touch ; others, which appeared more advanced, were softer and had a boggy feel. There was, however, no appearance of any thing like suppuration. He was ordered sulphate of quinine, chicken-broth, ale, and other light nourishment, and an opiate at night. On the 31st, a tumour appeared on the right side of his forehead, larger and raore painful than any of the rest. Another of a similar character showed itself on the right clavicle, which had been previously affected. Shortly after their appearance, vesicles were observable on their surfaces, such as generally precede mortification in cases of anthrax and malignant carbuncle. Next day he was evidently worse ; his pulse was 108; his fever, pain, and restlessness, unabated ; and a miliary eruption began to make its appearance over his chest and abdomen. The vesicles now began to increase on the surface of the tumour; his fever and restlessness were aggravated ; and his mind, which had been hitherto collected, began to wander. His restlessness was so excessive, that he could not remain for a moment in the same position ; and being a person of much mechanical ingenuity he had a set of pulleys constructed and fas- tened to his bedstead, so that he could move himself in various directions. His medicines and diet, with the addition of claret, and opiates at night, were continued as before. On the 6th of August he was still worse; the tumour on the head con- tinued to enlarge, and decided sloughing had taken place. The tumour on the clavicle presented the same aggravation in appearance and cha- racter, and a fresh tumour had appeared on the back of his head. A pus- tular eruption now began to make its appearance over his body, chiefly over the abdomen and limbs ; his symptoms became aggravated in every respect; the delirium and watchfulness increased ; and he died on the 10th of August, about thirty-three days from the commencement of the disease. He attributed his illness to attending horses, four of which had died of button-farcy ; and what is also curious, his nephew, who had also been engaged about the diseased animals, had fever of a typhoid charac- ter, with maculse of a larger sort than usual, but ultimately recovered. 612 CLINICAL MEDICINE. The symptoms of glanders in the human subject have been so fully de- tailed by Dr. Elliotson, Dr. Hutton,* and others, that it only remains for me to make a few observations connected with this subject. In the first place, it may be observed that most diseases produced by the deleterious effect 0f animal poisons on the economy, show a tendency to cause not only fever, often of a malignant character, but also various forms of ex- ternal disease, chiefly limited to the superficial glands, subcutaneous cell- ular tissue, and skin. In urticaria, small-pox, and measles, the external disease is chiefly limited to the skin ; in scarlatina, we have often swell- ing of the parotid gland, with infiltration of the adjacent cellular tissue in addition to the cutaneous eruption ; in syphilis, and cases of dissecting wounds, we have disease of the skin frequently combined with an affec- tion of the superficial lymphatic glands. The same observation applies to typhus, many cases of which are characterized by an eruption of spots over different parts of the body, or by the occurrence of what are termed petechias. X)n these matters I need not enlarge, as you are all acquainted with them ; but that vesicles and pustules very similar to those observed in dissecting wounds, and other diseases produced by the direct intro- duction of animal poison into the system, may arise from the action of morbid changes spontaneously occurring in the body, is a fact which ad- mits of being proved, and opens to us a new and interesting field of in- quiry. Thus, in cases of typhus, where the effect of a pressure or some other accident has occasioned bed-sores of a bad character, and even where there are no bed-sores present, I have on several occasions seen low secondary fever produced, and have observed vesicles or pustules appear on the skin, similar to those described by Mr. Colles as accom- panying the fever of dissecting wounds. An example of this occurred some time ago at this hospital, and you have recently witnessed another in the case of a young man recovering from typhus. It might be argued that the secondary fever and eruption in such cases arise from the ab- sorption of morbid matter into the system, and I am willing to admit that there is some colour of argument for this statement, where the patient labours under bed-sores of a bad and gangrenous character ; but that this explanation is not the true one appears from the case of the young man to which I have alluded. He had no bed-sores to account for the secon- dary fever and eruption ; and we can only explain the circumstance by supposing that it is the result of a poison generated in the system during the course of fever. This is particularly deserving of notice, as I am not aware that any author on typhus has noticed this symptom, or pointed out the circumstances under which it occurs.f The same phenomenon is oc- * See Reports of the Dublin Pathological Society. f While these pages were passing through the press, I have been informed by my friend Surgeon MacDonneil, Clinical Clerk to Dr. Stokes and me. at the Meath Hospital, of a case at this moment under the care of my talented colleague; and as it strongly corroborates the views above mentioned, I shall take the liberty of introducing it here;— A man, aged 40, was admitted into the Meath Hospital, Oct. 29, 1842, labouring under typhus fever, with delirium tremens and pneumonia of the right lung. He slowly but gradu- ally recovered till the 10th of November, when two of the characteristic vesicles of Colles were observed on the palmar aspect of the right thumb. It was remarked by my colleague to the pupils, that these pufetules indicated an extremely had state of the constitution, and that they were, in all probability, but the precursors of more serious symptoms. From this period till the 17th, his pulse remained quick (140), weak, and falteiing; the pneumonia remained sta- tionary ; and in addition, he was attacked with pleuritis of the lower and fiont part of the right side and pericarditis. These latter complications yielded quickly to treatment, but the pneu- MORBID POISONS GENERATED IN THE SYSTEM. 613 casionally observed, where, in consequence of external injury, diffuse cell- ular inflammation has taken place. Thus, several years ago, a woman was admitted into the Meath Hospital, who had diffuse cellular inflamma- tion in consequence of receiving a kick on the chest. After a few days, Colles's pustules appeared on different parts of the body, and she died with symptoms of croup. On dissection, the croupy symptoms were found to depend on an eruption of vesicles filled with opaque serum, over the lining membrane of the larynx and trachea. Something analogous to this was observed in the case of Wallace ; and the coincidence is further strengthened by the frequent occurrence of disease of the lining membrane of the larynx and trachea in many other febrile affections, accompanied by cutaneous eruption—as small-pox, measles, syphilis, and scarlatina. Another point which is deserving attention with reference to the pheno- mena of external disease, in cases where animal poisons have been gene- rated in the system or arisen from infection, is the occurrence of tumours in different parts of the body, partaking of the characters of fumncular in- flammation or carbuncle, and running through a somewhat similar course. These tumours formed a very prominent feature in the case of Wallace; and, in the gentleman who laboured under button-farcy, they constituted one of the most important symptoms of the disease. We also observe something similar to this in that form of venereal which Mr. Carmichael terms tubercular, and which is characterized by the appearance of small, hard, dark red tumours, on various parts of the body, which exhibit a very imperfect tendency to suppuration, and frequently give rise to sores of a bad and unfavourable character. Another circumstance observed in Dr. M'Donnell's case deserves some share of attention; I allude to the white elevated margins, like wheals, around the redness which more immedi- ately encircled each cluster of achores, and which we are to look upon as in a less advanced stage of its progress, being as it were, only the first stage of the latter. It is a curious fact, that on many occasions a pre- ternatural degree of whiteness precedes the redness and congestive pur- ple hue which ushers in mortification. This is generally known in the case of the nose when frost-bitten, and which always appears preter- naturally white in the commencement. Something analogous to this was observed in some cases of bad typhus treated here in 1826 and 1827. The nose sometimes assumed a peculiar white colour, and not unfrequently exhibited a tendency to mortification. When first seen it had a preterna- tural whiteness, and looked very like a nose made of white wax; in the course of a few hours it changed to a purplish red, and exhibited symp- toms of approaching gangrene. Again, in urticaria, we often see some portions of the inflamed skin assume a white colour, and the same occur- monia continued in the'same state as before. On the 19th, the report states, that he slept very little, was kept awake by pain extending down the inside of left leg, and had frequent short rigors. On examining the limb, it was found to present the usual appearance of phleg- masia dolens ; it was white, its symmetry perfect, but by measurement in different situations, was found to be three inches thicker than the opposite one. There was very little effusion into the knee-joint; the power of motion was almost lost, and he complained of excessive pain in the groin and along the course of the saphena vein, greatly increased by pressure; the pustules had burst and formed scabs, which, when they dropped off, left the skin underneath whole and healthy. As the man is still in hospital, I am unable to give the termination of the case, but which, as far as it goes, is, I think, strongly confirmative of mv views. It is worthy of note, that in this case the poison, whatever it was, that gave rise to the pustules and subse- quently to the phlegmasia dolens, was generated in the system itself during the course of a typhus fever: here there was no bed-sore, wound, or other local affection, which could be supposed capable of originating the poison. 614 CLINICAL MEDICINE. rence raay be noticed likewise in the wheals caused by nettles or the stings of bees. In general, we connect the idea of integumental inflammation with the appearance of redness; and this phenomenon is explained on the hypothesis that a preternatural quantity of blood is circulating in the in- flamed parts. How, then, are we to account for the facts I have men- tioned ? To what cause are we to attribute the co-existence of increased vascularity, and a remarkable whiteness or pallor of the parts?—a state displayed in a very remarkable manner in phlegmasia dolens. I think the explanation is not very difficult when we recollect that the capillary ves- sels of the white tissues of the body contain no red blood in their healthy state. It is easy to conceive that in certain stages of inflammation the quantity of serous or white blood circulating in any of these tissues may be suddenly much increased, and that this increase may be accompanied by all the phenomena of inflammation except redness. In certain cases, as phlegmasia dolens, the colour is permanently white ; in other cases the white is exchanged for redness, when the inflammation has increased in intensity; but perhaps we should not use this expression, for the pheno- mena of phlegmasia dolens prove that a white inflammation raay be quite as intense as red inflammation,—a fact which we saw exhibited in a re- markable manner in the case of a woman in this hospital, labouring under phlegmasia dolens, and in wrhom the disease suddenly attacked the eye, and destroyed it in a short space of time—disorganising it rapidly without the supervention of any redness during this destructive process. I never had any hopes of this woman's recovery, because, in addition to the phlegmasia dolens, she had fever and inflammation of the mucous membrane of the intestinal canal and lungs. She laboured under fever, vomiting, and irritability of the stomach ; she had a severe diarrhoea, tym- panitis, and a swollen state of the abdomen, with turgescence of the veins on its surface, so as to bear some resemblance to dropsy. She had a con- stant harassing bronchitic cough ; in fact, a combination of unfavourable symptoms, which rendered her ease hopeless ; and in spite of all the usual remedies, stupes, leeching, blisters, &c, she grew progressively worse, and sank under her complicated load of disease. I shall not detain you by a detail of her case, and a recapitulation of the therapeutic agents employed in endeavouring to arrest her complaint, but shall proceed to make some observations with respect to the phenomena observed by Mr. Hudson on dissection. " On opening the thorax, there was no serum discovered in the pleural cavities, but there was a considerable quantity in the pericardium. The left pleura was adherent at all points. The lungs were healthy, with the exception of some edema posteriorly; the bronchi contained a quantity of sanguinolent frothy fluid, but in other re- spects presented a natural appearance. The right side of the heart con- tained fibrin, the left some coagulated blood ; the valves were healthy. The stomach and intestines presented no sanguineous engorgement, and were apparently free from disease ; the liver was large and much con- gested ; the spleen large, soft, and almost pulpy ; the kidneys pale, with patches of white degeneration. The uterus exhibited nothing remarkable, except the loaded state of the spermatic veins, which were very large and tortuous ; the veins of the mesentery were also congested. The vena cava inferior was healthy down as far as its juncture with the renal vein, below which it was thickened, and filled with a fibrinous substance, vary- ing in its consistence, and adhering to the inner coat of the vessel. On PHLEGMASIA DOLENS OF THE EYE. 615 • laying bare the femoral vein, the subcutaneous cellular tissue was found to be infiltrated with serum, the granules of fat much firmer and more dis- tinct than natural, and the intervening cellular membrane thickened and opaque. The superficial fascia was dense, white, and of a flaky appear- ance, the lymphatic glands in the groin were large, full of serum, and closely matted together by condensed cellular tissue. It was extremely difficult to detach the iliac, femoral, and saphena veins, in consequence of their strong adhesions to their sheaths and the surrounding organised lymph, in which they were imbedded. These, together with the popliteal vein, were similar in condition to the inferior cava, except that the sub- stance they contained was thinner, of a brown colour, and somewhat purulent appearance. In the remainder of the saphena, and in the veins near the foot, there was a plug of coagulum, they were otherwise healthy. The iliac and femoral arteries contained a small quantity of blood ; the other arteries were empty." You perceive, gentlemen, that all these last-mentioned parts, so accurately detailed by Mr. Hudson, presented, each in succession, marks of inflammation. The subcutaneous cellular membrane is infiltrated, the granules of fat altered, the cells in which they are deposited increased in size, the superficial fascia dense, white, and of a flaky appearance, all indicative of the existence of inflammation. It is found extremely difficult to detach the femoral and saphena veins from their sheath, or from the firm organised lymph in which they lay. As the result of long-continued inflammation, a large quantity of lymph is poured out along the track of the vessels, and this mats them together in such a manner as to present considerable obstruction to their detachment. The veins and lymphatic glands also exhibit distinct proofs of inflamma- tory action. Why do I make this recapitulation ? Because I think it is necessary to impress upon your minds the fact that all those tissues, and not merely the veins or lymphatics, are engaged in phlegmasia dolens. Was there any part spared ? Did the cellular tissue, or the fat, or the external surface of the veins escape ? No—all were enveloped in the sarae inflammatory mischief.* I think you cannot have a better proof than this, that the phenomena of phlegmasia dolens do not depend on inflammation of either veins or lymphatics solely. In confirmation of this opinion, I may observe, that I lately saw a case, in which both saphenas became inflamed and obliterated, in consequence of a cutaneous eruption, and yet the gentleman had no accompanying phlegmasia dolens. Let us pass over this subject and come to the eye. What is the state of the eye in this woman ? She awoke on the morning of the 24th of January with intense pain in the eyeball, and complete blindness of the affected eye, being unable to distinguish light from darkness. On ex- amination, there was immense serous chemosis discovered, so great, in fact, as almost to conceal the cornea, which appeared, as it were, sunk and buried in it. This chemosis was so exquisitely tender, that she could not bear the eyelids to be touched. Nevertheless, it presented a charac- ter totally distinct from any other species of acute chemosis we are ac- quainted with, its colour being almost white. The exceedingly small portion of cornea which was visible appeared to be opaque. Her symptoms continued with undiminished intensity up to the period of her decease. On examining the eye after death, the cornea was found to be perfectly transparent, and the chemosis to have nearly disappeared. * These views were advanced by Hull, in 1800, and subsequently advocated by Lee. 616 CLINICAL MEDICINE. The iris had lost its natural grey colour, and become nearly white, and its surface was covered with long flakes of lymph, both anteriorly and posteriorly. The aqueous humour was turbid, and had portions of curdy lymph floating in it. The crystalline lens was opaque and of a light brownish tint. The vitreous humour was of a dull yellowish colour, and had its consistence altered, for, on opening it, the fluid which dropped out was thick and ropy. On this case Mr. Hamilton, who was then one of my clinical clerks, has made the following remarks :—" The only disease in which the sight is instantly destroyed is amaurosis, of which some instances are on record ; but it would be impossible to look on this as a case of amaurosis, where the eye exhibited so many simultaneous organic lesions. The chemosis in this case differs very much from that which accompanies any of the varieties of ophthalmia, or conjunctivitis; in the former it was white, in all the latter it is red, of various degrees of intensity. There is a great difference in the manner in which sight is destroyed by any of the forms of ophthalmia, and that which has charac- terized this affection ; in the common forms we have destruction slowly accomplished by ulceration and sloughing of the cornea, hypopium, adhesions, and prolapsus of the iris, &c. Neither does it resemble rheu- matic or gouty inflammation of the iris ; for in these instances sight is not annihilated at once, and there is a degree of redness, arising from a par- ticular arrangement of the sclerotic vessels. The colour which the iris presented is also peculiar to this disease. In common iritis the colour never becomes so white, nor is it ever covered by the same kind of flaky lymph ; the lymph that is effused being a more homogeneous fluid, which either forms a thin layer in front of the lens, giving it a hazy appearance, or contracting adhesions so as to change the form of the pupil, or existing in the shape of globules on the surface of the iris, or gravitating towards the bottom to constitute hypopium. None of the writers on diseases of the eye whom I have consulted describe any such appearance; nor have I witnessed any thing similar among the numerous cases of syphilitic and idiopathic iritis which are treated at this hospital. I think there can be little doubt of its being a disease sui generis, differing from other dis- eases of the eye, not only in its leading features but in all its particular symptoms." Such is the interesting detail of this remarkable case given by Mr. Hamilton. The woman awakes suddenly from sleep one morning during the progress of her complaint, feels an intense pain in the eyeball, and finds her sight completely gone. This is a very remarkable circumstance. Again, you have the cellular tissue of the conjunctiva attacked by a rapid inflammation of precisely the same character as that which we noticed to prevail so extensively in a similar tissue in the lower extremity. The prin- cipal part of the exhalation which results from the inflammation is deposited in the subconjunctival cellular membrane, forming an enormous protube- rance which nearly shuts out the cornea from view, exquisitely tender to the touch, but white and exsanguineous in its colour. I do not hesitate to affirm that in this new species of affection we have witnessed a case of phlegmasia dolens affecting the eye, perfectly identical in all its characters, and differing in no single material point from the inflammation which attacked the lower extremity. In the leg we have various tissues engaged in the inflammatory process, the skin, cellular tissue, adipose substance, fascia, arteries, veins, and lymphatics; in the eye we have the conjunc- PURULENT VESICLES. 617 tiva, iris, aqueous and vitreous humours and crystalline lens involved in one common mischief. Their identity is farther corroborated by the nature of the pain common to both, the sudden appearance of the disease, the exquisite tenderness of the eye, and from the fact that there is no other species of disease on record with which we could class this novel disease. It is a form of disease hitherto unknown, and I believe we may claim the honour of having first described it. It was not iritis, nor oph- thalmia, nor amaurosis. In iritis there is pain in the, forehead, sight is not instantaneously destroyed, the conjunctiva is red and very seldom exhibits much turgescence ; but here, vision is annihilated as if by a flash of lightning; there is a wall formed round the cornea which hides it from our view, but its hue is pale and bloodless. There is not a single feature in it by which the most anxious and critical inquirer could trace any resemblance between it and amaurosis, except the single and unsup- ported circumstance of sudden bereavement of vision. It is unnecessary for me to contrast it with any kind of ophthalmia, as their phenomena, progress, and termination, are so essentially dissimilar. All that we have seen of it authorizes us to conclude that we have witnessed a disease hitherto unknown and undescribed, phlegmasia dolens of the eye. Postscript.—On Purulent Vesicles.—A woman named Green was admitted into the Meath Hospital, with erysipelas of the head and neck, accompanied by high cerebral symptoms, the consequences of a contused wound of the scalp. On the second day of her admission, we observed a vesicle of a peculiar character on the right hand. It was about the size of a small pea, full of pus and surrounded by a base of a deep red hue about the size of a shilling. Between the shoulders, two more vesi- cles, exactly like the first, were discovered. The erysipelas and head symptoms gradually disappeared under the action of mercury, and the vesicles burst, and left an encrustation which soon fell off, leaving a newly-formed and healthy cuticle underneath. A day or two after the appearance of the \Tesicles on Green, a girl who had been in the hospital about six weeks, labouring under general debility, palpitations, and excessive action of the heart, extreme irritability of the stomach, depending on amenorrhcea of seven months' duration, presented on the forefinger of her left hand a well-marked vesicle, of the sarae size and character as those noticed in Green's case. Though she had a good number of boils in other parts, she had only the one vesicle, which also burst, scabbed, and the crust fell off, leaving the cuticle underneath quite healthy. In the same ward with Green was another girl named Scully, affected with symptoms, the consequence of suppressed catamenia, who was also attacked after Green with an eruption of the same kind of vesicles, on both hands. At first the parts became red and itchy, then small vesicles filled with serum appeared, which, when they had attained the size of a small pea, became filled with pus. Each vesicle was surrounded by a deep red base. Some of them were as large as those of poraphylix. One very large vesicle was observed to have one half distended with pus, and the other with serum. They were extremely itchy, and the red base was very pain- ful. These vesicles extended over both arms up to the elbows, continued longer than in the two preceding cases, and then terminated in the same manner. But in this instance their disappearance was immediately fol- 618 CLINICAL MEDICINE. lowed by inflammation and abscesses of the left mamma, producing great suffering, and attended by painful periostitis of both shins. Under appro- priate treatment she eventually recovered. Two cases of dropsy, in the chronic ward, next claim our attention. Both have occurred in persons who have previously enjoyed tolerably good health, and in both the disease seemed to be unaccompanied by organic lesion of .any important viscus. One of the patients, J. Aus- tin, states that he has been ill two months before he came into hospi- tal, and acknowledges that his illness was the result of long-continued habits of inebriety. Careless and intemperate in his mode of life, and frequently exposed to cold and wet, he got an attack of bronchitis, ac- companied by a sense of constriction about the chest, and difficulty in breathing. He was bled for this, and states that the bleeding relieved his dyspnoea ; but about this period he remarked that an anasarcous swelling appeared in his face, neck, and chest. In this case we have a specimen of the ordinary history of dropsy in this country:—first, intemperate habits, next, exposure to cold, followed by bronchitis or pneumonia, and then dropsy, commencing in the face, chest, and upper extremities. I have on a former occasion pointed out to the class the importance of observing in what part of the body the drop- sical swelling first appears, because, by doing so, we obtain a more accu- rate idea of its nature, and are furnished with a clue towards discovering its source. Dropsy is generally the consequence of organic disease of some deep-seated viscus. When it is produced by thoracic disease, as bronchitis, pneumonia, or affections of the heart, it is said that the swell- ing always begins in the face, neck, trunk, and upper extremities ; when it depends upon chronic hepatitis, disease of the spleen, obstruction of the system of the vena porta, or disease of the mesenteric glands, the swelling commences in the abdomen, and then proceeds to the lower ex- tremities ; but when it arises from mere debility, the consequence of hec- tic fever, long-continued diarrhoea, or a cachectic state of the system, the effusion is first observed in the lower extremities, coming on in the even- ing, and again disappearing towards morning. The history of dropsical swellings, therefore, by informing us in what part they first appeared, is often sufficient to indicate the general nature of the producing cause. When this man came into the hospital, his cough had disappeared, and there were not any unequivocal symptoms of disease of the heart, but he had considerable dropsical swelling of the face, chest, and superficial parts of the abdomen ; his appetite was bad, and on examining his urine, we found it loaded with albumen, and of the specific gravity of 1029. Though he had no fever or dyspnoea at the time, we commenced the treatment by general bleeding, because he was a person of rather robust constitution, and on account of his dropsy having originated in cold. In persons who are able to bear bleeding, and where the disease has commenced in an acute form, you may often commence the treatment of dropsy by a single bleeding with great advantage, even though there be no fever or local inflammation present. We next prescribed an aperient injection, to be followed by a vapour-bath. I then, by way of trial, gave him an elec- tuary containing some diaphoretic medicines, and found that it acted well on the skin, and that sweating could be easily induced. This furnished me with a key to the after-treatment. Whenever you find that sweating DROPSY IN ACUTE BRONCHITIS. 619 can be easily brought on in dropsical cases, you should obey the hint given by nature. You should not, under such circumstances, have re- course to mercury, or hydragogue purgatives, or diuretics ; you are to open the passage which nature has pointed out, you are to encourage dia- phoresis, and you may rely upon it that you will in this way effect an easier, safer, and more permanent cure than you could by any of the various modes employed for similar purposes. We therefore gave this man a powder containing four grains of Dover's powder and five of nitrate of potash, three times a-day. The Dover's powder is tempered by combining it with nitrate of potash, which is an antiphlogistic, and prevents the former from exercising a heating effect on the system. Hav- ing continued these powders for seven or eight days, we commenced the exhibition of opium, in doses of half a grain, four times a-day, to be in- creased after a few days to half a grain every fourth hour. Under the use of vapour-baths used daily, and opium to the amount of three grains in the twenty-four hours, the man has improved wonderfully, and the dropsical swelling is fast subsiding. Opium has here, you may have re- marked, produced no bad effects. The tongue is neither dry nor furred, and it has not any of that appearance which is observed in persons who are in the habit of taking opium ; his appetite is unimpaired, his bowels regular, and his strength undiminished. Now, why did I give opium in this case ? The more advanced stu- dents will perceive, that I have treated it nearly in the same way as I treat cases of diabetes. There seems to be an analogy between chronic dropsy and diabetes, and experience has proved to me that this mode of treatment is most likely to be attended with success. I shall not dwell on this point at present, but shall content myself by referring to a paper in the second part of this work, observing here, that opium and otber diaphoretics increase strength, remove the dropsical swelling, diminish the quantity of albumen in the urine, and bring on convalescence with- out producing any bad effects on the head or digestive system. I am anxious that you should attend to this case and watch the result; for the treatment is quite different from that employed by others. I say this without meaning to claim any originality ; but 1 may be permitted to say, that it is a mode differing very much from those generally pursued. It cannot be used in cases where fever or local inflammation is present; but when the local and general excitement has been subdued, or when the case is chronic and unaccompanied by quick pulse, or any symptoms of visceral inflammation, it may be employed with safety and advantage. The second case is that of the patient Matthew Gray, a man of middle age, and rather robust constitution. On admission, he stated that he had been dropsical for about twelve days, and complained of cough, dyspnoea, constriction of chest, and feverish symptoras. His cough was hard, short, and incessant, preventing sleep, and increased by every attempt at full inspiration. He had general wheezing, much oppression about the chest, and scanty expectoration of frothy mucus. His pulse was 84, soft and rather weak: he complained of nausea and loss of appetite, and had edema of the lower extremities. On examining the chest, I found it sound clear on percussion, and that the physical signs present were those of bronchitis passing into the stage of super-secretion. In addition to this, there were symptoms of engorgement in the lower and posterior parts of the lung. 620 CLINICAL MEDICINE. Here, then, we had a case of dropsy supervening on acute bronchitis. I therefore ordered him to be blooded immediately, and afterwards to have cupping-glasses applied over the congested part of the lung. The local abstraction of blood was followed by remarkably good effects; it relieved the cough and constriction of chest, and diminished materially the pulmonary congestion. I next prescribed the following mixture, of which he was directed to take one tablespoonful every hour:— R. Mistura? amygdalarum, 5 xij. Antimonii tarlarizati granum, Nitratis potassae, ^jij- Tincturae hyoscyami, ^iss. Tincturae digitalis, gss. A mixture like this is well adapted for such a case ; it removes the febrile condition of the system, and, by its demulcent and sedative proper- ties, allays the cough and bronchitic irritation at the same time that it de- termines to the kidneys. Those medicines which are termed demulcent, are frequently of great value in the treatment of bronchitis ; you will often derive more benefit from gum arabic, spermaceti, almond emulsion, and the like, than from any other class of remedies. In the present case, we combined them with sedatives and narcotics ; and as the remedies pre- scribed under such circumstances should be antiphlogistic, we added a grain of tartar emetic and two drachms of nitrate of potash. I have already spoken of the powerful antiphlogistic properties of a combination of tartar emetic and nitre, and dwelt on the benefits derived from it in many forms of inflammatory disease ; so that it is unnecessary for me to say any thing at present on the subject. It is obvious to all, that the tinctures wTere added on account of their sedative and narcotic properties, tending to remove irritation and induce sleep, of the wTant of which the patient complained. But you may ask me, why I did not order opium : simply because the disease was in its acute stage, and at a period when opium is apt to produce excitement of the system, and aggravation of the local symptoms. Instead of opium, I gave hyoscyamus, which neither increases heat, produces headache, nor checks expectoration ; and to this was added digitalis, a narcotic possessed of considerable antiphlogistic properties. Of all the narcotics, digitalis may be given with the greatest safety in cases where antiphlogistic treatraent is required. It is unnecessary for me to follow up this case through all its details. It will be sufficient to state, that by gradually changing the nature of the treatment as inflammation declined, and particularly by the proper em- ployment of powerful purgatives, I have succeeded in producing a rapid amendment in his symptoras. It may be, however, necessary to explain why I used purgatives, and in what way they were exhibited. In cases where extensive bronchitis has given rise to pulmonary engorgement and dropsy, when you have relieved the acute symptoms by bleeding, leeches, or cupping, and other antiphlogistic means, and when there only remain some wheezing, oppression of the chest, and rather copious expectoration, you will often effect a vast deal of good by the judicious employment of powerful purgatives. You will clear the chest, relieve the breathing, and diminish the dropsical effusion. In the present instance, the patient took the following bolus :— TREATMENT OF DROPSY. 621 R. Pulv. jalapae—rhei—scammoniae, aa gr. v. Elaterii, gr. ss. Bitartratis potassae—sulphatis potassae, aa gss. Syrupi zingiberis, q. s., ut fiat bolus. This acted powerfully, and its operation was followed by marked dimi- nution of the pulmonary engorgement and dropsical swelling. I have frequently endeavoured to impress upon the class the truth of an observa- tion made by Dr. Paris, that in the exhibition of remedies, much better effects are obtained by combining several analogous remedies in small quantities, than by giving a single one in a large dose. By combining substances which are of the same nature, that is to say, which are indi- vidually capable of exerting the same effect on the system, we are capable of producing more decided effects, even though these substances be given in diminished quantity, than if we prescribed any one ingredient of the combination in a full dose. I refer to this general principle, in order to explain why I had recourse to so many different medicines, instead of employing a single powerful ingredient in considerable quantity. It ex- plains why, instead of giving at once fifteen grains of the powder of jalap, I gave five grains of jalap, five of rhubarb, and five of scammony, and added to these half a grain of elaterium, and a small quantity of cream of tartar and sulphate of potass. With respect to elaterium, I may observe, that it has been strongly recommended in those cases of dropsy where there is no irritation of the digestive system present. Its action on the intestinal tube is very energetic, and from the quantity of watery secretion which it generally brings away, it is of great utility in removing anasar- cous swellings. These are the principal observations which I have to offer with respect to this case. I may mention, that as the patient complained much of restlessness, we prescribed half a grain of morphia, to be taken at bed- time. This succeeded in producing sleep, a most important point in the treatraent of all acute affections. We have now omitted the use of the more powerful remedies, and have prescribed to-day a decoction of Ice- land moss, with tincture of opium, to act as a pectoral demulcent, and he has been allowed chicken-broth and jelly. He is going on at present in a very satisfactory way, but it will be necessary to watch him care- fully during his convalescence, and obviate the occurrence of a relapse. If discharged at present, and before convalescence is perfectly established, he would in all probability relapse, and soon become much worse than ever. Hence I intend to keep him here for a month or six weeks. As long as I have been attached to public hospitals, I have made it a fixed rule, in all cases where a cure was possible, to keep the patient until it was confirmed. Whenever I was obliged, under the pressure of urgent necessity, to dismiss a case before healthy action was completely re-estab- lished ; or whenever patients left the hospital prematurely of their own accord, I have observed that such persons, particularly if placed in the lower ranks of life, and subject to the nuraberiess accidents and exposures of poverty, almost invariably returned in a far worse condition than be- fore. It is much better, though perhaps it does not .make so striking an appearance in hospital returns, that a certain number of patients should receive all the benefits derivable from such institutions, than that a greater number should pass through them in the year, and be hurried out of them in a state of imperfect convalescence. This observation particularly applies 622 CLINICAL MEDICINE. to fever hospitals, and is, I fear, too little attended to in this city. Cer- tain I am, that a vast number of the cases of incurable pulmonary and intestinal disease which are admitted annually into the Meath Hospital, have had their origin during the state of debility in which the patients were then dismissed from a fever hospital. Improper diet, imperfect clothing, bad lodging, damp rooms, are borne by the constitutions of the poor with comparative impunity as long as they are in a state of health ; but not so when they are debilitated by a recent attack of fever, treated or maltreated by active remedies, and dismissed from hospital in a week or ten days after the crisis has taken place. . How injurious to persons so debilitated the change from the warmth and comfort of a hospital to the cold and desolation of a damp garret or cellar ! Add to this, that many of them, at the time of their discharge, still evidently bear the marks of mercurial action in their system, and many have their hair very short, in consequence of the head having been shaved during their illness. Hence many catch colds that affect the ears or eyes; many become deaf, and not a few get sore eyes ; while the number of those in whom the sequelae of the fever rapidly induce incurable chronic diseases is so great, that, were the balance of the account to be fairly struck out, it would be found fever hospitals do less good to the public health than is generally imagined. A patient who is at present in the chronic ward presents some circum- stances worthy of observation, as connected with peculiar varieties in the alvine discharge. She has been labouring for some time under melaena, and, as you have observed, passes daily a large quantity of dejections from her bowels, as black as ink. The colour of matters discharged from the bowels is subject to very great variety. In some cases they are clay- coloured or whitish, somewhat like barm ; and I have seen them still whiter, and approaching the hue of milk. It is in cases of the latter kind, where the discharges are of a milky appearance, that persons have been said to pass chyle, and their emaciation has been attributed to a deficiency of nutriment depending on this cause. This, however, is not the fact: in some cases of chronic dysentery and diarrhoea, a fluid whitish discharge takes place from the rectum, but this is not chyle, it is only the changed mucous secretion of the irritated portion of the bowel. It is very curious to observe what different products the same set of secreting vessels will give rise to, according to the mode in which their vital action is affected. In other cases the discharges from the bowels consist of fatty matter, which bears a strong resemblance to wax, or adipocire. Again, we may have them of a very dark, or even black colour. I have seen the stools quite black in particular forms of dyspepsia. Some time ago I attended a gentleman at Drumcondra, who exhibited this change in the colour of the intestinal secretions to a very remarkable degree. He was a very large man, accustomed to eat and drink very heartily, having, no doubt, a very capacious stomach and bowels, and a great quantity of fluids and solids. I mention this in order to give some explanation of the enormous quantities of this black fluid which he passed by stool and vomiting. After complaining for a considerable time of dyspeptic symptoms, he got an attack of vomiting ; and as he drank freely of diluents during the act of emesis, the quantity of this black fluid which he threw up was amazing; indeed, I might say, without exaggeration, that he vomited by the gallon. With this he had eructations of sulphureted hydrogen to such an extent, that it was almost impossible to remain in the same room with him. His PECULIAR ALVINE DISCHARGES —MEL^NA. 623 tongue was as black as ink, and though frequently cleansed, resumed in a short tirae its former hue. He also passed an enormous quantity of the same stuff by stool. This matter I ascertained, by numerous observations and experiments, to be a secretion from the mucous membrane of the bowels, and not depraved bile, or blood changed by the acid secretions of the bowels. Black stools may also depend upon the presence of other matters, as in cases of melama. Melaena consists of a discharge of gru- mous blood from the intestines, either with or without black matter. The following is the way in which it occurs : Blood is secreted slowly into the intestinal tube ; while it remains there it is acted on by the acid secre- tions of the intestines, the effect of which is to change the colouring mat- ter into a black, and in this state it is passed by stool.* Again, there are other cases in which the discharges from the bowels are found of a tarry and viscid consistence, and having a greenish-black appearance: this would appear to be connected with a vitiated state of the biliary secre- tion. I have spoken here of three species of black discharge, each of a dif- ferent kind, and requiring to have a distinction made between them for practical purposes. Now it is said, if blood be present you can easily re- cognise it by putting a portion of the discharge inclosed in a small linen bag, into warm water, wrhen, after remaining some time, the linen will be stained of a reddish colour. If you take a portion of the tarry dis- charge, and drop a little of it into water, it will communicate to it a yel- lowish stain. On the other hand, the black fluid, which consists of vitiated mucous secretion, will not impart either a red or yellow7 tinge. I may further observe, that various substances used medicinally com- municate a particular tinge to the alvine discharges. Thus acetate of lead, when it meets with sulphureted hydrogen in the intestines, changes the stools to a black colour. Again, many of the salts of iron have the same property. Other substances, such as logwood, bilberries, &c, im- part to them a red tinge, while the continued use of chalk-mixture is apt to render them whitish or of the colour of pipe-clay. This is apt to give rise to suspicions of the existence of obstruction of the liver; and in one instance I was deceived for some time by it myself. With respect to the greenish-coloured discharges, they are those which are most frequently met with, particularly in children, and are therefore entitled to a greater degree of consideration. There is nothing more common than to meet with cases of this green discharge during the period of infancy ; and I regret to state that a great deal of error has prevailed on the subject. Greenish stools are generally looked upon as a sign that the child's liver is out of order, and as an indication for giving calomel. This, however, is by no means true ; they not unfrequently depend upon irritation of the intestinal mucous membrane approaching to inflammation. The proper mode of treatment here consists in adopting measures calculated to remove irritability. In such cases, warm baths, the application of rubefacient liniments to the abdomen, the use of antacids, such as chalk-mixture, the carbonates of soda and ammonia, small doses of laudanum, and hydrarg. - The blood effused in meleena, coagulates in the bowels, and being exposed to heat and air, turns black, and often becomes fetid. When retained very long, the colouring matter may be washed away, and the coagulated fibrin left. In a dissection of a woman who died of meleena, at Berlin, I found in the large intestines many hard balls, the size of apples, and con- sisting of fibrin, deposited in concentric layers, evidently the result of successive separations from the blood, effused during several different attacks. 624 CLINICAL MEDICINE. c. creta with Dover's powder, form the best remedies; and their opera- tion will be very much assisted by a careful attention to diet. You will sometimes, it is true, meet with greenish discharges in adults, but then they are not so fluid as those of children, nor are they attended with the same irritability of the gastro-intestinal mucous membrane. Here the best plan of treatment is the Abernethian : blue pill at night, and a mild aperient in the morning, will be sufficient to correct the intestinal derange- ment, particularly if assisted by a well-regulated diet, and exercise in the open air. But in children the greenish discharge is often of a much more acute character, and more closely allied to inflammation, or rather irrita- tion ; although in some cases it may go on for a considerable time with- out producing any acute disorganization. It is on account of the property which calomel and other mercurials, exhibited internally, possess of caus- ing irritation in the first instance, and if pushed farther, inflammation of the mucous membrane of the intestines, that they are also apt to produce discharges from the bowels, copious, fluid, and mixed with green mucous flocculi, resembling closely chopped spinach. Sometimes the dejections consist of this green mucus nearly unmixed with any thing else, and then they appear like semi-fluid boiled spinach. Now most practitioners think that this green colour is derived frora bile which the mercurial has brought down in unusually great quantities frora the liver, excited to a more energetic act of secretion. It has nothing to do with the bile in many cases, but is entirely derived from the irritated merabrane of the intestines. Long ago I pointed out, and was the first to point out, this fact, in the Dublin Hospital Reports. It has very important practical bearings. CLINICAL LECTURES, BY W. W. GERHARD, M.D. CLINICAL LECTURES. LECTURE I. Acute articular rheumatism—Connection with inflammation of the cardiac membranes— Treatment, bleeding, opiates, &c. I shall to-day, gentlemen, take up the subject of acute articular rheuma- tism, as it is especially prevalent at this season of the year, when the number of other acute diseases is very limited. In summer we have acute abdominal inflammations, and in winter affections of the pulmonary organs, while, during the spring and early summer months, serous inflam- mations, both of the internal and external membranes, are most common. Acute rheumatisra bears some striking relations with the inflammations of internal serous membranes, from the similarity of the mode of treatment which often becomes necessary in both affections, and from the frequent complication of the latter with the former disease. In almost every severe case of rheumatism under notice, there co-exists inflamraation of the covering of the heart, or of the serous merabrane lining its cavities. Since this connection between the pathology of articular rheumatism and that of diseases of the heart and its membranes, has been clearly traced, the dis- ease has attracted much interest. I say clearly traced, for the general fact had been long since pointed out, although the subject was not pre- cisely understood. That is, it was in the same situation as many other parts of pathology ; affording an indistinct view of the truth, but without that well-defined character which is nowT required, according to the rules of rigid logic which we endeavour to apply to the study of pathology. The line of connection has only been drawn in a definite manner, for a few years past, between acute articular rheumatism, and endocarditis, or inflammation of the lining membrane of the cavities of the heart, and peri- carditis, or inflammation of the membrane surrounding it. Dr. Bouillaud, of Paris, has paid particular attention to this subject ; he tells us that at least one-half the acute articular rheumatic affections are complicated with pericarditis. In this estimate he is probably wrong, unless with pericar- ditis we are permitted to include endocarditis. A large number of mild cases doubtless run their course, without any complication of the kind, but it is usually otherwise when the disease appears under a severe type, and we might "say that many raore than half the severe cases, probably two-thirds, are complicated with some inflammation of the heart. Of the other third, a large portion present signs of some functional disturbance, thouo-h not of positive inflammation. Mild cases are slow in their action upon the heart, but, in the severer forms, the advance is rapid, and dis- ease of the heart succeeds almost immediately after the first appearance of the articular symptoms, la chronic cases, the progress of the cardiac 628 GERHARD'S CLINICAL LECTURES. affections is slow, and an individual not well acquainted with the disease might be deceived as to their existence. We have thus traced two forms of the disease, and I propose bringing under your notice two cases now under treatment in the Philadelphia Hospital, to exemplify them. The first is that of John Robb, who was admitted into the ward No. 2, on the 11th of April. Previous to his admission, he had been ill but a short time ; being an inmate of the Aims-House, he was able to resort to medical assistance quite as soon as is usual in private practice. He had been working on the farm of the establishment for eight months previous to his attack, and had enjoyed good health. On the morning of the sixth, he complained of slight pains in his shoulder, but continued at work ; at eleven, p.m., he was taken with severe pain in the hip, which lasted four or five hours, and then, diminishing in the hip, went to the knee. On the seventh it ceased in the right knee and attacked the left. Now, from the character of the affection, thus shown, we can, without going farther, make our diagnosis. I allude to its metastatic character, as exhibited in its leaving one joint and settling in another. This is almost distinctive of rheumatism. There was no pain in the ankles, but there was slight pain near the toe. You here mark the course of the disease onwards ; it has reached the toe, and shows a disposition to attack the whole foot. There had been pain in the right wrist, from an hour before the man's entrance into the hospital. On the ninth and tenth, he had pain in the breast, which he referred to a spot below the praecordia, in the region of the diaphragm, and which lasted twenty-four hours, and was increased by coughing. Such pain is usually owing to disease of the heart, which may be merely muscular, but it is more frequently caused by inflammation of the serous membranes lining or covering the heart. This man had been exposed to no causes of disease other than those which he was in the habit of encountering. He had, it is true, been wet while working on the farm, but this was not uncommon with him : he had been long accustomed to working in the rain. This shows how cau- tious we should be in admitting causes of disease ; some physicians might be disposed to attribute the attack of rheuraatism to the last wetting, which could manifestly exercise no greater influence upon the man than a series of previous exposures to the same cause, of no recent occurrence. I look upon the particular season of the year as the principal excitant of the disease, and it is for this reason that I have thought it a fitting subject to bring before you at the opening of my course. If you take the trouble to inquire, you will find that at this time the prevalence of rheumatisra and rheumatic pains is remarkable. But»an accidental exposure will often develop what might otherwise have remained dormant, and thus the dis- ease, like many others, must be referred to two different causes, a general and an accidental one. The influence of the former is in this case much greater than that of the latter. The case before you being of an acute character, its previous history is not nearly so important as the present state of the individual. It is otherwise in chronic affections, in which the whole anterior history is all- important. The condition of the patient at the time of his admission on the eleventh, was as follows. The face was slightly flushed, and presented an expres- ACUTE RHEUMATISM. 629 sion of pain. This pain in acute rheumatisra, is remarkable ; it usually prevents all exercise, and confines the patient to bed. There was slight soreness in the shoulder, but without swelling or heat; no pain or swelling in the left arm, slight soreness in the right elbow, and severe pain, swelling, and heat in the wrist. The same pain, swelling, and heat extended to all the joints of the hand and fingers, excepting the thumb. There was some pain in both knees, especially in the left; none in the ankles ; a little in the right hip, no tenderness of the spine, no cephalalgia ; tenderness on pressure along the region of the ribs; this was probably the remains of the diaphragmatic pleurisy. The impulse of the heart was feeble, the second sound nearly lost, the first much roughened, dulness on percussion nearly natural. Treatment, one grain of opium every four hours. The digestive organs were healthy. Now, let us analyze this case. The first fact worth recollecting is the absence of tenderness of the spine. This establishes the diagnosis betwreen simple rheumatism and that which is allied to neuralgia. Hence, the mode of treatment which proves so excellent in the latter affection may here fail. The state of the heart indicated merely slight valvular disease, and some muscular impediment; there was no effusion, the dulness on percussion being natural, and no creaking sound being heard. The treatment in this case was after a plan of practice in New England, from which quarter it has been lately strongly recommended ; the internal' administration of opiates, pushed till felt by the patient. During the twelfth, six pills of opium containing each a grain, were exhibited, but there was no diminution of pain. Neither sleep nor cepha- lalgia had been induced by the opium. This is an important therapeutic point, demonstrating the antagonising action which pain exerts in regard to the effects of opium. The first sound of the heart was still rough, but the impulse rather less ; no increase of flatness. The state of the heart was, therefore, slightly improved. Pulse eighty-four, of moderate size and regular; a grain of opium was ordered every two hours, and a laxa- tive enema administered. On the evening of this day there was some cephalalgia, although no deviation of the pupils from the natural state. The dose of opium was diminished to a grain every three hours. Sleep was interrupted by twinges of pain; sweating at night. Eruption of sudamina; pulse seventy-two ; pain in right arra increased and extending to the shoulder. Less pain and swelling in the knees, but increase of both in the feet. The action of the heart was more regular and feeble, and the sound less rough. The disease, you perceive, was not in any manner arrested, although you note a decided improvement in the condition of the heart. There was costiveness from the opium, but this, you will soon see, disap- peared. Same prescription of opium continued during the thirteenth ; hop poultices to most of the painful joints ; laxative enema. On the fourteenth, the pain having diminished throughout the right arm, began in the left hand and wrist. Here is another point of interest ; the translation of the pain from the right to the left limb by metastasis. This is a common thing in articular rheumatisra, and, as in this case, the pain does not usually quite cease in one joint before it begins in the other. There was slight pain between the shoulders, and diminution of the pain in the knees and feet ; pulse seventy-six, fuller and regular; this is 630 GERHARD'S CLINICAL LECTURES. somewhat an exception to its usual condition in the disease, it being generally frequent, small, and tense. Skin warm and dry ; sleep very irregular; tongue moist, with a yellowish coat; appetite bad; thirst; three or four stools since the enema ; the opium had, therefore, induced no costiveness. No cephalalgia or dizziness ; slight flush ; eyes natural. Opium continued, hop poultice and laudanum to the left wrist. On the fifteenth, the left hand was worse, and there was pain in the sole of the right foot. The other pains were better, moisture rather than sweating. Opium continued. The sixteenth, less expression of pain, and less flush ; soreness in both shoulders, with slight swelling, but not much constant pain. Slight sore- ness of the left elbow ; much swelling, pain, and heat of the left hand ; right hand nearly free from swelling, still slightly painful, but motion returned ; pains much diminished in the legs ; pain at the ensiform carti- lage ; palpitations frequent after slight exertions ; pulse seventy-two, and soft; decided roughness, almost rasping, in the first sound of the heart, which was not very loud, and heard most distinctly to the left of the nipple, second sound nearly lost. Under the sternum, both sounds of the right side distinctly heard and clear, the first only a little roughened. The praecordial dulness commenced only at the left margin of the sternum, and extended to the nipple. The morbid alteration was, therefore, con- fined to the left side of the heart, implicating the valves ; there was besides effusion into the pericardium. The opium pills were continued during yesterday and last night every three hours. Hop poultices. Last night the pupils were somewhat contracted, and little sensible to the light. To-day the face was flushed, and presented an expression of stupor. Disposition to sleep ; pupils rather large ; no cephalalgia ; sleep interrupted by pain, shooting from the swollen joints. Pulse eighty-eight —softer. Swelling less marked in the left hand. Slight swelling and pain in both knees. No pain in the breast. Impulse of the heart almost lost; both sounds very feeble, without roughness. The disease of the valves is therefore diminished. Percussion slightly dull at the upper por- tion of the left side ; flat, down from the third rib to the same extent as yesterday. Prominence obviously increased. These latter signs are ex- plained by the increased effusion into the pericardium. Still slight diar- rhoea ; three or four stools in the twenty-four hours. Skin moist, without sweating. A grain of opium every four hours. This case, gentlemen, of acute disease of the heart, occurring in the course and as a direct consequence of acute articular rheumatism, may serve as a type of the affection, which I shall now make the subject of some general remarks, and have occasion to refer to hereafter. There are several peculiarities to be alluded to. In the first place, the change- able character of the affection, shifting, as you have seen it, from joint to joint, denotes the nature of the disease. This is well understood, and universally admitted. But I would have you remark that there was no metastasis to the heart. The disease of the heart appeared, during the most acute stage of the rheumatic fever, which afterwards continued with unabated severity. This is almost always the case : cases of metastasis are quite exceptional, and the cardiac inflammation is not only most fre- quent, but is also most severe during the height of the articular inflamma- tion. By physical examination, we ascertained that the pain in the praecordial region proceeded first, from disease of the valves, indicated ACUTE RHEUMATISM. 631 by the roughness of the sound ; secondly, frora effusion, shown by the unnatural dulness on percussion, imperfect action of the heart, &c. Another symptom to be noticed is the sweating, which was very slight from the first or second day, although it is generally very profuse in acute rheumatism. It is this sweating in rheumatism which has suggested the employment of Dover's powder, and other sudorifics, in its treatment. In this case opium was alone resorted to, to afford a better test of the powers of the remedy. The diarrhoea is another feature worth remarking, co-existing, as it did, with the large doses of opium. It was a purely accidental complication, but its occurrence demonstrates that opium,in very large doses, continued for some time, and given much in the same way as the large doses of tartar emetic are by the contra-stimulants, does not produce the same effects as in ordinary doses, thus illustrating a therapeutic law, that reme- dies, in over-doses, do not act upon the system in the same manner as when administered in the usual quantities. Were it not for this law, pa- tients would die from the action of certain remedies now frequently pre- scribed. How could tartar emetic be given in the high doses required by the contra-stimulant practice in pneumonia, or calomel, as it is pre- scribed in the diseases of certain sections of our country ? The pathology of the disease under consideration is still very obscure, although its symptoms are well understood. How much of the disease is allied to neuralgia, or connected with an affection of the nervous system, and how much belongs to local inflamraation, are points that are still un- settled. It is, in this respect, analogous to hooping-cough, and some other diseases. We are also embarrassed as to effectual curative means for arresting the progress of the affection, though we have any number of palliatives. For the present I refrain from entering largely into the patho- logy of rheumatism, but shall consider it partly as nervous and partly as inflammatory in its character. Certain inflammations of internal organs which occur in rheumatism, such as pericarditis, lose this mixed charac- ter, and become decided phlegmasias; they are accordingly treated with- out reference to disease of the joints. When the complication of pericar- ditis proves fatal, and the opportunity, otherwise rare, of examining per- sons who die with rheumatism, is obtained, there is often almost a total absence of lesion in the joints ; but the pericarditis offers the same anato- mical lesions, as if it had been induced by exposure to cold, or injury, or some other ordinary cause. The affection of the joints depends so much on a nervous cause, that it presents very slight traces of inflammation. It seldom or never terminates in suppuration, or the other usual terminations of inflammation. Dr. Chomel states, that pus is not found in rheumatic joints; the very rare cases in which it is met with, he considers to be mere accidental complications. This opinion, if somewhat modified, is probably the correct one ; that is, rheumatic, differs from ordinary inflam- raation in the absence of pus, and its want of fixedness of position ; but ordinary local inflammation raay ensue and constitute a complication. Not so with the accompanying internal inflammations ; they result in the secretion of pus, and effusion of lymph, and are fixed in their location. If the pathology of the disease is obscure, equally so is the therapeutics, it being more than doubtful whether we possess any settled or absolute method of treatment. This subject is very clear, no doubt, to some authors ; but, unfortunately, practitioners generally are in the dark. Thus 632 GERHARD'S CLINICAL LECTURES. Bouillaud, who regards the affection as merely inflammatory, depletes to the utmost possible extent; and for this exaggerated depletory practice claims great success. His success may have been great, but others who have followed the practice, perhaps without the same enthusiastic confi- dence, have not been so fortunate. I have given the practice a very fair trial, with every disposition to see it succeed, and, although I have afforded relief by one or two moderate bleedings, if persisted in, the result was unfavourable ; if pericarditis were present, it was only partially re- lieved, while the rheumatic affection of the muscular substance of the heart often increased. Besides, the ulterior results of excessive blood-letting are generally mischievous. We thus merely return to the old practice of one or two bleedings at the commencement of the affection ; a practice, the utility of which is sanctioned by long experience. Another practice, originating, I believe, in New England, and recom- mended by Dr. Webb, of Providence, is that which has been followed in the present case—consisting in the administration of very large doses of opium. I have tried it in two cases, in both of which it failed. It succeeded in stupifying the patient, and rendered him less sensible of pain, but produced no decided impression on the disease. It did not prevent the change of place, nor did it remove the pain or swelling. These symptoms persisted, and retained their usual mutability of cha- racter. Last summer, I pushed the remedy to such an extent as to induce decided narcotism, yet I failed to cut short the disease. The remedy may occasionally obtain the success which is claimed for it, but it is clearly no specific. Sudorifics constitute the treatment adopted by some, from a notion that artificial sweating is but an imitation of the curative process of nature. This is certainly not the case ; for the sweating is often profuse, while the violence of the disease is persisting. If, however, the discharge be sup- pressed, from cold or any other cause, it will be proper to resort to sudo- rifics, to revive this natural secretion, and restore to the patient what he has been deprived of; for in such cases the suppression of sweat is cer- tainly productive of harm, and increases the suffering of the patient. Other remedies have been recommended, as narcotics and purgatives, particularly the colchicum, and, what is analogous to it, the veratria. The colchicum is used in this country and in England, but it is not much employed in France. It is very useful as a palliative, though far from being absolutely curative. I have seen it stop the severer symptoms of the disease, for as much as five or six successive days, without curing the disorder. I often use it at the hospital without other medicines, pre- ferring, as I do, the administration of simple remedies, particularly in hospital practice, to insure their accuracy of administration, and to enable us to judge of their effects. By giving the wine of the roots or seeds, alone, we may avoid the severe purgation resulting from Scudamore's mixture; but purging may be of service, if the patient can readily bear the motion necessary for the evacuation of the bowTels. But the disad- vantage attending frequent rising is apt to more than destroy the good arising frora the revulsive effects of the purging. In medicine, as well as in surgery, inflamed parts must be kept at rest. In general, however, it is better to combine the colchicum with some opiate, as laudanum or black drop ; in doses of half a drachm of the wine of the seeds, or even more if tolerated by the patient, and ten to twenty ACUTE RHEUMATISM. 633 drops of laudanum every two, three, or four hours. The preparations of colchicum are so irregular in strength that it is very difficult to state these with precision. A slight impression upon the stomach and bowels is the best guide. These views, as to the effects of remedial agents in rheumatism, differ but little from those of Dr. Chorael, who, perhaps, has raore than a due share of skepticism in relation to therapeutics. It is true, however, that when diseases, after running a certain course, get well of themselves, they are apt to deceive us as to the value of the remedies employed in treating them. This, I think, is the case with Drs. Bouillaud and Webb. For the opinions of the former of these physicians on this subject, I refer you to Bell's Select Medical Library (1837); and for Dr. Webb's, to the Boston Medical and Surgical Journal, for last year. I am not disposed to enter into a history of all the different forms of treatment which have been recommended in rheumatism. Of external applications, cups to the spine, as a counter-irritant, is a most valuable palliative ; and, if the neuralgic element of the disease predominate, cupping along the spine will sometimes produce a real arrest of rheuma- tism. But when the joints are the principal seat of the disease, in most cases much is not to be expected from cups or leeches to the spine ; they do better near the joints. Other applications to the parts are directed for the benefit of moisture and warmth. For this purpose, anodyne poultices are useful ; none is better than one of hops, steeped in hot water, or vinegar and water, sprinkled with a little laudanum. These are very convenient applications, but cannot be accommodated to all the joints. Opiate frictions may be used, such as a mixture of warm oil and laudanum. I refrain from lead-water, or spirituous, or other stimulating embrocations, as the danger of the internal affection, endocarditis, or pericarditis, is somewhat increased by driving the affection from the joint. This prac- tice must be reserved for the sub-acute variety of the disease. Other local applications of a soothing character may be resorted to, such as the experience of every practitioner will suggest. In the North, there are other remedies, the virtues of which are much extolled, such as the green hellebore, actaea racemosa, &c. These plants have been tried here, but without the success which is claimed for them. This want of success may depend on our obtaining them only in the dry state, in which their virtues are impaired. But I cannot believe that this is the sole cause of failure ; for the most decided action of the remedies will some- times be produced without curing the rheumatism. Though not immediately dangerous, few affections are ultimately more mischievous than acute rheumatism. Diseases of the heart are so apt to originate with it, and to continue after its cessation, that we must hail any plan of treatment likely to exercise a curative influence over it. I have therefore tested the opiate practice, as the last which has been recom- mended, watching very carefully its effects. I certainly pushed it as far as was prudent ; I was not warranted in giving more than one grain every two hours, particularly as I could not see the patient after each dose, a precaution which is always advisable when giving high doses of opium. In other cases of the disease, I am willing to try other modes of treat- ment which are highly recommended, although I fear that they are all merely palliative, and as such only may do good ; at last, we raay find 634 GERHARD'S CLINICAL LECTURES. some one more efficacious than the others. I am doubtful as to the im- mediate success, though strong in hope. I cannot help agreeing with Chomel, skeptical as he is generally, in believing inflammatory rheuma- tism an affection not to be cut short by remedies, after having seen so much protracted suffering from it; even in the case of physicians them- selves, treated under the most favourable circumstances, it has been pro- longed to four or five weeks and upwards. What is the natural duration of acute rheuraatism ? It is not precisely fixed, but is scarcely ever less than two weeks, and may last for five or six months ; at least, the immediate effects may continue so long. Like most diseases that run a determined course, it averages two or three weeks. Although I do not believe that in most cases it can be suddenly cut short after the pain and swelling of the joints are considerable, yet an ap- propriate treatment is useful as a palliative, and diminishes the mischie- vous results. In a few words, the treatment which I would recommend consists in one or two general bleedings, opiates combined with tartarized antimony or colchicum, and if the pain be very severe, local depletion is useful for those joints which are nearly in the state of ordinary acute or chronic inflammation. Purging and other remedies are directed when specially indicated. This of course is a mere outline of treatment, which requires frequent modification. Of the second patient whom I mentioned, my time will allow me to say little or nothing. He offers signs of disease of the heart different from those of the last, chronic dilatation and slight hypertrophy, without dis- ease of the valves, the sounds not being at all roughened. There is effu- sion into the pericardium, indicated by increased dulness on percussion. Further details I reserve for another occasion. LECTURE II. Continuation of acute rheumatism—Rubeola, or measles, in adults and children—Symptoms —Complications—Treatment. I will again call your attention to the case of the man Robb, who was under notice as subject to acute articular rheumatism. The opiate prac- tice had been carried out with decided but gradual improvement. Yes- terday, however, there was a return of the affection, but under a much less severe type, marking the stage following the acute form of the disease, in which the symptoms are swelling and mere soreness, rather than pain or heat. With the reappearance of the affection in this modified shape, the impulse of the heart, which had been increasing, has been for two days much diminished. There is at present an effusion of about a pint of liquid into the pericardium. The dulness on percussion is so manifest as to leave no doubt of this fact. It is not frora the siraple presence of unusual dulness, that we draw our conclusion, but because we have seen this dulness notably increase, from day to day, since the patient has been under inspection. A prominence of the chest over the region of the heart has also appeared, in a marked raanner, during this time. Another proof MEASLES. 635 of the effusion is the absence of the impulse of the heart, which is next to nothing. You recollect the roughness of the two sounds of the heart, par- ticularly the first; this roughness has diminished as effusion has gone on. In proportion, then, as the pericarditis advanced towards secretion, have the signs of endocarditis become less evident. This fact, which exem- plifies a general rule of pathology, is worth recollecting. Of pericarditis the physical signs are, mainly, the increase of prominence and dulness, with faintness of the impulse of the heart, while endocarditis is to be re- cognised by increased action of the organ, and the roughened sound, sometimes amounting to that termed rasping. The physical signs of these two affections, particularly of pericarditis, are exceedingly easy of recog- nition, so much so, that, knowing what they are, you will hardly fail to detect them. The two diseases are not likely, I have told you, to exist together under an equally severe type. The same thing is true of pleu- risy and pneumonia ; they may coexist, but very severe pleurisy and pneumonia do not go together. If, for example, the pleurisy be aggra- vated by the compression of the lung, it impedes the development of acute inflammation. The law of pathology, founded on the twTo cases I have adduced, you will find generally to hold good. I shall here con- clude my remarks on the case of rheumatism : the opiate practice was continued till yesterday, when it was modified by the substitution of a single dose of Dover's powder at night, in place of the opium pills. It is my intention in this course of lectures, gentlemen, to take up the various acute diseases in succession, as they come before our notice, at the hospital, preserving, as far as possible, the natural connection amongst them. A very unusual affection in general hospital practice has lately claimed your attention, I mean rubeola. To see it pervading epidemically the wards of adults is a phenomenon which I have never before witnessed, and hardly expect again to observe ; as it is a disease which usually ap- pears but once during life, and is generally confined to childhood. Dur- ing the last six weeks, however, there have been as many as seven or eight cases in my single service, and three or four in the other wards. My recent cases were as follows : Morris, a man of nearly forty ; Perry, a lad of eighteen, and three others of nearly the same age. Previous to detailing the symptoms which characterize rubeola, I shall make a few remarks on its pathology. The pathology of measles, like that of other exanthematous affections, is to be divided into two parts, one comprising the morbid changes in the body, which are characteristic of and essential to the disease, the other being those which are merely accidental. The first are of course to be looked on as pathognomonic. The description of the affection given by Sydenham is so good, and agrees so accurately with its appearance at the present day, that I shall read it to you at length, and adopt it, in most particulars, in preference to modern accounts. It cannot be amended materially, except by exa- mining the symptoms with the aid of the numerical method ; a task which, at present, I am not able to undertake.* This excellent description of Sydenham's shows his powers of observa- tion in favourable contrast with some of modern times. His general account of the disease holds good in the cases which we observed at the hospital. Thus, our symptoras of the first day, like his, were chilliness ♦ It was then read. 636 GERHARD'S CLINICAL LECTURES. and cold shiverings. The second day we had the catarrhal symptoms, connected with coryza and the flow of tears, as described by Sydenham. This is the best sign to distinguish measles in its incipient stage from other exanthemata. In this stage, the other exanthematous affections offer no mark by which they can be diagnosticated with any certainty. They have, at this time, numerous symptoras in common, including some belonging to other febrile diseases. Thus, in scarlatina, the sore throat is by no means sufficiently characteristic, and small-pox may, at its com- mencement, be very readily mistaken for typhoid fever. Dr. Louis, who certainly is most accurately familiar with typhoid fever, has more than once mistaken for it the incubation of small-pox. The symptoms that follow7, as the sick stomach, loss of appetite, slight cough, heaviness of the head and eyes, occur now just as they did in the time of Sydenham. The only irregularity in Sydenham's description consists in the large red wheals, which have not, in our cases, made their appearance, nor have I often observed them. The swelling of the eyelids continues the same. The vomiting occurs particularly in children, and not in adults ; we did not notice it in these cases. Looseness of the bowels is the next symptom mentioned. This is not now a constant symptom in the early stages of measles, but it is to be recollected, that the descriptive account of the disease by Sydenham has reference to an epidemic which took place in 1670. The diarrhoea I set down as an accidental symptom, and, as such, it probably complicated the epidemic of that year, just as it does in our time those of other seasons. We next pass to his description of the eruption, which he characterizes most accurately. We have it now, as then, appearing first in the form of red spots, resembling flea-bites, which gradually coalesce into semicircu- lar, crescentic, and circular shapes, showing themselves first on the face, and spreading thence over the rest of the body. As the eruption in- creases, there is a diminution of the other symptoms. The eruption is found in the mouth and throat, as well as on the skin. In the case of negroes, it is of course detected only in the eyes and throat. In the pha- rynx and palate, as elsewhere, the eruption is not so much elevated above the epithelium, as it is above the surface of the skin. The next part of the description is doubtful—that is, the mode of disappearance of the eruption. It does not totally disappear on the eighth or ninth day, as alleged by Sydenham, for traces of it remain for some time afterwards, in copper-coloured spots, as shown in the cases in our wards; even after the spots entirely disappear the skin remains rough and dry. I do not at this time intend to go more largely into the ordinary symptoms of measles, for I can scarcely add any thing to the graphic description which I have read to you from Sydenham. While at Paris, and at the Hopital des Enfans Malades, I collected a mass of observations on this subject; but not yet having been able to analyze them, I must defer presenting them to you to some future time. I shall now call your attention to two of the accidental symptoms which may complicate the regular course of measles, and often become the sources of great danger. The first is bronchitis of a severe character. A slight bronchitis may be looked upon as a necessary symptom of the disease ; it is to be deemed accidental when it appears under an aggravated type, or when the inflam- mation runs into the parenchyma of the lungs, and takes on the form of lobular pneumonia, which is similar to the pneumonia following the bron- MEASLES —COMPLICATIONS. 637 chitis of young children. This accidental symptom occurred in the man Morris, whom you recollect in the first ward, about the eighth or ninth day, when the eruption was fading, and our attention was directed to the development of moist rhonchi on the right side of the chest, showing the existence of severe bronchitis, with considerable dulness on the middle and posterior part, and some on the anterior region of the left side—a common seat of lobular pneumonia in measles. Instead of getting well, the man has remained ill, exemplifying the general rule, that, when lobu- lar pneumonia is developed, after the subsidence of the eruption, it lasts for a considerable length of time. The signs by which its appearance is to be detected, are dulness on percussion, with a sub-crepitant rhonchus, and a slightly bronchial respiration. In place of attacking the mass of the lung, and rendering it solid, the inflammation appears in the isolated lobules, leaving among them portions of the lung still permeable to the air, which prevent the development of loud bronchial respiration. The respiration, in the very early stages of the disorder, and in the portion of the lungs which is not inflamed, is not lost, but rendered louder, and roughened. In the case of the boy Perry, the pneumonia appeared on the eleventh day of the disease, after the eruption had entirely subsided, no traces of it being left but a few copper-coloured spots. His right lung was attacked, as is commonly the case ; perhaps, from its greater size, and from the cir- cumstances of the patient's lying upon the right side. The lower, and not the middle and"upper lobes, was attacked ; in this respect as well as in others, it is like ordinary pneumonia, but differs from it in the loudness and looseness of the crepitus, which ceases in regular inflammatory pneu- monia as soon as the entire substance of the lungs becomes solidified. In the boy's case, as in that of Morris, convalescence has been very slowly established, and is yet by no means perfect ; he is still lingering in a somewhat critical condition. In the case of Morris, I entertained, for a time, some fear of the existence of tubercles, the development of which is thought to follow attacks of measles : I say, is thought, for I am by no means certain that there is any necessary connection between the two affections. The treatment proper to meet this complication of measles is neces- sarily various. At the Hopital des Enfans Malades, during my residence, local depletion by cups and leeches was largely employed by Dr. Guersent. But the debility, consequent on this mode of treatment, was favourable to the reproduction of the disease in other parts of the lungs, especially as the pneumonia was observed almost invariably in children of feeble constitu- tion. The proper rule for the employment of bleeding leeches, is to confine them to cases in which there is excessive dyspnoea, and a rapid extension of the pneumonia is going on. It extends through the lung most rapidly, in stout, robust children, and in them leeching does good. In the ordinary lobular pneumonia, as well as in that which follows measles, after one or two cuppings, the best treatment consists in small doses of ipecacuanha. By persevering with this remedy, until the expec- toration, or rather the secretion (for with children there is no expectora- tion, as they swallow the discharge), is freer, the patient is relieved, and we raay then complete the cure, by the exhibition of tonics and a generous diet. Above all, attention is to be directed to position. If the child he constantly on its back, the development of pneumonia is almost certain. 638 GERHARD'S CLINICAL LECTURES. It must, therefore, be moved frequently from one side to the other, and be from time to time raised in bed or carried about. In addition to ipecacuanha in expectorant doses, the sulphate of quinine and some pre- paration of iron, in small quantities, may be given, combined with a generous diet, if the child should become feeble, and the quantity of red blood should diminish. You will find, that in my lectures, gentlemen, I am not at all disposed to insist on too rigid a diet. I have seen so much mischief result from the continued enforcement of a rigid diet, in accord- ance with the mode of practice which was prevalent in France a few years ago, that it is with great caution, and no little reluctance, that I ven- ture upon it, except for a short period. In some of the wards of the Enfans Malades, the practice was to place the children on a rigid diet, and the results were certainly far from favourable. In the cases under notice, by pursuing the practice indicated, we have, in a great measure, succeeded in getting rid of the accidental symptoms. But there is still some cough, and other traces of lingering bronchitis. What is now the proper treatment ? It should be principally hygienic. The patients are to go freely into the open air, taking internally, at the same time, some of the milder tonics. The next accidental symptom, likely to complicate the course of measles, is severe diarrhoea, near to the close or after the termination of the disease. At the Enfans Malades, the children died in two ways when measles proved fatal,—of lobular pneumonia, during the active period of the affection, and of diarrhoea, at the end of it. The lobular pneumonia usually showed itself about the sixth day, the bronchitis appearing much earlier ; but the diarrhoea does not usually come on until the eruption is almost over and desquamation wTas taking place. If this diarrhoea be but slight, no danger need be apprehended from it, and we rather avoid much interference with it. Indeed, it is generally looked upon as a safeguard to the child, and is, therefore, suffered to run on. But I do not consider the diarrhoea as slight and not to be checked, if it exceed four, five, or six stools during the day, and continue until it is accompanied by emacia- tion of the child, with paleness and dryness of skin. This variety of con- secutive diarrhoea depends comraonly upon a particular state of the mucous membranes, in which they are pale and soft, seeming to be acted on by .the altered fluids in the body, and instead of being themselves the seat of very active disease. I showed you the other day, at an autopsy, a similar state of the mucous membrane, but occurring in the stomach ; in this case, however, it was probably produced by the action of the fluids after death. This state of the mucous membranes, as it occurs in measles, I do not regard as an effect of inflammation, nor is it to be treated as such. Depletion, of any sort, here does no good, nor do remedies specially directed to the bowels always prove of much service. You must act on the skin until its functions are restored, and for this purpose nothing is better than the sulphur bath, made by dissolving the sulphuret of potassa in water. I have seen children recover, at the Enfans Malades, under this treatment with astonishing rapidity. It not only relieves the particular symptom to which it is addressed, but much improves the general con- dition of the patient. Indeed, it was remarked by Jadelot, that the sarae remedy, employed for the management of itch, not only cured that affec- tion, but besides left the patient in a general state of health and embon- point. If the sulphur bath cannot be administered, one of warm salt MEASLES —DIARRHOEA. 639 water may be substituted. In addition to this treatment, adapted to the skin, slight opiates may be resorted to, with small doses of ipecacuanha, and astringents, which are supposed by some to act chemically upon the bowels. But depletion, by leeches or cups, must be abstained from, and the diet should be nutritious, but of a nature to leave little residue for the colon. The last variety of accidental lesion which occurs during measles is acute diarrhoea during the height of the affection. This complication I have not witnessed during the epidemic at the hospital, though it wras a very frequent occurrence at the Enfans Malades, in 1832, which was just before the cessation of the Asiatic cholera at Paris. That epidemic of measles was probably similar in its character to one described by Syden- ham. The disorder is dependent on acute inflammation of the colon, and shows itself at the most intense period of the eruption ; it is attended, generally, with the usual symptoms of dysentery, considerable pain, stools small in quantity, containing slime, sometimes patches of false membrane, and blood ; in fact, we have a regular attack of acute dysentery, compli- cating the measles. The complication is, I believe, most apt to occur in the summer months of the year. That is, measles are subject to the general rule of pathology, which determines the nature of the accidental symptoms attending self-limited diseases. Thus, in the typhus fever which was epidemic here during 1836 and part of 1837, we had, during the winter, symptoras of the acute affection most usual in winter, as those of the chest, and, in summer, it was complicated with diseases which are endemic in hot weather, as dysentery and disorders of the alimentary canal. Neither of these accidental affections was in any manner a neces- sary accompaniment to the typhus. The complications of measles follow the same rule, except that both the inflammations of the lungs and the bowels are more frequent than in typhus fever; we have, in other words, very generally lobular pneumonia occurring in the measles of winter and early spring, and affections of the alimentary canal when the epidemic takes place in the summer months, particularly July and August. The post-mortem appearances, in this affection, differ from those of ordinary diarrhoea. If closely examined, the colon and rectum are found to be covered with patches of lymph, and their mucous membrane is much disorganised, and of a violet tint, as in severe dysentery. So uni- versal were these appearances on dissection, during the epidemic at the Enfans Malades, to which I have just alluded, that a gentleman, who was observing it, thought that he had discovered a new law of pathology, and that there was a constant connection between rubeola and inflamma- tion of the colon. He was, however, mistaken, and from his error we may see the importance of observing with care the phenomena of several epidemics, and of again and again repeating these observations, before we allow ourselves to make from them any general deductions. The treatment at the Enfans Malades for the dysenteric symptoms was the same that is employed in ordinary dysentery. It was attended with no great success, but it must be remembered that severe dysentery is at all times a difficult affection to treat. The remedies, however, should certainly be the same when dysentery forms the complication of which we have been speaking as in the common variety where it is the primary dis- order. In the early stage we must have recourse to antiphlogistics, used with some freedom, by leeches and cups to the region of the colon and 640 GERHARD'S CLINICAL LECTURES. the anus. The dysentery differs essentially, as I have before said, from the diarrhoea occurring at the close of measles, and we have no fears here about the propriety of an energetic antiphlogistic treatment ; it affords prompt and great relief. We may afterwards administer opiates in very small quantities, and moderate doses of ipecacuanha. Calomel is so rarely employed in France, that I never saw it prescribed in those cases, and have not been able to test its efficacy in this affection frequently enough to speak of the advantages of using it. The after-management of the dysentery of measles is also much the same as of common dysentery, except that the former will be found to be of greater obstinacy than the latter usually is. From these details, then, we deduce the following corollary. In mea- sles, as in other diseases of known duration, we have one constant set of symptoms, as the eruption, and febrile movement with anorexia, thirst, restlessness, &c.; and next, a series of accidental symptoms, which ex- tend from the slight bronchitis, necessary to the affection, to severe bron- chitis and lobular pneumonia, and from the slight attendant diarrhoea, to diarrhoea of the subacute form, and severe inflammatory dysentery. It is to these accidental symptoms that you are to pay particular attention ; and by doing so, I am persuaded you will much diminish the mortality of measles, which depends, as in typhus fever and small-pox, mainly on the severity of the accidental complications. There remain to be noticed some varieties of measles, not observed here in the late epidemic. The first variety occurs in the other exanthe- mata, and consists in an imperfect development of the eruption. This is not so frequent in measles as in scarlatina ; but we have occasionally coryza, a flow of water frora the eyes, and cough, with but a very slight eruption, or one that is confined to the face. This is still a genuine, al- though an anomalous form of measles. The second variety consists in the severe complication of internal in- flammation with the eruption, which disappears soon after the beginning of the disease, and may be looked upon as suppressed. You then have universal bronchitis, the whole mucous membrane being affected with in- flammation of an intense character, instead of the usual slight blush. We have then a grave internal affection, occasioned by the want of action on the surface of the body, the disease being, as it were, concentrated in the internal organs. This variety is always attended with great danger. It is to be treated by active counter-irritation of the skin, to supply the place of the absent eruption : for this purpose, sinapisms, the warm bath, and ihe like remedies are to be resorted to. 'fhe third variety is the black measles, or rubeola nigra. This is not a real variety. It occurs in feeble children, in whom the blood is in a dis- solved state, as from scurvy ; or it may depend on the sudden develop- ment of lobular pneumonia, preventing the proper decarbonization of the blood in the lungs, and giving it a general dark tint. These varieties are almost the only ones that you will meet with in practice, and on which it is therefore proper to dwell. Rubeola sine catarrho I have never seen—I scarcely believe in its existence. Some change in the bronchial raucous membrane is always to be detected ; there is a dry rhonchus indicating a thickening of it, or we have at least some traces, of a moist secretion. Cough is not a necessary attendant upon a slight bronchitis, and it is impossible to decide with certainty upon its SEROUS MEMBRANES. 641 non-existence without a very careful examination, and I suspect it is the absence of close observation that has given rise to the variety of rubeola sine catarrho. I have presented to you to-day but few clinical illustrations, as I was desirous of giving you a somewhat detailed descriptive notice of measles, a disease of frequent occurrence, and which now prevails epidemically. I have insisted particularly upon the importance of the accidental symp- toms which are most frequent, for although other organs, as the brain and the windpipe, are sometimes the seat of grave lesions, they are not usually so much affected as the thoracic and abdominal viscera. There is an- other complication which is not rare in some epidemics, that is, the gan- grenous sore mouth of children, of which I shall treat at a future time. Measles is perhaps a more frequent cause of after ill health than any of the other exanthemata. The bad effects of small-pox and scarlatina are usually confined to the course of the disease ; they destroy life at this period or soon after. But measles, though less dangerous during the eruption, may leave behind it greater organic lesions than either of the others. The effects of lobular pneumonia and diarrhoea are not easily got rid of; and, after a supposed convalescence from measles, we but too often see our little patients wasting away from emaciation, and after a lapse of a few months, perishing from the consequence of one or other of these dangerous complications, or from tubercles in the lungs, the lym- phatic glands, or the follicles of the intestines. LECTURE III. Inflammations of serous membranes—Pathological anatomy—General symptoms—Pleurisy— Tuberculous peritonitis, &c. In my lectures on pathological anatomy I have already pointed out to you the distinctive characters of the inflammations of the serous membranes. As you, no doubt, remember, these characters consist in the bright arte- rial injection of the membrane, and the secretion ^ito its cavity of lymph, serum and pus. The lymph is secreted very early ; I once detected it in a case of pneumothorax which proved fatal in an hour after the perfora- tion : at first it is secreted in the form of minute points scattered thickly over the inflamed surface ; as these points become more numerous, they gradually run together, until the whole surface is covered by a tolerably uniform coating of lymph, which is then called a false membrane. Por- tions of the lymph are afterwards detected in flakes interspersed through the serum. The liquid consists chiefly of serum, which is slightly turbid from the admixture of lymph, and of a small portion of pus, which gives it a yellowish tinge. The pus is not abundant in acute inflammations, and in subjects of a feeble constitution is scarcely perceptible ; but when the inflammation becomes chronic the proportion of pus gradually becomes more considerable, until it at last forms the whole of the liquid. It is then called an empyema when formed in the pleura. The manner in which the gradual absorption of the liquid occurs, and the two surfaces of lymph become organised, and finally adhere together, 42 642 GERHARD'S CLINICAL LECTURES. must also have become so familiar to you as to require no further descrip- tion at present. Serous inflammations may be either primary or secondary. When secondary, they are usually dependent, first, on the previous existence of inflammatory rheumatism, secondly, on disease of the organs which they invest, and thirdly, on the existence of a tuberculous diathesis. I shall not now dwell upon the rheumatic causes of serous inflammation, as I entered into this subject, at a former lecture, when speaking of a case of acute articular rheumatism in which pericarditis occurred. Its connec- tion, too, with disease of the parenchymatous tissues covered by serous membranes, we shall discuss at length, on some future occasion, when we may see that inflammation of the lungs, liver, that, in fact, every lesion of an organ, gives rise to more or less inflammation of its serous covering. This process is an effort of nature to isolate and protect the diseased organ. The third cause of serous inflammation, that is, the existence of a tubercular diathesis, is the most complicated, and presents the most numerous points for examination : into some of these we shall enter in the present lecture. The connection between serous inflammation and tubercles is the more important, from its enabling us to recognise a num- ber of tubercular cases, otherwise obscure, by reasoning upon the law of pathology, that tubercles are so often connected with inflammation of these membranes. In addition to those above mentioned, there may be other causes of secondary serous inflammation ; they may be mechanical, as perforations, outward violence by blows, and the like, and the influence of cold which may be felt in the membrane surrounding the joints, intestines, lungs and heart, producing a primary inflamraation. That secondary serous inflammations are not of much more frequent occurrence than they are, is to me a matter of surprise, when I reflect upon the close connection of the organs with their serous investment; at all events, they are comparatively of * in ore importance than the primary forms, from their greater fatality. There are certain signs common to serous and other inflammations, by which they are generally ushered in. These are chill, fever, and sweating, with a general malaise, or feeling of wretchedness, loss of appetite, thirst, and in fact the ordinary febrile symptoms. They may, however, be entirely absent, and I have seen patients die of acute peritonitis without either fever, thirst, or severe pain. The pain accompanying serous inflam- mation is usually sufficiently indicative of its character. It may be said to be specific, being lancinating, sharp, acute, resembling such as would be inflicted by the stab of a knife. It is ordinarily described by patients in these terms ; it may, however, be so slight as not to confine the patient to bed, in fact, not severe enough to enable him to localize the disease. Patients often come into the ward, with the general febrile symptoms above mentioned, without local suffering enough to allow them to fix the particular seat of their disease. It is obvious, then, that we cannot trust to the character of pain, in determining the nature of the affection, but must resort to physical examination, the phenomena of which, resulting from the identity of the liquid secreted, will be always the sarae. There is, besides, a disordered action of the organ invested by the serous membrane ; in pericarditis, of the heart, in pleurisy, of the lungs, and in peritonitis, although not so distinctly marked as in other infiam- SEROUS MEMBRANES. 643 mations, there is generally sufficient evidence of disturbance in the action of the bowels. The state of the pulse is another sign, supposed to be especially cha- racteristic of this disease. But you recollect that, in the case of the man Robb, the pulse was merely moderately frequent, seventy-six per minute, notwithstanding the pericardium was inflamed ; and, in another patient, labouring also under intense serous inflammation, you noticed also that it was very nearly of the same frequency, that is, decidedly not febrile. The character of the pulse is, therefore, a faithless sign of the existence of serous inflammation ; it may be peculiar, small, wiry, and of intense activity, in which case bleeding is demanded without delay ; but these distinctive features are not always present. In the patient noticed to-day, the pleurisy wras nearly, though not entirely, latent. The woman, whose case was before you, had neither pain nor fever, although there was an effusion into the pleura of a quart and more in amount. The signs of this effusion were merely physical. This latent pleurisy is a common affection with old people, many of whom perish frora it, when supposed to die simply from the decay of old age. In young persons these diseases are not so often latent, except in a very chronic form, or where the patient has been exhausted by previous illness. An example of this was furnished by the case that terminated yesterday fatally at the hospital. It occurred in a patient who had been labouring under chronic peritonitis for a year previously, and who was taken about a week since with a slight increase of his ordinary pain, accompanied by severe prostration, which carried hira off in a few days. An exception to this rule, however, occurred at the Pennsylvania Hospital three years since in the case of a man who was run over upon the belly by a cart. He suffered but little pain, from the first day, and was afterwards suddenly carried off, although the only alarming symptom was extreme exhaus- tion. Very extensive peritonitis existed, but without pain, although the intestines were covered with lymph. You see, therefore, how difficult it is to recognise the presence of serous inflammations, from the functional signs which are presented. If we had no other means of examination, or if we omitted physical exploration, because there were no special symp- toms to arrest and direct our attention, we should be constantly in error. For example, it is a very common occurrence with labouring men, suf- fering from chronic effusions into the pleurae, to complain of pain, not in the region of the pleura, but lower down, in the flanks, whence they are sometimes treated merely for lumbago. In such cases, there is absolutely no rational symptom to indicate the nature of the disease and the proper mode of treatment: it is by the local signs only that the true character of the affection can be traced. The duration of serous inflammations is by no means fixed. It may be divided into two periods, the one including the time that passes during the increase of the effusion ; the other that during its stationary and declining stage. After effusion has taken place, it is not possible to cure the patient abruptly ; time is absolutely required for the consolidation of the false merabrane, and for the absorption of the pus and serum that have been secreted. In all acute inflammations of serous membranes, if you see the case only after effusion has taken place, you may safely predict that your patient will not be well, at least, for several days; and the rapidity of the recovery will depend upon the quantity of liquid which 644 GERHARD'S CLINICAL LECTURES. has been effused, and the time it has remained in the pleura. But, if you are called to a case, say of pleurisy, at the beginning of the attack, while there is merely slight inflamraation without much effusion, the patient may get well abruptly, and the morbid secretion may be limited to a little lymph, which is a necessary consequence of all serous inflam- mations. I do not intend now to enter at length into the peculiarities of treatment, nor into a detail of the physical signs, belonging to the varieties of serous inflammations, except so far as they may be exemplified by the cases which I shall bring before your notice. The remarks wThich I have just now made were necessary in order to make clear a number of cases, the histories of which I shall presently relate to you. You must bear in mind the distinction which I made between primary and secondary serous inflammations. The first of these is rarely fatal, except in the brain or heart; by interference, you may shorten its course, but you expect it to get well under any circumstances. Inflammations of this character depend merely on atmospheric vicissitudes or other such cause, and are not pre- ceded by a tubercular lesion, or connected with this diathesis, nor are they the result of a perforation, which is generally irremediable. When you have a secondary serous inflammation, you are to look upon it in most cases as an effort of nature for the preservation of the part; and when it is complicated with inflammation of the parenchyma of the organ which it invests, it is a curative and preservative process, and is not to be interfered with, unless it is of that severe character which endangers the life of the patient. The first illustration, which I shall bring before you to-day, is the ter- mination of the case of the man Robb. At the last lecture, I mentioned to you that the rheumatism was almost cured. The affection of the heart was then, and is still, persisting, although it is now chiefly limited to the internal membrane of the heart, and the symptoms are still so severe as to prevent the man's yet leaving his bed—a proof of the difficulty of sud- denly arresting diseases of this nature. These cases of serous inflamma- tion, occurring during an attack of rheumatism, generally assume a cha- racter altogether independent of the course of the latter affection : the great fire goes out, but the smaller burns slowly on. Not only, indeed, does this cardiac inflammation run its course, but it often leaves behind it'organic changes in the heart, that may last for a succession of years, or for life, in the form of thickening of the valves, or adhesion of the lamina? of the pericardium. Numerous cases of extensive disease of the heart take their origin in an attack of rheumatism ; they may, on the other hand, be of a slight character, and entail no greater disturbance of the economy than slight palpitations, and an inability to use the same amount of active exercise as in perfect health.* The next case I shall notice is somewhat curious ; it is pleurisy, oc- curring in a young Irish-woman, Isabella M'Gargee. In December, 1837, she was exposed to great fatigue, and suffered much mental anxiety dur- * This patient was perfectly cured by rest, some local depletion, and a blister: his cure was absolute, for three years after he was engaged in very laborious work without the slightest disagreeable feeling about the heart, or any abnormal sound. In most cases I use depletion more freely, but from the general aspect of this case I was induced to resort to bleeding of any kind in a very moderate degree, and the result was extremely favourable. It should be remem- bered that there wus little pain and no febrile excitement. These afforded the chief reasons for abstaining from much active treatment. PLEURISY. 645 ing the illness of a relative ; she was then taken ill wTith severe pain in the region of the heart, dyspnoea and palpitation ; for these symptoms she was bled and blistered with relief. Her health, however, was not entirely restored ; there was still palpitation, at times cough and some oppression. At the beginning of April, she worked very hard in a damp cellar, wash- ing clothes, and was seized, in a day or two afterwards, with fever and pain in the right side, extending from the breast towards the nipple, and much increased by respiration, or by the cough, which was short and dry, not frequent. There was also pain caused by lying on the affected side, with considerable oppression. The gradual increase of these symptoms obliged the patient to enter the hospital. There was no edema of the limbs, and but moderate palpitation ; there was no important previous treatment, and the patient was not strictly confined to her bed. We now inquire if the disease can here be recognised at the first glance, from the detail of symptoras gathered frora the patient. It cannot. Let us enter into an examination of the symptoms. In the first place, can the affection be neuralgia ? It has some points of resemblance with this dis- ease, but it differs from it in many particulars which are sufficiently well marked. First, it is not common for any considerable degree of cough to exist in neuralgia, nor have we in it a steady, local pain, as in the case described. Another set of symptoras, which establishes the difference between the two affections, is that belonging to the countenance, the medical physiognomy of the case. This is characteristic, not of neural- gia, but of an intense pectoral disturbance. Satisfying ourselves that it is not neuralgia, we make a general diag- nosis of an acute disease of the chest, first, from the severity of the dys- pnoea present, established by the spasmodic contraction of the chest and of the nostrils ; and, secondly, by the alteration in the colour of the coun- tenance, in the dark blue tinge of the lips and flush of the cheeks. This is not purple enough for the existence of pneumonia, and we, therefore, infer, that our case is, probably, one of bronchitis, pleurisy, or acute phthisis. Having carried our examination thus far, let us proceed to discriminate between'the affections, to which we have reduced the case. This can be done only by physical exploration, without which it is impossible to re- cognise with absolute certainty the distinctive features of the disease. What, then, are the physical signs which establish the character of the affection before us? First, we have an abnormal development of one side of the chest, at the lower part, and diminishing gradually in ascend- ing. This, at once, settles satisfactorily the nature of the affection ; it is a pleurisy. Had the development been confined to the anterior part of the chest, it might have been emphysema, or, had it been local, pericar- ditis ; but only a pleuritic effusion could have made it what it was. Next, we have immobility of the ribs : in the present case this could result only from pain, from distension, or from old adhesions. Ihe history of the case disproves the probability of the existence of old adhesions on the right side ; so that from the pain, then, we again deduce the presence of acute pleurisy. , . , Continuing the examination, we next proceed to percussion, which yielded the following results. There was flatness in the lower posterior half of the side of the thorax, and of the lower third on the anterior part; as well as of the lower half of the axilla. Thus far, we can diagnosticate, 646 GERHARD'S CLINICAL LECTURES. with certainty, the existence of pleurisy ; the flatness followed the line of gravity, or, in other words, corresponded with the situation of the liquid, which, following the ordinary laws of liquids, accumulated in the bottom of the chest, just as if it had been contained in a common bag. We continued the examination by auscultation. Had the disease been pneumonia, we should have had bronchial respiration and a dry crepitus. This was not the case, as the lung was quite permeable to the air, and not a hard, solid mass. There was no rhonchus, for there was no liquid in the bronchial tubes. The physical signs, then, have led us to a cer- tain conclusion as to the nature of the affection. In many cases of pleu- risy, when the lung is more condensed, we have, however, a bronchial respiration, but no crepitus, unless complicated with pneumonia. The next question that presents itself is, as to the primary or consecu- tive character of the disease. To solve this question we entered upon an examination by auscultation of the other side of the chest ; there was, here, no evidence of the existence of tubercles, in any great numbers, but, from the fact of there being some dulness on percussion, there was reason to suspect their presence, though not to determine it with any cer- tainty. Besides, from the circumstance of the mutability of the situation of the pain, as there had been, you know, a previous attack on the other side of the chest, the existence of tubercles was rendered probable. It is a law of pathology, that, if a pleurisy appear on one side of the chest, and some time afterwards showT itself on the other, it, in all likelihood, is de- pendent on the presence of tubercles. This law of the double pleurisy, as it is called, was discovered by Dr. Louis, and, in most cases, may be relied on with certainty. I infer, then, that, in this case, the pleurisy was probably tubercular. Besides the suspicion of tubercles as a predisposing cause of pleurisy, the patient is labouring under an undoubted disease of the heart. It began during the acute inflamraation of the early part of the winter, when the pericardium was involved at the same tirae with the pleura. As a con- sequence of that inflammation, we have hypertrophy and dilatation of the heart. The treatment of this patient has been active ; she was bled to sixteen ounces, was cupped, and has since taken tartarized antimony and digi- talis. Under these remedies, with rest and restricted diet, she is rapidly improving. The remedy here used, tartar emetic, is found to answer perfectly well in the management of pleurisy. It increases the sweating, and promotes absorption directly ; the digitalis has a similar action through the medium of the kidneys. In pleurisy, when the inflamraation is circumscribed, local depletion is the best treatment. This acts very promptly in serous inflammations, although it has but slight influence over the inflammations of parenchymatous structures. In the latter case relief is afforded only in proportion to the quantity of blood abstracted, while in pleurisy it is in proportion to the nearness of the point of abstraction to the seat of pain. The pain is relieved, also, by the application of warmth to the part, by poultices and fomentations. These, however, are not to be withdrawn suddenly, or without the substitution of a thick pad of carded cotton or wadding; otherwise they only do harm, by the alternation of heat and cold which takes place. The advantages of these local applications can- not be too highly estimated. I often rely more upon them than upon TREATMENT OF PLEURISY. 647 more powerful remedies, which, if they relieve pain, at the sarae time diminish the strength. The treatment of ordinary simple pleurisy is not a very complicated affair. And I would remark, that every case, in which there is no posi- tive evidence of a change in the functions of nutrition, even though there may be strong ground of suspicion of a tuberculous or other chronic dis- ease, is to be regarded in the treatment as a simple pleurisy. The treat- ment of Dr. Louis, which I do not, however, follow in all cases, consists in small bleedings, combined with the internal administration of tartar emetic, nitre, digitalis, and diuretics. Of sixty cases that I saw him treat, he lost not one. It may be inferred, that is an effectual plan of treatment for siraple pleurisy. I may add, that, in a siraple case, if effusion take place, you need not be very uneasy, if it is slow to absorb, provided the case is otherwise proceeding well. Of the remedies, by which chronic pleurisy is to be managed (meaning, by chronic pleurisy, cases of more than a month's duration), I shall not now treat in full, giving you merely a general summary of them. Blis- ters, which, in the early periods of acute pleurisy, are not often necessary, and do harm twice for once that they do good, are of signal service in chronic pleurisy, scarcely ever doing mischief, and often affecting a rapid absorption of the liquid effused. They are to be applied not once, but repeatedly. Under their influence, absorption sometimes takes place, with astonishing quickness : indeed, it seems, in a few instances, as if the fluid was directly poured out from the interior of the chest to the blistered surface by a sort of endosmosis. Mercurials, in small doses, are not much used by the French, either alone, or in combination with squills and digi- talis. But in cases approaching in character to hydrothorax, great ad- vantage will be derived from a treatment with calomel, squills, and digi- talis, or the simple action of the mercurials alone, either pushed to ptya- lism, or nearly so, will be found very powerful, both in the advanced stages of the acute and in nearly every period of chronic pleurisy. Even an obvious but slight tuberculous complication does not always forbid the use of mercury in these cases. In addition to treatment by medicines ; travelling, a sea voyage, distractions, a simple change of place, will be of much service. The importance of travelling is greatest in those cases in which we fear the complication of a tuberculous diathesis. Whether there be already formed tubercles in the lung, or merely the constitutional tendency to these affections, I am quite sure that by this means and by attention to other hygienic circumstances, patients are often preserved from a threatened consumption. In addition to the case illustrative of one of the most simple serous inflammations, I shall say a few words respecting another case, in which pleurisy occurred, as a well-marked complication. The case was one ot pneumonia, consecutive upon tubercles, the existence ot which was known by unequivocal signs at the upper part of the lung. I here was something, however, engrafted on the pneumonia. This was pleurisy, which was detected by a sign which often occurs in the latter stage of the affection and is then pathognomonic, the bruit de frottement a sound caused by the friction of the surfaces of the pleura, lined with false mem- brane upon each other. It resembles the sound produced by the rub- bing of leather or India rubber, and is the same grating sound that was heard over the heart of the man Robb, but in the present case it is pro- 648 GERHARD'S CLINICAL LECTURES. duced by respiration, and is synchronous with it. It is, also, fugitive in its character, and disappears when the membranes become consolidated. I shall conclude with one other case, which terminated fatally a few days since, demonstrative of One of the causes of serous inflammations, the details and phenomena of which will serve as a key for future inves- tigations. It was a case of chronic tubercular peritonitis. My reasons for this diagnosis were based upon the conformation of the abdomen, which was irregularly distended with gas, upon the existence of lanci- nating, griping pains, or alternations of costiveness and looseness of the bowels, and upon the pain caused by motion, or the distension consequent upon eating ; there was, besides, nausea and vomiting. The peritonitis occurred here without any obvious cause, and was, therefore, not primary. For there is a law of the economy that chronic peritonitis is nearly always, particularly in young persons, dependent on the presence of tubercles. In addition to this general law of pathology, the great alteration in the nutri- tive functions made the diagnosis of the development of tubercles much more certain. It was at first doubtful, from the large distension of the abdomen from serum ; but the water here was soon absorbed, and there was no recurrence of ascites. There was evidence also of tubercles in the lungs, although not very decidedly marked. Had there been no physical signs of phthisis the case would have been still positive, but we found a sufficient number of signs for the local diagnosis of tubercles. Most commonly, tubercles appear in the lungs of adults before they are deposited in other parts of the body ; but, in this instance, the applica- tion of this general law failed. The patient, some days before his death, was seized with sudden prostration, under which he rapidly sank, and with some increase of the abdominal pain. After death, the following appearances were discovered. There was effusion of serum and pus into the abdomen ; in the upper portion there was merely serum and lymph, and, in the lower, the intestines were agglutinated by false membranes perfectly organised, not vascular, but there was red injection in the upper part from a more recent inflamma- tion. The cause of this difference was perforation of the intestines from tuberculous ulceration of the glands of Peyer, two of which had ulcerated through all the coats of the intestine into the peritoneum. The pathology of these perforations is the following:—A tubercular follicle in the intes- tine enlarges and softens, and is discharged into the calibre of the gut. The ulcer left does not heal, and, passing into the chronic state, advances towrards the serous covering of the intestine, which is sometimes destroyed. The peritoneal inflammation is only an attempt of nature to preserve life by preventing the discharge of fecal matter into the peritoneum. It fails, because the mischief done is too considerable to admit of reparation. In the lungs, the only evidence of the presence of tubercles were half a dozen grey granulations, that could be felt, but scarcely seen ; while, in the peritoneum as well as in the intestines, they existed to such an extent as to cause disorganization. This disease is unusually rife among ne- groes ; indeed, it is sometimes called consumption of the negroes, in the southern parts of our country. It rarely attacks adult males, more com- monly females, and is very prevalent with children, in whom it forms one of the diseases known as tabes mesenterica, although the mesenteric glands are not invariably affected. To recapitulate my remarks of to-day :—Serous inflammations may ap- ACUTE INFLAMMATIONS OF THE HEART. 649 pear as primary and secondary. When primary, they are not dangerous, except in the brain ; but they are so when secondary, because compli- cated with some previous lesion, and occurring in exhausted subjects. They are to be treated, in both instances, on pretty much the same prin- ciples, by depletion, and acting on the skin with alteratives in the more chronic stages. If excessive pain exist, narcotics may be used to relieve it, with the topical applications you may see every day employed at the hospital. For the proper study of tubercular diseases, gentlemen, a knowledge of the pathology of serous membranes is indispensable. Previous, then, to entering upon the examination of the former affections, I have introduced the subject of serous inflammations to facilitate our future investigations. The study of tubercular diseases is not, as you have also seen, to be con- fined to the chest, but to be extended to all the organs of the body, as you will more fully learn at a later period. The tuberculous affection of the abdomen, which has been under con- sideration to-day, though not the most common form of the disease in our latitudes, is one of the most prevalent in southern climates, and is on that account the more interesting to many of you. LECTURE IV. Acute inflammations of the membranes of the heart—Pericarditis—Endocarditis.* During the past summer I have very frequently alluded to the inflamma- tions of the membranes of the heart. It has so happened that we have had a very unusual number of these diseases ; you have seen more cases of the kind within the past six months than I have observed within the last two or three years, and it is very improbable that you will again witness so many cases of these affections, in the same short space of time. The serous inflammations have been almost endemic in our city, and, if we except a moderate proportion of bowel affections, they have constituted the prevailing diseases of this period. It was for this reason that I commenced the course with acute rheuma- tism, and then passed on to the consideration of the serous inflammations so closely connected with it. Amongst these, the subject of the mem- branous inflammations of the heart was accidentally introduced ; but I did not then point out to you the numerous interesting questions arising from the study of these inflammations, which you will find of difficult diagnosis, unless you are thoroughly acquainted with their pathology and with the means of physical exploration. Without the aid of the physical signs of the disease, the inflammations of the heart cannot be recognised, except in a very small proportion of cases. You have had a recent illustration of this fact: a patient, whose case I shall presently detail you, has been evidently labouring under pericarditis of considerable intensity ; the effu- sion of lymph and serum occurred, as it were, under our own eyes, and you were able to trace the gradual consolidation of the lymph, when adhesions began to form between the two surfaces of the pericardium, yet the patient complained of no pain whatever in the chest, and no uneasiness * This lecture was given some months after the preceding. 650 GERHARD'S CLINICAL LECTURES. other than that caused by the rheumatic inflammation of the joints which preceded the pericarditis. In but two or three cases was the pain suffi- ciently considerable to induce us to suspect the occurrence of any affection of the heart; one of these cases, attended with pain and the best marked, was that of Robb, which I mentioned when speaking of inflammatory rheumatism. He suffered some pain, but it was usually inconsiderable, until his entire recovery. The other two were blacks, who wrere affected with inflammation of both membranes of the heart, and recovered, but died afterwards of a consecutive dropsy. These latter patients had reco- vered entirely of the cardiac affection, and, in all probability, would not have fallen victims to the dropsy had they not both laboured under a cancerous disease. When you examine more fully the history of the cases, you will find the other rational signs equally obscure ; I can affirm that the obscurity was not owing to a want of appreciation of these signs, for I examined the cases in your presence with the most scrupulous accuracy, and you can bear witness to the precautions taken to elicit every practicable symptom in the case. The inflammations of the heart are, therefore, to a great degree, latent, and you must commence their study, with the con- viction that their diagnosis is impossible, in a large proportion of cases, without a thorough knowledge of their pathology and a sufficient acquaint- ance with the physical signs of disease. But if this knowledge be possess- ed, and some of you have already attained it, there is no part of medicine more perfectly demonstrative in its character, or which is governed by more unvarying laws, as to the progress and termination of these diseases. I will now relate to you some of these cases, and we can compare them together to ascertain how far these remarks are confirmed or invali- dated by your own observation. At all events you have been eye-witnesses of the facts which I detail to you, and the circumstances of the cases will, therefore, be more completely impressed upon your mind, and will carry with them a force of conviction and a clearness of detail, which could never result from a purely didactic lecture. The first case I shall give you is that of a patient, now convalescing in our wards from pericarditis, nearly uncomplicated with inflamraation of the internal membrane of the heart. It occurred, as is most commonly the case, during an attack of acute inflammatory rheumatisra, and had just appeared when the patient came under your observation. The following symptoms were dictated in your presence:— " David Dargan, aged thirty-eight, a lime-burner, accustomed to drink freely, entered ray ward September the 2d. On the 28lh of August, after drinking rather more freely than usual, he was taken with convulsions and became slightly deranged ; he was bled, returned for a short tirae to consciousness, and again became incapable of recollection. On the 29th he was stupid and could answer no questions ; the stupor was unaccom- panied by distortion or active delirium. No muttering ; no return of convulsions. Digestive functions good. He was cupped freely to the nucha twice ; pediluvia were applied ; he took nitre and the effervescing mixture, and was purged. In two days he recovered his intellect, but not entirely his memory. Consciousness not quite perfect until the 2d. On his return to consciousness, he had pains in both legs, hands, and shoulders, with swelling. From the 1st to the 2d there was increase of pain and heat, and on the 2d, there was redness. No edema or palpitations. There was PERICARDITIS AND ENDOCARDITIS. 651 intense cephalalgia, which was relieved by cupping. For the last three or four years he had fluttering of the heart after exercise, and was short-breathed at the same time. This began after an illness of seven months' duration, the result of intermittent fever. He had rheumatism ten years ago, after being exposed to rain, and two or three times before, but merely local in the shoulders, not confining him to bed. He recollected no other illness, never had syphilis. At the beginning of the pains, on the 28th, had a severe chill, but none after. " His condition, on the 2d, wras as follows : swelling, heat, and pain in the ankles and feet; slight swelling of the knees ; and redness and swel- ling of the hands in nearly all the joints. Some pain, but no swelling, in both shoulders, but none-in the elbows. Pulse ninety, full, nearly regular. Tongue moist and natural. Appetite good; no nausea; stools regular. Skin generally warm, scarcely moist. Both sounds of the heart heard in the whole praecordial region, varying, but never perfectly natural. The first sound more or less roughened, the second heard distinctly, rather sharp : between the two, or rather at the commencement of the second, was heard a very evident bruit de frottement, wrhich could be detected over the whole praecordial region, but was most distinct over the left margin of the sternum, more marked in the erect than in the recumbent posture. Impulse of the heart increased and irregular. Percussion dull from the right margin of the sternum to the nipple, and from the fourth rib downwards. No pain, no dyspnoea, almost no cough, no uneasiness on percussion. Spinal tenderness from the seventh dorsal vertebra to the fifth cervical, more severe on the spine than on the adjoining parts. Cups were ordered to the whole length of the spine, with a sixth of a grain of tartar emetic and opium each, every twT0 hours, and low diet. " On the 3d, there was great alleviation of the rheumatic symptoras. No cough or pain across the chest; no palpitation. Creaking sound in the praecordial region more distinct than on the 2d, extending over the whole region, and synchronous with the diastole, varying in intensity and tone. Impulse of the heart diminished, more diffused. Sounds much less loud, and both heard distinctly, the first less rough than on the 2d. Prominence rather greater. Percussion dull to an inch and a half beyond the nipple, thence to right margin of the sternum. Respiration posteriorly, vesicular throughout the chest, resonance of the voice doubtful; opium and tartar emetic continued, twice the quantity of the former, with cups to the praecordia. " On the 4th the pain and swelling were rather less, but there was great weakness, which may have been owing to the tartar emetic. Other symptoms better. Eight ounces of blood had been taken from the chest, by the cups. Percussion now quite clear within the nipple, dulness extending nearly an inch and a quarter from mid-sternum. Sounds of the heart much louder, the first offering only a moderate bruit de soufflet; the second, near the point of the sternum almost replaced by a simple creaking sound, which prolonged itself also into the first, but less dis- tinctly ; heard all over the heart, less towards its left margin, very loud along its whole sternal region, at times giving a musical tone. When the patient was erect, the impulse of the heart was stronger, and the creaking more frequent, in fact converted into an incessant grating. Eight ounces of blood were again taken from the praecordia by cups, and the opium and tartar emetic continued. 652 GERHARD'S CLINICAL LECTURES. " On the 5th, the pain was less severe in the hands, more so in the shoulders and muscular parts of the arms ; soreness in the muscles of the thighs, less in the feet ; increase of swelling and puffiness in the knees, but not of pain and swelling. No spinal tenderness, cough, or oppres- sion ; sleep disturbed by pain ; prominence greater than yesterday ; per- cussion clear, however, except for an inch and a half at the point of the sternum ; impulse of the heart greater, clearer, sharper ; first sound dimi- nished, grating much less distinct, heard chiefly at the point of the sternum. On sitting up, the action of the heart was stronger, the grating much more distinct, heard under the same circumstances as before ; three stools since last evening ; when he took half a grain of ipecacuanha and five grains of Dover's powder, twice. To-day, five grains of Dover's powder, four times a-day, and cups to the spine. " On the 6th, no swelling in the knees, almost no soreness, less of both in the feet, none in the left hand, almost none in the right ; soreness and swelling in the shoulders not diminished ; no soreness of the back or breast. Pulse ninety-two, regular, and softer. Sweating profuse, no chilliness. First sound of the heart very short and faint. Second, loud, masked by the creaking sound. Percussion duller, to an inch wdthin the nipple ; impulse rather stronger. Cups between the shoulders, and Dover's powder continued. " On the 7th, countenance gay ; shoulders better; no swelling of the hands, almost no stiffness ; knees natural ; very slight swelling in the ankles, with a little pain in the right. No spinal tenderness. (Has been cupped four times ; twice to praecordia, eight ounces, each time ; twice to spine, six ounces ; twice cupped, before his entrance, to the nucha, seven ounces ; and had been bled from the arm.) Pulse quick, regular, ninety-five. No prominence in the praecordia. Percussion perfectly clear. Dulness very incomplete everywhere. Impulse of the heart more clear; first sound prolonged ; creaking in the second limited to the point of the sternum, disappearing when he rises. Sweating profuse, constant. Urine rather increased. No chills. Dover's powder continued ; hop poultice to the feet. " On the 8th, soreness almost ceased in the feet, a little effusion in the knees, but no increase of pain ; slight soreness in the points of both shoulders. Pulse one hundred and eight, thrilling, regular. Sweating continues. Impulse of the heart much stronger, first sound nearly natural, a little prolonged ; bruit du cuir so faint at the beginning of the second that it would have seemed doubtful, if not previously heard. Treatraent continued with cups between the shoulders. " On the 9th, has pain only in the knees and hips ; less in the shoul- ders since the cupping. Sweating, still continues. Pulse one hundred and two, quick, thrilling, and resisting. Appetite good ; no nausea ; three or four stools daily. Respiration now heard over the whole praecor- dial region ; impulse stronger, creaking quite decided in the second sound ; first still blowing, less than last evening, when the pulse rose ten to fifteen beats. Dry cups were applied to knees last evening with relief to the pain. Treatment continued. " On the 11th, no pain in the hands; some cephalalgia. Pupils a little contracted. Some wrinkling of forehead. Expression anxious. Pulse one hundred, full, thrilling, softer than yesterday. Slight subsul- tus ; talking in sleep, says he is accustomed to it when well; sweating PERICARDITIS AND ENDOCARDITIS. 653 continues ; five stools in the twenty-four hours ; legs restored to motion, almost no swelling ; stiffness of right shoulder and arm, including elbow ; slight of left ; feels no uneasiness in the chest ; a little soreness appa- rently in the pectoral muscle of both sides; first sound of the heart and impulse natural; creaking scarcely heard (has taken no medicine in the last twenty-four hours); four ounces of wine in whey, and an assafcetida plaster to the epigastrium. " 12th. Last evening, about seven o'clock, had more tremour, more subsultus, countenance the same ; took four ounces of the assafoetida- mixture, every two hours. Enema of twenty drops of laudanum. Slept well during the night, awoke once or twice only. Pulse ninety-six, full, soft; pains not increased. Soreness felt now only in the shoulder-joints. Bruit de soufflet. harsher than yesterday ; a little rasping, creaking, indis- tinct ; second sound very clear. Percussion nearly as before, a little less clear; assafcetida-mixture continued ; wine omitted ; full diet. " 13th. Muttering during sleep ; pain less ; two stools in twenty-four hours. Impulse of the heart louder and clearer; both sounds louder, particularly second, which is still a little blowing, still subsultus ; sweat- ing. Pulse ninety-two, feeble, regular; continue assafcetida. " 17th. Still has pain in legs and arms ; drowsiness constant : no sub- sultus ; intellect quite clear. Pulse one hundred, regular, small ; motion returned to every joint, but some stiffness in shoulders and knees ; sweat- ing abundant. Both sounds of heart heard ; creaking not ceased ; more diffuse, less loud. Dulness of percussion not increased. Chamomile tea. "18th. Sitting up; no pain except slight in shoulders and knees; sounds of heart natural, except slight creaking in second. Convalescence confirmed. " 19th. Perfectly free from pain, except when moving ; then suffers from soreness of limbs ; skin cool, pleasant; appetite good ; sounds of the heart clear; creaking barely perceptible. " 20th. Continues well ; remains a few days longer to confirm his con- valescence." When you examine the history and progress of this case, you will see upon what facts the diagnosis of pericarditis is based. We must then examine other cases which have terminated fatally, in order to test the correctness of the laws of diagnosis, which I shall lay down. We have, fortunately, lost no patient in the present course, during the continuance of the pericarditis ; but we shall be able to obtain the necessary evidence from an examination of those cases which terminated fatally of some acci- dental disease after the termination of the pericarditis, and we then can compare those cases with others that have terminated unfavourably at a previous period/ The signs of pericarditis in one patient varied according to the stage of the disease. During the period of effusion, which had already begun when the patient came under our observation, five or six days after the commencement of the rheumatism, we had the physical signs of pericar- ditis, which are clearly described by Dr. Louis. That is, flatness on per- cussion to a much greater extent and to a more considerable degree than occurs in a healthy subject, decided prominence of the praecordial re- gion, which was distended and raised up by the liquid, and dulness of the sounds of the heart with feebleness of impulse. Now, these signs * Some cases of this kind were then mentioned. 654 GERHARD'S CLINICAL LECTURES. become the more characteristic from their constant variation ; the quantity of liquid scarcely remained the same for two consecutive days, and you, therefore, found the signs of the disease to increase during the time that it augmented, while they diminished very rapidly when the pericarditis declined. Had the dulness and the prominence of the praecordial region been permanent, the case could still have been recognised, but there might have remained some room for doubt; for chronic enlargement of the heart, particularly if complicated with effusions of serum into the peri- cardium, resembles a case of pericarditis in most of its physical signs. The resemblance ceases when you watch the case for several consecutive days. There was another sign indicative of pericarditis, which also served to point out to you the variety and stage of the disease. It was the sound produced by the rubbing together of the two surfaces of the pericardium covered wTith lymph. This sound occurs during the systole and diastole of the heart, especially the latter; it was, therefore, most evident during the second sound of the heart which occurs during its dilatation. This new- sound was so loud as, in some measure, to conceal the natural second sound of the heart, which was, however, never entirely destroyed, but could always be detected by a practised ear, as it were, combined with the new adventitious sound. The second cardiac sound was not lost, be- cause it depends on valvular contraction, and the valves of the heart re- mained nearly in the normal state ; now, had the disease been complicated with much inflammation of the internal membrane, as was the case with the man Robb, to which I have previously alluded, the motion of the valves would no longer have remained free, and we should have found either that the second sound was altogether lost, or much changed from its natural character. The cause of the grating sound is nearly the same in inflammation of the pericardium and of the pleurae; that is, in both cases it arises from the friction of two surfaces of serous membranes raore or less coated with lymph ; it is not precisely similar in the two cases, because the quick action of the heart differs greatly from the slow gra- dual movement of the lungs in the act of respiration. The grating sound of pericarditis, therefore, is more sharp and quick, but less loud and pro- longed than that of pleurisy. It is useless to describe this sound to you, for you have heard it for yourselves, which answers better than any de- scription ; those who have not heard it, may readily distinguish it by its creaking, like the sound produced by rubbing together two pieces of moist leather, whence it has been sometimes called the " bruit de cuir," or leather sound ; a trivial name, which is by no means so expressive as that of rubbing or grating sound. It cannot be recognised by one not previously acquainted with the natural sounds of the heart, with which the slighter shades of this adventitious sound may be confounded. You could distinguish it readily in the present instance by a careful analysis of the sounds when you found that the sharp clear tone of the second sound was more or less obscured by this rasping sound extending over the whole anterior surface of the heart, especially at its middle portion. There is but little difficulty in distinguishing the grating sound of peri- carditis from the rasping sound caused by thickening or vegetations upon the valves ; the latter is more frequent in the Systole, is always heard most distinctly at the region of the valves, and is not attended with a sensation of grating, which is quite perceptible to the touch in most cases PERICARDITIS AND ENDOCARDITIS. 655 of pericarditis. WThen there is but little effusion the little grating sound is more important as a sign, for there is this very dulness on percussion and no prominence. As the lymph became consolidated, the grating sound gradually de- clined, but it has not yet disappeared, although the patient is now in full convalescence. Nor do you generally find that this sound will disappear quickly ; for, if the lymph form prominences on the surface of the heart, it may remain for several months, at least until it is so far absorbed as no longer to present rough projections for the grating of the two surfaces together. The sounds of the heart, properly so called, were both distinguishable throughout the whole of this case ; they were somewhat feeble, had lost a little of their natural clearness and seemed distant ; but neither of them was either very much changed, or had lost its due proportion. In simple pericarditis, you will find that this is usually the case. It is true, that the motion of the heart is never quite free, and its sounds do not retain their full development, but it is also true that the slight aberration from the normal sound which occurs in simple pericarditis, is very different frora the rasping or very rough bellowTs-sound heard in cases of endocarditis ; whether this latter disease be simple or merely a complication of the peri- carditis. You had a beautiful illustration of this distinction when you examined the case of the patient Robb, which was described when speak- ing of acute articular rheumatism. In him there was both endocarditis and pericarditis, and we had the distension and dulness of sound indica- tive of pericarditis, with the rough and harsh sound, caused by the thick- ening and consequent stiffness of the valves. The chain of proof of what I have just advanced is, with me, conclusive ; for I have seen cases of both endocarditis and pericarditis quite uncomplicated one with the other, and, therefore, well suited for studying the signs of these diseases in their simple state. I have again seen other cases in which the symptoms of one disease greatly predominated, without being perfectly unmixed one with the other. Some of these cases terminated fatally, and the examina- tion after death proved the correctness of the diagnosis. The most recent cases of heart disease of the kind to which I am now alluding, were fur- nished by two patients affected wTith pneumonia ; both died of the pneu- monia, which was aggravated by the disease of the heart, although this latter affection was not, in itself, sufficient to cause death ; and we could, therefore, test our diagnosis as applied to a membranous inflammation of the heart of moderate severity and in itself not fatal. The first case occurred in the last winter ; it began with laryngitis, attended by extreme prostration ; the patient was then attacked with pneumonia, of which he died. During the course of the pneumonia, the patient was taken with pericarditis ; there was a manifest dulness in the praecordial region, a slight prominence, and a distinct, though feeble creaking sound, chiefly heard during the dilatation of the heart. The sounds of the heart scarcely differed from the normal standard, although the impulse was somewhat feeble. As there was some obscurity in the case, the patient was, at my request, examined by my colleague, Dr. Pennock, who concurred with me in the diagnosis. The patient died, some days afterwards, from the pneumonia ; on the autopsy we found patches of false merabrane scattered over the surface of the pericardium, proving the existence of pericarditis. There was no liquid in the peri- 656 GERHARD'S CLINICAL LECTURES. cardium ; this again corresponded with the accuracy of the diagnosis, for, previously to the death of the patient, the pericarditis had evidently de- clined, and the dulness on percussion had been gradually replaced by the natural resonance. This case, which occurred during the course of the present winter, afforded conclusive evidence of the actual relation between the signs of pericarditis and the corresponding anatomical lesions. The second case presented itself more recently; it was that of a man ill with pneumonia which had advanced to the period of suppuration, previously to his admission. This patient offered, during life, the signs of uncomplicated endocarditis; there was a dull confused action of the heart, neither of the natural sounds being very distinct ; their rhythm was also somewhat changed. The impulse was diffused and labouring. There was but a very slight increase of the natural dulness on percussion, at the praecordial region, and there was no creaking sound. I considered this case as one of endocarditis, without much valvular alteration, and mentioned my reasons for this diagnosis to several of you, who were then present. The patient died of the mingled effects of the pneumonia and the endocarditis, and, as you remember, we found the internal membrane of the heart reddened, as well as that of the orifice of the aorta ; it was covered with a delicate membrane that could be detached from it in strips of considerable length. On examination of this membrane by the aid of a magnifying lens, we found that it was apparently organised and traversed by numerous blood-vessels. LECTURE V. Tubercular meningitis—Case—Anatomical characters—Symptoms. I shall continue to-day, gentlemen, the subject of inflammations of the serous membranes, and take up the consideration of a case which came under your notice at the hospital, a day or two since, and presented an example of inflammation of the serous membrane investing the brain. We may the more properly enter upon the subject at this time, as it will facilitate our future examination of the diseases of the substance of the brain. The patient, of whom I have spoken, died in the ward No. 3, and was not under my immediate care. He was a carpenter by trade, and had suffered severely in early life from scrofulous affections ; both his feet had been ulcerated from this cause, some time previous to his admission. He also laboured under disease of the heart, and entered the hospital for hy- drothorax, the cavities of both pleurae being filled with water, and suffer- ing under an extreme and distressing dyspnoea. He was relieved from these symptoms by salivation, combined with the use of digitalis and squill. He got rid of his shortness of breath, and was able to work in the out-wards of the establishment, where he continued, until the breaking out of the epidemic of measles, with which disease he was taken on the second of April. He suffered considerably from the measles, but gradu- ally became convalescent, till, on the twenty-eighth of April, he offered some symptoms of a cerebral affection ; that is, unusual dulness, stupor, TUBERCULAR MENINGITIS. 657 and oppression. On the first of May, the cerebral symptoms became so well marked, that they were recognised as those of meningitis by the physician in attendance. At that date he was in the following condition. For two days previously he had manifested great restlessness, with occa- sional incoherence and hallucinations. Skin warm ; pulse full and strong, the bis feriens character, which attended his convalescence from measles, having ceased from the twenty-ninth of April. This bis feriens pulse, a frequent sign of convalescence from the measles, which was well marked in this case, ceased, you see, the moment he was taken with the new disease of the brain. The thirtieth, venesection ^ix. ; the crassamentum of the blood was tolerably firm, and it was neither cupped nor sizy, about one-half of it being serum. The man at this time answered questions slowly. The conjunctiva was slightly injected. The tongue pale, moist, slightly furred. The pupils insensible to light, although he still recog- nised objects. No cephalalgia. The abdomen resonant; not painful on pressure, except in the hypogastric and pubic regions, where it was also distended and flat on percussion. Percussion of the left side of the chest resonant, except in the praecordial region ; respiration pure. Percussion of the right side resonant, but less so than the left. Impulse of the heart strong ; the first sound prolonged, attended with strong bellows-murmur in the neighbourhood of the nipple, the same character of the first sound observed between the second and third ribs ; the second sound rough- ened, and heard over an unusually large extent of the right side. A purgative of salts and senna was prescribed, and a blister to the nape of the neck, dressed with mercurial ointment. On the third the countenance was rather less dull than on the first, and he answered questions better : had been delirious the night before. There was some grinding of the teeth. The skin was moderately warm and hot. Pulse ninety per minute, and much smaller. Conjunctiva much redder ; a discharge of a small quantity of yellowish matter from the right eye. In the afternoon, there was some strabismus and increased stupor. An injection of oil of turpentine and castor oil was administered. and cold applied to the head. On the fourth there was very great stupor ; the eyes were closed, and the patient could not be roused to answer questions. The head was turned to the right side ; the right eye inflamed as before ; the pupil of the left eye smaller than yesterday. Pulse about eighty-five, irregular and moderately strong. Bowels opened three times by the injection. Abdomen supple, and not distended. Cold to the head continued; calo- mel, followed by senna and salts. The same day the man died. The symptoras here, you perceive, were not those which denote active, violent inflammation, but were simply dulness of the intellect, stupor, Avith grinding of the teeth, &c. The treatment was commenced by a bleeding which would have been larger, if the previous disease of the patient had not rendered him too feeble to bear it, and was followed by purging, and an attempt to mer- curialize the patient, which latter failed, from the short time that elapsed between the administration of the remedies and the man's death. The following appearances were found in the brain twenty-four hours Marked adhesion between the dura mater and the merabrane beneath. The vessels of the dura mater were more congested than usual. In taking 43 658 GERHARD'S CLINICAL LECTURES. the brain from the cranium about two ounces of fluid escaped. The large vessels of the pia mater were much congested ; the capillary vessels of a bright red tint,—inosculating. In the middle part of the right side, the convolutions were flattened ; on this side, the injection of the pia mater extended to that portion dipping into the convolutions, and it adhered strongly to the cerebral substance. The injection and adhesions were less marked towards the posterior portion. At the anterior extremity, the arachnoid membrane was opaque ; the injection and adhesion somewhat less than at the middle. On the left side this bright injection occupied the middle half, and was confined almost exclusively to'the small arterial vessels. Pia mater less adherent than on the right side. Arachnoid slightly opaque, throughout the whole extent presenting a few minute granulations, near the parietal protuberance. The cortical substance on both sides was of a rosy tint, a little brighter on the left than on the right. That portion of the arachnoid covering the fissure betwTeen the hemi- spheres, and at the summit of the brain, was slightly roughened. Corpus callosum softened. Fornix and septum lucidum pulpy. The right ven- tricle was larger than the left; the quantity of serum contained not known. The thalami and corpora striata were pale. At the base of the brain, the colour was in a great measure lost, from the commencement of decom- position ; but in the whole anterior hemisphere injection of the small vessels was manifest. There were small adhesions between the anterior lobes of the brain. Fissure of Sylvius, on the left side, strongly adherent, by a solid deposit around the vessels, part of which, in the form of granu- lations, was still distinct. On the right side the same thickening occurred around the vessels, but the newly-formed matter was less abundant than on the left side ; it still presented tuberculous granulations, less in size than a pin's head. The arachnoid was opaque and extremely thickened ; the thickening of this membrane extended backwards over the chiasm of the optic nerves, which it slightly invested. Towards the cerebellum the thickening of the membranes became more marked at the upper portion, at the point of junction with the cerebrum ; the double secretion was there distinct, consisting, in part, of minute granulations, beneath the mem- brane, and in its thickness ; and, in part, of a thick, opaque, hard sub- stance, filling up the space between them. The cerebellum was lirm, like the rest of the brain. There were no tubercles in the lungs, or the viscera of the abdomen. The state of the lymphatic glands was unfortunately not noted by the gen- tlemen who made the examination. From the former scrofulous disease, these glands were probably tubercular. It is to be inferred, then, that the disease of the brain was here of an inflammatory character, from the injection and thickening of the arachnoid membrane. It was evidently of the tuberculous variety, from the granu- lations which were found scattered beneath the arachnoid—it was a case of tubercular meningitis. The bright injection of the arachnoid, which is limited to the smaller vessels, is a very good diagnostic sign of inflamma- tion ; had it been observed in the larger vessels merely, I should have regarded it as a simple congestion. In the present instance we have, then, only the alteration in the membranes of the brain, to account for the cerebral symptoms, as the substance of the organ is not at all affected. This subject of tubercular meningitis, gentlemen, is one that will present itself frequently to your notice, as it is a disease very common with TUBERCULAR MENINGITIS. 659 children, and by no means rare in adults. It is generally slow and insid- ious in its progress, and requires a very careful examination to distinguish it, particularly in its early stage. I have taken for the subject of some general remarks to-day on this disease, a case in which we have had the pathological phenomena very clearly presented to us, and in which the indications, previous to death, were sufficient for a correct diagnosis of the affection. This case, I may remark, exemplifies the occasional effect of measles, in giving rise to the development of tubercles, to which I alluded at my last lecture. This individual, we learned, had an attack of brain fever (so termed by his mother) many years ago, by which his mind was at the time con- siderably affected. This was probably a scrofulous inflammation of the same character as that which finally carried him off Children may recover from these tubercular cerebral affections, and, at some subsequent periods of their lives, present the sarae symptoms in a more marked manner, from a new secretion or, as it were, second crop of tubercles in the membranes of the brain. So, patients may partially and temporarily recover from pulmonary phthisis, as was shown to you in a late autopsy, where co- existing with the cavities which immediately preceded the death of the patient, were distinct traces of the operation of a former cure, in the hardened cicatrices, which we found in various parts of the lung. The man whose case we are considering, had probably recovered from an attack of tubercular meningitis, early in life, and he might have remained well, had not the occurrence of measles awakened the slumbering tuber- cular disposition, and caused a fresh development of the affection which now proved fatal. This subject of tubercular meningitis I investigated very fully some years ago at the Children's Hospital at Paris, and obtained some impor- tant results as to the nature and cause of the affection. The first point of inquiry, upon entering on the subject, is, have wTe any evidence of the existence of tubercles, elsewhere than in the brain and its membranes, in this affection ? In the children who died from this form of inflammation of the brain, I found tubercles in the bronchial glands or other organs of the body, as well as in the substance and membranes of the brain, where they were found from the size of a pin's head to that of a large pea. There was but one evident exception to this rule, out of thirty cases, that were analyzed in a paper, which I published in the American Jour- nal, in 1834. In the exceptional case, there were tuberculous granula- tions in the membranes of the brain, but not in other viscera. The coin- cidence of tubercles in various parts besides the brain conclusively proves, that a general tuberculous diathesis existed in these subjects, for in no other class of acute disease does the same rule obtain. In a few cases, however, the tuberculous deposit may not appear except in the membranes of the brain. Having determined the point as to the general tubercular nature of the disease ; the next matter to be investigated is, the causes on which de- pends the development of the affection. Unquestionably, the scrofulous diathesis is the strongest predisposing cause of this affection, using the word scrofulous as significative alike of the tubercular and strumous tem- perament. In almost all the cases in which the cerebral affection occurs in adults, a scrofulous disease has previously existed, and perhaps been cured in some other part of the body, as the lower extremities, the glands 660 GERHARD'S CLINICAL LECTURES. of the neck, the lungs, and elsewhere. As to the exciting causes of the disease, they escaped us almost entirely ; in the majority of cases, at the Enfans Malades, we could detect no antecedent fact, which could at all account for the development of the tubercular disease of the brain. The measles, however, in the case under notice, is to be looked upon as the accidental cause of the development of the disease ; and I may- make the general remark, that, whenever, in a scrofulous child, you have an acute disease accompanied with fever, you may look for the develop- ment of inflammation of the brain, and are to watch your case with ex- ceeding care. The prognosis, in tubercular meningitis, must, generally, be more or less unfortunate, particularly in hospital practice. This deduction I base upon the observations made by myself and my friend Dr. Rufz, at the Children's Hospital at Paris, where, for one or two that got well, forty died. Indeed, Charpentier, who observed ten years ago in the same hospital, went so far as to say that he never saw one case recover. Yet, in private practice you will find the results much more favourable. In the hospital at Paris, the children were badly fed, confined in close rooms, and the treatment prescribed was not so minutely carried into execution as in private practice. I have not seen many children with this com- plaint since my return to Philadelphia, but those cases which I have seen were generally but not always fatal. A striking instance occurred in the child of one of our nurses ; she was a girl of four or five years of age, and recovered entirely, but a second attack came on, a year or more after the first, and proved fatal. The adults who are taken with tuberculous meningitis, nearly all labour under phthisis pulmonalis, which complication contributes not a little to the fatal termination of the affection. These cases are, of course, not fair standards for estimating the powers of treatraent. In many cases, also, of this disease, the existence of tubercles in the lungs may not be ascer- tained during life, although they may be found after death. This was the case with a negro, whom I examined some years ago at the Pennsylvania Hospital. (See American Journal, 1836.) During life he had neither cough nor expectoration, but I found, after death, numerous miliary tu- bercles in the lungs, as well as in the brain ; in other words, the man laboured under general acute tubercular disease, which, from similarity in the size and appearance of the granulations, must have commenced nearly at the same tirae in the lungs and brain, but had not attained a large size in either organ. Generally, we meet with the disease in adults, under circumstances that preclude the hope of a cure ; but, in children you may entertain a fair hope of success, if you see the case early ; if it has ad- vanced so far as the second stage of the disease, you have but a slight prospect of saving the child from speedy death. The symptoms differ in children and in adults. In adults, the disease appears in patients actually labouring under phthisis, or of a decidedly strumous diathesis ; while it often shows itself in children, who are in the enjoyment of tolerably good health, notwithstanding some latent tendency to scrofulous diseases. Whenever, therefore, in children, the symptoms which I shall describe as characteristic of the forming stage of the disease, present themselves, the physician should put himself upon the watch, though they are not to be looked upon as invariably indicative of the result in question. Tubercular meningitis may begin in two ways :— TUBERCULAR MENINGITIS. 661 First, it may come on abruptly, as ordinary acute meningitis, with vomit- ing, chill, and fever. The cerebral symptoms may appear, however, without even the prelude of vomiting ; in adults this symptom is com- monly wanting. When its approach is more gradual, the following order of phenomena is observed :— For the first few days the child merely evinces unusual restlessness and irritability, showing signs of excitement of the brain. He avoids light and sound, frora the extreme sensibility of the eyes and ears. We have also a change in the intelligence, if the child be old enough to permit such attention to be noticed. First, it is simply excited ; the child is raore lively and acute, and more attentive to external objects than before. Afterwards the countenance becomes changed ; the cheeks are flushed, the eyes unusually bright, and a well-marked frown and wrinkle are to be noticed on the forehead. This is one of the most important signs of the early stage of the disease ; and at this period, it is essential to recognise all the symptoms, and this peculiar expression you may consider charac- teristic. This, together with the bright red flush upon the cheek, the nurses in the Children's Hospital used to look upon as an unfailing mark of the approach of the disease. The decubitus is at this time but slightly altered. But we often meet with some secondary symptoms, which, al- though they are not always present, are of some moment ; these are nau- sea or vomiting, constipation, and fever, which is at first of a mild cha- racter. We now pass to the second stage, comprising the symptoras which were first observed in the man who had just died ; those of the forming stage were lost in the decline of the measles. These symptoms are deli- rium, which cannot of course be very accurately observed in children, particularly if they are very young. But some signs of it may be gene- rally detected, especially at night, in the quick answers and altered man- ner of the child. This delirium differs from that of ordinary acute menin- gitis, in which the patient is violent, noisy, and loquacious. Here there is mere dulness and stupor, somewhat similar to the delirium of typhus fever ; the child is not very violent, makes no efforts to w#lk about or to do mischief, but remains in a state of dull muttering. I was impressed by this peculiarity of the delirium of tubercular menin- gitis, in two cases which came under my observation at the Pennsylvania Hospital three years since. In one, of so moderate a character was the delirium, that the patient was admitted for simple insanity. The only other symptoms that attracted attention, upon his admission, were a pecu- liar hobble and limp in his gait. We found the traces of several scrofu- lous disorders, which had been cured, and the man had also a slight cough, of which he had complained for two years past. The patient was constipated before his entrance, and shortly afterwards vomiting ensued, and then the cerebral symptoms became more decided. The paralysis occurred very early, from the coincidence of softening and inflamraation of the substance of the brain with that of the membranes. At first, in fact, I thought it was paralysis, from mere softening of the brain. Afterwards, I began to doubt, and regarded the case as one of tuberculous meningitis: finally, the autopsy cleared up all obscurity. The paralysis was found to be dependent on softening of the brain, and the delirium arose from tubercular meningitis with effusion of lymph at the base. This complication of lesions necessarily gave rise to the intermix- 662 GERHARD'S CLINICAL LECTURES. ture of the symptoms of meningeal with those of cerebral inflamraation ; in practice this coincidence is by no means rare, and it is not often diffi- cult to detect it. The seat of the disease was here the same as in the case of the man Crane ; the deposit of tubercles was along the blood- vessels, following the ordinary law which regulates the secretion of tuber- cular matter. Besides the delirium of the second stage, we meet with alteration of the senses, as in the case of Crane. The pupils are generally dilated, mode- rately and gradually ; in some cases, they are contracted, but, as was ob- served by Dr. Stewardson in the present case, it is difficult to tell if they are permanently contracted, being at one time contracted, and at another dilated. These alterations of the pupils are most important signs, parti- cularly when accompanied by the muttering delirium. Lesions of motility next present themselves. These consist at first principally in subsultus or even spasms, as in typhus fever; indeed I have sometimes hesitated for a little while in my diagnosis, between the two affections. Paralysis is by no means a necessary symptom in the second stage of meningitis. But we have then the beginning of another symp- tom, rigidity. In the case of a man now in the wards, this stiffness could be detected only by careful examination of the elbow, but it may be usually very early ascertained with proper caution. This rigidity differs frora contraction, which is a more advanced degree of it, and is more rarely met with in this form of meningitis. Rigidity is not here confined to one side of the body, as in apoplexy and softening of the brain, for the tubercles are secreted, on both sides of the base of the brain, and, hence, the symptoras of disease of the membranes are rarely confined to one-half the body, while those of the cerebral substance are as rarely extended beyond it. These are the chief cerebral symptoms of the second stage of the affec- tion. We now pass to another set, those of the digestive organs. Vom- iting is one of the most constant symptoms of tubercular meningitis in children, but it rarely continues beyond the first stage. Another peculiar and important symptom is constipation. In the second of the two pa- tients in the Pennsylvania Hospital, to whom I have alluded, the case was at first looked upon by his physician as one of simple constipation ; and the true nature of the complaint was suspected only when it was found that the symptora did not yield to purging. This gives as a valuable therapeutic indication, in the treatment of the affection—that is, the pro- priety of purging. The appetite is generally lost from the beginning of the affection. The thirst is in proportion to the degree of fever present. The state of the pulse may be learned from the case of Crane. In him, the bis feriens pulse, of 60 and 66 per minute, existing during the con- valescence of measles, rose at once to 90, and continued at this point till the third stage, when it sank again to 85. It was therefore simply febrile in the second stage, and irregular in the first and third. It is rarely slow, and slowness may be looked upon as a good symptom, except in the third stage. The other symptoms are less significant in their character, and I would merely refer you to the memoirs which I published in the American Jour- nal, in the years 1834-5. In the third stage, or after effusion of serum, pus, or lymph has taken place, the ordinary termination of serous inflammation, to which I called TUBERCULAR MENINGITIS —TREATMENT. 663 your attention in my last lecture ; we have a subsidence of the acute febrile disturbance, the pulse is often preternaturally slow, coma comes on with partial paralysis frora the pressure of the effusion, which is not necessarily confined to one side of the body, and is slow and gradual in its advances. I have given you merely a slight sketch of the pathological anatomy of this affection, as I do not, in this course, intend to dwell, at any great length, upon this subject. The treatment of tubercular meningitis, to the consideration of which we now pass, involves many important questions. It must vary, according to the severity of the actual symptoms, and the circumstance of the existence of a previous tubercular disease. If the patient is in the third stage of phthisis pulmonalis, you can of course do little or nothing. If this be not the case, however, you may, I think, do much. The case must be at first treated as one of simple meningitis. Your object should be to get rid of the acute inflammation of the brain, which increases necessarily the disposition to tubercular secretion, and raay at once kill the patient. You must not, however, deplete to the same extent that would be advisable if there were no tubercular deposi- tion. You are to steer a middle course. My plan is to resort to blood- letting, general and local, unless the development of tubercles be very far advanced. I have recourse to general blood-letting once, and once only, even in adults. It is an old remark of writers, that inflammations of the membranes of the brain generally bear excessive depletion worse than those of other organs, but always tolerate well the local abstraction of blood. Local bleeding is to be directed, so long as the patient can bear it, that is to say, until he becomes pale, and the flush is gone, whether the other symptoms abate or not. After depletion, I was formerly in the habit of placing blisters to the back of the neck. I am now in the practice of applying them behind the ears. The discharge can here be kept up longer, and will act more steadily, and the sore can be better dressed ; the patient may be mercurialized by dressing these blisters with mercurial ointment. The discharge by the blisters I keep up, until the patient is perfectly well. Another remedy is counter-irritation elsewhere than near the head. The feet are apt to be cold ; they are to be plunged into hot water from time to time, to be clothed with flannel, and rubbed occasionally with cayenne pepper. But you are to abstain from further blistering ; it only serves to create fever, and is generally mischievous. Sinapisms may be used, but the surface is not to be vesicated. The next remedy to be employed is purging. If the patient be strong and robust, it answers a very good purpose, and in a few rare cases at once relieves him. But in children, if relief be not afforded by one or two pur- gative doses, it is proper to be cautious as to their employment. With children I begin with a mercurial purge, from four to eight grains of calo- mel, to be followed by a saline purgative, or, still better, some castor-oil. Mercurials are used by the French merely for the purpose of purging; of course they do not salivate, and, when persisted in, do no good. As soon as the acute stage of the disease has abated, you must commence with mercurial dressings and frictions of the abdomen. These are of most ser- vice in the sub-acute variety of the disease. ^ I have now detailed you the ordinary practice to be observed in the management of tubercular meningitis. To one or two points your atten- tion is to be particularly directed. You must carefully watch the moment 664 GERHARD'S CLINICAL LECTURES. when it is proper to stop blood-letting, and immediately after commence the introduction of mercury into the system, and continue it until the active period is past. After the third stage of the disease is established, and paralysis makes its appearance, treatment can do no good. The affection is then fatal, be- cause the functions of the brain are so much interfered with that the pa- tient must necessarily perish. Tubercular serous inflammations are not elsewhere so fatal, as when they occur in the membranes of the brain. When secondary peritonitis and pleurisy destroy life, death usually follows frcm perforation of the glands of Peyer, or perforation of the lungs. The tuberculous inflammations of these membranes, however, assume a much higher importance from their tendency to return and even to at- tack other portions of the body. Besides, they certainly favour the de- velopment of tubercles, in cases in which the patient had previously pre- sented merely the signs of the diathesis which precedes this morbid de- posit. For a more complete account of this connection, I must refer you to my lectures on pathological anatomy. The symptoms and treatment of tuberculous meningitis you will find detailed in the memoirs which I published in the American Journal, in the years 1834-5, as well as in the paper of my friend, Dr. Rufz. LECTURE VI. Peritonitis fiom cancer of liver—Acute Meningitis—Diagnosis—Symptoms—Treatment. It is my intention, to-day, gentlemen, to continue the discussion of in- flammations of the serous membranes, with particular reference to the sub- ject of meningitis. Previously, however, to entering upon this latter topic, I shall call your attention to a case of serous inflammation, which termi- nated, a day or two ago, at the hospital, and at the post-mortem exami- nation of which most of you were present yesterday morning. We had, you recollect, acute peritonitis, pervading the whole of the abdomen, the result of a chronic disease of the liver. This disease of the liver was sus- pected, during the lifetime of the patient, there being sufficient evidence of the enlargement and hardening of the organ. The nature of the affec- tion we found to be cancerous; rounded deposits having the anatomical characters of vascular sarcoma, were scattered throughout the substance of the liver, offering very fair specimens of this variety of soft cancer. I shall not now enter into an examination of the subject of cancer, but shall confine myself to the acute inflammation of the serous membrane, which was induced by the carcinomatous disease. This case of secondary peri- tonitis exemplifies the law I enunciated to you, at a previous lecture. Serous inflammations, with the exception of those of the membranes of the brain, are not very dangerous, unless they occur as secondary to a primary lesion of an organ, or are connected with a cachectic state. This secondary inflammation, which is very frequent in the peritoneum, may be either acute or chronic. In the present instance, it was acute, and, probably, arose from the cancerous tumours approaching the surface of the ACUTE PERITONITIS. 665 liver. Examples of the chronic secondary inflammation of the peritoneum are most frequent in phthisis, when they are connected with a tuberculous deposit in the serous merabrane itself, as was demonstrated to you in one of my last lectures on pathological anatomy. In the present instance the peritonitis was acute ; it was only within the last two or three days of the patient's life that he was seized with acute pain over the whole of the abdomen, accompanied with great ten- derness on pressure. A tumour was distinctly felt, which I described to you as similar to the pointing of an abscess, and induced me to suspect the presence of suppuration. After the occurrence of the acute pain, the patient sank rapidly, without any other of the usual symptoras of perito- nitis, as vomiting, &c, but his prostration was extremely great. Pros- tration of this character is a striking symptom of the secondary serous in- flammation of the peritoneum, and is a most valuable sign in leading us to our diagnosis. You have seen it before in a case of pericarditis suc- ceeding gangrene of the lungs, and also in the case of a black man affected with tuberculous pleurisy. Whenever you have sudden and extreme prostration, supervening upon a chronic disease, in any of the great cavities, you may suspect the existence of secondary inflammation of their serous coats; but it is much more intense in peritonitis than in pleurisy or pericarditis. This was the character of the tubercular peritonitis, de- pending on perforation of the intestine, noticed in a preceding lecture ; and I have, at other times, pointed out to you instances in which there was the same kind of perforation into the cavity of the pleura, following ulceration of the lungs. Perforation is by no means necessary to the pro- duction of these secondary inflammations of serous membranes ; in the case now before us, the exciting cause was the irritation of the cancerous masses in the liver, but just beneath the peritoneum. The same disease may occur in the ovaries, uterus, and other parts, producing similar results. Another example of secondary peritonitis is the affection, generally designated as puerperal fever, a term which is now usually limited to peritonitis, although some physicians are still in the habit of including all febrile diseases of women in child-bed under this head. It is imperative, however, to distinguish between these affections. The true secondary peritonitis of puerperal women depends upon the inflammation of the uterus or its veins, or else upon the irritation consequent upon delivery ; but it is rendered more frequent and more severe by the strong tendency to suppuration, which extends to all the membranes and organs of puer- peral women, and gives rise to the various affections which are sometimes called puerperal fever. The anatomical signs in this case were similar to those observed in the other cases of serous inflammation, which have come under your notice just now, from their great prevalence in spring and the beginning of summer. Thus, to study pathology, you see how necessary it is to pass through seasons and even cycles of disease. In these serous inflamma- tions, you see how interlocked they are with all other diseases, occurring sometimes as idiopathic, but in the large majority of cases as secondary affections ; the first class being rarely fatal, except when attacking the membranes of the brain. Continuing the subject of special serous inflam- mations, I shall now proceed to take up the subject of meningitis. Meningitis may be easily confounded with other affections of the brain. 666 GERHARD'S CLINICAL LECTURES. We had a case a few weeks ago, of a surgical patient, affected with dis- ease of the urethra, in which it was with some difficulty that we made out, even after death, a satisfactory diagnosis, the point being settled with certainty, only by the presence of a slight quantity of pus. I was called to the case, a short time before the man's death, when the* only striking symptom was delirium, which I looked upon as merely the concluding act of life. The true nature of the affection was, however, revealed by a post-mortem examination. We found, first, a bright injection of the pia mater, which is characteristic of inflammation, particularly if there be no serum present.. Injection of the large vessels is not indicative of inflam- mation, but merely of congestion ; the two not usually co-existing to- gether—a bright arterial tint denoting the one, while the other gives a dark blue colour to the surface implicated. The injection was in this case spread over the whole surface of the membrane ; this is generally the case, although it predominates at one portion, either the base or the summit of the brain. Here, the inflammation wTas most evident at the summit, involving the faculties of the intelligence ; while, in children, it usually occupies the base and is connected with a disturbance of the senses. The distinction I make here, coincides with one of the leading points of phrenology, which allots th,e faculties of the intellect and of the senses to different portions of the brain. Although I look upon the details of this science as still founded only upon the imagination, yet the great fact, that the intellect is connected with the summit, and the senses with the base of the brain, is unquestionably true, and confirmed by patholo- gical observations. The roughness of the serous coat, the arachnoid membrane, is the next point to be noticed in this case. It might seem, that mere effusion of liquid would be enough to characterize inflammation of this merabrane. This is not so, however; when it is in a healthy state, there exists a liquid, which is clear and transparent, but in the early stages of real in- flammation, it becomes altered in quality and deficient in quantity. The inflammation is not so much that of the arachnoid membrane as of the subjacent pia mater, in the meshes of which the morbid products are chiefly retained. True inflamraation of the arachnoid is of very rare oc- currence. In the present case, we found pus mixed with lymph in the pia mater, giving a yellowish appearance to the membrane. The three great pathological features, then, of this case, frora which we concluded that it was one of acute meningitis, were the injection of the small vessels of the arachnoid, the roughening of this membrane, and the deposit of lymph and pus beneath it. The consideration of this case offers another point of much interest— the connection between affections of the urinary organs and diseases of the brain. Ten years since, ray attention was first directed to this sub- ject, upon observing a raan labouring under stricture and thickening of the lining merabrane of the urethra, to ray great astonishment, perish suddenly from cerebral symptoms. At the Pennsylvania Hospital, two or three years ago, I noticed the death of a man from similar symptoms of disease of the brain, after a few days' illness, who had been previously suffering from inflammation of the neck of the bladder and urethra. Various writers, and particularly Lalleraand, have called attention to this subject. Dr. Lalleraand has dwelt, especially upon the connection be- tween diurnal seminal emissions dependent upon chronic inflammation, ACUTE MENINGITIS. 667 and the development of cerebral disease. The cases of this character, described by Lallemand, he usually traced to gonorrhoea, which, occa- sioning a thickening of the neck of the bladder, the vesiculae seminales, and the ductus ejaculatorius, left the latter in a patulous condition, allowing a discharge of semen to take place without ejaculation, during the acts of urining or fecating. The dependence of cerebral disease upon causes of this nature, is therefore a highly important fact, which will assist you in understanding some affections otherwise not easily explicable, for the seminal weakness, of long continuance, enfeebles the understanding, and, finally, the brain is disordered to such an extent, that medical relief is sought for. I have had several cases of this character, in wThich the affection was supposed to be connected with a nervous temperament, and was, in short, referred to various other causes than the correct one, but, in every instance, I wTas able to make out the previous existence of chronic gonorrhoea, producing the condition of the urino-genital organs which I have described, and, through this means, giving rise to functional cerebro- nervous disturbance. At first this is purely nervous, but after it has lasted for a few days it may become inflammatory. When the nervous disease is replaced by the organic one, you will find that the symptoras become much more permanent, and more or less paralysis soon follows. M. Lallemand treats these affections by directing his remedies to the urinary organs. In the case of the man at the Pennsylvania Hospital, to whose death, with cerebral symptoms, I have alluded, we found upon examination after death the vesiculae seminales and ductus ejaculatorius destroyed ; an abscess behind the verumontanum, filled with pus ; and the coats of the bladder contracted and thickened. The particular history of the case was not taken, but it illustrates finely, how chronic diseases of the urethra give rise to affections of the brain : and how causes, trivial in themselves, may produce serious and fatal functional disturbances. Death, to use the words of M. Lallemand, may be the result of a series of illnesses, dating their origin from an attack of gonorrhoea ; which is in itself an insignificant affection. From this digression, I return to the subject of inflammation of the membranes of the brain. The case of the man Brown, which has been under your notice for some time past, at the hospital, will serve as a fair illustration of the subject. We have no example in the hospital of acute meningitis, but the case of Brown, which is of the sub-acute form, being more slow in its progress, and better marked in its character, will very properly serve as introductory to the study of the acute type of the dis- ease. This man was taken ill with cephalalgia, in the region of the fore- head and frontal sinuses. We inferred, as we had a right to, that it was not a case of secondary meningitis, from the absence of any previous ill health. Soon after the commencement of the headache, the senses became implicated ; the sight of the left eye was impaired, and the hearing was disturbed with tinnitus, buzzing, resembling the noise produced by a saw, and as the affection declined, it was like the humming of bees. These comparisons are the patient's own expressions, and were not elicited by any leading questions; they are, therefore, the more descriptive of the symptoms. WTith the advance of the disease, there were dulness, sadness, *nd somnolency, but no delirium. There was contraction about the eye- brows and the root of the nose, forming, as I mentioned when noticing 668 GERHARD'S CLINICAL LECTURES. this symptom in the lecture on tubercular meningitis, one of the best marked signs of meningeal inflammation. The contraction was, in this case, of a permanent character, and would have enabled any one, at all accustomed to the affection, at once to recognise it. There was no para- lysis ; no subsultus. The inflamraation was confined to the anterior and inferior parts of the brain, not extending to the summit, as the faculties of the intelligence were but little impaired, nor was there much lesion of the cerebral substance, for there was neither paralysis nor rigidity. After establishing the symptoms, the question starts itself, with what affections might this case be confounded ? With very few. First, it could not be acute meningitis. The tongue was natural, and, although there was some constipation, there was no nausea or vomiting; there was no cough ; nor was there any unnatural excitement of the pulse, and no dreaded delirium or intense excitement of the brain. The inflamraation was then limited to a small spot of the brain, for had it been raore ex- tended, the pulse must have shown it, by becoming unduly excited. The same absence of paralysis which showed that there could be but little cerebral lesion, would indicate that the disease did not depend upon large tubercles, or other chronic tumours of the membranes, for these lesions speedily produce palsy. By way of exclusion, therefore, we suc- ceeded in localizing the affection, and we recognised meningitis attacking the anterior portion and base of the brain. In addition to its anti-febrile character, its course, which lasted a month, a much longer duration than belongs to the acute form of the affection, and its gradual decline, satis- factorily demonstrated its sub-acute progress. The prognosis was an important point, which came up for discussion, at the period of the man's entrance into the hospital. It was at first doubtful; was the meningitis secondary, and dependent on the presence of a tumour or tubercles, or the like ? After the lapse of two or three days, it was clear that there was no chronic disease, but that the affection was a mere local phrenitis or meningitis. We made our minds up to this conclusion, from the evident absence of all symptoras of an impaired con- stitution. The man had not been ill before the time of his recent attack, he had never called for the aid of a physician, nor had his friends ; I say his friends, because in chronic cerebral affections the patient himself is often afraid to call attention to his symptoms, and the first application for medical relief is on the part of his friends, as the evidence of some de- cided mental aberration or change of feeling or habits is forced upon them. The treatment proper in acute meningitis is sufficiently well exempli- fied by that pursued in this case. There are certain great laws well laid dowTn for the management of this affection, which are much more clearly understood than the subject of therapeutics in general, owing, I think, to the fact, that close observation is more easy in meningitis, from its rapid and well-defined symptoms, than in diseases of the thorax or abdomen. The following are the points to be attended to in treating acute meningitis. Blood-letting, in patients who give evidence of tolerable strength, em- bonpoint, and previous good health, is always advisable ; but in the acute form of the disease, depletion becomes a measure of absolute necessity, and, if it be neglected, your chance of saving your patient is but small. Should your bleeding be large or small? It is best to take a considerable quantity of blood at once from the patient, if he be a stout and healthy man ; you may thus, sometimes, immediately arrest the disease. When ACUTE MENINGITIS. 669 serving in the Pennsylvania Hospital, I had a case illustrative of the good effects of this practice, and of the great importance of a correct diagnosis in cerebral affections. A man was brought into the cells, said to be labouring under mania a potu : he was a sailor, who had just made a voyage from Boston ; he had been drinking to excess, but had also been working hard, exposed to a very hot sun. Upon examination, I found the signs he exhibited to be not those of ordinary mania a potu ; his head was hot, his pulse quick, in short, he was in the first stage of acute inflam- raation of the brain. I bled him largely, between twenty and thirty ounces, and he was, I may say, instantly cured. It is true, that the next day I directed a slight cupping, a purge, and the like, but they were merely by way of precaution. Had this patient been treated by opiates as a case of mania a potu, he must almost infallibly have died. Such cases I have seen treated in this manner in hospitals, for so common a vice is drunk- enness in this country, that all diseases of the brain occurring in intempe- rate persons are apt to be indiscriminately regarded as the effects of ex- cessive indulgence in ardent spirits. When I was a resident physician in the Aims-House Hospital, a woman was brought in with a fracture of the skull, upon which arachnitis supervened. She was treated as a case of mania a potu, by a gentleman who was writing a thesis on this subject ; his mind was consequently absorbed by this single variety of cerebral affection, and a most unfortunate error was committed. She died ; and upon examination after death, spiculae of bone were found driven in upon the dura mater! After you have bled once largely, it is best to limit a repetition of gene- ral bleeding to cases of individuals of a very plethoric habit. In place of general depletion, keep up cupping and leeching, which, if persisted in with regularity, will do much good. As to cupping, every thing de- pends upon the manner in which it is applied. In the case of Brown, all the cuppings were of service except one, when the cups were applied to the temples ; here it seemed only to augment the irritation—the pressure of the cups very near the seat of disease causing an afflux of blood to the part. The cups, which were applied to the back of the neck, all did good. I do not speak of cups to the forehead, because nobody thinks of using them in that quarter. My advice, then, is to cup rarely to the tem- ples, and generally to the back of the neck ; leeches behind the ears may be employed with much advantage ; in this very case, I found leeching behind the ears of service, when the cupping ceased to do good, showing the mere change in the manner of abstracting blood to be of essential im- portance. Leeching, then, is to be sometimes resorted to, though cups are generally to be preferred in taking blood locally, from the ease with which the quantity may be regulated, and the facility with which they may be applied ; but if you find the patient very excitable, leeches are much more certain than cups, and relieve more with the loss of a less quantity of blood. In very acute meningitis, you have within your control another power- ful remedy, and one that is quite as important as any of the others—ice to the head. It is to be applied with caution, and you are to judge of its producing an effect by the supervention of faintness, languor, or paleness of the face. In hospitals, the ice may be applied in a tranquillizing chair, but in private practice, where you have no such convenience, a bandage with a bladder of pounded ice raay be employed for this purpose ; you 670 GERHARD'S CLINICAL LECTURES. must be careful to renew the application as soon as the ice melts, other- wise the alternation of heat and cold thus produced may do harm. The use of ice I would continue for several days, until there was a decided abatement of the acute symptoms. It is a great point in the management of this disease, to have for the patient proper attendance of persons who can control him. For this purpose one, two, or three men nurses will be indispensable in private practice, where those means of restraint are want- ing, which are to be met with in lunatic hospitals. The next remedy I shall mention acts on the same principle as the last, and is intended to produce revulsion from the head ; it is the application of warmth and stimulating poultices to the extremities. I was treating a patient some time ago with ice to the head, in whom, although the ice was evidently doing good, it produced pallor and languor, and the symp- toms abated but little ; upon examination, finding the feet cold, I directed warm stockings to be put on them, had sinapisms applied, and ordered them to be occasionally plunged into warm water, which was followed by an evident amelioration of the symptoms. Unless you attend to these precautions, you will lose much of the good that may be derived from the application of cold to the head. Upon trifles like this, success in a great measure depends in the management of this affection ; indeed in thera- peutics the advantage which one practitioner has over another, depends chiefly upon his attention to minute and seemingly unimportant details. Although it may be somewhat irrelevant, I cannot here forget to caution you against falling into those habits of careless and hasty prescribing, which are sometimes produced by a negligent attention to the practice of public institutions. The advantages of hospitals are inestimable to one who uses them in a right spirit; that is, as schools of diagnosis, and of the great therapeutic indications. But you must remember that in pri- vate practice you must carefully direct or even superintend in person, a multitude of details, which are usually attended to in hospitals by well- trained nurses, aided by the system which exists in all well-conducted institutions. Much of the reputation of Dr. Physickasa practical physician, depended on a strict attention to these minuter points of detail, and he had, there- fore, often better success in the management of even medical cases, than persons who were perhaps more familiar with pathology, but not equally attentive to these particulars. Purging is a remedy which has been almost from time imraemorial adopted in the treatment of acute inflammations of the brain. The saline purgatives combined with senna, or a mercurial purge, are those generally employed. I prefer a mercurial purge, as it serves a double object, by acting on the liver, and preparing the way for ptyalism, if it should after- wards become necessary ; it is besides a good preparation for the saline articles. I would begin by ten grains of calomel, followed up the next day by a dose of salts and senna ; should the calomel not purge, it will salivate, which is not to be dreaded. After, at least, a single mercurial purge, you may give doses of senna and salts,—a robust patient will re- quire half an ounce of each ; these, by inducing serous discharges from the bowels, will have a derivative effect. Afterwards your object should not be to produce violent purging, but to keep up a moderate looseness of the bowels. Should the delirium not yield to depletion and purging, these remedies ACUTE MENINGITIS. 671 should not be continued after the strength of the patient begins to decline, but you must now have recourse to mercury in small doses, and to blis- ters. Mercurials, like tartarized antimony, act as antagonists to inflam- mation, and may with propriety be employed in the second stage, or in the subacute form of the affection. They would have been highly appro- priate in the case of Brown, in whom we should have prescribed them, had the disease not yielded in the first instance to the local depletory treatment. It is best to continue the use of mercury until ptyalism is pro- duced. By effecting this, I have succeeded in curing a large proportion of the cases which have occurred in ray wards of the hospital. An in- teresting case happened last summer, which, perhaps, some of you may- recollect. It was that of a young man who had been a clerk at Mobile, and who on his way to Philadelphia, by the Mississippi river, had been taken ill with fever and delirium at Cincinnati, from which he recovered with difficulty. He came to Philadelphia not quite well, having still some symptoms of cerebral disease. He was taken ill again and brought to the hospital. He was then in a state of high cerebral excitement, being occasionally rational, and relapsing again into delirium ; throughout the night he would be in a state of great liveliness, loquacious, restless, with his senses considerably excited. From the history of the case, I con- cluded it to be one originally of acute meningitis, which had now become chronic, and began the treatment of it with blisters and local depletion, but the delirium did not yield, until a mild mercurial course was pre- sented. Another case I may mention was that of a young sailor, who was taken ill under circumstances which I do not now recollect. He had pleurisy first, and afterwards meningitis, and the disease did not abate till after a mercurial course. The symptoms were not the violent deli- rium of the last-mentioned patient, but mere stupor, dulness of the senses, and constant disposition to throw his head strongly backwards. Neither of these cases was dependent on the presence of tubercles or other chro- nic lesion. We come next to speak of blisters, which, it might seem at first sight, would be proper at an earlier period of the affection. This is not the case, however ; in the first stage they seem only to irritate, and decidedly augment the extreme agitation and violent delirium ; they should be de- layed till the acute symptoms subside, when they may be applied over the occipital region, extending to the back of the neck. They are to be rarely applied over the whole scalp, where they give great pain. The same law that regulates the employment of leeching or cupping is appli- cable here ; the blisters do more good at some distance from, than im- mediately over the inflamed portion of the brain; when the disease is more chronic, it is often useful to keep a blister discharging behind each ear, as I have already advised in the treatment of acute hydrocephalus. Caustic issues or incisions over the fontanelles have been recommended in chronic meningitis, but as they are very inconvenient, they have not been generally used, though I see no reason why they should not be em- ployed in certain cases, especially where there is reason to apprehend that the disease has followed an injury of the head. The plan of treatment which I have given will succeed in curing the majority of cases of acute meningitis. If, however, the affection should not yield, and passes into the chronic state, the patient remains necessa- rily more or less insane, and is apt to sink into the third stage of insanity 672 GERHARD'S CLINICAL LECTURES. or dementia. He becomes utterly incoherent, and the case usually ter- minates in a very curious but totally incurable variety of paralysis, called the paralysis of the insane. In the beginning of this kind of insanity, when the appearances of active inflammation have in a great degree subsided, cold affusions upon the head, repeated several times daily, mild laxatives, a sparing diet, ab- stinence from all excitement or exposure to the sun, with gentle exercise, prove the most useful remedies. In short, the treatment must be ex- tremely mild, but persevere while a hope remains of saving your patient from the worst species of insanity. When acute meningitis is fatal, the patient generally dies at the end of the second, or in the third stage of the disease, or he may die from me- ningeal apoplexy. I have twice or thrice seen a patient in the Aims- House, labouring under meningitis, become suddenly comatose, with stertorous breathing and loss of power of the limbs. The symptoms were those of apoplexy, arising from effusion of blood, not into the substance of the brain, but on the surface of both hemispheres into the membranes, which, from its pressure, is therefore necessarily fatal. Whether the inflamraation of the membranes of the brain be acute or not, as soon as the third stage, or that of effusion of lymph or pus super- venes, the delirium becomes less violent, the disturbance of the senses is succeeded by a total abolition of them, the patient neither seeing nor feel- ing. There is a gradual supervention of paralysis ; sudden dilatation of the pupils in place of alternate contractions ; and there is usually, but not always, strabismus. This stage is necessarily fatal, there being no possi- bility of a recovery. • To recapitulate briefly the course of my remarks to-day—you have had your attention called to the anatomical characters of certain serous inflam- mations, and after tracing the connection between cerebral affections and those of the genito-urinary organs, I have entered at length into the treat- ment of acute meningitis, basing my remarks upon a case of the sub-acute variety which has been lately under notice at the hospital. I have not gone into more details of the symptoms of acute meningitis, waiting till they present themselves to our notice, which, from our knowdedge of the course of these affections, must be the case during the summer. The sub- acute variety is the only one which I am now able to demonstrate, by reference to a case actually under your notice. LECTURE VII. Chronic meningitis—Apoplexy—Paralysis of the insane. At my last lecture I continued the subject of inflammations of the brain, dwelling particularly upon that of acute meningitis, which I was able to illustrate by a case of the sub-acute form of the affection, at that time under your notice at the hospital. I merely alluded at the time to the subject of chronic meningitis, without entering into it at any length, and I, therefore, propose now to say a few words upon it, as it properly be- longs to this period of my course. We have a large number of cases of CHRONIC MENINGITIS. 673 this affection in the wards of the hospital. I shall select the best marked of them, that of Urweiler, a German, to whose history and symptoms I shall briefly call your attention. This man, two or three years ago, having previously enjoyed good health, received a blow on the head, the effects of which, at the time, were not very seriously felt. He suffered slight headache, pain, &c, which, however, soon abated. But, after a lapse of time, the powers of his mind began to fail, and he became, finally, entirely deranged, and in addition to this disorder of the intellect, paralysis is gradually supervening. This latter symptom, as you may have observed in the hospital, is a very common accompaniment of insanity, chiefly of dementia; it is, however, often met with in persons in whom insanity is not yet developed, the functions of motility being attacked before the intellect is much impaired. The disease is, therefore, often to be recog- nised at first by the mere disorder in the powers of movement, and may ordinarily be detected as follows. Slight symptoms of mental aberration are presented, often not well marked, but, again, rapidly becoming strongly characterized, and running into the worst degree of madness—incoherence. The organs of locomotion become also affected, the first symptoms being a failure in the power of walking ; but feebleness of the upper extremities does not often show itself at first ; a hobble or limp is noticed, generally, at first, on one side of the body only. Other changes then take place, the upper extremities becoming involved, the face slightly distorted, the tongue is protruded with difficulty, and the speech thick ; these symp- toms, however, are often indistinct at first, with the exception of the fail- ure in the power of walking, which alwTays shows itself. The symptoms, for the most part, gradually but slowly advance, scarcely ever retro- grading. If the patient is insane, when the partial paralysis appears, the affection is nearly always fatal. Dr. Calmeil, who was connected with the lunatic hospital at Charenton, near Paris, considered it always fatal ; and my own prognosis accords very nearly with his opinion. It is some- what singular that this disease is much more frequent in men than women ; although very common at the Bicetre and Charenton, it is comparatively rare at the Salpetriere, where none but women are admitted. In the diagnosis of this affection you must not, however, be too confi- dent; it is necessary that the cerebral symptoms should be permanent, and not merely limited "to the slight disturbance of brain which occasionally results from disordered abdominal functions. If you are not quite sure, therefore, watch the patient for a little while, and the case will become clear. I shall not now enter at length into the pathological features of the af- fection, merely bringing before you two cases that came under my notice some time ago. One was of a gentleman, who died about two years since; he had been hurt by a fall, from the consequences of which he seemed to have recovered; but two or three years subsequently his walk- ing began to fail, soon afterwards his mind, and a short time only passed after the development of these symptoms, before he died. On examina- tion after death we found the membranes of the brain universally thick- ened. The other case was that of a man, who had been a master of a vessel in the merchant-service; just previous to his attack, he had been suffering from a soreness of throat, which improved but little under a treat- ment consisting chiefly of local applications; symptoms of disease of the brain soon appeared, and the man entered the Pennsylvania Hospital. At 44 674 GERHARD'S CLINICAL LECTURES. this time he had incomplete paralysis of the lower extremities and of the left arm, with painful deglutition; these symptoms went on slowly, but finally destroyed the patient. After death, we detected a slight thicken- ing of the membranes lining the ventricles, and wTere astonished to find how little the medullary substance of the brain was affected, and that the cortical substance was merely in the normal state. Treatment in chronic meningitis is available only when the functions of motility are not impaired, and those of the intellect alone are affected. The mode of treatment to be resorted to, consists in a regulated diet, blis- ters to the nape of the neck and behind the ears, and cold affusions twice or thrice a-day. Although I cannot affirm that I have entirely cured any patients labouring under actual paralysis, I have certainly, by the plan detailed to you, restored several in whom the disease had proceeded no farther than the affection of the mind. The patient Urweiler is much better, speaks with greater ease, and has obviously more strength in the limbs. The next disease of the brain which I shall notice, offers, at this time, several cases in the wards of the hospital, and will be often encountered by you in the course of your practice—I mean apoplexy. Of the cases in the hospital, one is a recent one, and two, in the black wards, occurred as far back as a year ago. The term apoplexy is often used very indefi- nitely. It is applied to four different pathological states: 1st, true apo- plexy, or hemorrhage into the substance of the brain or its membranes; 2d, simple congestion, or preternatural fulness of the vessels of the brain; 3d, serous apoplexy, in which the brain is oppressed and its functions im- peded by a large serous effusion ; 4th, nervous apoplexy, in which many of the symptoms, such as loss of consciousness, &c, are developed with- out any appreciable organic lesion. I shall here employ it to signify an actual hemorrhage into the substance or beneath the membranes of the brain, excluding mere effusions of serum, all cases where there is no or- ganic lesion of the brain, as well as those in which mere congestion occurs, an affection which is most frequent during the summer season, and at the close of the winter. These cases are all confounded with true apoplexy, and indiscriminately classed under the same name; sometimes, indeed, when no one function of the brain is disordered, the terra apoplexy is given to sudden deaths. A man will fall down dead, perhaps, with some coma- tose symptoms from disease of the heart, and his death is at once referred to apoplexy; whereas, genuine apoplexy almost never causes instantane- ous death. When the case terminates fatally, it is usually after a lapse of some months, from paralysis. It sometimes proves fatal in the course of a few minutes, or half an hour; but in these cases there is usually blood effused into the ventricles, and it is not common for it to terminate before the end of several hours, even when most severe. The exceptions to the rule, that sudden death does not follow apoplexy, are indeed so rare, that you may pretty safely pronounce an instantaneous death to be independent of this cause. These very sudden deaths are usually owing to diseases of the heart, although in some of them no organic lesion whatever can be found of any organ.* There was an example of this sudden death a few months since at the hospital, in a patient who was labouring under a chronic disease of the heart, who died during my visit. I found him in his ordi- nary condition, and had just left the ward, when I was suddenly called back and found him dead. * Memoir of Dr. Louis. APOPLEXY. 675 The anatomical characters of apoplexy are easily ascertained, and may be divided into two great varieties—in the first and most common, the effusion of blood takes place into the substance of the brain, in the other it takes place into the membranes. Any spot in the brain raay be the seat of the hemorrhage, but it is generally the thalamus of the optic nerves and the corpus striatum. The blood is sometimes poured out in such quantity as to break into the ventricles, and even force asunder the septum between them, so that it presses upon both hemispheres of the brain; but it is gene- rally confined to a single spot, on one hemisphere. The character of the clot is always the sarae; it consists of a mass of dark coagulated blood, surrounded by the tissue of the brain, which is, to a certain extent, ecchymosed and softened: this softening may be either the effects of previous disease, or the consequence of the apoplexy. Dr. Rochoux, who observed at the Bicetre hospital, thinks that apoplexy al- ways depends upon the previous existence of local softening in the brain, the hemorrhage afterwards taking place in the diseased portion. My own, and the general opinion is, that in the large majority of cases, softening of the brain around the clot is a consequence of the pressure from the blood thrown out, the hemorrhage itself depending upon a disorder of the circu- lation. The cause of the deranged circulation is sometimes hypertrophy of the heart, which increases the impetus of the blood; at other times, the cause is to be sought for in a diseased state of the arteries and capillary vessels, either of the brain itself or of the whole system. But although the opinion of Dr. Rochoux is too exclusive, it is by no means unfounded, for there is a certain if not a larger proportion of cases, in which the evi- dence is decidedly in favour of previous lesion of the cerebral substance. These cases are somewhat analogous to the hemorrhage which follows dis- eased uterus, or the advanced stages of pulmonary tubercles. After the clot has been some time in contact with the substance of the brain, it is in a measure isolated by the formation of a cyst which com- pletely surrounds it. It is afterwards gradually absorbed, absorption taking place in the following order : first, the serum disappears ; secondly, the colouring matter ; and, thirdly, the fibrin of the blood. After a lapse of some months, the cyst only remains, in one of two conditions :—it is either entirely hollow, and lined with a new serous coat, or a little cel- lular substance occupies the old seat of the apoplexy, and then the cyst is either imperfect or entirely obliterated. In one of these two forms, the parts are invariably found. This succession of lesions has been perfectly well illustrated by the cases which have been just now under our notice, for there are particular symptoms, corresponding to each stage of the disorder. One was that of the old woman, in ward No. IV., in whom there was a complication also of softening of the brain. For, in addition to the paralysis which follows hemorrhage, we have strong contraction of the flexor muscles on the paralyzed side, so violent, that pain is given to the patient by an attempt to extend them. She had been well, we learned, two weeks before the attack, which determines it at once to have been of an acute character. The next point would be the manner in which it occurred,—was it sudden or gradual ? This we cannot settle satisfactorily, from our inability to ascertain the previous history of the case. The paralysis might arise either frora acute softening or apoplexy, and as the distinctive characters of these two affections chiefly depend upon 676 GERHARD'S CLINICAL LECTURES. the abrupt commencement of the latter, and the more gradual progress of the former, it is evident that we cannot make a positive diagnosis. The rigidity which is so striking in the paralyzed side of the body, is pro- duced by softening, but this softening may be merely secondary to the hemorrhage. It does not take place in the beginning of apoplexy, it follows when the parts around the clot become inflamed ; whereas, in in- flammation of the brain, the numbness, stiffness, and rigidity follow in rapid succession, from the onset of the affection, and precede perfect paralysis. There is another fact showing the case to be apoplexy ; that is, the extent of the paralysis, which is rarely so great in inflammatory or non-inflam- matory softening of the brain. In acute and sub-acute meningitis, as I have before remarked, attacking the summit of the brain, you have deli- rium of a more or less violent character, the mind being always com- promised ; if it involve the base of the brain, you have alteration of the functions of motion, as subsultus, spasms, &c, and the sight is affected, but, as there is no paralysis at first, you cannot confound these diseases with apoplexy. Another point of some importance, in making a diagnosis of apoplexy, is to distinguish it, during the first few hours of the affection, from mere congestion of the brain. This is not so easy at first, as after the lapse of a few hours ; but there are some peculiarities about these affections, which, if closely attended to, will serve to draw the line of distinction. In the first place, after the first few minutes of the loss of consciousness, which usually occurs at the beginning of both, there is paralysis of one side alone, in true apoplexy. In congestion, on the other hand, there is scarcely ever complete paralysis of either, but there is generally some difficulty of motion in both. Persons attacked with apoplexy are not so commonly of the same full habit of body as those who suffer from active congestion, so that this plethora is alone sufficient to induce you to suspect the case to be congestion. A nice diagnosis, at the beginning of the two affections, is not very important; it is only after they have advanced beyond the first stage, that it becomes of consequence, as regards the treatment, to distinguish between the two. For every case, offering the symptoms of loss of consciousness, difficult breathing, turgescence of the vessels of the face, &c, but one course of treatment is to be thought of, the actively depletory. But after the subsidence of these immediate symp- toms, cases which thus far offered the same character, demand a widely different plan of treatment. I have already alluded to cases of effusion of serum on the brain, which are sometimes confounded with apoplexy from hemorrhage, and, are termed serous apoplexy—a term often used to denote the presence of comatose symptoms, without hemorrhage. This serous apoplexy may occur from the effusion of serum beneath the membranes, or into the ven- tricles of the brain ; in the latter case, it is not unfrequent in mania a potu, and also in some diseases of a chronic character. These cases, however, of comatose symptoms from serous effusion are of rare occur- rence, except at the close of cerebral diseases of easy diagnosis. Sudden coma, entirely independent of organic disease of the brain, sometimes appears, as the consequence of a previous chronic disease of various viscera, or even of anemia, under circumstances calculated not a little to puzzle the practitioner. A case of this sort occurred the winter before last, in my wards of the hospital. A seaman who had been ex- APOPLEXY. 677 posed to great hardships, and had contracted a disease of the liver in the East Indies, of which he bore well-marked evidence in a pale-yellow, jaundiced skin, came into the ward complaining of neuralgic pains in the feet unattended with fever. He had no symptoms whatever of disorder of the brain, or of the thorax ; nor of the abdomen, except those indicative of a diseased liver. After remaining for a short tirae in the hospital, he was one night found with comatose symptoms, stertorous breathing, &c, having been seen, only an hour before, walking across the ward for a cup of water. I saw him only an hour before his death, in a state in which it was exceedingly difficult to arrive at a correct diagnosis ; I, however, came to the conclusion that it was not apoplexy, from the fact of the symptoms not being limited to one side of the body. An examination after death revealed no alteration whatever of the brain, except a very trivial quantity of serum beneath the arachnoid. He had, therefore, coma, loss of consciousness, and stertorous breathing, during life, without any lesion of the brain. Symptoms of the same character occur from the effects of heat upon the nervous system, during the warm season. During the intensely hot weather of the summer of 1830, I witnessed the opening of the bodies of twenty or thirty persons who died from this cause ; we found no organic disease of the brain, but merely a slight congestion, such as is observed in other acute diseases, which it would be idle to set down as a cause of death. These were the appearances in those only who died suddenly of exposure to heat; for if time elapses for reaction to come on, inflammation of the brain may take place, but it is then a secondary affection. The other two cases of apoplexy, occurring in the hospital, to which I shall direct your notice, offer varieties of the disease different from the first described. They were black men, who entered the wards in a state of complete paralysis of one side of the body, one of them scarcely able to speak. He could articulate but the monosyllable no, which he an- swered to all questions whatever that were put to him. He seemed con- scious of the ridiculous nature of this invariable answer, but could not increase his vocabulary for several months, when he was gradually able to pronounce the shorter words, and now speaks very well, although there is still paralysis of one side of the body. In the other, the speech was merely thick, but his mind remained tolerably clear. They continued in this state for several weeks, and as the process of the absorption of the clot advanced, the intelligence brightened, but the paralysis remained. These were cases of hemiplegia, one side of the body being affected ; that opposite to the side of the brain, in which the hemorrhage occurred. This latter conclusion we drew from a law of pathology to that effect, which is almost without an exception in its operation. There may be one, two, or three abnormal cases out of a thousand, but, in making your con- clusion, you may safely leave them out of the estimate. As the next consideration, in the study of the diagnosis, we had not only paralysis of the lower portion of the body, but also of the upper ex- tremity, and the muscles of the face, with disturbance of the intellect and senses, establishing, of course, the seat of disease to be the brain. The stiffness of the limbs was gradual in its progress, caused by inflammation around the clot; but the paralysis was, at the time of the patient's en- trance, perfect; and the mouth was drawn towards the side which was not paralyzed, which is the reverse of what occurs in cerebral inflamma- 678 GERHARD'S CLINICAL LECTURES. tion where the paralysis is active, that is, the mouth is drawn towards the palsied side. Our diagnosis and prognosis were at once made out; there was a hemorrhage on one side of the brain, and it was incurable, because the paralysis was complete, in which cases it is for life, but when it is in- complete the patient may frequently recover. The liability of apoplexy to return is a matter of notoriety, and a point perfectly well understood in the world ; you should, therefore, in all cases where it has once occurred, be on the watch, looking for a recurrence of the hemorrhage, which nearly always takes place near the same spot, be- tween the thalamus and corpus striatum. The cases under notice were not fair specimens for testing the treat- ment proper for the paralysis of apoplexy ; but some of you raay recollect a case, which occurred last summer, of incomplete paralysis in a woman, which yielded entirely to treatment in a week. Dr. Foville of Rouen, explains the different success of the treatment in paralysis from hemorrhage by the occurrence in some cases of an actual rupture of the fibres of the brain, while in others these fibres are merely separated by the effused blood without being torn across. I am myself inclined to this opinion, and be- lieve that the medullary fibres are actually broken in most cases of com- plete hemiplegia. The routine of treatment in apoplexy is simple and familiar to all medical men. Very free bleeding is of course indispensable, in all patients, who are at all plethoric ; if of a pale, anemic complexion, it is to be practised with some reserve. Purging, foot-baths, and cupping are to be resorted to, although the latter is not of the same value here as in meningitis, where it is our sheet-anchor. I here indicate merely the general outline of treatment to be pursued in apoplexy, not entering into any details on the subject. In regard to depletion, I may remark that it is a point of some delicacy to determine how far to carry it. My rule is, to continue depleting until the circulation in the vessels of the head is lessened, which is to be ascertained as well from the appearance of the eye and countenance as from the pulse. Purging I also push to some extent ; but you must be careful not to purge too violently, or that state of chronic softening of the mucous membrane of the intestinal canal, which was mentioned in a previous lecture as a frequent accompaniment of the exanthemata, may occur; it is a most unpleasant complication in paraly- tics, who rarely resist a diarrhoea long, however much they raay have been previously benefited by purges. Blisters, setons, and issues, are all used in apoplexy, but with indifferent success, although the keeping up of a discharge by these means, is excessively useful in chronic meningitis. If, however, the apoplectic symptoms are pertinacious, these remedies may be tried once or twice, and continued according to the effect produced. If you are called to a patient suffering from apoplexy, after the full mischief of the hemorrhage is produced, and perfect paralysis is estab- lished, it is your duty to announce at once to the friends of the patient the impossibility of his ultimate recovery, explaining to them the nature and amount of organic lesions existing in the brain, and the impossibility of an entire cure. The last point in the treatment of apoplexy to which your attention must be directed, is the sores which are likely to occur about the sacrum, trochanters, &c, if the patient is obliged to keep his bed for any length of time. The bladder is also apt to become diseased in this affection, and you must watch and guard against too long a retention of the urine. ACUTE SOFTENING OF THE BRAIN. 679 I shall conclude this lecture, by saying a very few words on the subject of acute or inflammatory softening of the brain. This affection is dis- tinguished from apoplexy, by the presence of fever, dizziness, and vertigo from the very beginning ; while you will rarely observe any febrile move- ment, in cerebral hemorrhage, till some time after the effusion of blood has taken place. The numbness of the limbs, which is a common symp- tom in softening of the brain, comes on very gradually, and, although the intellect is feeble from the first, yet the impairment of its faculties is com- paratively slow in its advance, there being at first, and for some time, merely dulness, and no active delirium afterwards. In a black man, under my care, four years ago, at the Pennsylvania Hospital, the delirium assumed the character of well-marked mania. This maniacal delirium is different from the more active kind occurring during the inflammation of the membranes and cortical substance of the brain. It is an affection which rarely occurs, except in the young and middle-aged, and is not to be classed with chronic softening of the brain, which is a sort of necrosis, or gangrene of this organ, and is met with only in old persons. In this latter disease, there is no active febrile movement whatever, the patient advancing, with unfailing certainty, from bad to worse, to death. The affection is dependent, according to Dr. Carswell, on a cartilaginous con- dition of the blood-vessels. Dr. Rostan, of the Salpetriere Hospital, ob- served the disease on a large scale, and has published a monograph upon the subject, in which he states it to be beyond the reach of treatraent. In this country, I regret to say, that our experience does not materially differ from that of Dr. Rostan. The acute softening is, then, nothing but cerebritis or inflammation of the brain, while the chronic disease is almost the reverse of inflammation. As the latter affection is incurable, and occurs exclusively, or nearly so, in very old people, it is of little importance in a therapeutic point of view : but the acute softening may be cured in many cases if treated vigorously from the first. This treatraent is similar to that recommended for menin- gitis, except that general depletion should be much more insisted upon ; local bleeding being of comparatively little value, at least in the early stages of the disease. The pain is often so slight in this disease as to lead the observer into an erroneous belief, that there is but little the matter with the patient, until either paralysis or decided mania supervenes. Hence a numbness of the side, if connected with disagreeable sensations in the head, or many signs of vascular congestion, ought to be treated with energy. LECTURE VIII. Apoplexy and inflammation of the brain (continued)—Functional diseases of the brain. I shall, this afternoon, again call your attention to some organic and functional diseases of the brain. It was my intention to have confined myself to the subject of functional cerebral diseases, but, owing to the termination of one of the cases of apoplexy, followed by acute softening of the brain, noticed in the lecture on these subjects, at the post-mortem examination of which some of you were present this morning, I am in- 680 GERHARD'S CLINICAL LECTURES. duced to recur to the topic. The impossibility of understanding the sub- ject of organic diseases of the brain without a knowledge of their patho- logy, is well exemplified by the case under consideration, while, on the other hand, you have seen how exactly the phenomena after death coin- cided with what we were able, from the symptoms during life, to announce would be the case, and how entirely the prognosis as well as diagnosis has been confirmed by the result. This case was that of Fisher, one of the blacks alluded to in Lecture VII. He entered the hospital a short time after having been seized with loss of consciousness, and other symptoms denoting an attack of apoplexy. The inflammation, excited by the clot of blood thrown out, induced an inflammatory softening of the structure of the brain, which seems some- times to be a useful process, and promotes absorption of the clot; it oc- curs from the same cause that gives rise to inflammations wherever a foreign substance is present in any portion of the body. The train of symptoms, announcing the existence of acute softening of the brain, we treated by cupping, purging, and a regulated diet, not using general bleeding from the enfeebled condition of the patient. Under this treat- ment, he was slowly getting better—he could crawl about the ward, and could articulate short sentences, when yesterday he was seized with a fit of convulsions, as the nurse termed it, and was found by one of the resi- dent physicians in the state of coma, with dilated pupils, &c, which soon terminated in death. The examination after death, this morning, ex- plained the occurrence of these symptoms. We found, first, the remains of the old apoplexy, which had taken place a year ago, probably a few days before the man's admission, as nearly as we could gather from his imperfect account of himself. The disease had occurred at several different points of the left hemisphere of the brain. The left corpus striatum was shrunk and shrivelled up, and unnaturally hard and indurated. On incising it, at the depth of the eighth of an inch, a well-marked cyst was found, rather raore than an inch long, and half an inch broad, lined with the usual serous membrane, which was not quite complete ; a part of the walls of the cyst were composed of loose cellular substance, filled with an opaque liquid. This serous mem- brane, lining the cavity, was not a true but an adventitious serous mem- brane, or rather sero-cellular, such as is thrown out in inflammation of the pleurae and pericardium. I have already told you, in a previous lecture, that these cysts are left after the complete absorption of the clot of blood. The evidence that they really arise from this cause is entirely complete ; it might, indeed, be inferred from the facts which relate to the cases just pointed out; but if you are not able to follow every step of the reasoning, I would refer you to the work of Dr. Rochoux. The cyst in question occupied one of the usual seats of cerebral hemorrhage. In addition to these morbid changes, there were the traces of a large apoplectic extravasation on the side of the brain, the conformation of which was obviously altered by a depression on the middle lobe of the left hemisphere, just behind the temporal muscle, quite unconnected wTith any alteration of the bone. The membranes adhered very closely to the substance of the brain, and beneath them was a partial softening of the medullary substance, which was of a light yellow or cream colour to the depth of about an inch, with APOPLEXY. 681 complete destruction of the cortical substance in a space of two and a half or three inches square, that is, in the whole extent of the depression, necessarily rendering that portion of the brain totally unfit for use. At the posterior part of this softened portion was an imperfect cyst, more than an inch long, the walls of which were formed by a loose cellular substance, extending to the distance of from a quarter to a third of an inch. Near the centre of the same hemisphere, about an inch from the summit of the brain, was a third cyst, scarcely an inch long, of about half that breadth, and somewhat flattened. Its walls were formed by a hard and yellow medullary substance, and it wras filled with a transparent liquid. One- fourth of the left hemisphere of the brain was, you thus see, destroyed ; it was, besides, distorted and drawn back, to a degree that I never before witnessed ; even the-anterior portion of the brain was turned partially round and backward ; this distortion may have interfered not a little with the exercise of the functions of the brain, and was the necessary result of cicatrization after a complete loss of cerebral substance. From this disorganised condition of the brain, which rendered a large portion of it as useless as if it had been separated from the body, and caused the entire removal by absorption of another part, you may under- stand the cause of the complete paralysis of the right side of the body, and its necessary incurability, which I predicted. But in addition to the im- mediate consequences of the apoplexy, other changes had taken place in the brain, not necessarily the result of hemorrhage ; these were connected with the recent active inflammation, from which the patient perished, as was shown by the softening around the old cyst. A symptom worth noticing w7as the loss of power of articulation, under which, you remember, the man laboured for a long period ; his answers were confined to the word no, and were afterwards brief and confused. Now there was no lesion, except that caused by the contraction, in the anterior part of the brain, which, of course, disproves Bouillaud's asser- tion, that the vocal powers are connected with this portion—a point which had, indeed, been previously satisfactorily settled by the observations of Andral and others. In this instance, the cortical substance of the brain was affected, although not in the anterior portion ; the cortical substance, I have no doubt, presides over the functions of the intelligence and of the voice. The corpus striatum is supposed to preside over the faculties of motion of the upper extremity; and here, you see, the patient regained the power of walking, though not that of moving his arra. This, however, proves nothing ; for it is a regular occurrence in hemiplegia following apoplexy. The therapeutics of this case are important ; the impossibility of curing it is sufficiently evident, and consequently, the necessity of confining your efforts in similar cases to such a plan of treatment as will palliate and improve the symptoms. Hence too, you may doubt as to the propriety of addressing stimulating remedies to the brain and nervous system, as nux vomica, or its active principle strychnia, to relieve a paralysis dependent on destruction of the cerebral structure. These remedies were much in voo-ue at one of our institutions a few years ago, for the treatment of apoplectic hemiplegia. I witnessed most of the cases, and I never saw them produce decidedly good effects, although pushed so far, in some cases, as to produce convulsions. Many patients, afflicted with hemi- plegia, in a degree recovered; but this occurred frora the mere process 682 GERHARD'S CLINICAL LECTURES. of absorption of the clot, and not from the effect of the remedy. Indeed, I must candidly express my opinion against the usefulness of the remedy ; and I am convinced that it often increases the activity of the circulation in the brain, surrounding the clot, from the over-stimulation of this organ. It is a valuable remedy in neuralgic paralysis, where there is functional disorder of the brain, or mere want of tone in the limb ; but when there is any considerable derangement of the cerebral structure, I am quite sure that it is often a hurtful medicine, even when given in minute doses, and suspended as soon as its effects appear. I make these remarks upon the strychnia, because its use seemed indicated in one of these cases of para- lysis ; and although I anticipated but little effect from it, I consented to its administration ; but it very soon became necessary to suspend it, frora the increase of the difficulty of speech, and rigidity of the limbs. I am aware that many physicians of high judgment employ and recommend the strychnia ; but my own observations, which were the more unbiassed, as they were made upon the practice of others, and not upon my own, have led me to a different conclusion. The true therapeutics in paralysis from apoplexy, consist first in subduing the inflammatory symptoras or the active congestion of the brain, by blood-letting, appropriate applications to the head, and purging ; afterwards in waiting patiently and quietly, in keeping from the patient all causes of irritation, and in regulating his diet; and after the clot has been removed, in addressing gentle stimulation to the paralyzed part; or what is better, in directing the patient to move it himself. Even this slight, and, as it were, natural mode of exciting the brain, may be attended wdth inconvenience. I lately directed a patient, in whom the paralysis was already of some months' standing, to move his arm every day by a powerful effort of will, and he went on until he suc- ceeded in raising his hand to his head, but the brain became excited, he wras stupid, and his speech thicker, and I was compelled to make hira desist. Avoid, then, all causes of excitement, whether medicinal or other, in these cases of paralysis, which are either the mere effect of a considerable rupture of the fibres of the brain, or are connected with the subsequent inflammation till very late in the treatment, and let it be con- fined to external stimulation. The case which we have just been noticing, illustrates extremely well the advantages of a knowledge of pathological anatomy, in the study of diagnosis. We were able to define with exactness the morbid condition of the brain, as you may see from the previous lecture, which corresponds precisely with that which a post-mortem examination has laid open. Now this verification, by means of examination after death of the lesions in a certain number of diseases, enables us to form a much more vivid and dis- tinct picture of the state of the analogous cases. We conceive, as it were, in our mind, a well-defined picture, and by a sort of second sight, can discover most of the changes, which are, under ordinary circumstances, completely concealed. If we gain but little direct assistance in therapeu- tics from pathological anatomy, we obtain a sort of touchstone, by which we judge of the power of remedies, and thus acquire ra*)re accurate notions of the effect of medicinal agents; we learn to discriminate between the natural course of a disease and the modifications impressed upon it by art. In itself, pathological anatomy is a mere instrument; but by its aid we are enabled to know positively a multitude of facts, which we can barely con- jecture from the unaided study of symptoms. Now, I would impress upon FUNCTIONAL DISORDERS OF THE BRAIN. 683 you the necessity of not attaching an exaggerated importance to what is a mere means of investigation ; you must never isolate the lesions of an organ from the symptoms which accompany them. I am the more earnest in insisting upon this matter, because you might imagine, from the careful pathological investigations which I endeavour to make, that I value this sort of knowledge for its own sake; this would be an error in which I should be loath to fall. In concluding these lectures upon diseases of the brain, I have some few remarks to make upon certain functional affections of that organ, oc- curring during the course of various disorders of the body. These affec- tions are very numerous, and often not a little puzzling in their character. For example, you no doubt supposed, when listening to the detail of symp- toms denoting tubercular meningitis, that the features of the disease must be always clearly marked, and yet there are affections that sometimes simu- late it to a degree that will embarrass a very experienced observer. It is no easy matter always to distinguish between diseases of the brain itself, and those which are symptomatic of other affections. Now,this can only be done by becoming so familiar with these functional changes, that you raay at once hold them up, as it were, in your mind's eye, and diagnosti- cate between them and the true cerebral diseases, by a rapid process of comparison, or as it is sometimes termed, by way of exclusion. That is, you run over the list of these analogous disorders, and then rapidly leave them out of your calculations, because some essential symptoms may be wanting. First, in fevers, intermittent and continued, particularly the latter, there occurs a train of cerebral symptoms which are placed amongst the most important symptoms of these disorders. Continued fevers, in this section of country, are almost wholly the typhus and typhoid fevers, with the ex- ception of the occasional occurrence of such as are styled bilious and ephe- mera], and are in themselves of little importance. In Paris, continued fever rarely takes any other type than the typhoid; while in Ireland and Great Britain, it is generally the typhus. In both these fevers, the brain is affected at the commencement, but in a less degree than in meningitis, the early symptoms of both being headache and dizziness, with loss of strength. In the second stage, there is stupor of great intensity in typhus and of slighter in typhoid, often running into delirium. We have, at this time also, in typhus, considerable disorder of the nervous system, indicated by spasms and subsultus, resembling those which occur in delirium tre- mens. The senses, also, are impaired in the second stage of both these affections, but more severely in typhus than in typhoid fever. In the last stage we have coma, complete loss of the powers of intelligence and of motion, and very nearly complete suspension of the senses. Sometimes we have violent, noisy delirium, which is to be looked upon as an irre- gular symptom, usually depending upon an accidental complication of me- ningitis with the fever ; when this violent delirium occurs, it is always to be considered and treated as a secondary meningitis. The ordinary mode- rate cerebral symptoms are, as it were, es.sential to the disease, and do not demand special interference, unless they should become intense, when they may be the immediate cause of death, and must then be treated as inflammations of the brain, by local depletion with cups and leeches, and by cold to the head, and the like. If this secondary meningitis of fever occur very iate in the disease, general bleeding is not often advisable. 684 GERHARD'S CLINICAL LECTURES. Treatment, although useless in slight cerebral symptoms, becomes essen- tial when they reach a high degree of activity. After coma supervenes, it is proper to abandon a depletory course and the cold affusions, and you are now to resort to counter-irritants, sinapisms to the feet, blisters to the nucha, and to the temples or over the posterior part of the head—remedies which are improper during the violent stage of the secondary meningitis. In the partial epidemic of typhus which occurred last winter, the fever was attended with more active cerebral symptoms than had previously shown themselves. I used local treatraent, in nearly every case, with extreme advantage, and found that, after removing the meningitis, the fever was almost free from danger. In the intermittent and remittent fevers, the functions of the brain un- dergo alteration, although there is rarely active inflammation of the organ. There is less disturbance of the powers of motion than in typhus and ty- phoid fevers, subsultus seldom occurring. The senses are not affected, and except in the height of the paroxysm, there is little ringing in the ears. These symptoms, however, are sometimes present in the malignant intermittents that we meet with in our hospitals, in the summer, occurring principally in sailors who have contracted the affection on the coast of North Carolina. In such cases, local depletion is not often advisable, for the cerebral symptoms are not confined to the paroxysm, nor do they re- semble those of acute meningitis ; they are rather loss of memory, sighing, and other signs of enfeebled nervous energy. They are best managed by large doses of quinine during the interval, and during the paroxysm by wine and volatile alkali. Upon these symptoms the danger of malignant intermittents chiefly depends. Of course this mode of treatraent is not designed for those cases in which there are signs of more active vascular excitement, requiring the treatment of the acute cerebral symptoms of typhus, or to cases in which the face presents a deep red or purple flush, as is the case in the apoplectic form of congestive disease. In pneumonia, there is usually some slight disturbance of the brain, which, indeed, accompanies, in a greater or less degree, all febrile affec- tions. Special treatment is required, only when there is either active delirium, or much stupor. When these exist, the case may be very rea- dily mistaken by one not well accustomed to recognise pneumonia. In the cerebral complications of pneumonia, the peculiar flush of the face, the dyspnoea, and dilatation of the nostrils, serve to distinguish the nature of the affection, while, if there be meningitis of a primary character, it will be marked by the brightness or injection of the eyes, frowm of the forehead, and absence of the purple hue, and dark red flush. In the cerebral complication of pneumonia, a special treatment is occasionally demanded, consisting of purging, and antiphlogistics directed to the brain. In inflammations of the serous merabranes of the thorax or abdomen, the brain is rarely implicated, except to a slight extent, corresponding with the vascular excitement. The same may be remarked of inflamma- tion of the mucous membranes ; in that of the bowels, the functions of the brain are not usually disordered, except in the last stage. If, how- ever, the mucous merabrane of a large extent of the alimentary canal be simultaneously attacked, then the brain sympathizes, and delirium very commonly ensues. In very severe epidemics of malignant dysentery there is also extreme prostration of the nervous functions, somewhat similar to what occurs in intermittent fevers. DELIRIUM TREMENS. 685 The connection between functional disorder of the brain and anemia, was alluded to in the last lecture, and illustrated very strikingly, by the history of a case which I then detailed. The sympathetic affection of the brain, in jaundice, is well known. We have a patient at this time, in the hospital, labouring under chronic gastritis and jaundice, in whom this cerebral alteration, depending on jaundice, is very manifest, and last year there were several marked cases of this kind. It is not, at least at first, of an inflammatory character; the symptoms being merely stupor and prostration, with subsultus, and particularly, loss of the memory. This set of symptoms indicates the connection which exists between this affec- tion and malignant intermittent and remittent fevers, and in both it de- pends, in my opinion, upon the altered state of the blood which accom- panies hepatic disease. Treatment is to be confined almost entirely to sinapisms and blisters, and occasionally some slight stimulants in addition to the general treatment for jaundice—cupping or other depletion should be rarely used. But if the more settled and acute symptoms of meningitis supervene, the treatment must at once be antiphlogistic. Dr. Marsh, an Irish physician of eminence, has also called the attention of the profession to the cerebral symptoms of jaundice, and recognises their great danger. Anemia, dependent on a vitiated condition of the liver, is attended with many cerebral symptoms, sometimes these belong rather to the nervous system and spinal column than to the brain ; in other cases there are many signs of disturbed action of the brain itself. It is to be treated by tonics, iron, porter, and a generous diet. But in many disordered conditions of the cerebral functions, the proper remedies are to be found amongst the narcotics and antispasmodics. On the same principle is based the prac- tice, recommended by Dr. Graves, for the sleeplessness and slight delirium in the latter stages of typhous fever, consisting in a combination of opium and tartar emetic. This is an excellent remedy ; the antimonial slightly nauseates, promotes gentle perspiration, and predisposes to sleep. The virtues of Dover's powder depend on the combination of opium with an analogous medicine, ipecacuanha, and, if the alimentary canal be in an irritated condition, this combination is to be preferred. I have entered thus minutely into the detail of these functional cerebral symptoras, and into the points which distinguish them in different affec- tions, because the symptoms, which are laid down in books, are more or less analogous in all these affections. The order of symptoms, however, is very different, and diagnosis becomes comparatively easy if wTe attend to their successive development. LECTURE IX. Delirium tremens—Symptoms—Stages—Varieties—Complications—Treatment. Delirium tremens is an affection which has special claims upon your at- tention, from the lamentable frequency of its occurrence in our country. It is here, amongst the labouring classes, particularly the Irish,* one of the * The very happy reformation which has taken place among the Catholic Irish require? this statement to be modified. 686 GERHARD'S CLINICAL LECTURES. most common of diseases, although in France and other continental coun- tries of Europe, it is comparatively rare. During ray residence in Paris I did not see a single case of it: in the hospitals of that city it is a disease that is never thought of, in patients who enter with cerebral symptoras, although with us cases of delirium tremens are more numerous in our hos- pitals than those of all other cerebral diseases together. I now present a case of simple delirium tremens. The patient has been a drunkard from his twelfth year, and he is now upwards of forty; the fit of intoxication which gave rise to his present disorder commenced before Christmas, and continued until his entrance into the hospital a few days since. On looking at this man, the first thing that strikes your attention is a universal restlessness ; the whole body is affected with tremours ; when he holds out his hand, he is unable to keep it still ; his tongue, when pro- truded, is similarly agitated, but not to the same degree. Besides these tremours, last night, and several preceding nights, the patient was affected with hallucinations of mind ; these are still present, but are much less manifest than they have been. As I have stated in a previous lecture, fear is an almost constant characteristic of these hallucinations of delirium tremens; but the fear is less of present, than of absent and imaginary ob- jects. From this fact we derive an important lesson in the treatment of this disorder; that is, never to excite the fears of the patient, but to re- lieve them as far as possible by permitting him to have free intercourse with others; this will divert his mind from those terrifying objects which his imagination brings before him. The patient is always conscious of these hallucinations until his intelligence is entirely destroyed. They are most frequent and distressing when he is shut up in a cell; in company they are much less so, and more under the control of his mind. In consideration of this subject, the important question occurs to us, what is mania a potu, or delirium tremens? It is not inflammation of the brain or its membranes; for the symptoms of these diseases are constant; there is a permanent disorder of intellect, and a lesion of muscular power throughout many parts of the body. In delirium tremens, on the contrary, there is no such constant and decided muscular disorder; there is no rigi- dity or paralysis, but only agitation and inability to keep still. Nor is there any positive defect of vision, or of the other senses, other than illu- sions or hallucinations; they are still perfectly retained, and entirely under the control of the patient. The condition of the intellect is likewise dif- ferent; in inflammation of the brain there are rarely hallucinations, pro- perly speaking, but a more or less complete destruction of consciousness and aberration of intellectual power; in both these respects, we observe an opposite condition in delirium tremens. This marked difference in the symptoras is explained by a reference to the pathology of the two diseases. In inflammation, there is injection of the membranes or substance of the brain, with thickening of the former, and various other organic lesions. In delirium tremens there is no organic change ; the only abnormal ap- pearance which can be detected, is an effusion of serum into the ventri- cles of the brain, and a preternatural moisture of the cerebral substance. This superabundance of fluid arises from the continued irritation to wdiich the brain is subject, and the slowness with which it occurs; it is not the cause of the symptoms; they are produced by the irritation, which, after it has continued for a longer or shorter period, gives rise to the effusion. The two diseases also differ in their progress. Mania a potu, like mea- DELIRIUM TREMENS. 687 sles, scarlatina, &c, has a definite course and a natural termination ; it must disappear after a certain time, unless the attack be a very severe one. No treatment is of any further use in the mild cases than to diminish the inconveniences of the disorder ; any treatment which is not directed to this simple end, proves injurious by irritating and harassing the patient. Delirium tremens begins in two different ways. The most common is that in which from some cause, as accident, disease, or resolution of the patient, or inability to obtain intoxicating drinks, the patient suddenly gives up his accustomed stimulus. This is the most simple variety, and under ordinary circumstances, after a period of restlessness of two to three days, passes through a natural crisis, consisting in a prolonged sleep of some hours, and terminates in recovery. If no untoward circumstances occur, the sleep will follow of itself, and the disease is therefore strictly a self- limited one ; treatment merely assuaging the suffering of the patient and diminishing the mortality. The second mode of invasion is that in which the delirium tremens is most apt to be complicated with inflamraation or congestion of the brain or stomach, or with convulsions. The patient con- tinues to drink freely until his attack, but the stimulant is taken irregularly, or acts irregularly, strongly exciting the brain at one moment, and then leaving the patient in a state of depression. The circulation is often much excited, and the face flushed, and the eyes injected. These cases are apt to be attended with convulsions of a mixed form, sometimes resulting in apoplexy, at others epilepsy. These convulsions sometimes, though rarely, occur immediately on a debauch, more frequently, however, they take place in patients who are in a state of vascular as well as nervous excite- ment from intemperance, and suddenly abandon all stimulants. The con- vulsions, and indeed this variety of the disease, are not so frequent in the poor as in those who, with more means of gratifying their vicious desires, are sunk into greater debauchery. The hallucinations and other disturb- ances of the intelligence are less marked in this variety than in the ordi- nary form. We may state this by saying, that the vascular and nervous symptoms are more developed, but the intellectual less so. For the study of ordinary delirium tremens, it is convenient to divide the disease into three stages :— (a) First Stage. This is well known amongst drunkards as the horrors: a term which expresses the aspect of the patient, which is that of extreme anxiety and agitation, and the distressing feelings of fear which the patient experiences. The anxious alarming expression is one of the most cha- racteristic symptoms of the disease, and with the tremour, which is equally remarkable^ it constitutes the only pathognomonic character. The tremour extends to the whole muscular system, but as it may be to a certain ex- tent restrained by a voluntary effort of the will, or by supporting the weaker muscles of the limbs against the trunk, it is sometimes not very obvious unless the patient is directed to put out his tongue, or to hold up his hands, where it is at once perceived. The restlessness and tremour are the most frequent and important symptoms of the first stage of the dis- order, but are by no means the only ones ; the others, however, are only accessory or secondary, and vary with each patient. As a general rule, the pulse is feeble and frequent, the mind is unable to direct itself long to any single subject, and the pupils are slightly contracted. The complex- ion is extremely variable ; it is often pale if the patient has not been long addicted to intemperance, but, in the majority of cases, it retains the usual 688 GERHARD'S CLINICAL LECTURES. tint of the drunkard's countenance. The appetite fails, the bowels are often constipated, and there is generally more or less thirst. In this stage of the complaint the restlessness continues throughout the night, and of course the patient is unable to sleep: sometimes, the sleeplessness is the first symptom of the disease, but in the majority of cases it attends the restlessness, and is strictly proportioned to it. The agitation may gradu- ally subside and the patient recover, or the disease may pass into the next stage. (6) The second stage of the complaint presents the same symptoms as the first, but in an exaggerated degree, the tremours, restlessness, and in- somnia are increased, and the appetite is more completely destroyed. The pupils are more contracted ; if, however, the patient has not taken opium, the contraction of the pupils is never very great. The distinctive symptora of the second stage, is the illusions which at first occur only at night, when the patient is left alone, and in the dark. These halluci- nations are perfectly under the control of the understanding when the courage of the patient is revived by light and society : he is then perfectly aware of their nature, and will often laugh at his own fancies. The illu- sions are not confined to the night, if this stage become more confirmed, but they still remain perfectly under the control of the will and of the in- telligence ; if the disease continue, the illusions become more and raore frequent, and cease to be recognised by the patient, that is, they are com- pletely confounded with real objects. The attention may still be directed to surrounding objects, and the patient is capable of answering ordinary questions with perfect correctness, if he is addressed in a sharp, decided tone of voice, and there is no incoherence in his answers, so long as his attention can be commanded. These illusions are nearly always of an alarming kind, and are as varied in their nature as the objects which hap- pen to be most familiar to the patients ; devils, guns, fire, serpents, and the like, are the most common objects of his fear. At other times he feels a vague dread that his life will be taken, and earnestly entreats that it may be spared. These illusions are so well characterized, that they have always been regarded as the essential character of true delirium tremens ; this is nearly but not absolutely correct, for, in some cases, the tremours are not attended with illusions, but on the contrary, the mind of the pa- tient is almost clear, and the disease may prove fatal, although no illusions present themselves, by the occurrence of convulsions or sudden insensi- bility. Still, in the regular simple variety, of which I am now treating, the illusions may be regarded as a constant symptom. The other symp- toras of the second stage are not pathognomonic, and with the exception of the countenance, which retains the same restless expression as in the first stage, are not even characteristic. The pulse is frequent, and gene- rally small, the frequency evidently depending rather upon the extreme agitation of the patient than any regular connection between the state of the circulation and the disease. The appetite rarely returns during this stage, although this is sometimes the case ; the tongue is generally furred, but rarely dry. The skin remains moist throughout this stage, and if the efforts of the patient to escape from confinement be constant, or if his agi- tation be very great, the sweat is often very profuse. This sweat is of a different character from that wThich generally occurs during the third stage of the disorder, and seems to be strictly dependent upon the constant ex- ercise which the agitation of the patient obliges him to take. The second DELIRIUM TREMENS. 689 stage may gradually decline, and the patient fall asleep, and recover ; or it may pass into the next stage. Sleep is nothing but the indication of the recovery ; it follows rather than precedes the decline of symptoms. The insomnia arises from the extreme nervous disturbance which is the essential element of the disease, and although the fatigue of the patient may be extreme, he is still altogether unable to sleep. Let the nervous agitation be quieted by any means, and sleep will immediately follow, and will finally complete the restoration. This is the true rationale of the close connection between sleep and recovery, which has certainly been misunderstood, and has led to erroneous deductions as to the treat- ment of the disease. If the disease be completely removed, the patient will sleep for a long time, and will generally awake perfectly restored. In some cases, however, the recovery after prolonged sleep is not com- plete, but the disease recurs again, and is not completely cured until a day or two afterwards. If the prolonged sleep occur naturally, it is always productive of great relief to the patient, but if it be forced by the opera- tion of narcotics in large doses, instead of conducing to recovery, it will sometimes end fatally, and the patient may then die without awaking. A short sleep of one, two, or three hours is refreshing, but is not usually fol- lowed by immediate recovery, although it affords an evidence of the gra- dual decline of the disease. If delirium tremens be well treated, or if the disease be essentially mild, but few cases pass beyond the second stage ; recovery taking place without difficulty. (c) The third stage is attended, like the others, with a symptom which is characteristic ; that is, incoherence. The illusions either cease, or they are no longer connected,—the patient passing from one object to the other with great rapidity, and not reasoning correctly or connectedly upon the images which are presented to his mind. He becomes feeble, but is, at the same time, extremely agitated, and can only be retained in bed by the constant watchfulness of an attendant, or by straps or bandages. The sweat becomes profuse, the skin sometimes cold, at others warm, and pupils greatly contracted. The contraction sometimes ceases before death, and may be succeeded by a morbid dilatation, if there be much serous effusion upon the brain. The senses become gradually more and more obtuse, from the first appearance of incoherence ; the patient generally loses his power of attention, and can with great difficulty be induced to direct his attention to surrounding objects, and as the disease advances, he becomes completely comatose, and generally lies in a state of insensi- bility for some time before death. The pulse gradually fails during this period, and the patient often presents symptoms of nervous disturbance, which are very analogous to those which take place in cases of typhus fever, such as subsultus, spasmodic tremours of the muscles generally, and muttering delirium. . ,. , Emetics have frequently been employed for the cure of this disorder. They act by producing relaxation and diaphoresis, and in some cases this practice succeeds very well. . But in other cases (especially in that sort which is not unfrequently met with in private practice where the disorder is brought on, not by a fit of intoxication, but by a long course of free drinking), emetics may do a great deal of harm ; instead ot tranquillizing the system, they sometimes produce a great deal of prostration which, in some cases that I have seen, has undoubtedly been the cause of death. Tartar emetic is particularly liable to this objection. 45 :r 6-t~M $ „ 4"/^- '**■"?', ft /f m „ /jr>/h/£* ^JL^u3 *2 '}>?*'&&. 690 GERHARD'S CLINICAL LECTURES. Of the various other remedies employed in the treatment of delirium tremens, opiates have probably received most attention. I formerly used these remedies in almost every case, though not in as large doses as some of my brethren ; but when I was a resident physician in this hospital, we were directed to give opium in very large doses,—frequently as much as 1 ) four grains every two or three hours, until sleep was procured. The pa- tients, for the most part, got well under this treatment; but in estimating the value of a particular plan of treatment, we ought to consider the pro- portional success of this and other plans. A comparison of this sort will prove that opium is not the most effective remedy in mania a potu* In conjunction with this remedy certain hygienic regulations were also en- forced at the time to which I have alluded. The patients were locked up in cells, and if very disorderly, that is in every severe case, they were confined in a strait jacket, or tied in bed, with gloves and straps. The practice of the hospital has never been to give opium to the exclu- sion of other remedies; it was alwrays the custom to use cups and cold applications to the head, purgatives and various other remedies, when they seemed necessary. From time to time a change would be made in the practice, and the affection would either be treated upon empirical grounds, in accordance with the varying symptoms, or the emetic practice would be pursued. But the plan of treatment, by opiates and confinement, is the one that was almost universally practised in Philadelphia several years ago, with variable results. In my own practice 1 have gradually diminished the quantity of opium which I formerly gave, and for some time past have not used it at all. Instead of it, I have relied in bad cases upon the stimulant treatment which had been always followed in some plans; that is, the use of stimulating remedies, particularly alcoholic liquors. These articles I first employed in conjunction with opium, or prescribed them without opiates, in two different conditions: 1st, in the slighter cases, or those of incipient delirium tremens; or 2dly, in the severe cases where opium had been employed but was followed by distress of mind and stupor. But at present I use them singly. This treatment has diminished the mortality of the disease. The change which I have adopted in the hy- gienic rules has also contributed very decidedly to this result. Instead of confining the patients, I let them walk about and enjoy the company of others as much as they choose : merely taking care that some one should be near them to prevent accidents. I was led to this change by observing that the hallucinations which attend the disorder were more distressing when the patients wTere in a state of confinement than when they were allowed to walk about as much as they wished. As I have already remarked, they are capable of controlling these hallucinations, until the intellect is entirely destroyed ; and they can do so the more easily when they are surrounded by ohjects which serve to engage their attention. Confinement always irritates them, and increases their ravings, so that the third stage, in w7hich the intellect is entirely destroyed, is apt to be brought on very speedily. I have very often tested this by a simple experiment; a man who was confined to his bed by a strait jacket, or something of the kind, I have frequently directed to be dressed, have soothed him by conversation, and after requiring a promise that he would conduct himself with propriety, I have very seldom found reason to be dissatisfied with the result. On the contrary, the disease wTould almost ^ ,>l* * frr~~* — rvT^.^^ ( u^ W.. u4a^ ^ Ov^ uw,^^ J^Iu DELIRIUM TREMENS. 691 invariably become milder, and the necessity of confinement cease. It is true that confinement is often necessary at night, from the impossibility of always providing a sufficient number of attendants. I therefore (with the exception just stated) allow the patient to have full liberty, the only restraint being the presence of the keeper: sometimes, also, I direct them to be set at work, which serves still farther to distract their attention. + The proportional mortality under the two plans of treatment which I have detailed, is represented in the following summary, comprising the number of cases treated amongst the men for the space of 5^ years—that is, from the 20th of May, 1834, to the 13th of November, 1839. The whole number of cases admitted for delirium tremens, or intemperance which was expected to terminate in delirium tremens, was 1241. Of these, there were 1198 whites, and only 43 men of colour. Of the whole number, 708 were decided cases of delirium tremens, 60 were slight cases, and 430 cases of mere intemperance. Of the latter, some termi- nated in decided delirium tremens, and others proved fatal from diseases (such as pneumonia) contracted during the fit of drunkenness, for which they had been sent to the lunatic asylum. So that this class furnishes a considerable number of bad cases. Of the whole number 121 cases proved fatal. That is, a fraction less than one in ten. In the first year, from May, 1834, to the same date, 1835, the number of admissions was 141 ; of these, 18 died : that is, rather more than one in eight. In the second year, the number of cases was 211, the deaths 24, or a little more than one in nine. The third year, in 301 cases there were 47 deaths, a much larger proportion than in preceding years, one in 6|y, but depending upon an accidental cause, that is, the coincidence of an epidemic of typhus, which attacked many of the debauched subjects of intemperance: some of them were sent to the lunatic asylum as labour- ing merely under the effects of intemperance, and could not be afterwards removed to the proper ward. In the fourth year, beginning May, 1837, of 206 cases, 19 only proved fatal, that is, about one in eleven. This was a decided amelioration, and coincides precisely with the epoch at which the change of practice was introduced. In the fifth year the mortality went on diminishing, and was less than one in twenty-six ; or of 274 cases, 9 only were fatal; and amongst these cases, the mortality was certainly greatest in those which were treated chiefly according to the method formerly pursued at the hospital. Finally, in the six months, ending November, 1839, the mortality was only one in 33f, that is, 4 cases out of 135 ; and of these four, one entered moribund, and was not, therefore, treated in the hospital ; ano- ther had inflicted upon himself several fractures and other injuries, by leaping from a third story window, in a fit of delirium tremens, pre- viously to his entrance. The others, it is believed, were also complicated cases. The preceding summary of the results of the treatment, is extracted from a lecture which I delivered at the Philadelphia Hospital, in Decem- ber, 1839. The results of the treatment for the last year, up to October, 1840, have been still raore satisfactory. The number of cases of the sequelae of intoxication, and of delirium tremens in the three stages, ad- mitted into the men's wards of the Philadelphia Hospital, from O-tober 12, 1839, to October 12, 1840, is 223. Of these, 61 were classed under 692 GERHARD'S CLINICAL LECTURES. the head of intoxication, or its immediate sequelae, some of them passing into delirium tremens. If we exclude the whole of these 61 cases, there remain 162 cases of decided delirium tremens ; of these, 87 were admitted in the first stage, 73 in the second, and 2 in the third : 160 cases reco- vered, and one remained convalescent, who is since well (Oct. 16). One only proved fatal: this patient was admitted in the third stage of the disease, and died in a few hours after his entrance ; he had been treated with opium, and a box of pills, which he was taking, was sent to the hos- pital with him. Of course, this apparent exception confirms the general conclusion, that the disease terminates favourably in every instance, when treated according to the method recommended. Up to the present date, August, 1841, from November, 1840, the mor- tality, including complicated and moribund cases, has been about one per cent. That is, in no case in which the stimulant practice was thought necessary did it fail, except in those in which, frora the late adraission of the patient, or some other accidental cause, it was not fairly tried ; and counting all such, the ratio still remains insignificant ; while the opiate practice yielded a large mortality under the same circumstances. I do not, however, think it necessary to resort to alcoholic stimulants in slight cases ; and still less in the slight gastric nervous disorder which follows simple intemperance, but does not amount to delirium tremens ; some- times it is better to avoid them carefully under these circumstances. The plan of treatment which I have found to answer best, is as fol- lows :— If a patient come under your care partially intoxicated, but still labour- ing under some of the premonitory signs of delirium tremens, give him an emetic of ipecacuanha : he will in general be disposed to sleep after its operation ; when he awakes, or soon after taking the medicine, if he does not sleep, he will complain of gastric uneasiness, and often of slight nervous symptoras. Fresh air, exercise, and a strong infusion of gentian, or some other bitter, with capsicum or ginger, will then do much to allay the irritability of the stomach and diminish his discomfort. Alcoholic stimulants are not necessary in such cases ; and these simple remedies constitute my usual treatment. If the disease promise to become raore protracted, a mixture of lac assafoetidae, with tincture of valerian (ammoniated) and Hoffman's ano- dyne (3SS. of each of the latter remedies with ^iij. of lac assafcetida every two hours) are of great benefit in tranquillizing the patient. As a drink, he may take a bitter infusion with an aromatic. These remedies, with exercise, and as nutritious a diet as the stomach of the patient will bear, are sufficient to remove the symptoms if they are slight. If the disease become more decided, and pass to hallucinations, espe- cially if these are not recognised as such by the patient, the stimulant practice may be resorted to. The severity of the disease from the first is, however, a better guide than the mere occurrence of hallucinations. Thus, if the disease be very violent, even before any hallucination can be detected, the patient raay take alcoholic stimulants; but it is especially in those cases in which both tremours and hallucinations are present that the stimulant practice is applicable. The same treatment is indicated when the patient is threatened with convulsions ; but if the face be flushed, and more or less livid, the cold affusion, or the simple application of ice to the head, should be conjoined with the stimulants. DELIRIUM TREMENS. 693 Various alcoholic preparations will answer the same end. Whiskey with quassia is by no means palatable, and at the same time suits well with many drunkards, but some of them are nauseated by it and require brandy, gin, or the like. The dose is necessarily very various: on no account, and under no circumstances, is it either necessary or proper to give a sufficient quantity to render intoxication possible. Our object is the very reverse of this : it is simply to tranquillize the agitation of the nerves by small doses of a poison to which the patient has been accus- tomed, but not toxicological doses ; and these small doses may seem large in some patients, although they are in reality small compared with their habitual allowance. For most purposes, one ounce of the above-men- tioned stimulants may be given every three or four hours ; in bad cases, two ounces may be given every two hours, for a few doses, and then in a less dose. In very few cases was this quantity exceeded, and then only for a very short period, when the life of the patient appeared dependent upon the prompt revival of his sinking powers. If the patient be feeble, the stimulant may be given in the form of milk-punch, or in arrow-root. The largest dose is generally required for a single day, afterwards it should be gradually lessened, and after a sound sleep, or as soon as there is a decided diminution of the tremours, all alcoholic remedies raay be given up and supplied by a simple bitter infusion, or the assafcetida mix- ture. In some cases the cure takes place, as it were, abruptly, and the patient is at once restored to health ; in others, after the cessation of vio- lent symptoms, the patient may remain in a nervous state with some tre- mours, but no decided hallucinations : there is at the same time in many cases some indications of active excitement of the brain. This state of things is, however, much less frequent after the alcoholic than the opiate practice ; but in either case, the best remedies are a smart purgative, exercise in the fresh air, and cold affusions on the head. There are often complications which require some modifications of the treatment, but they are less frequent than in the opiate practice. The most common is gastritis ; to a greater or less extent it may be said to be natural with drunkards, and ceases in a great degree as soon as the cause is removed ; if it be not very intense, it requires no special treatment. This slight gastritis is often attended with vomiting, which ceases after an emetic, or the administration of the usual stimulants. If, however, the disease be severe, with red tongue, and great tenderness, and constant vomiting, all stimulants should for a time be suspended, or they may be given in small quantities and iced. Bladders, or cloths, containing ice, may be applied to the epigastrium, the proper diet for gastritis directed, and cups and leeches may be used if the former remedies prove insuffi- cient. When the gastritis becomes very intense, the symptoms of delirium tremens in general subside, and seem displaced by it ; and the brain symptoms become then secondary to gastritis, such as fixed but muttering delirium. These are often confounded with those proper to delirium tremens. Congestion or inflamraation of the brain may complicate, replace, or succeed to delirium tremens: when they appear as mere com- plications they may often be relieved by the means I have indicated without suspending the treatment proper to the disease. But if the vas- cular disturbance of the brain constitutes the disease, and the delirium tremens is either not developed or disappears, the treatment becomes that which is adapted to the particular cerebral state, and venesection is some- 694 GERHARD'S CLINICAL LECTURES. times under these circumstances of immense value ; but, as a general rule, local bleeding, revulsi\res, and refrigerant applications, are better means of restoring the balance of the system. These vascular affections of the brain are always produced in some individuals after a debauch, or even moderate indulgence ; in a few they may occur upon taking a single glass of wine. Of course, in the latter case they are dependent upon a peculiar idiosyncrasy, in which a very small dose of an alcoholic stimulant acts as a virulent poison. If the vascular excitement of the brain from a debauch be not attended with the symptoms of real delirium tremens, or if they be very slight, and be concealed as it were beneath those of excitement, then it is very clear that the case should not be treated as one of de- lirium tremens;—an error of diagnosis in this respect would be mis- chievous. In pointing out to you a mode of treatment which a long experience has shown to be safe and remarkably certain in its results, I am very far from excluding other means as injurious ; on the contrary, many of them may be used in connection with the stimulant practice, or may be substi- tuted for it, if you have strong objections to this mode of treatment. Should you prefer opium, I would warn you against giving it in very large doses, except you can observe the condition of your patient before administering each of them. By combining opium with tartar emetic or ipecacuanha, you may succeed in producing calm or sleep in smaller doses than if given alone. Although it wTas the remedy formerly relied upon in the hospital, I have not administered it for two years, except in rare cases for some intercurrent disease, such as dysentery. In some in- stances, as of fractures of limbs, &c, it may be necessary to use opium, but these are rare: there is another case in which it may be of service, that is, when the patient is tranquil, but still sleeps little ; a moderate dose of opium is then at times of service. In recommending to you a practice of this kind, I do so simply because I believe it to be a duty to inform you of the results of my experience in the treatraent of this disorder. The great success of the treatment is a matter of demonstration ; while there can be no possible objection to the practice, except the fear of giving something like a sanction to the asser- tions occasionally made by drunkards, that they cannot do without their stimulants. This, however, is clearly an error: the continued use of alcoholic liquors even as a remedy is always injurious and reprehensible ; but this is very different from their employment during the two or three days of an attack of delirium tremens. The examination of the records of the hospital do not show that the admissions for delirium tremens of the same individuals are at all influ- enced by the treatment in previous attacks, whatever that may have been ; on the contrary, there is strong reason for believing that such is not the case. The thirst for alcoholic drinks, once acquired, can only be over- come by a moral action and a strong will on the part of the patient ; hence, it is extreraely rare to find a drunkard reformed from fear of illness or suffering. The will to abstain, for it requires an act of strong volition, must come from other reasons; and the influence of the societies which are now labouring in the reformation of the intemperate, is certainly en- hanced by the support which they receive from mutual encouragement giving strength to the feeble will of the intemperate. After a treatment, or after an attack without treatment, of delirium tre- DYSENTERY. 695 mens, the patient should break up his old habits of association of tirae and place, take a journey, engage in some new and active employment. Shower-baths, or simple cold baths, with some light purgatives, are use- ful in dissipating the remains of the disease, and in favouring sleep when the disease is no longer in its most active stage, but is not entirely re- moved.* LECTURE X. Dysentery—Varieties—Diagnosis—Anatomical lesions—Treatment. Dysentery is a disease of unfrequent occurrence in the cold seasons of the year. It is most commonly met with in summer and fall, the liability of inflammation being transferred with the approach to winter, from the bowels to the lungs. I, however, present two cases of dysentery, one of the acute, the other of the subacute form. The latter is that of a man aged sixty-five years ; he has generally en- joyed good health : on his first admission into the hospital, he had inter- mittent fever, from which he recovered, and went about his usual em- ployment. About a fortnight after this (on the 1st of October), he was again admitted, having been seized with dysentery two days before. It came on with frequent discharges frora the bowels, which were watery, and passed with little pain. In a few days the character of the stools changed ; they became yellowish, and were composed of thin fecal mat- ter, mixed with mucus ; but there was no blood. The patient has also suffered pains, but of no great severity, along the course of the colon, from the caecum to the sigmoid flexure. He has not experienced nausea ; his appetite has been tolerable ; he has suffered little from thirst. The skin has been harsh and dry, with considerable emaciation, and a coun- tenance indicative of griping pain in the bowels ; the features which give to it this expression, are the frown on the brow and compression of the lips. The degree of emaciation has varied frequently with the intensity of the case ; being on one day extreme,—the next much diminished. The pulse has been sometimes quick, sometimes slow ; it now beats 96 in the minute. The skin is cool; there is, therefore, very little fever, nor has there been much at any time in the course of the disease. The tongue has been, throughout, dry, cracked, and red, as it almost always is in severe cases of chronic dysentery. This appearance of the tongue is not so frequent in acute dysentery, because the inflammation requires some * Since the time at which this lecture was delivered, I have seen no reason for making an important change in the opinions I had at that time formed from a very extended observation of delirium tremens. I still rely mainly on the alcoholic remedies in cases of the d.sease and believe that they, either alone or given in conjunction with some other st.mulant, constitute the surest means of bringing the disease to an early resolution. I do not, however, object so stron-lv to the use of opium in private practice as in hospitals. It there seems to be oftener a matter of necessity to give opiates than it is in the wards or cells of a h,spual, where provision fe made for the convenient treatment of patients labouring under delirium tremens. In hos- pital even the use of opium ought not to be neglected ; it is often a valuable adjunct to the other remedies for the disease and may be given with safely, provided it be not adm.n.stered use less- To without inquiring carefully into the condition of the pat.ent But ,t is certamly no on he whole the best or safest remedy for the treatment of cases ot del.num tremens. It ought o be used as a useful assistant to the other means of treatment, and not to be regarded as the only agent capable of quieting the nervous disturbance, which constitutes the main feature of the disease. June, 1848. 696 GERHARD'S CLINICAL LECTURES. time to extend itself up the alimentary canal. In chronic cases we often find this condition of the tongue attended with a disagreeable taste, and even ulcers in the mouth. The patient's tongue is now become natural; abdomen slightly tender, and not retracted. The acute case is that of a woman, forty years of age. She was adrait- ted on the 12th of November. During the summer, she had an attack of dysentery, and has since been confined in the wards with rheumatism, but had recovered. Her present illness commenced on the 10th inst. The discharges were frequent and watery ; on the 12th they contained mucus with some blood. She has had fever, but no chills ; nausea, but no vomiting. 15th. The countenance is anxious ; abdomen extremely tender and pain- ful; stools passed every hour; they contain mucus, but no blood. To-day (16th) the blood has reappeared in the stools. This disappear- ance and reappearance of blood in the stools are of frequent occurrence in acute dysentery. The history of the case shows that the stomach has re- mained nearly intact, the disease being confined to the large intestine. Present condition of the patient.—The countenance is very slightly flushed, especially the lips ; there is no compression of the lips, as in the former case ; the countenance expresses nausea and disgust, rather than griping pain. The skin is moist and pleasant, but has been warm and more dry. The tongue is covered with a brownish fur, but moist; there is some pain on pressure all over the abdomen, but it is especially severe in the trans- verse colon and sigmoid flexure ; pulse moderately strong, but compressi- ble, and beats 110. The intellect is confused and weak, but this condi- tion is habitual to this woman, and is not connected with the disease. I now present a case of tubercular diarrhoea ; a disease having a close analogy to dysentery. The disease has continued for two months, the pa- tient having for some time previous been labouring under phthisis pulmo- nalis. Since the commencement of the diarrhoea the pain in the chest has continued, but the cough has declined, as almost always occurs in such cases. The diarrhoea seems to act uniformly as a revulsive, and stills the cough, or sometimes removes it for a time. The patient passes five or six stools daily ; they consist of ordinary fecal matter, mixed with serum, but no mucus or blood. The diagnosis of dysentery is, in general, easy in acute cases. The tor- mina and tenesmus, and peculiar stools are sufficient to distinguish it. But in the chronic form of the disease the diagnosis is more difficult, as it is apt to be confounded with that form of diarrhoea which is produced by a tubercular condition of the follicles of the small and large intestine, and is usually preceded by a similar condition of the lungs. We are to distin- guish them by the history of the case. Tubercular diarrhoea is, in most cases, preceded by phthisis pulmonalis, that is, the disease generally begins in the lungs before it attacks the bowels. The discharges are generally irregular as to amount and frequency, and they differ in nature also from those of dysentery, as is proved by reference to the above cases. Anatomical lesions.—Dysentery is an inilammation of the large intestine, as is sufficiently indicated by the position of the pain. This inflammation and its consequences in some cases extend a short distance into the small intestine, and even to the stomach; but it always commences in the large intestine, and is generally confined to it. It mostlybegins towards the lower end of the colon, and is sometimes restricted altogether to within a short DYSENTERY. 697 distance from the anus. The inflammation produces ulceration in various degrees; thickening of the mucus, and other coats; contraction of the cali- bre of the intestine, from the spasm of the muscular fibres ; and also slough- ing of the mucous membrane, which may thus be extensively detached. The mucous follicles suffer much from the disease, and the ulceration gene- rally begins in them, and then assumes a regularly rounded form ; then smaller ulcers run together, and finally give rise to the extensive destruc- tion of the mucous coat which occurs in most bad cases of dysentery. The anatomical lesions of this disease are of importance for the prognosis; for when you have become familiar with them you may readily understand how slow the intestine is to recover its normal condition; indeed, it is apt to remain for a long time more or less diseased, notwithstanding the dimi- nution of the symptoms. The contraction of the gut is one of the greatest obstacles to perfect cure when the ulceration has been extensive, for it can no longer bear the distension caused by the passage of fecal matter, and every new process of defecation is a new irritant to the denuded surface. It is, however, surprising to find that the intestine will sometimes, though rarely, regain a healthy state after the most extensive sloughing and ulce- ration. That is, it will regain very nearly a normal condition, but, per- haps, remain a little raore irritable than usual. These remarks are appli- cable to the protracted cases of the disease, where the ulceration is deeply seated, and the powers of restoration have declined. When the disease is acute, the most extended ulcers will cicatrize kindly, and leave behind a smooth cicatrix, with puckered edges. These I have often seen months and years after an attack of acute dysentery, in patients who have died of diseases in no way connected with it. The depth of the ulcers is, there- fore, raore important than their extent. But the inflammation of the colon is not all ; there is something more ; and you will rarely find that patients can be said to labour under a local disease if the dysentery be severe. But although in the simple state it is certainly little else than a mere colitis, the complications render it danger- ous, chiefly because the blood and the cerebral system are involved. Still, the inflammation of the colon is, in all cases, the fixed anatomical character of the disease. Treatment of dysentery.—In the acute form of the disease, the treatment is sufficiently simple. The usual antiphlogistic means are required, with local applications to the inflamed mucous merabrane, calculated to allay its irritability and remove its morbid secretions; these local remedies are narcotics and laxatives. In the practice of this hospital, especially during the present year, we rarely find it necessary to bleed. We give first a dose of castor-oil, and then make use of the oily mixture. Calomel, either alone, or combined with opium or ipecacuanha, is by far the best remedy in severe cases; we sometimes also use ipecacuanha alone, or Dover's powder. In most cases mercurials are sufficient to effect a cure as soon as they produce ptyalism, or just before, when the symptoms of acute dy- sentery often cease at once. Half, or a quarter of a grain of calomel, every two hours, will salivate in three or four days. It is usually combined with opium, to allay the griping, and prevent purging; or the pulv. ipecac, et opii may be employed in place of the opium, to effect the same objects. I also frequently use ipecacuanha, either alone, or combined with opium or calomel. In the case of subacute dysentery before us, I have employed these remedies, at times resorting to the acetate of lead, and various astrin- 698 GERHARD'S CLINICAL LECTURES. gents, without much advantage; Dover's powder has produced the most benefit. In the acute case you saw to-day, I gave half a grain of calomel, with three grains of Dover's powder, every two hours. I rarely employ calomel as a purgative in this disease. I use it for a few days only, to produce its specific antiphlogistic effect,—that is, until slight ptyalism is induced. If it is not then attended with good effects, it should be given up : a continuance of its use will do much injury, and tend to increase the ulceration of the bowels. This is a peculiarity in the action of mercurials ; in many acute inflam- matory diseases, the advantages to be gained are when the point of very slight ptyalism is reached, which is a test of the operation of the remedy, and the system may then be regarded as saturated. I am quite convinced that if, from any peculiarity of the system, or from the disease assuming an unusual tendency to the spreading of the ulcerations, mercury should be administered after ptyalism has been produced without benefit, the patient is decidedly injured. The remedy is best adapted to the inflam- matory forms of the disorder, and, as we shall presently see, is least fitted for the sloughing or malignant variety. Of the particular remedies in dysentery, purgatives have been exten- sively employed. We use many articles of this class in the hospital: the best is admitted to be castor oil, which purges sufficiently to carry off the vitiated secretions, without producing much irritation. To prevent the oil from acting too harshly, and to lessen the irritability of the bowels, laudanum may be advantageously combined with it. The oleaginous mix- ture is a good formula for their combination ; of this we give half an ounce every two hours, till it begins to act on the bowels.* Rhubarb will also answer well as a purgative, and when the active symptoms have declined, the spiced syrup answers better than any other remedy. Venesection is sometimes required in acute dysentery, when the pulse is strong and corded ; but we have not found it necessary in any case which has occurred in this hospital during the present year. The epidemic character of the disease has not been of the violent inflammatory character, which is a cardinal point in the diseases of the mucous surface, and seems necessary to the perfect cessation of the disease. I would not have you to misun- derstand me—the term restoration of the secretions has been much abused and used vaguely. It means simply, in this case, to bring about the natural secretions of mucus, &c, in place of the diseased ones of blood and lymph. A certain set of remedies tend directly to produce this effect, and by restoring the natural secretions, they not only prove that the dis- ease is ceasing, but they contribute to its cessation by producing deple- tion in the most effectual way, that is, through the natural emunctories of the part. Cups and leeches to the abdomen, along the course of the colon, are also frequently advisable ; the latter may also be applied around the anus, for the purpose of drawing blood from the hemorrhoidal vessels, * In giving the oil mixture, it is important to select such a formula as will render it agree- able, or at leasl not disgusting to the stomach. The following is a good oue :—&. 01 ricini, 5*i. ; Tinct. card. comp.. 3!.; Aq. cinam,, sjiiss.; Gum acac. q. s. ad faciend mist. To the mixture we may add half a drachm, or forty minims, of laudanum—in a few cases even a larger quantity. The dose is a tablespoonful every two hours, or less frequently if the disease be declining. At the beginning of dysentery, when the stomach is quite healthy, it is better to give oil as a purgative, in doses of half an ounce, repeated once or twice, with ten to twenty drops of laudanum. At the end of the disease the bowels sometimes act irregularly, and the oil is then useful in very small doses, that is, a teaspoonful. DYSENTERY. 699 and relieving the tenesmus. Warm fomentations are very often bene- ficially employed. But these measures, however important, cannot alone be relied on for the cure of the disease ; we must restore the secretions to their healthy condition. This is a principal, though not the only object for which we employ calomel, with opiates, &c. The action of opium in dysentery is peculiar : in the first place, italics the local pain and general irritability; and secondly, it quiets the spasmodic movements of the intestine, and thereby facilitates the process of cicatrization. But it may likewise produce bad effects; it tends to lock up the bowels, and prevent the discharge of the morbid secretions. To obviate this disadvantage we seldom use it alone, but combine it with castor oil, calomel, or ipecac. It may sometimes, however, be employed singly, either at the commence- ment or towards the close of the disease ; but never during the height of the inflammation. Opium is also used by injection. In this city, opiate injections in dysentery have not been much employed till within the last few years; and in the country their use is still very limited, but in this hospital we are in the habit of using them very largely. Frora twenty to forty drops of laudanum may be administered in this way, but not more, for dangerous consequences from time to time result from the frequent employment of large quantities of so powerful a narcotic, particularly when given by the rectum, in which mode of administration its action upon the brain is more irregular than when given in any other way. We usually inject twenty drops of laudanum mixed with a small portion of mucilage, every two, three, or four hours, according to the severity of the tenesmus and the effects of the remedy ; thus, if the stools cease, or if the mind becomes confused, dull, or the patient sleepy, its use should be suspended. There is still another way in which opium may be employed in dysentery ; that is, by means of poultices sprinkled with laudanum, and applied to the abdomen, or to the anus.* Of the other remedies employed in dysentery, ipecacuanha, as we have already mentioned, is among the most useful. It is used either singly or combined with calomel or opium. A very effectual method of adminis- tering it, is in combination with extract of gentian and blue mass. This combination originated with Mr. Twining, and has been extensively and beneficially employed in India. It generally produces vomiting at first, but in a short time this effect ceases. I tried it largely in one epidemic ; its administration was followed by nausea and diaphoresis, and a consi- derable alleviation of the symptoms. It sometimes failed, but was gene- rally successful. The proportions are, six grains of ipecacuanha, four of blue mass, and five of the extract of gentian. Various other remedies have been employed in acute dysentery. They are principally antiphlogistics, such as saline purgatives, calomel in large doses, &c. These will doubtless answer in many of the ordinary cases of the disease. Malignant dysentery is a form of the disease requiring considerable modification in the treatment. It occurs for the most part, in hospitals, ships, camps, &c. We had an epidemic of it in Philadelphia in 1837, and some cases in 1838 ; it was so violent and so rapid in its progress as sometimes to produce gangrene of the intestines in two days. It is attended with great prostration of the vital powers ; subsultus tendinum, and various * This is very useful when the anus and rectum are too irritable to bear the mechanical action of an injection. 700 GERHARD'S CLINICAL LECTURES. other signs of debility and nervous disorder. All modes of treatment will frequently fail in this form of the disease. In the epidemic of 1837, we found it necessary to resort to stimuli, tonics and astringents ; as wine or brandy, cinchona or cascarilla, with the early use of kino, catechu, or chalk. Opium was also employed as a stimulus. Another variety is the S'ubacute, of which we have an example in the first case above detailed. It occurs mostly in persons above the age of forty ; and often appears to be the effect of irregular habits, or of the gradual decline of the powers of life. In these cases, besides a regulated diet, we find Dover's powder to be the most effectual remedy ; it succeeds better than mercurials alone, but it may be combined with them, espe- cially the hydrargyrum cum creta, which is one of the mildest and best. I generally give it in three-grain doses every four or six hours. Cases of subacute dysentery are unfrequent in summer, being most comraonly met with in the fall. We have had many cases of it in this hospital ; they have been principally confined to the lunatic wards—a circumstance which is explained by the debilitating effect which a disordered mind has upon the system. Besides the remedies already spoken of, the acids have been largely used in the treatment of dysentery. This practice originated in tropical climates, where lime-juice, vinegar and other vegetables were employed. The use of the mineral acids was mainly introduced by Dr. Hope, whose mixture of nitrous acid, camphor and laudanum, has been of late years so extensively used in bowel diseases. It often produces the best effects, but will not answer in the sloughing form of the diseases. It proves most effectual in the subacute variety, and sometimes in the acute, after the severity of the case has declined ; but in the ordinary cases of acute dysentery, the benefit produced by this mixture is very problematical. The dose is about half an ounce every two or three hours. The acid practice is founded on a peculiar change in the symptoms of the disease which occurs in dysentery. The stool and saliva become extremely alkaline, and even the urine and perspiration lose to a certain extent or altogether their excess of acid. In giving the mixture I have usually continued its administration until the excessive alkalinity of the secretions diminished or altogether ceased. Chronic dysentery is another form which we frequently meet with. We have a case of it at present in a woman who has been suffering with it for six or seven weeks. There was griping in the region of the trans- verse colon, but during the last week it has been slight ; there have been three discharges in the last ten or twelve hours; the skin is dry and harsh ; the patient is much emaciated ; this form of the affection, indeed, produces more emaciation than any other disease except cancer. Chronic dysentery may last for years, and produce extensive ulceration or sloughing ; and when even checked, is very liable to return. Treatment of Chronic Dysentery.—We must rely principally upon a regulated diet, of such a nature as will best agree with the patient ; for most persons farinaceous articles answer best, while others require animal food. Of the remedies to be employed, the best are opium and ipeca- cuanha with calomel, in minute doses. The nitrate of silver is often useful. In many cases, travelling by land or sea, particularly the latter, has operated very beneficially, by producing a general alteration and improve- ment in the system. This has been found to be particularly the case in DYSENTERY. 701 the dysentery of the East Indies. Sea-bathing or sulphur-baths are also of great benefit. From the preceding remarks you will understand that our treatment of dysentery must vary exceedingly in the different forms of the disease. The success of the treatment will, therefore, be various in different epi- demics. In the malignant, sloughing dysentery which occurs in camps, &c, the mortality is generally great, while, in some epidemics, it is com- paratively trifling ; we should not form a general opinion of the character of the disease from observation of a single epidemic, and still less, can wre estimate the success of our treatment, unless it has been tested in various epidemics and in different years. A multitude of remedies are often prescribed and used with great benefit in the treatment of the dis- ease ; the limits of this lecture will prevent me from even mentioning the greater part of them, but they will be in general suggested by the peculiar symptoms of each case, and you will often succeed, in the most obstinate cases, by attending to some apparently unimportant particulars, such as the condition of the skin, or some slight change in the diet or mode of life of the patient. In laying so much stress upon mercurials, I do not wish you to under- stand that I am in the habit of administering these remedies carelessly, or with unnecessary frequency. On the contrary, I would not use them in dysentery when mild purgatives will cure the disease readily ; it is only in severe cases that I prefer the mercurial treatment, which is unquestion- ably the most effectual and most rapid means of getting rid of the dis- order. There is no necessity for producing decided ptyalism ; a slight action upon the gums is sufficient to test the effects of the remedy. I have explained to you the anatomical lesions at length, because your prognosis is, in severe cases, to a great degree, founded upon their extent, and you will perceive that a complete cure can only take place when the ulcerations of the intestine are healed. LECTURE XI. Subacute dysentery (continued)—Pathology and treatment—Phthisis pulmonalis. I shall bring forward to-day a case of the subacute form of dysentery, and afterwards several cases of phthisis, for the purpose of illustrating some of the various modes in which this disease commences. The case of dysentery is one of a class not unfrequently met with dur- ing the winter months, in which not only the bowels, but the mucous membranes generally, are affected. The patient is a man of nearly titty years of age, and an habitual drunkard. A fortnight since he had an attack of delirium tremens, the symptoms of which continued during seve- ral days after his admission into the hospital. After an exposure to cold recently, he was seized with bronchitis, and the affection of the bowels for which he is at present under treatraent. The alvine discharges have been very frequent, sometimes several in the course of an hour; the pain was constant, but much more moderate than it usually is in the more acute variety of the disease. The character of the stools equally shows 702 GERHARD'S CLINICAL LECTURES. that it is not a case of acute dysentery ; they consist of ordinary thin, fecal matter, mixed with mucus, but at no tirae has either lymph or blood been present. This case is a very good exemplification of the nature of the discharges in subacute dysentery, and the changes which occur in them at different periods of the disease. At first they are either sero- mucous, or thin and feculent: subsequently their consistence and appear- ance become altered, and they present the characters observed at the pre- sent stage of the case before us. Blood and lymph are very seldom to be found ; but in place of them, there is sometimes a grumous, fetid matter, resembling the scrapings of a disorganised intestine, which evidently re- sults from partial sloughing of the bowel. Although the stools differ so strikingly frora those' of the acute form of the disease, subacute dysentery is still an inflammatory affection ; but the degree of action is moderate, on account either of the debilitated condi- tion of patients labouring under it, from old age, or irregular habits, or of the epidemic constitution of the season. A constitution of this sort, in- deed, appears to prevail at present, imparting to epidemic diseases a ten- dency to assume more or less of the characters of the case which we are considering. The principal features of the case are as follows : (Complete notes were not preserved.) J. G., admitted November 25th. The bowels are loose ; there is cough, with whitish expectoration ; patient much debilitated. The olea- ginous mixture was administered, and a small quantity of milk-punch was allowed. 2§th. The punch discontinued. 28^/i. Dysenteric symptoms more severe ; twelve discharges from the bowels in the course of five hours ; stools thin and watery, with very little feculent matter, but very fetid ; slight pain on pressure over the ab- domen ; cough continues ; mind confused and agitated. Six ounces of blood taken by cups placed over the colon, and the following combination prescribed: R. Pulv. Ipecac, et Opii, gr. vj. Hydrarg. Submuriat. gr. j. Ext. Krameriag, gr. v. M. To be repeated every three hours. Blisters also applied to the abdomen. 2Qth. The Dover's powder and rhatany in the above prescription were diminished to three grains each, and the calomel to one-eighth of a grain. It was found necessary to reduce the Dover's powder, be- cause it produced some symptoms of narcotism ; that is, contraction of the pupil, and confusion of mind, without diminishing the frequency of the stools. When such a state of things occurs, you must either dis- continue opiates, or reduce the quantity administered; else the nar- cotic raay accumulate in the system, and cause the patient to sink sud- denly and almost imperceptibly. In the earlier stages of acute dysentery, opium may often be given very largely without producing its characteristic effect. A case, of this variety occurred a few years since in one of the resident physicians of this hospital. He was attended by Dr. Horner and myself, and the quantity of opium was gradually increased to thirty grains a-day before the least effect was produced. But in the subacute form we cannot employ such large quantities with safety, and the remedy should be withheld, or its dose diminished, as soon as it produces its specific DYSENTERY. 703 effects. You must recollect, too, that even in the acute form of the dis- ease, you must give it very cautiously ; for mischief may in any case re- sult from it, if administered in a careless or rash manner. The rule is, to increase it gradually, and watch carefully its effects ; suspend it altogether, or diminish it greatly, the moment you find any signs of narcotism. The Dover's powder and calomel have been the active remedies used in the treatment of this case ; the extract of rhatany has been productive of no very decided benefit. The good effects of mercury in this disease (as remarked in a previous lecture) coincide with the occurrence of slight ptyalism,—which I find, upon examination, to have taken place in the patient before us. If it procures no amelioration of the symptoms at this characteristic period of its operation, mercury should be discontinued; and in all cases where there is sloughing of the mucous merabrane, and a gan- grenous fetor of the discharges, its use should be avoided, as it then un- doubtedly tends to aggravate the severity of the disease. You must have remarked that stimuli were employed in the early treat- ment of this case. The patient came in much debilitated from the effects of delirium tremens and previous dissipation, and a small quantity of milk- punch was therefore allowed. In all cases of this disease, indeed, in which there is an enfeebled condition of the vital energies, it is necessary to use stimuli. This is particularly true of the malignant or sloughing variety of dysentery, between which and the subacute there is an intimate connec- tion. The latter has a constant tendency to pass into the former; and from what has so frequently occurred in camps and hospitals, I have no doubt that the present case would assume the malignant form, if there were many of a similar character in the wards at the same time. If such a change should supervene, it would be necessary, as I have already remarked, to discontinue the use of mercurials, and to rely principally upon Dover's powder and stimuli. The cupping in this case produced only moderate benefit, whereas the blister operated very advantageously. It is one of those instances of mo- derate, but obstinate inflammatory action, to which blisters are so pecu- liarly adapted. Cupping or leeching would be better in the more violent and acute cases of dysentery. The woman who wTas brought before you two weeks since as a case of acute dysentery, and was treated with mercurials, is now quite well. The man who was labouring under the subacute form of the disease, at first improved considerably, by the use of Dover's powder and astringents, but afterwards sank again, and died on the 28th inst. The results of the post- mortem examinations are as follows, and show the cause of death. The following lesions are met with in the intestinal canal. The mucous coat of the rectum is of a bluish colour, and softened. As we pass up the colon, we find extensive ulcerations, some of which are cicatrized. There is a large cicatrix near the sigmoid flexure; the newly- formed membrane is thin and bluish; the old membrane, on the contrary, is much thickened, and to a still greater degree are the cellular and muscular coats. Farther up the ulcers are scattered about, of small size; the mu- cous membrane softened. Near the caecum the morbid changes are of more recent date ; the mucous membrane is highly injected, and patches of lymph are here and there observed. The ulcers are in the acute stage of their progress; they are of a rounded form, and are seen to have com- menced in the follicles of the intestine. We have here exemplified the 704 GERHARD'S CLINICAL LECTURES. different appearances in the acute and chronic forms of dysentery; in the upper part of the colon, where the former condition prevailed, the mucous membrane is of a bright red colour, as in acute inflammation of this tissue generally; but in the lower part, where the disease had become chronic, the colon is bluish. This examination also illustrates a remark which I made in a former lecture, that dysentery usually commences in the lower portion of the colon, and proceeds upwards in its course. The disease has also passed into the ileum, which is in a state of acute inflammation. There are bright red spots and patches of lymph, scattered over the mucous membrane, for some distance from the ileo-caecal valve. The glands of Peyer are altogether or nearly intact; in which circumstance you perceive a striking difference from the inflammation of the ileum which occurs in typhoid fever. This acute inflammation of the small intestine, supervening in the course of the dysentery, was the immediate cause of death. The mucous membrane becomes gradually more healthy as we ascend, but is more or less softened. The stomach also presents marks of inflammation. At the splenic ex- tremity the coats are very thin, and much softened : this condition was in a great measure produced by the action of the gastric juice, which had become altered in constitution, and excessively acid ; the merabranes at this point have an acid smell, and produce an unusually powerful reaction upon test paper. Throughout the remaining portions of this viscus the coats are white and opaque, from an alteration both in the fluids and the structure. There are dark red patches in several places. Near the pylo- rus there is a puckering of the mucous membrane, produced by a cicatrix. This membrane is generally softened, but the colour is not particularly red- dened. The coats of the pylorus are thickened and indurated, and there is a scirrhous formation in the cellular tissue ; its fibrous character is, how- ever, not yet distinctly marked. The symptoms produced by scirrhus of the pylorus, are difficulty of digestion, and vomiting from time to time, which may be so severe and repeated as to produce death. It may be re- marked that these scirrhous affections are frequently developed in consti- tutions where the diathesis has been latent, by depression of mind, parti- cularly in old persons. This is illustrated by the instance of Napoleon; and I recollect an equally striking case occurring in a Swiss emigrant. The liver is also affected in the present case, but lesions of this organ accompany dysentery far more frequently in hot than in cold and temperate climates. Its colour is a pale yellow, and it appears to be in the first stage of that alteration called the fatty degeneracy. The tests of this condition are the greasy appearance of the scalpel when drawn through the substance of the liver, and the bright flame produced by burning a piece of paper which has been moistened with the fatty fluid. The acini are also ob- served to be very distinct, and surrounded by vessels, producing an ap- pearance of great vascularity and incipient inflamraation of the liver. The fatty degeneracy in this case was probably produced by the habitual in- temperance of the patient, and subsequently increased by the dysentery. The spleen, which is so often found greatly enlarged and softened in various diseases, is here nearly of the natural size, but the texture is soft- ened. The cause of this change in the spleen is not well understood, but it appears to be in some way connected with an alteration of the blood. The spleen probably performs an important part in the formation of this fluid ; but what the precise office is, cannot be yet ascertained. PHTHISIS PULMONALIS. 705 From this examination you will perceive how readily the most exten- sive ulcerations of the mucous merabrane of the intestine will cicatrize, provided the muscular coat is not exposed by them. PHTHISIS PULMONALIS. I next proceed to bring to your notice several cases of phthisis pulmo- nalis, with the view of exemplifying some of its modes of origin ;—this is the more appropriate, as the present season (November) gives rise to few acute diseases. Case 1st.—You may recollect that this man came before you on the 23d inst., with many symptoms resembling those of intermittent fever. Since that time the skin has continued hot, with occasional sweats ; the pulse has usually beaten one hundred and sixteen in the minute ; yester- day, ninety-six ; it is also quick and irritable, jerking, and easily felt, but small and not corded. This character of the pulse is often important as a diagnostic sign ; it occurs in chronic diseases, or in acute diseases gra- dually passing into a chronic state, accompanied by a general disorder of the system. It is most frequently observed in incipient phthisis, particu- larly when this disease is attended by pleurisy. The respiration is, also, much more hurried than natural, being performed from thirty to thirty-six times a minute. Cough frequent; expectoration thin, white, and small in quantity ; tongue at present somewhat pale, and gradually cleaning. The respiration is resuming its natural character in the lower part of the right lung, owing to the decline of the pleurisy ; but it remains rude in the upper lobe of the lung ; a sign corresponding to the tuberculous con- dition of the part. The action of the heart continues exaggerated, and the second sound is still absent. The difficulty of walking also continues, but in a somewhat less degree ; it is dependent on an acute affection of the spine. The treatment of this case has consisted in the application of a blister to the cardiac region, and the administration of digitalis and Dover's powder, in the proportion of one-third of a grain of the former to three grains of the latter, the dose being repeated four times a-day. Considera- ble advantage has'resulted from these measures ; the inflammation which had existed being in a great measure overcome, and the inordinate action of the heart diminished. The digitalis and Dover's powder were given particularly with a view to the latter effect, and to allay the irritability of the pulse. This combination sometimes produces a dryness of the mouth, and of the alimentary canal generally, which is unfavourable to the due performance of the digestive functions : but it is by far the best mode of administering these remedies. I have introduced this case as an example of tubercular disease com- mencing with pleurisy. The tubercular deposition seems to be a result of the inflammation, as truly as are its ordinary consequences, effusion, adhesion, &c. In most patients the latter conditions would be the only effects of the inflammation ; but in the present case there existed a cachec- tic condition of the system, predisposing it to the development of phthisis ; hence this disease followed as a consequence of the inflammation. The inflammation which thus produces phthisis, may be seated in any of the tissues of the lungs : thus, it may be a bronchitis or a pneumonia, as well as a pleurisy. But it usually affects a serous membrane ; therefore, pleu- 46 706 GERHARD'S CLINICAL LECTURES. risy is more frequent than the other pulmonary inflammations preceding phthisis, just as peritonitis also is often the primary lesion in tuberculous deposits in the peritoneum. But these cases of inflammatory phthisis are by no means so frequent as those which commence gradually and slowly. Of this more common form we have an example in the next case. Case 2d.—The patient, who is a printer, has for a long time had a slight cough, and other symptoms of incipient phthisis. During the last summer, there was a great aggravation of all the symptoms, accompanied by a slight inflamraation of the bronchial tubes ; and the patient is now scarcely able to leave his bed. In this case, it is evident that the inflam- mation was the consequence, not the cause of the phthisis, as in the pre- ceding case. WTith regard to those cases of phthisis which I suppose to be caused by inflammation ; it may be argued by those opposed to this view of the origin of the disease, that the phthisis existed, but in a latent form, previously to the commencement of the inflammation. But those cases are exceedingly rare, in which the disease does not declare itself, either by some symptoms, or by physical signs. Hence, I feel compelled to believe, in contradiction to my former opinion, that phthisis may arise from inflammation, occurring in constitutions predisposed to the formation of tubercles. Case 3d.—This woman has had a slight cough for four years ; about three months since, after exposure to wet and cold, the cough and other symptoms were greatly aggravated. These circumstances are sufficient to show that, in this case also, the inflammatory symptoms supervened in the course of the phthisis, instead of preceding it. Case 4th.—This woman also has had a cough of four years' standing, which becarae very bad during the summer; after working in an exposed situation. During the last week there have been flying pains under the ribs of the right side. These pains arise from the slight and shifting pleurisy so often met with in cases of tubercular disease. These pleurisies are generally dry ; that is, unattended by effusion of serum. The expec- toration is copious ; the sputa are in round masses, and of the kind called, from this circumstance, nummular; they usually sink in water, but some- times float from their containing particles of air ; they consist of pus, mixed with mucus, and sometimes a portion of broken-down tubercular matter. In both these women, the skin has assumed a dusky, earthy colour, entirely distinct from the paleness which accompanies it; this hue is almost peculiar to phthisis. The sclerotica has that light blue tinge which is so frequently met with in constitutional cases of phthisis. The appetite has remained good ; indeed a good appetite, persisting for a long time in a patient affected with cough, and gradually becoming thin and pale, is one of the most constant indications of commencing phthisis pulmonalis ; in many cases the appetite is morbidly great. One of the patients is jaun- diced. This probably arises from a fatty degeneracy of the liver, accom- panied by enlargement; a condition very frequently occurring in this disease ; more particularly in female patients. The jaundice arising frora this cause must be carefully distinguished by the practitioner from that which depends upon primary affections of the liver, and is totally uncon- nected with any disease of the lungs. I have seen many cases of phthisis in which the liver was supposed to be the sole cause of the mischief. It is true, that in a large proportion of these patients the liver was fatty, but PHTHISIS PULMONALIS. 707 this condition arises from the phthisis, and is neither a primary lesion, nor one in itself of much importance. Case bth.—This man has been very recently admitted into the hospital. He is much emaciated, and has had a cough for four weeks ; the disease is therefore probably phthisis. This probability is rendered almost certain by the respiration being very deficient under one clavicle, and feeble under the other also. But there are as yet no signs of the existence of a cavity. The patient's account of the manner in which the disease com- menced, is this: After having been engaged at hard labour, out of doors, during the day, he was awakened from sleep in the night by a sudden fit of coughing and haemoptysis ; in a short time he discharged in this way a pint of blood. The haemoptysis lasted several days ; but for the last three weeks the sputa have contained no blood, but only a frothy matter. This is an example of the hemorrhagic variety of phthisis. The hemorrhage with which the disease commenced arose from the mucous raembrane of the bronchial tubes. In such cases the hardening of the pulmonary tissue, from the deposition of tubercular matter, does not generally com- mence early in the progress of the disease ; or rather, it does not soon proceed to a high degree of induration in any particular portion of the lung. The patient is a shoemaker: and we may remark that shoemakers are particularly subject to phthisis, from the confined and sedentary nature of their occupations. His constitution has always been delicate ; but he has never before had cough or pain in the chest, except after occasional ex- posure to cold. Immediately previous to the present attack, he was in the enjoyment of his usual degree of health. Case 6th.—The patient is, like the last, a shoemaker by trade, aged 42. He has had cough for nearly two years, but it has been generally unattended by pain; there has been merely a sense of oppression at the lower end of the sternum. In February, 1838, he had an attack of pleurisy, which left behind it the usual signs of contraction of the chest. He had no cough previously to the attack of pleurisy, except for a short time, about six months before, and occasionally during spells of inter- mittent fever. The case, therefore, appears to be one of the inflammatory variety of phthisis, having been preceded, as in the first of these cases, by inflammation of the pleura. Case 1th.—This is another example of phthisis commencing suddenly, with an attack of inflammation. The patient, a man 41 years of age, has had cough for eighteen months; it began after he had been working at the engines at a fire ; had previously been a stout, healthy man, and had never had a cough of any duration. The attack was one of considerable severity, but the patient was not confined to bed by it; he did light work for a year afterwards, but for the last six months, has been unable to per- form any kind of labour. He is much emaciated, and presents all the signs of confirmed phthisis. The cases of phthisis arising from inflammation are much raore fre- quently found in men accustomed to hard labour than in others, and espe- cially in those past the age of five-and-thirty. In younger persons, espe- cially females, the disease is raore frequent, and more commonly begins in a slow and insidious manner; inflammation may, and often does occur in those cases, but then it is strictly secondary, and depends either upon the irritation of tubercles in the lungs, or the accompanying fever. 708 GERHARD'S CLINICAL LECTURES. There are cases in which phthisis becomes a local disease only at a very late period, remaining for a long time constitutional, and apparently de- pendent, partly on the nervous, but, in a greater degree, on the vascular capillary system. Case 8th.—There are three modes in which phthisis commonly com- mences : first, slowly and gradually, indeed almost imperceptibly ; secondly, preceded by inflammation ; thirdly, commencing with a sudden attack of haemoptysis. This case is an instance of the third variety of the disease— the hemorrhagic. The patient entered last Saturday; he is a weaver by trade. This employment is a frequent predisposing cause of phthisis, from the circumstances in which weavers are placed. They work in close rooms, much the same way as shoemakers and printers, and fatigue excessively the thorax. There are other circumstances which aid in producing this predisposition in weavers; such as long confinement in one position, the dampness of the cellars in which they generally work, and the breathing of an atmosphere loaded wTith irritating effluvia, which arise from the woollen and cotton goods. The patient had been in good health pre- viously to the present attack; had never had a severe cough for any length of time, and had been temperate in his habits. His parents are still alive and healthy, so that the predisposition is probably not an hereditary one; though instances are occasionally met with in which consumption passes by one generation, and is transmitted from grandfather to grandson, with- out any indications of its presence at the intermediate point. The account given by the patient of the manner in which he was attacked, is this:—In February last, while engaged at work, he was suddenly seized with spit- ting of blood ; in the course of a fortnight he discharged in this way a very large quantity of blood; he thinks it amounted to six quarts,—but this estimate is, no doubt, much exaggerated. At last he coughed up a large coagulum of blood, by which he was nearly suffocated. From this time the haemoptysis ceased, but the cough continued without intermission ; the sputa are whitish and muco-purulent. About five months since, he began to be weak and emaciated, and has become more and more so ever since. Chills also commenced with the cough, and have constantly ac- companied it up to the present time. This is, therefore, another of those cases of phthisis which simulate intermittent or remittent fever at their commencement, and of which I have already spoken in the two preceding lectures. The tubercular fever, causing this resemblance, occurs in the earlier stages of phthisis, and is truly an irritative disease. Sometimes it assumes the remittent type. I have known two cases of this sort amongst my own acquaintances, which were mistaken for remittent fever, and treated as such; but, after some time, the true nature of the affection was explained, by the clear development of the local signs of phthisis. In the present case there would have been little difficulty in the diagnosis, for the hemorrhage would have made the character of the fever clear. But, in the majority of cases where haemoptysis does not precede the tubercu- lous disease, you will be often aided greatly in your diagnosis by the cha- racters of the fever. The patient has also suffered from profuse night-sweats, and here we have a circumstance which distinguishes this fever frora hectic. In the latter, the sweating is not so profuse as in the former; but the chills, on the contrary, are more severe. The patient's appetite has been bad for four or five months; he has had several attacks of diarrhoea, continuing PHTHISIS PULMONALIS. 709 two or three days at a time. Diarrhoea is a common attendant of phthisis pulmonalis, and generally arises from the deposit of tuberculous matter in the small intestines simultaneously with the same process in the lungs ; but the frequency and duration of its attacks vary greatly in different cases. You have remarked that the patient was seized with haemoptysis while at work; it is in this way that it often begins,—suddenly, and while the chest is exposed to some strain. Hemorrhage from the lungs, occurring in this sudden manner, is, in most cases, a sure sign of phthisis pulmonalis. It may sometimes arise from other causes, as disease of the heart, congestion of the lungs, or a mechanical cause, such as a strain ; but in five cases out of six, in men at least, it is followed by the local signs of tubercular disease. In women, however, it is not so valuable as a diagnostic sign; for in them it may follow suppression of the menses, and may, in fact, become a vicarious discharge. Though haemoptysis may arise, as I have said, from a sudden muscular effort, when there are no tubercles in the lungs,—yet, in the ma- jority of such instances, they either exist already, or there is a tendency to their formation; for whenever such a tendency exists, the bronchial mu- cous membrane will bleed frora very slight causes. I recollect an instance in which the haemoptysis was caused by jumping over a wall about five feet in height, and was followed by all the signs of phthisis ; and another in which it occurred from lifting a gate which had fallen. The tubercular diathesis, therefore, predisposes to hemorrhage from the lungs. It is true, that not a few cases of haemoptysis abort, as it were, before the tubercles are secreted to any amount; but when we find that the majority of patients in whom this symptom occurs, are afterwards affected with confirmed phthisis, it is perfectly consistent with the facts to believe that the hemor- rhage coincides with a condition of lungs which favours the tuberculous secretion, and which had in many cases given rise to a limited deposit of tubercles before the discharge of blood took place. Of the tubercular fever, which is an attendant of the disease in the pre- sent case, I have spoken more fully in the preceding lectures. The other general symptoms present nothing peculiar. The emaciation, you per- ceive, is considerable, and is accompanied by that dirty, earthy hue of the skin (raore especially of the face), which you have seen in several other patients. . . , The local signs are—1, cough; 2, expectoration: this at first consisted of mucus, afterwards becoming muco-purulent, with portions of broken- down tubercles; 3, dulness on percussion under one of the clavicles, with mucous rhonchi, and a commencing cavernous respiration. These last signs indicate the stage of the disease; they show that there is already some softening of the tubereular matter. This fact is also proved by the character of the sputa. Case 9th.—This patient has been a labourer on the canal, tietore the present illness he never had a cough, or any other sign of pulmonary dis- ease He has been sick for two years : the attack was gradual, and was produced by taking cold. Since that time there has been constant cough and expectoration ; the matter of the sputa is at this time muco-purulent, and somewhat nummular, and begins to be characteristic of this disease. Emaciation has been apparent for eight months: before this attack, the patient was a stout man. The skin is dry, pale, and dusky. There has been one attack of diarrhoea. There was fever, with profuse night-sweats, 710 GERHARD'S CLINICAL LECTURES. but no chills : it is therefore a modified form of hectic. At present there is not much fever—pulse 94. The expectoration consists of round masses floating in a thinner liquid, with small pieces of tubercular matter : at first it was mucous, then muco-purulent. The sputa takes its shape from the cavities in which it is found. We shall presently see that when these cavities are very large, the nummular character is no longer present. There has been no haemoptysis until two nights since, when about a spoon- ful of blood was discharged. Such small quantities are not important; they may arise from irritation of the bronchial membrane, and it is only when haemoptysis is considerable, that it becomes a sign of importance, and also pathognomonic of phthisis. Case 10th.—This patient was brought before you at the last lecture, as an example of tuberculous disease, coinciding w7ith inflammation of the serous membranes. Since that time, the breathing has continued much oppressed ; tongue dry and red ; pulse, 95 to 104 ; bowels constipated. The vesicular murmur has become more distinct on both sides of the chest. There has been an increasing pain in the praecordial regions, with a bruit de soufflet of the heart; respiration frequent and high. Yesterday, for the first time, I discovered a grating or creaking sound of the heart, indicative of pericarditis; the creaking being produced by lymph into the pericar- dium. The two surfaces of this membrane rub against each other, chiefly at the beginning of the diastole of the heart, and a grating sound is pro- duced by the spiral movement of the heart on its axis, during the dilata- tion of the ventricles. The patient, you will recollect, was first attacked by pleurisy ; since then, pericarditis has supervened, with more or less endocarditis. This case is, therefore, a good illustration of a circumstance to which I called your attention when I first brought it before you ; the connection between phthisis and inflammation of serous membranes. This patient has inflammation of all the serous membranes of the chest, occur- ring in succession. The pleurisy has declined as the pericarditis super- vened. Besides the signs already mentioned, the existence of pericar- ditis, attended with effusion, is indicated by feebleness of the impulse of the heart, flatness on percussion (extending over a larger space than that occupied by the natural dulness of the heart), and pain on pressure or percussion. The latter symptora, however, is not always present in peri- carditis ; in any of the serous membranes, in fact, inflammation may occur without the ordinary signs. But in this patient the flatness extends to at least double the usual spaces, and there is very decided pain at the region of the heart, which is increased by slight pressure, but is always more or less felt. The dyspnoea in this case is dependent partly on the pleurisy, partly on the pericarditis. The pulse is not invariably altered in inflammation of the heart or its membranes ; it is principally affected in endocarditis, which gives rise to more or less obstruction of the valves. In the present case, there is excitement of the pulse and slight irregu- larity. I shall now show you some cases of gangrene of the lungs, and bron- chitis, the symptoms of which more or less resemble those of phthisis, and the diagnosis becomes, therefore, frequently difficult. Gangrene of the lungs is by no means a frequent disease, it is oftener met with in hospitals than in private practice. It resembles phthisis, in- asmuch as it produces softening of the pulmonary tissue, and, conse- quently, the formation of cavities. It differs from it in the fetor of the GANGRENE OF THE LUNGS. 711 breath, and expectoration. The local signs, at the commencement of the disease, are imperfect. The causes of gangrene of the lungs are cold, an epidemic tendency of the atmosphere, intemperance, and depressing circumstances generally. In most cases, it arises from direct exposure, but sometimes it comes on gradually, and appears to be part of a general disease ; that is, it depends on a vitiation of the fluids, in the same way with dry gangrene, of which I have shown you an example. Case.—The patient is a boatman, forty years of age. He had enjoyed good health till about two months before his entrance into the hospital. At that time, being engaged at his occupation on the Schuylkill, he fell into the river, and was with difficulty saved from drowning. He felt ex- treraely cold, and could not speak for twenty minutes, but no sign of active disease followed for two weeks, other than feebleness and chilli- ness. Then a cough began, accompanied by pain in the lower part of the right axillary region ; the sputa have never contained blood, and have been fetid frora the beginning; appetite has been bad throughout; the patient continued to work regularly until November 30th ; but since that time he has been unable to perform any kind of labour. The treatraent, previously to his entrance into the hospital, consisted of venesection, and the application of a blister to the right side of the chest. The patient was admitted December 6th. At that time the symptoms were as follows : slight emaciation ; a dusky hue of the skin ; slight flush- ing of the face ; dilatation of the nostrils ; skin warm ; pulse 104, thrill- ing, moderately resisting ; respiration 22, high and laboured ; expectora- tion thick and homogeneous, of a dirty, greyish colour, and very fetid. On the right side, anteriorly, respiration vesicular throughout, with traces of the mucdus rale, hurried and harsh at the summit of the lung. On the left side, vesicular, with traces of both mucous and sonorous rhonchi. Posteriorly, on the right side, vesicular in upper lobe, hurried, and very feeble ; in lower lobe, scarcely any vesicular sound ; at the upper part, deep-seated, cavernous respiration, and imperfect pectoriloquy. Percus- sion gives a flat sound in the lower two-thirds of right side posteriorly ; clear anteriorly. The signs, therefore, indicated a cavity in the lower lobe of the rigbt lung, with an engorged condition of the surrounding tis- sue, accompanied by pleurisy. The treatment consisted in the use of chloride of soda, given in doses of twenty drops four times a-day, with nourishing diet. Quinine, porter, and brandy are often necessary ; the indications being to correct the fetor of the breath and expectoration, and support the system, while nature effects the elimination of the gangrenous tissue. A number of palliatives, such as opiates at night, will doubtless occur to you ; but you should be sparing of depletory measures ; they are rarely necessary, except when there is severe pleuritis near the gangrene ; and these should be limited to local bleeding, or, still better, to blisters. Gangrene of the lungs is to be distinguished from phthisis by these cir- cumstances : it usually begins suddenly, and runs its course rapidly ; the skin presents a more decidedly dusky hue in gangrene than in phthisis ; and the breath and expectoration are always fetid from the commence- ment of gangrene. The prognosis of the two diseases is also very dif- ferent. In gangrene, it is not necessarily unfavourable ; from one-third to one-half of the cases recover; in phthisis, on the contrary, our prog- nosis is almost always unfavourable after a cavity is formed. When gan- 712 GERHARD'S CLINICAL LECTURES. grene tends to a favourable termination, recovery generally takes place in a few weeks. Any improvement in the symptoms of phthisis, on the con- trary, is very gradually and slowly effected. There are two kinds of expectoration met with in gangrene of the lung. The most common is blackish, and resembles an inky sediment. The other kind, of which we have an example in the present case, is a greyish, frothy fluid, having some resemblance to yeast, with a fetid odour, which you may perceive is like that of putrid oysters. This, though the least common, is the most favourable variety of sputa. It is generally discharged in very large quantities—amounting, sometimes, to a pint or a quart daily. I have frequently described, in my lectures, the progress of cure in gangrene. When the sphacelated portion is thrown off, a cavity is formed, lined with the usual pus secreting false membrane, which gradually as- sumes the character of a mucous membrane. We shall watch the pro- gress of this case, and keep you informed of the result. The next case is one of bronchitis. The patient is a labourer, aged 35 years. He entered the hospital on the 2d instant, having been ill for two weeks. He was seized with cough, and pain along the sternum ; in the course of a week, he began to expectorate a muco-purulent matter, con- taining no blood ; during the most of the time he has been confined to bed. These signs indicate an acute disease, which might be mistaken for the acut^ form of phthisis. It is distinguished from it, by the absence of the irritable, jerking pulse of phthisis, described in our last lecture, and also, by the absence of the local signs of tubercular deposition. Thus there is no flatness on percussion under the clavicles ; and the mucous rhonchus is heard in the sound of respiration throughout the lower lobes of both lungs. But though bronchitis is thus distinguished from phthisis in the commencement, both by the general and local signs, yet it is very apt to terminate in the latter disease, and we ought always to anticipate such a result when it is prolonged, and occurs in young persons. The next case is a complication of phthisis and bronchitis. The patient is a boatman, 38 years of age, of intemperate habits. He had been sick for three months, and unable to work during the whole of his time: his illness was caused by falling into the canal: the next day he was seized with shivering and cough, unaccompanied by pain : the expectoration consisted of mucus mixed with pus, but no blood. On the 4th inst. he entered the hospital, and the symptoms were as follows:—There was abundant mucous rhonchus throughout both lungs, passing in certain por- tions into the sub-crepitant, while at the summit of the left lung, the per- cussion is dull and the respiration extremely bronchial. There is a quick, irritated pulse, some emaciation, and a dry, dusky skin. The sputa, although not nummular, are more purulent than is usual in most cases of bronchitis. The dyspnoea is much greater than in most cases of phthisis or uncomplicated bronchitis. This case began in the form of bronchitis : phthisis was developed sub- sequently, and the two diseases are now co-existent. This state of things is of frequent occurrence, particularly at advanced periods of life. At an earlier stage, when phthisis is developed in the course of a bronchitis, it is apt to commence more suddenly, and run its course more rapidly than in the present instance. The patient, you perceive, is but slightly emaciated, and .will probably get comparatively well: that is, the disease may con- PHTHISIS PULMONALIS. 713 tinue for years, with slight cough, &c, but may not shorten the patient's life ; the cavity in the lung remaining, but lined with a healthy membrane. I have known several cases of such comparative recovery from this form of disease ; and the chances of long life are not afterwards apparently affected by it. I repeat that phthisis pulmonalis may commence in several different forms: 1. It may commence slowly and gradually. This is the most common mode of origin, and is generally met with in cases where the tubercular diathesis is hereditary. The first symptoms of the disease are slight cough and expectoration ; the local physical signs are not present until a more advanced stage. It is very clear that in most of these cases the phthisis is nothing but a mode in which the general tuberculous disorder manifests itself, and that the disease can scarcely be considered local, although the largest deposit of tubercles is in the lungs, or perhaps the only deposit. In many of them no antecedent cause can be detected, in others something has produced a debilitating effect upon the constitution, such as grief, indifferent diet, confinement, &c, and the natural tendency to phthisis is called into action, or a new disposition to it is developed. 2. Phthisis may arise from inflammation. This variety is most common in robust persons, and is likewise, in most instances, dependent upon here- ditary predisposition, which imparts to inflamraation a tendency to termi- nate in the formation of tubercles. The most common seat of the inflam- mation preceding phthisis, is some one or other of the serous membranes; and the tubercles may at first be deposited either in the serous merabranes alone, in the lungs, or in both. The mucous membrane of the bronchial tubes may likewise be the seat of the inflammation; but phthisis beginning in the latter way, is more commonly met with in old persons, than that which begins by the serous membranes. Inflammation performs two distinct parts; in the first it is properly the cause of the tubercular deposition, which may occur some time after the inflammation, or take place during its progress. In the second, the secre- tion of tubercle is attended or followed by an acute inflammatory action in the organs, but the cause of the tubercles cannot be said to be the inflam- mation which attends their secretion. These inflammations often present some peculiar features, even when there is no actual deposit of tubercles. Thus, a slow inflammation, with an abundant secretion of mucus, will often attack the mucous membrane of the nasal fossa?, or the upper portion of the bronchial tubes, and then pass into phthisis. These slow, obstinate inflammations, are strictly scro- fulous, as much so as those of the large joints—coxalgia and white swel- ling- and yet they exercise only an indirect influence upon phthisis. 3.'The hemorrhagic variety. In this, haemoptysis, whether preceded by a violent effort or not, constitutes the first symptom. 4 There is a fourth form, which is by no means uncommon in certain climates and is met with occasionally wherever the disease shows itself. The patient suffers, at first, not from a disease of the lungs, or from any tuberculous disorder, but from dyspepsia, chronic disease of the liver, or some other affection of the abdominal viscera, either of an acute or chronic nature During the course, or at the termination of these diseases, the tuberculous attack commences and develops itself in the lungs, because 714 GERHARD'S CLINICAL LECTURES. these organs are especially subject to tubercles from a peculiar law of the economy. In climates where the diseases of the abdominal viscera are very frequent, phthisis is thus obscure at first, because its symptoms are blended with those of the original disease. The same thing is true of dyspepsia, which often masks the early stages of phthisis, especially in those cases in which the patient does not labour under simple dyspepsia, but under that variety which is connected with a scrofulous constitution. But these different forms of phthisis, though differing so much in their origin, after a certain period present the same character; they are all at- tended by emaciation, cough, expectoration consisting of pus and softened tubercular matter, hectic fever, and all the other signs which mark the more advanced stage of the disease. The progress of phthisis is most rapid when produced by inflamraation of the serous membranes, especially in young subjects; it is less so yvhen preceded by bronchial inflammation. The hemorrhagic variety is likewise rapid in its course; the slowest of all is that which is constitutional and hereditary. All of these forms are liable to be confounded with other diseases: thus, the first may be mistaken for simple serous inflammation ; the second for bronchitis; the third for hemor- rhage arising from other causes. We might multiply the varieties of phthisis almost to an indefinite num- ber, but the preceding are the most important, and may be considered as the landmarks in the study of the disease ; under one or other of these classes, all other forms may be included. There are likewise other tuber- cular affections, not commencing in the lungs, and only implicating them secondarily; but phthisis pulmonalis is by far the most frequent form in which the tubercular diathesis develops itself in adults. I will conclude the lecture by showing you some very interesting patho- logical specimens, which illustrate this subject. They are the lungs and intestines of a subject who lately died of phthisis in its most aggravated form. I could only refer to the case at the last lecture; the patient, a young man, being then so feeble as to render it improper to bring him before you. The physical signs, during life, indicated the existence of a large cavity in the left lung: many of you have heard the cavernous, am- phoric, and gurgling sounds of respiration, which were extremely distinct. In the course of his illness, the patient also had tubercular diarrhoea. You will at once recognise the existence of a cavity in the upper lobe of the left lung, by the falling in of its parietes as I hold it up. This whole lobe, indeed, is converted into a mere sac, nothing of the normal structure remaining, except the pleura, and a thin layer of the tissue of the lungs on its inner face. The large size of this cavity accounts for the great distinct- ness of the amphoric respiration in the last stages of the disease. The cavity is lined by a false membrane, and contains a considerable quantity of rauco-purulent fluid mixed with particles of tubercular matter. The rauco-purulent matter is a secretion from the false merabrane; and the con- tents of the cavity differ from the expectoration only, in not containing saliva, which is mixed with them afterwards. The sputa in this case were not of the nummular form, of which I showed you a specimen just now, for some days before the death of the patient, because the cavity was too large for their formation. You will notice several bands or bridles pass- ing from one side of the cavity to the other: these consist of blood-vessels which have resisted the ulceration longer than the surrounding tissue: sometimes, however, they are opened by this process, and hemorrhage is PHTHISIS PULMONALIS. 715 the result, which is often instantly fatal. The rest of the left lung is infil- trated with greyish tubercular matter to such an extent, that scarcely a trace of the healthy tissues can be found. The tubercles are partly softened, and small cavities are seen here and there : these gave rise to the gurgling sound of respiration. In the right lung, the lower lobe is in a comparatively healthy condi- tion. The tissue of the upper lobe is engorged with blood ; tubercular masses are scattered through every part of it ; they are of a yellowish- white colour, and no signs of softening are yet perceptible. In order that you may see the connection between the lesions and their physical signs, I will read some extracts from the notes of the case.—Nov. 4th. Respiration throughout right side expansive and full, but a little harsh. Left side, cavernous respiration with distinct pectoriloquy, most evident near the sternum, about the second rib.—Nov. 24th. Anteriorly, very loose gurgling, with cavernous respiration throughout the whole of the left side. Puerile respiration in the right side. Posteriorly, on the left side, very loose mucous rhonchus, with gurgling throughout; but there is a little vesicular murmur near the scapula. Respiration rude in upper third of right lung.—27th. Left side, anteriorly, respiration amphoric above ; loose gurgling in the lower third. Posteriorly (same side), gur- gling and cavernous respiration in the lower half, and at the summit; in the intermediate space, respiration distinctly cavernous, but mixed with a vesicular murmur. I will now examine the intestinal canal. The mesenteric glands are enlarged, of an irregularly rounded shape, and are entirely converted into tubercular matter. This condition of things, when the tuberculous de- posit is confined to the mesenteric' glands and adjacent parts, constitutes the disease called tabes mesenterica. In most cases of this sort, there are likewise tubercles, either in the peritoneum, or the follicles of the intes- tine : here they are found in both situations. Large intestine.—In the colon there are some ulcers in the follicles, with slight inflammation of the mucous coat. Near the rectum are innu- merable ulcers of small size, which appear like so many distinct points, because they have commenced in the separate follicles. Small intestine.—Near the ileo-caecal valve are numerous ulcers, evi- dently commencing in the glands of Peyer. Some of these glands still remain, but much enlarged, and containing yellowish tubercular matter, which is still of a firm consistence. Here you may distinctly trace the changes which take place in the follicles, from the first deposition of the tubercular matter to its complete softening, and final discharge by ulcera- tion. The other viscera were not examined, on account of the short time which remained for us to make the examination previously to the lecture. There is no doubt, however, that tubercles existed in several other organs, particularly the bronchial glands and the spleen, which are amongst the most frequent seats of these deposits. 716 GERHARD'S CLINICAL LECTURES. LECTURE XII. Phthisis pulmonalis—Pathological characters of gangrene of the lungs. We have another case of phthisis pulmonalis ; some remarks may serve to give you some further knowledge of its history and diagnosis. The case before us is another example of the ordinary variety of phthisis, which commences gradually, and without any assignable cause. The patient is a printer, forty-seven years of age, formerly of intemperate habits, but since the commencement of the disease he has been perfectly temperate. Last winter a cough commenced, but so gradually that the patient is un- able to fix the time of its first occurrence ; during the last four months it has been much more severe and constant, and accompanied by hoarseness. There has been at no time spitting of blood ; the expectoration was at first mucous, afterwards muco-purulent and somewhat nummular: this change in the character of the expectoration took place about the time that the hoarseness commenced. The left side of the chest is somewhat contracted ; the respiration is cavernous, w*ith distinct pectoriloquy. These signs show the existence of a cavity, but it seems to be rather of an indo- lent nature. The hoarseness in this case is owing to inflammation attack- ing the larynx, and causing thickening of its lining membrane, and of the vocal cords ; this inflammation often passes into ulceration ; it is some- times painful, but often there is scarcely a slight tickling felt at the part. I find on making pressure upon the larynx, that the patient complains of no pain, except just below the thyroid cartilage. This inflamraation is the result of the irritation of the tubercular matter and other discharges which pass over the bronchial merabrane, and it may take place at several different points of the respiratory passages—the larynx, the trachea, or the bronchi. This variety of inflammation is strictly secondary, and very dif- ferent from that which occurs in the early stages of phthisis, in which the tracheal irritation is the cause developing tubercles, and not the result of their softening. There is generally considerable soreness attending the inflammation when the phthisis is acute ; in more chronic cases it is slight, or altogether absent. This inflammation of the air-passages, in the cases of which I speak, is secondary ; in others, as I have already repeatedly remarked, it may precede the development of phthisis. The other symp- toms in the present case are of the usual kind : the skin is dry and harsh ; there is general emaciation, with roundness and prominence of the ends of the fingers ; the pulse is quick, tense, and irritated ; there are chills about the middle of the day, followed by fever in the afternoon, and cold sweats at night. The fever, therefore, has the regular paroxysmal charac- ter of hectic. You have now seen cases of several varieties of phthisis, differing in their origin and progress ; it is time to say something of the diagnosis of this affection. The diseases with which it is most liable to be confounded, are bronchitis, pneumonia, and pleurisy, whether of the acute or of the chronic form ; since phthisis, also, may be either acute or chronic. It may likewise be accompanied by any of these inflammations, and it be- comes important to*distinguish such cases from those of simple inflamma- PHTHISIS PULMONALIS. 717 tion. The diagnosis of tubercular disease depends both on the general and the local signs. The first circumstance to be attended to, is the general appearance of the patient. The frame is emaciated ; the skin is of a pale and earthy aspect; there is a restless expression of countenance, indicating the working of a slow disease, and entirely different from the alteration of the features which attends acute disorders. The emaciation shows itself very early in the hands and fingers,—the ends of the latter retaining their fulness for some time, and appearing rounded and promi- nent ; the nails are likewise turned inwards. Emaciation is a sign of great importance in the diagnosis of phthisis and other tuberculous dis- eases ; particularly if you find that the patient is losing flesh, although he eats nearly as much as in good health. When this sign is conjoined with others indicative of phthisis, the diagnosis becomes almost certain. The earthy hue of the skin is attended by a bluish tinge of the sclerotica, which very often occurs in phthisis. We likewise observe a change in the circulation. There is a peculiar fever attending tubercular disease, and characterized by a quick, jerking pulse, the result of excessive irritation. This fever is accompanied by chills and sweating,—the former being at first very slight, while the latter is much more copious than in most other acute diseases. This peculiar condition of the pulse and sharp febrile excitement, are most important in the diagnosis of general tuberculous disease of an acute kind. It is, how- ever, quite as well marked when the tubercles are rapidly developed in the lungs, as when they are deposited at the same time in several of the organs. The observation of these general signs should cause us to sus- pect the existence of phthisis, and lead us to the examination of the local signs. If, upon an inquiry into the latter, we are unable to ascertain the existence of any other disease, we are led, by a process of exclusion, to a confirmation of our original suspicions. We also derive some important points of information from a considera- tion of the predisposing causes of the disease. Thus, the sex exercises some influence ; phthisis is rather more frequent in females. Age is a more important circumstance : phthisis is more frequent in young persons, and is rarely met with after the age of thirty-five. When it does occur after this period, it generally depends upon some accidental cause, as inflammation, &c. The course of the disease is another thing to be consi- dered ; phthisis is in most cases slow in its progress: the diseases with which it is liable to be confounded are more generally acute. The last and most important circumstance in the diagnosis of this dis- ease, is an attention to the local signs. The first of these is usually an uneasy sensation in the chest, very different from the pain of inflammation. It varies greatly as to its position, sometimes shifting from one side to the other, or felt under the sternum. Pain, however, may be present in the commencement of phthisis, when it is complicated with intercurrent pleurisy. The cough is constant, but rather more severe at night, or early in the morning, than throughout the day; it is at first short, and so insig- nificant as hardly to attract notice, and attended by mucous expectora- tion ; in the progress of the disease it becomes loose, and the expectora- tion 'is muco-purulent and nummular; in a still more advanced stage, the cough is very loose,—the expectoration consists of pus mixed with soft- ened tubercular matter, and loses its nummular character. The physical signs are not obvious at the commencement. The first 718 GERHARD'S CLINICAL LECTURES. thing observed is generally a feebleness of respiration at the upper part of the lungs, which afterwards changes into rudeness ; this arises from the obstruction of the lung by the tuberculous deposit. We next perceive a crackling sound under the clavicle, indicative of the commencement of softening. There is likewise a dulness on percussion at the summit of the lung. In the advanced stages there is gurgling, with cavernous and amphoric respiration, and more or less perfect pectoriloquy. There are certain secondary symptoms regularly occurring in phthisis. One of these is hectic fever; at first the fever attending tuberculous dis- ease is not hectic ; I have pointed out the difference in a previous lecture. When hectic is developed, it is recognised by the chills and sweating which accompany it; the flush on the cheeks, &c.; it is always parox- ysmal. The loss of appetite, and decline of digestive power, do not depend upon the deposit of tubercles, but upon the fever which attends it; they differ in no way from the same symptoms which ordinarily ac- company febrile diseases. The diarrhoea of phthisis, however, often de- pends upon the formation of tubercles. It is intermittent, very irregular in its character, occurring sometimes frequently in the course of the dis- ease, sometimes only once or twice. Its immediate cause, in most cases, is the development of tubercles in the glands of Peyer, which, conse- quently, become inflamed and ulcerated ; but diarrhoea in phthisis may arise from the same causes as in other diseases; in the latter case, its symptoms and progress are entirely similar. Hemorrhage is another of the accidental or secondary symptoms of phthisis ; the blood is either discharged directly frora the lungs by a slight cough, or it is swallowed, and afterwards ejected frora the stomach. If the hemorrhage be profuse, that is, not less than two or three ounces in a day, it is considered almost pathognomonic of phthisis, especially in males ; in females, it is not so certain as a diagnostic sign, for hemorrhages from different parts of the body often arise from suppression of the menses, &c, and are, in fact, vicarious discharges ; but in men, as I observed in the last lecture, in at least five cases out of six, abundant haemoptysis arises from tubercular disease of the lungs. The fact that haemoptysis is a very important sign of phthisis has been long known, but Dr. Louis has rendered the profession a decided service, by proving that the value of the sign was even greater than had hitherto been believed. Many cases of this hemorrhagic variety of phthisis terminate in recovery ; it is, in fact, the least unfavourable form of the disease, and therefore the value of the symptom is sometimes un- derrated, because in the minds of many physicians, the word phthisis and death are considered as almost inseparable. This form of the disease is probably less fatal than others, simply because the flow of blood re- lieves, to some extent, the vessels of the lungs, and appears to be a natural safety-valve, which diminishes the tendency to the tuberculous secretion. The case of gangrene of the lungs which I showed you last week has since terminated fatally, and I will now present to you the results of the post-mortem examination. You will recollect that I then stated that the disease affected the lower lobe of the right lung : it rapidly extended itself, and the patient sank in proportion. There is, in fact, no specific treatment by which the disease can be arrested ; all that we can do is to support the system until nature accomplishes the cure, if such is her design. The pa- thological appearances of gangrene of the lungs are closely connected with GANGRENE OF THE LUNGS. 719 and explain, the symptoms during life, viz., fetor of the breath and expec- toration, lividity of the countenance, and the physical signs of a cavity in the chest. This case occurred in consequence of the patient falling into the river: the gangrene probably commenced about twTo weeks afterwards, and has continued for several weeks previously to his entrance into the hospital: since that time it has been constantly advancing. If the pro- gress of the disorganization could have been checked, it is probable that the case would have terminated favourably, for the mischief already done was not necessarily fatal. You will at once perceive the excessive fetor of the lung, and its dark green colour over the lower lobe. As I lift it up, the surface of the lung sinks towards the cavity, wrhich occupies the greater part of the lower lobe of the left lung. The cavity rapidly in- creased in size during the last days of life, as was proved by the enormous quantity of matter expectorated, amounting to at least a pint in the course of the twenty-four hours. The immediate cause of death, however, was dyspnoea, arising from inflammation attacking the heart. Pleurisy, in a greater or less degree, always attends gangrene of the lungs ; here wre have the proof of its existence, in the false membrane which covers the surface of the pleura. This inflamraation of the pleura, producing false membranes, and adhesions of the lung to the ribs, tends to prevent the perforation of the pleura, and the discharge of the gangre- nous matter into the cavity of the chest. From the existence of amphoric respiration, perforation might have been suspected in the present instance, had we seen the patient only on the last day or two of life: but you now see that no such thing has occurred, and that the amphoric respiration was owing to the great size of the cavity. The lung is much softened around the cavity, and yields readily to the knife. The cavity is large enough to hold the fist: it is seated entirely in the lower lobe, having been first formed at its upper part: the disease very rarely attacks the upper lobe. By an examination of the walls of the cavity, we will be able to determine whether any process had commenced for the cure of the disease; when this does take place, it is by means of a false raembrane which is formed around the cavity, and secretes pus and mucus, as is shown by the cha- racter of the sputa. But here we see no appearance of a false merabrane nor of pus or mucus: the cavity contains a gangrenous slough, and a quan- tity of the offensive matter which was so copiously expectorated during life. The walls are blackish, and gradually pass into the healthy lung. The existence of cavities formed in this way, is known by nearly the same physical signs as those which are observed in phthisis ; but the fetor of the breath and expectoration is sufficient to distinguish the two diseases, independently of various other circumstances. The mucous merabrane of the bronchi is inflamed in consequence of the passage of the gangrenous sputa over it: in some cases this matter is swallowed, and produces severe diarrhoea. The upper lobe of the left lung is healthy, with the exception of a few miliary tubercles scattered through its summit. The right lung became inflamed in the progress of the case. The pleura is covered by a false membrane of the consistence of cellular tissue, which is very brightly injected. This inflammation was one of the causes of death. The substance of the lung is healthy, with the exception of a slight engorgement and induration in the centre, which probably constitute the first stage of gangrene, and a few tubercles in the upper lobe. Upon examining the heart, we find traces of former pericarditis, in the 720 GERHARD'S CLINICAL LECTURES. patches of lymph on the surface of the pericardium, and the serous effusion into its cavity. The heart is of the natural size : its muscular structure is in the normal condition, and its lining membrane is also nearly natural, but not entirely so; there is a slight thickening in the left ventricle, and also of the semilunar valve of the aorta. The right side of the heart is frequently found perfectly healthy, though the left be greatly diseased: in this case we perceive merely a slight opacity of the internal merabrane of the right ventricle. The valves of the pulmonary artery are quite healthy. The spleen is enlarged and softened ; this appears to depend upon the vitiation of the blood produced by gangrene, in the same way with the livid hue of the skin. The liver is fatty, and of a lighter colour than na- tural. This fatty degeneration in males is frequently the consequence of intemperate habits: it is also very common in phthisis, more particularly that of females. In the progress of this alteration, the cellular tissue unit- ing the acini becomes more developed than natural, while the acini seem to disappear, their places being occupied by fat. LECTURE XIII. Phthisis pulmonalis (concluded)—Cases—Treatment. I will to-day conclude the subject of phthisis for the present course, by showing you one or two cases of the disease, and saying a few words in relation to its treatment. I shall occupy the remainder of the hour with some cases of cerebral and cardiac disease, and the results of a post- mortem examination of an individual who recently died of phthisis compli- cated with serous inflammations of the heart and lungs. I will first present to you a case of phthisis, commencing in a different mode from any of which I have yet spoken. The patient was attacked about two years since with coxalgia, from which he has never entirely recovered. The treatment consisted in the use of blisters and a seton ; the discharge from the latter, after having continued for some time, was allowed to cease. About eight weeks after, he was seized with cough, which still continues, with other signs of phthisis ; for a few days of the period which has elapsed since the commencement of the cough, there has also been haemoptysis. The phthisis in this case evidently com- menced with a scrofulous disease of the hip-joint; for in two months after the discharge established for the cure of the coxalgia had ceased, the symptoras of phthisis began, and have since progressed in the regular order. The scrofulous diathesis, therefore, before affecting the lungs, de- veloped itself externally. Cases of this sort are by no means rare ; the external scrofulous disease may be seated in other parts than the hip; sometimes, for example, it occurs in the form of fistula in ano. An im- portant practical question occurs in relation to such cases: Ought we to endeavour to cure the external disease ? If we do, there is great danger that the irritation may be transferred to the lungs, and lead to the deve- lopment of tubercles : on the contrary, if we suffer the disease to proceed unmolested, the constitutional irritation arising from it may destroy the patient, or give rise indirectly to the formation of tubercles in the lungs, PHTHISIS PULMONALIS. 721 by producing a condition of the system favourable to this result. The proper course would seem to be, not to check the external disease too suddenly, but, if possible, to subdue it by degrees. Some time ago we had a case here, which illustrated the effects of an opposite plan of treat- ment. The patient was first attacked with tubercular meningitis ; after recovering from that, he had fistula in ano ; this was cured, phthisis con- sequently supervened, and the man died. These cases are extremely common, and you will see many such in your practice. The case now before us is also one in point. The arrest of these external discharges may likewise give rise to other diseases, among which are diseases of the heart, and inflammation of the lungs; the latter in such cases being often of a more chronic character than in ordinary pneumonia. Case 2. We have here an example of phthisis occurring in old age ; the patient is sixty-two years old. He has been employed in one of the oyster-cellars of this city,—a situation, from its dampness, and also its darkness, extremely favourable to the development of phthisis. He has had cough for seven years, but it has never been severe till the com- mencement of the past summer. There is now well-marked cavernous respiration, with pectoriloquy, and other signs of cavity in the upper lobes of both lungs. Phthisis occurring at such an advanced age is extremely rare. But experience shows us that no age is exempt from this disease. Tubercles are found even in the fcetus, and at every period of life. They are most frequently met with, however, about the fifth year, and after- wards frora the fifteenth to the twenty-fifth. Cases of phthisis, or other tuberculous diseases, occurring in old persons, are much more frequently observed in hospitals than in private practice. I next introduce these men, formerly patients, but now employed in the house, in whom cavities in the lungs have been more or less perfectly healed. The first is a case of phthisis, in which a cavity became cica- trized after it had continued to a very advanced stage, but was reproduced upon a second attack of the disease. The patient entered the hospital about three years since, with all the signs of a cavity in the right lung ; dulness on percussion, cavernous respiration, &c, were very well marked. He remained in the wards for several months, during which time his con- dition was constantly improving : he was then discharged, and was, to all appearances, nearly well,—a small cavity, however, still remained, with slight cough and expectoration. After he had been out of the hospital about five months, he had an attack of intermittent fever, which continued for some weeks. After he recovered from the fever, he had a second attack of phthisis, or, as it were, a new crop of tubercles, for which he was under treatment in our wards. He is again much improved, though still feeble. The local signs indicate a partial consolidation of the lung by the process of cicatrization ; thus, there is dulness on percussion, and a diminution of the natural vesicular respiration. These indications of a cicatrix exist where formerly were heard a strong cavernous respiration, and all the other signs of a cavity of considerable size. The cure in this case, then, is only partial. But in the case which I now present to you, there has been a complete restoration. The patient, in the year 1835, had an attack of gangrene of the lungs, which continued for several months, with very fetid expectora- tion, and all the other symptoms of this affection. The local signs indi- cated a cavity large enough to contain the fist. After a time the expec- 47 722 GERHARD'S CLINICAL LECTURES. toration became muco-purulent,—a change which indicated an arrest of the gangrene, and the formation of a false membrane on the surface of the cavity. The man, as you see, is now stout, free frora dyspnoea, and in every respect perfectly healthy. There was no scrofulous vice in the con- stitution, tending to reproduce the cavity, as happened in the preceding case. The disease was caused by cold and intemperance. As the man has now been well for nearly six years, the cure may be considered com- plete.* You see, therefore, that it is possible to cure a cavity in the lungs, how- ever infrequent may be the occurrence of such a result, especially in phthi- sis, where new crops of tubercles are so liable to form. The treatment, in all such cases, is entirely negative ; there is, in fact, no remedy for the lesion. All that we can do is to palliate the symptoms, and support the constitution of the patient till nature, if she be so disposed, accomplishes the cure. Generally, the prognosis, after a cavity has been once formed, is altogether unfavourable ; we always look for the death of the patient, whether the cavity be the result of a tubercular deposition, or of any other lesion. But before the cavity is formed, our chances of success are much greater. In hospitals, however, our prospects, in either case, are far less encouraging than in private practice. We are entirely unable to adopt those measures which are most essential to a successful issue ; we can only employ medicinal remedies; in relation to food, clothing, air, exer- cise, &c, the means at our command are necessarily very limited and imperfect. In private practice, on the contrary, we are enabled more successfully to combat the general disease, by changing, as far as possi- ble, the whole constitution of our patients ; for this purpose, we direct a change of scenes and of climate by travelling, which is our principal re- liance in such cases. In the treatment of phthisis, you will find that there is great practical importance in the classification of the disease into several varieties, which I have called your attention to in preceding lectures. The inflammatory variety may frequently be arrested in the earlier stages by the ordinary antiphlogistic means which we employ in cases of simple inflammation. In that variety which commences slowly and gradually, on the contrary, we derive little or no aid from this plan of treatment. The treatment of phthisis, therefore, must be as various as the different forms of the disease. In the ordinary slow cases, we must attempt to change, as it were, the whole being and nature of our patient, in the same manner as we do with regard to the mental constitution in the treatment of insanity. By thus producing a change in the constitution, we endeavour to cause the ex- pulsion of the tubercular vice. For the details, I must refer you to the different treatises which have been written on the disease. It is unfortunate that the treatment of phthisis proper should be so limited, that is, as to the strictly curative treatment. If it be inflammatory, it is more immediately within the power of medicine, and a removal of the local inflammation, which is acting as a continual irritant upon the con- stitution, bringing about at last decided phthisis, is our first object, and then the patient will often pass little by little into perfect health, or he will remain in a feeble condition, which requires a change of air, a long voy- age, or some other constitutional renovation, to remove the remains of the disorder. But if these patients be improperly treated, and suffered to * This patient is still perfectly well, 1848. PNEUMONIA. 723 remain suffering from chronic inflammation, or if they are exhausted by what is termed very vigorous treatment, they may readily pass into phthi- sis. This is especially the case as regards chronic pleurisy: a suitable antiphlogistic treatment is necessary, but an eye must always be kept to the state of the patient's general health, and the strongest efforts should be made to keep up the strength and aid the constitution in throwing off the disease, if already developing itself, or in acquiring that vigour which is opposed to tuberculous disease. In such cases a mercurial treatment is admissible, and I believe that the safest mode in many cases would be to mercurialize rapidly, as recommended by Drs. Graves and O'Bierne, were it not for the different susceptibility of patients to the action of mer- cury, which must render this mode of treatment at times injurious. It is better, therefore, on the whole, to give mercury in more minute doses, and to discontinue it as soon as a constitutional impression is made. It is impossible, however, to exercise too much caution as to the use of mer- cury in individuals attacked or threatened with phthisis, and from my ex- perience in its use I would limit it to the very beginning of the disease, when associated with chronic pleurisy, or perhaps pneumonia : for there is a tuberculous inflammation of the lung which is slow to resolve itself. As to the treatment of the disease, properly speaking, it is so well laid down in different treatises upon the subject, that I must restrict my re- marks upon it to my lectures on the diseases of the chest, where the sub- ject is necessarily enlarged upon. LECTURE XIV. Pneumonia — Jaundice — Tubercular meningitis — Pathology of laryngitis and laryngeal phthisis. We have lately had several patients convalescent from acute diseases, especially inflammatory affections of the lungs. I shall conclude the lecture with a few remarks on the tubercular affection of the membranes of the brain, so common among children, and with the demonstration of some pathological specimens illustrating the history of laryngitis. Case 1.—In the two preceding lectures I spoke to you of a man la- bouring under an acute disease of the lungs, the severity of which ren- dered itimproper to remove him from the ward. He is now before you in a state of convalescence. This man entered the hospital about a month since, at which time he presented the signs of pneumonia, complicated with an incipient tubercular affection—the latter impressing certain modifi- cations upon the character of the former. Under the treatment which was adopted, the patient at first did very well; but suddenly grew much worse, in consequence of the supervention of pleurisy, followed by copious effusion. The distress produced by this complication added to that imme- diately consequent upon the proper affection of the lungs, and brought the patient to the brink of the grave. The dyspnoea and prostration of the system were extreme. In this condition of things, a mild, depletive plan was pursued ; the great depression of the recuperative powers of the patient put all active measures of the kind out of the question. A single cup was, therefore, applied, and repeated according to the necessity 724 GERHARD'S CLINICAL LECTURES. of the case; at the same time the patient was put upon the use of mercury. This treatment was soon followed by an improvement in the aspect of the case, which, however, was not very decided, until the action of the mercury was made manifest by the occurrence of slight ptyalism. From that time (seven or eight days since), the patient has been steadily improving. But convalescence, in a case like the present, is never so rapid as it is in simple pneumonia. This is owing partly to the tubercular diathesis of the patient; in part, also, to the abundance of the pleuritic effusion, which always requires a certain time for its removal by absorption, more parti- cularly when it co-exists with pneumonia or tubercles. The case is one of considerable interest, as illustrating the advantages of very moderate depletion, and of the judicious employment of mercury in certain forms of acute pulmonary disease. In relation to the latter remedy, I have re- peatedly urged upon your attention, that we employ it in acute affections, not for the purpose of salivating our patients, but of producing its specific constitutional influence. Its effect upon the mouth is the mark of this influence, or of the saturation of the system with mercury; after the slightest possible redness of the gums is produced, the influence of the remedy cannot be rendered more complete and decided, no matter how copiously it be given. Case 2.—This is an instance of pneumonia so mild as hardly to require any treatment. The patient is a man aged forty-nine ; he is of robust frame, and has led an active life, having been for some years a soldier in the Peninsula; he has generally enjoyed good health. He has lately been employed in cutting ice. On the 19th he was taken ill; the first sign of the disorder was a chill. This was followed by cough, but no pain in the chest; the expectoration has been viscid from the first, but has never been coloured with blood ; at no time has the patient been con- fined to bed. On the 25th he entered the hospital,—and, on examining his chest, the physical signs of pneumonia were detected. The following pectoral mixture was ordered :— R. Ext. Hyoscyami, gr. viij. Syrup Polyg. Senega:, |j. Mucilag. Acaciae, 3 v. Ft. Mist. 27th. The hot infusion of eupatorium was ordered. Under the action of this remedy, the disease passed off by a copious diaphoresis: the patient is still sweating. He may now be considered as convalescent. It would appear, therefore, that only eight days elapsed from the com- mencement to the crisis of the disease. This seems to be in contradiction to a rule which I laid down in a preceding lecture, viz., that the usual duration of pneumonia is from fourteen to twenty-one days. But it is to be remarked that although the general signs indicate the declension of the disease, the local signs still exist; there are yet manifest some dulness on percussion, and crepitant rhonchus. By the time that these have disap- peared, the case will probably be brought nearly within the minimum which I have stated. This is the usual course of mild cases of pneumonia. In cases like the present, no active treatment, and little, indeed, of any kind is requisite. Hot diaphoretic and nauseating drinks, are the best possible remedies. Such instances of mild attacks are less frequent in PNEUMONIA. 725 pneumonia than in most other diseases, and the expectant and palliative treatment just mentioned, is rarely worthy of confidence. But when such cases do occur, a more active treatment only puts the patient to inconve- nience, without resulting in adequate benefit. I wish particularly to in- culcate this principle, that, when a disease is tending to a favourable ter- mination, all measures of an active kind should be dispensed with; it should be a matter of conscience with the physician not to harass the patient with unnecessary applications. An opposite course of practice tends, in no small degree, to throw discredit on the profession. This hurtful officiousness arises not from any defect or error in the plan of instruction in our schools, but from an idea which is so apt to be enter- tained by every student from the commencement of his studies, viz., that every disease is recognised by certain signs, and requires for its cure a certain set of remedies. So that whenever the symptoms indicate the existence of inflammation, bleeding, purgation, and revulsion at once suggest themselves to his mind. It requires experience to teach him that there are, in fact, many cases of inflamraation, and still more of continued fevers, which require no such violent measures. Case 3.—In this case we have pursued a plan of treatment precisely the reverse of that adopted in the preceding one. Very free bleeding and other depletory measures have been resorted to, but not with a correspond- ing amelioration of the symptoms, because they were not practised until the disease had made considerable progress. The patient, Shepherd, was seized with pneumonia on the 8th inst.; he was admitted into the hospital on the 18th ; so that ten days had elapsed before any attack upon the dis- ease was made. The treatraent was commenced by the abstraction of twenty ounces of blood from the arm; this was followed by cups to the side, which were repeated three times; the patient was also placed upon the use of the infus. eupatorii. Notwithstanding these active measures, the disease continued to advance, with very slight modification of the symp- toms. The combination of opium, digitalis, and calomel, of which I have already so often spoken, was then ordered, mainly with the view of ob- taining the antiphlogistic action of the mercury. Two days after his en- trance, the patient was taken with singultus, which came on at particular periods in the days, and continued for an hour or two at each attack. Hic- cough is a symptora of grave import in inflammatory affections, and is in- jurious in itself, inasmuch as it serves to exhaust the strength of the pa- tient. It seems not to depend directly on the inflammation, but on a sym- pathetic irritation of the nerves of the diaphragm. It is a symptora which is more frequently met with in some seasons than in others ; during the past year we have not had many instances of it. As it was not quieted by the treatment already adopted, assafcetida was ordered with this view ; this failing, the oil of amber was ordered, in doses of six drops, repeated according to circumstances. Under this treatment, the singultus gradually subsided, and the disease took a favourable turn. . At the last lecture I remarked to you that the duration of this case would probably not be shortened by the active practice which had been pursued and the result has verified the remark. Bleeding, however copious, will not cut short an inflammatory disease, unless practised soon after its inva- sion • a few hours may carry the affection beyond the point at which de- pletion may cause it to abort. After it has passed this point, bleeding, though it does not arrest the course of the disease, is still of use, by pal- 726 GERHARD'S CLINICAL LECTURES. Hating its inconveniences, and diminishing its tendency to run into fatal disorganizations. Little change was perceptible in the condition of the patient until the 25th, when he was somewhat better. On the 26th he appeared to be in a state of convalescence. On the 27th this favourable change was still more evident. The face was pale and sunken ; I have already stated that this subsidence of the features after the fulness and flushing produced by inflammatory excitement, is one of the best signs of convalescence. The pulse had fallen from ninety-six to eighty ; it was soft and tremulous. The respiration had also fallen from thirty to twenty in the minute. No doubt therefore could exist as to the fact of the patient's convalescence; the simultaneous subsidence of the respiration and the pulse rendered it per- fectly certain. On the contrary, if the pulse had become slower, while the respiration retained its frequency, we should have concluded that the pa- tient was in a much worse condition. The duration of this attack of pneumonia was nineteen days, which is within the average which I stated in my remarks upon Case 1. Pneumo- nia, in fact, has a natural duration, and one principal object to be aimed at in its treatment, after the disease is established, is to prevent accidental circumstances frora interfering with the natural tendency of the disease to terminate at a certain period. Jaundice.—The patient, aged 45, entered the hospital on the 23d inst. He had always enjoyed good health until last summer, when he had an attack of dysentery. On the 22d, after exposure to wet and cold, he was seized with cough, and the same evening he had a chill, attended with pain at the xiphoid cartilage. On the 23d he was jaundiced; the skin, conjunctiva, and urine, were of a deep yellow, and every object appeared to his sight to be of the same colour ; the skin was moderately warm; there was no headache, but pain and tenderness in the right hypochondrium, which obliged the patient to lie on the left side ; expectoration was slight; pulse moderately full. Venesection, cupping over the region of the liver, and a diaphoretic infusion, were ordered. 24th. Patient more jaundiced ; pain had extended to epigastrium ; slight signs of bronchitis observed. Cups repeated, and an infusion of senna, with sulphate of magnesia, ordered. 26th. Patient now complained of headache, and vertigo, depression of mind, &c. Bleeding repeated. $ gjFrom this tirae the symptoms rapidly abated, and few remains of the disorder are now perceptible. The skin is only slightly coloured on the breast; the vision has become natural; the skin is moist: it has never been hot, however, at any time in the progress of the case. The most prominent symptom of this case, besides the alteration in the colour of the skin, was the tenderness in the right hypochondriac and epi- gastric regions, accompanied by dulness on percussion. It was inferred from these signs that the liver was congested, and slightly inflamed. In- flammation of the liver is by no means a common occurrence in the winter season. The prevailing inflammatory diseases are those of the lungs, heart, and fibrous tissues of the extremities; the abdominal viscera are more rarely affected. But this man's previous history affords a very sufficient reason for the occurrence of hepatitis in his case. Last summer he had an attack of dysentery; now, a severe dysentery hardly ever passes through its course without involving the liver in a greater or less degree. There JAUNDICE. 727 is, therefore, a strong presumption, that this man's liver was at that time affected; it was naturally left in a condition favourable to the return of disease, upon the occurrence of the usual causes. This circumstance de- termined the deleterious impression of cold to the liver rather than to the lungs. Jaundice depends on a great variety of causes. When acute, as in the present case, and dependent on congestion and slight inflammation of the liver, it is in general easily cured. It yielded in this case to bleeding, cupping over the liver, and saline purgatives. Mercury was not employed at all in the treatment: the only character in which it could have been used with propriety was that of an evacuant,—and in this case it seemed to offer no particular advantages over saline and other purgatives. You will re- collect that in the numerous instances recently brought to your notice in which this article was employed it was not as a purgative, but as an anti- phlogistic remedy in certain stages of inflammatory affections. Headache was an important symptom in this case, and its occurrence induced us to repeat the bleeding. In all cases of jaundice, indeed, cere- bral symptoms demand particular attention : for it is usually in consequence of the supervention of cerebral affections that this disease proves fatal. The cause of this complication is the suppression of the biliary secretion, the elements of which being retained in the blood, act like a poison upon the system, especially on the brain. In like raanner, urea, if retained in the blood, proves deleterious. In fact, all diseases of the liver or kidneys, attended with suppression of their secretions, are followed by coma, and other signs of cerebral oppression, in consequence of which they terminate fatally. It is in this way that the granular affection of the kidneys, called "Bright's disease," often proves fatal. When the cerebral symptoms are active, the proper treatment is general and local bleeding, cold applica- tions, &c. But in jaundice it is often impossible to remove them until the bile is eliminated from the blood ; this is effected slowly, and by a process of nature. If the symptoms are attended with much depression of the vital energies, depletion becomes improper, and we have to rely on other means, the most effectual of which experience proves to be sinapisms and blisters. . . At the last lecture I introduced a raan labouring under acute laryngitis, upon whom an operation was performed in your presence, but without success. This case was one of acute, grafted on chronic laryngitis. The affection was originally acute (having commenced about a year ago), but became chronic, and continued so till ten days before the patient's entrance ; it then became acute, and the symptoms were strongly marked at the time of his entrance. It was likewise observed that the lungs were affected,—but in what way, the signs were too obscure to enable us pre- cisely to determine. The lungs were pervious to the air, so that there was little dulness on percussion ; but the respiration was feeble through- out the right side, and some crepitus was distinguished below. It was hence inferred that the lung was congested, but nothing else could be made out with any certainty : as you will presently see, these signs were owino- to the development of miliary, tubercular granulations, in great abundance, with congestion of the surrounding tissues. The operation of laryngotomy, performed by Dr. Gibson, produced some relief for the mo- ment • but the dyspnoea returned every time the artificial opening became 728 GERHARD'S CLINICAL LECTURES. obstructed, and not more than half an hour elapsed before the man died of suffocation. The operation was resorted to as the only chance of pro- longing life ; but even if it had been raore successful for the time, it could not, in the end, have saved the patient—for an immense number of grey- ish, semi-transparent, tubercular granulations, had filled the upper and a part of the lower lobe of the right lung, and the upper and a part of the lower lobe of the left. But, had the condition of the patient been such as to allow a full examination and positive diagnosis, the operation would still have been justifiable, as the only means of securing to the patient a few more hours or days of life. The immediate cause of the intense dyspnoea under which the patient laboured, was edema of the larynx, and inflammation of the trachea and bronchiae. The former offered a very great obstacle to the passage of the air through the rima glottidis—while the trachea and bronchi were lined by a layer of very viscid mucus, which interposed a further obstacle to its entrance into the lungs. The matter lining the air-passages was not, pro- perly speaking, a false membrane, but it was so dense that it could be detached in shreds of considerable length. There was likewise an ulcera- tion of the lining membrane of the larynx, between the posterior extre- mities of the vocal cords, and extending to the cricoid cartilage. This case is one of interest, inasmuch as it illustrates the connection between laryngitis and phthisis. Laryngitis sometimes occurs as the pri- mary, sometimes as the secondary disease. The latter was the case in a patient who lately died in the female wards; during the progress of a tubercular affection, she was attacked with laryngitis, which was indi- cated by the ordinary symptoras, dyspnoea and aphonia. When laryngitis occurs as the original affection, it raay continue for years, attended with more or less cough, hoarseness, and dyspnoea, but without any indications of disease in the pulmonary tissue. At last ulceration occurs; at this point, in a very large proportion of cases, tubercles are developed in the lungs. In this variety of phthisis the tubercles are generally greyish, semi-transparent granules, of small size, and uniformly diffused through the lung. Consequently, phthisis following laryngitis, is one of the most intractable varieties of the disease. In all cases where the affection of the larynx has advanced to ulceration, we apprehend the supervention of phthisis. Almost the only variety forming an exception to the rule, is that form of ulceration of cartilages and of the mucous membrane which occurs in secondary syphilis. But it is easy to discriminate such cases by the general condition of the patient, the history of the affection, &c. Besides, ulceration of the larynx consequent on syphilis almost always extends rapidly into the cartilages. The prognosis of laryngitis is never grave until ulceration has occurred: if there be merely thickening of the membrane, a cure may frequently be effected ; but if ulceration takes place, this result can hardly be hoped for. If the dyspnoea should be excessive, and threaten suffocation, an opera- tion for its relief is the only resource. There are several different methods of performing such an operation. Dr. Gibson, in the case which wTe have been considering, preferred laryngotomy. This is usually done by making a transverse incision through the crico-thyroid membrane. In France, the operation for croup is often performed, and at the present day surgeons generally are in favour of tracheotomy. In this operation, a longitudinal incision is made into the trachea, which is kept open for the passage of LARYNGITIS. 729 air, either by means of a canula, or of a blunt hook applied to each edge of the incision. This operation is preferred to laryngotoray ; inasmuch as it admits of a more extensive opening, through which the false mem- brane may be pulled away. I now show you the larynx and trachea of the man who died after the operation of laryngotomy was performed. The lining merabrane of the larynx was at first highly injected ; but by maceration in water, the blood has been almost entirely washed out. However, you can still perceive the edematous state of the glottis. This edema was produced by the effusion of serum under the mucous membrane, in the same raanner that it is effused from the surface of inflamed serous membranes. The mucous raembrane is softened ; at the posterior part of the larynx is a large ulcer, and many smaller ones are scattered over the remaining portions of the larynx, as well as the upper part of the trachea. The mucous membrane of the trachea, like that of the larynx, was highly injected. The epiglottis is slightly thickened at its lower part. In the crico-thyroid membrane, you see the opening made by the operation ; it is not quite so large, in fact, as the natural opening of the glottis ; it therefore easily became obstructed by the viscid secretions which filled up the air-passages. The upper lobe of the left lung, and all the lobes of the right one, con- tain an immense number of small, grey, semi-transparent granulations. In the right lung, they are so numerous as to have almost obliterated its vesicular structure. A tubercular deposition of this kind never occurs, except in acute phthisis. The right lung is likewise congested, particu- larly at the lower part, over which the crepitant rhonchus was heard during life. At the summit of the lung is a cicatrized cavity, containing a mass of calcareous matter. The surrounding parenchyma is puckered and contracted by the cicatrix, and the adjacent pleura is covered by adhesions. These appearances indicate the former existence of tubercles ; these were probably deposited at the same tirae the chronic laryngitis occurred, and were removed by the absorption of their animal matter, the calcareous portion remaining behind and constituting the white masses which you here see. Here are the lungs of another patient, who entered the hospital in the last stage of phthisis, and died within forty-eight hours. I show them to you for the purpose of contrasting the early, with the latter stages of the affection. At the summit of one lung is a large cavity, and in that of the opposite one are numerous small granulations, of recent origin. When the tubercular granulations are deposited in great numbers through the pulmonary tissue, the disease is almost always acute, and, in fact, is iden- tical with what is often called the " galloping consumption." The termina- tion of this variety, which is almost always fatal, occurs in two ways: in the one the patient dies of dyspnoea, and you find, as in the present case, the lungs excessively congested, through all that portion of them in which the granulations are deposited. The death then actually takes place by suf- focation. I have seen some examples of it; one of the first was some years ago, when I was a resident pupil of this hospital. A black, who had been labouring under the disease for some time, with much dyspnoea, called to us one day while making the visit, that he was strangling, and died almost immediately ; the lungs were excessively congested, and almost stuffed with these granulations. In most cases, the disease passes on to softening at the summit, at least 730 GERHARD'S CLINICAL LECTURES. of the lungs, while the rest of the tissue is engorged and filled with the granulations. In these cases there is high fever, sweating, and generally intense dyspnoea. The cough, however, raay be very slight. You will find the respiration generally feeble, and the chest less sonorous than usual. There lately occurred a disease of the brain, which I am accidentally prevented from showing you, and which was interesting as an illustration of an affection of which I may perhaps speak more fully at a future time, —tubercular diseases of the membranes of the brain. The case was that of an adult. On opening the cranium, tubercular granulations were found beneath the merabranes, both on the superior surface and base of the brain ; in the intervals left by them, the membranes were injected, and covered with lymph. The affection probably followed the development of tuber- cles in the lungs ; the examination was not extended to these organs. The deposition of tubercles under the membranes of the brain was followed by acute inflammation, which resulted in effusion, and softening of the cerebral substance. This was indicated by rigidity and paralysis of the extremities ; muttering delirium ; subsultus tendinum ; contraction, and afterwards dilatation of the pupils ; distortion of the mouth. The occur- rence of symptoms of meningitis in the course of tubercular phthisis, may be considered sufficiently certain evidence of the development of the affec- tion of which I am speaking. In children it is indicated by the signs commonly described as belonging to acute hydrocephalus. This disease, so called, which is frequent from the age of two years up to puberty, is neither more nor less than tubercular meningitis ; the inflammation is usually attended with effusion into the ventricles or on the surface of the brain, and from this circumstance the ordinary appellation of the disease is derived. But the effusion is altogether an accidental matter; and so is the softening which sometimes occurs. It is the tubercular deposit, and the concomitant inflammation, which constitute the essential characteris- tics. LECTURE XV. Typhus and typhoid fever—Symptoms—Treatment. In the works of many writers on the continued fevers of Great Britain and Ireland, you will find that the only distinction admitted by them, as to the nature of these diseases, is that of the degree of severity of the symp- toms. Thence the common division into typhus mitior and gravior ; terras indicative only of the greater or less intensity of these disorders. In France no efficient attempt was made to trace the distinctive characters of the different affections classed under the name typhoid until the year 1806, when the work of Petit and Serres was published. These writers found that in the forms, such as they witnessed at Paris, there was a con- stant anatomical lesion seated in the abdomen and occupying the follicles of the ileum, especially the agglomerated patches, or, as they are often called, the glands of Peyer, seated near the ileo-csecal valve, the mesen- teric glands, and the spleen. These alterations were inflammatory, the affection of the glands of Peyer being attended with redness, thickening, TYPHUS AND TYPHOID FEVER. 731 and often passing into ulceration, while the mesenteric glands were en- larged, reddened, and softened, and the spleen was enlarged and soft- ened. The evidence of inflammation was indeed perfect, except as re- garded the spleen, of which the lesion might be regarded as dependent either upon inflammatory softening, or as the result of an alteration of the fluids of the body. The after-investigations of Dr. Louis proved this matter much more conclusively. In his excellent work upon typhoid fever he has shown that the disease is uniform, and accompanied by a regularly-developed series of symptoms, not occurring in a confused manner, but forming to- gether a well-characterized whole. It was this uniformity which enabled him to designate the disease in such a manner that there is now no diffi- culty in separating the cases of it which are met with from those of the different affections classed under the vaguely used terms—typhus and typhoid fever. In Great Britain, and still more frequently in Ireland, another disease, which is endemic in those countries, is called typhus fever, and resembles in many particulars the typhoid fever described by Dr. Louis. It differs from it in its symptoms, but especially in its mode of extension and in its anatomical characters. The latter are not fixed and regular ; on the con- trary, the organs are diseased in so many different degrees, that observa- tion proves that there is no one uniform anatomical character, unless it be the condition of the blood, which is evidently altered in many cases, and probably so in others, in which the demonstrative proof is wanting. The lesion of the glands of Peyer is not met with in this disorder, unless it be in a straggling case of typhoid fever, classed among the cases of typhus ; or in a complicated case, which is extremely rare, but I believe occasion- ally met with. The deductions of Dr. Louis, as to the anatomical lesions of typhoid fever, have not therefore lost any of their value ; they still remain true as applied to the disease described by him ; but they are not applicable to the English typhus, or, as Dr. Graves calls it, the maculated fever. In order to prevent confusion in these terms, I have for some years past used the term typhoid fever, as applicable to the fever described by Petit and Serres, Louis, and even by Rcederer and Wagler, and I restrict the term typhus to the disease described by the British writers, and not attended by the intestinal lesion. This distinction is gradually passing into com- mon use in the United States. At one time I was disposed to adopt the term typhus mitior as applicable to typhoid fever, but I found that there were many cases and various epidemics of typhus fever in w'hich the symptoms of the disease were extremely light and the mortality inconsi- derable, but still the leading characters all remained, and the identity in the symptoms of the disorder was in nowise weakened. The terms mitior and gravior raay, therefore, very properly be used to designate merely the degrees of severity of the affection, and not to distinguish two different forms of disease ; the former is happily the more frequent form ; the lat- ter appears only in a few places, or in close confined ships and hospitals, where a number of men are crowded together. The symptoms of typhoid fever are not all found in every case ; that is, some one or more of those which are considered leading symptoms may be wanting, but the group of those which remain is in every case, or nearly so, quite large enough to identify the disorder. For convenience, 732 GERHARD'S CLINICAL LECTURES. you may divide them into distinct groups; first, those of the cerebral and nervous system ; secondly, of the skin ; thirdly, of the abdominal viscera ; and, lastly, of the thoracic organs. Those of the first series are, loss of strength and prostration, which occurs very early in this disease, singing in the ears, vertigo, and not unfrequently epistaxis. The pains in the head and limbs are not so vio- lent as in the remittent or intermittent fevers. There is more frequently chilliness than a regularly defined chill. These are usually the earliest symptoras, followed after some days by slight diarrhoea and other abdomi- nal disturbance. The brain symptoms increase slowly, the patient be- comes dull and stupid; if the disease be violent, he may become coma- tose. Delirium is not invariable, although it is rarely quite wanting ; but if the disease be mild, it shows itself only at night, and for a short time. In severe cases the delirium is violent, and if this be complicated with meningitis, the patient may fall into the wildest ravings ; it is in general much more mild and low, or muttering. In fatal cases coma almost al- ways precedes death. In typhus wTe have a different succession of symptoms, and a difference in their development. From the very first attack of the disease the stupor is the most prominent symptom ; sometimes the intelligence of the patient is in some degree preserved, although he seems to be in a dreamy, stupid condition, almost inattentive to surrounding objects, but still capable of answering correctly and continuously when his attention is excited. The recollection of the patient after the attack is extremely confused, and the stupor resembles in many respects a state of somnambulism. Besides the stupor, headache, dizziness, and tinnitus, are all amongst the early symp- toras of typhus, but the strength is much less broken down than in typhoid fever. If the disease advances, the patient becomes comatose at a much earlier period than in typhoid fever, and generally dies, if the case be fatal, of the brain symptoras. Delirium is a very frequent symptom ; indeed there are few cases in which it is totally absent ; it is almost always of the still, muttering kind, except when complicated with inflammatory action of the brain. The cerebral symptoras of the two forms of fever differ less from each other than many other groups of symptoms, but there is, in the majority of cases, a greater difference in the character of the symptoms than is easily described ; especially as regards the stupor, which is much deeper and more disproportioned to the other symptoras in typhus than in typhoid fever. The external symptoms of the two diseases vary ; you have seen that both are attended with a cutaneous exanthema, but in typhus this is general, extending over the whole body ; in typhoid fever it is limited to the anterior part of the trunk, that is, the abdomen and thorax, rarely reaching as far as the thighs. The typhous eruption consists of a measle- like rash, slightly elevated, of a light red at first, but after the second day, or in severe and malignant cases, from the first, of a darker tint. The papulae are rounded and vary in size, frora an alraost imperceptible point to the breadth of nearly a line. The rash is not, strictly speaking, pete- chial, that is, if the term petechiae be confined to ecchymoses of blood in the derm, but it is fpequently called by this term, and in the papers which I have published in 1837 the word is used in this sense. The rash gra- dually subsides after four or five days, but it is sometimes visible for ten, twelve, or even fourteen days. It appears usually about the third day of TYPHUS AND TYPHOID FEVER. 733 the fever. There is no other eruption which is peculiar to typhus ; suda- mina are, however, occasionally met with about the groins, and other parts where the skin is thin, especially during the hot weather. The measle-like eruption is evidently an exanthema, and very similar to the papular eruption of measles in its development and progress ; and, frora its constant occurrence, Dr. Graves calls the disease the maculated typhus. The eruption of typhoid fever is papular, but the spots are rather larger, about a line in length, elliptical, more elevated, few in number, often not exceeding six or eight, and rarely more than thirty ; they appear a little later than those of typhus, but last about the same time. The sudamina are much more frequent than those of typhous fever, and often appear in two different crops, one early in the disease, and another just before con- valescence. It is not yet settled whether any form of continued fever is met with wfiich cannot be referred to one of these classes : I have myself seen none. But we must remember that some of the symptoms of typhus occur in many diseases in which the blood is more or less altered, such as phlebi- tis, asthenic pneumonia, &c, and thus may be confounded with these diseases, just as certain stages of remittent fever are often called by the same name, and regarded as mere varieties of typhus. But there is not in any of these cases the complete series of symptoms, although some isolated ones may be met with, in diseases which resemble in some re- spects these fevers, but are without the characteristic eruptions. The symptoms connected with other organs vary in the two fevers. The abdominal symptoms of typhoid fever are, diarrhoea, which is a fre- quent though not invariable symptom, flatulence with tympanitic disten- sion, pains in the abdomen, sometimes at the epigastrium, at others in the iliac fossa. In typhus no one of these symptoms is found, except as a rare and accidental complication. The thirst and anorexia are common to the two diseases ; but the former symptora is generally more marked in typhus, the latter in typhoid fever. The thoracic symptoms are but moderate in mild cases of these fevers. In the typhoid the bronchial mucous membrane is congested, especially in the smaller tubes. The congestion produces a slight sibilant rhonchus, and may of course pass into bronchitis or pneumonia of a severe character. In typhus the lungs are also congested, but it is in a different way. The posterior part along the spine seems full of blood ; causing at times a mucous rhonchus, but preventing in a great degree the air from passing into the smaller tubes. This condition of the lungs seems more depend- ent upon the state of the blood than that of the mucous membrane, pro- perly speaking, which is only secondarily involved. The action of the heart is not violent in either disease ; on the contrary it is often enfeebled, especially in typhus, in which the loss of power of the heart is one of the strongest indications for a stimulating practice. The pulse is more frequent in typhus than in typhoid fever. The capil- lary circulation is more or less altered in both diseases; hence the skin is dull and of a dusky tint, and at the face is often of a deep red colour, as if excessively congested, and the blood circulates slowly through the ves- sels, especially in typhus. The capillary vessels of the conjunctiva are injected in typhus, and full of blood, which circulates rather slowly through them ; but in typhoid fever we have rather a bright eye than the dull, heavy, bloodshot one of the former disease. The medical physiognomy 734 GERHARD'S CLINICAL LECTURES. of the patient, which is mainly dependent upon the capillary circulation, is one of the best diagnostic signs of the two diseases, but it is very diffi- cult to describe. There are some other circumstances which are of interest in relation to this matter. One is, that typhus fever spares no age, is more severe amongst the aged and those in middle life than the young, and generally prevails as an epidemic, extending itself by contagion, or direct propaga- tion, from an infected individual, or still raore frequently from a mass of infected individuals, to others. Typhoid fever, on the other hand, rarely assumes this infectious character, and is rarely epidemic, probably it is scarcely infectious, except when prevailing epidemically. I never met with a case of the genuine typhus in this country before the year 1836, but typhoid fever is always a common sporadic disease, especially in the northern parts of the United States. I have seen both varieties in newly- arrived passengers from emigrant ships, but rarely in the same ship. The typhus attacked a much larger number of patients than the typhoid, and was often increased in severity in direct proportion to the number attacked. In some of these ships the disease was evidently propagated from one indi- vidual, who contrived to embark while labouring under the disease, and then those sleeping in the same berth with him were the first attacked. The origin of the fever was clearly transatlantic in all such cases, and in fact it was merely the Irish typhus, carried over to America by Irish emi- grants, and sometimes propagating itself afterwards. The treatment of mild cases of typhus is extremely simple : regarding it, as I do, as a self-limited disease, which necessarily tends to recovery unless arrested by some accident, I content myself with the simplest mea- sures, acting as it were in the direction of the disorder, but not opposing any obstacle to the natural working of disease which tends to relieve itself. At first I give the patient a dose of oil, which generally relieves his giddiness, and direct a mustard foot-bath at night, sometimes twice a-day, and give him either simple lemonade, a neutral mixture, or what is still better the solution of the acetate of ammonia. Should the face become flushed, a few cups may be applied to the. nucha and behind the ears ; but if the patient merely complain of great giddiness and deafness, with- out increase of the vascular action about the brain, dry cups are nearly as useful as the scarified. The oil maybe repeated during the course of the disease if the patient be constipated. No other treatment is necessary during the mild form of the disorder; indeed any treatment can scarcely be said to be necessary ; but it is useful, and diminishes the severity of the symptoms, and I am convinced, from long and careful observation of this disease, that even therapeutic means cannot be made more active without injury to the patient. At the close of the fever, however mild it may be, there is always an incomplete collapse ; the patient may then take wine-whey and a more nutritious diet; but I agree fully with Dr. Gra\res, that in any stage of typhous fever, a regimen of almost starvation is rarely justifiable. In more severe cases of the disease decided treatment is necessary ; we must guard against the complications, the accidental symptoms, and sup- port the strength of the patient when recovering. The lectures of Dr. Graves are full of important practical illustrations of these points, which I am not able to enlarge upon without going far beyond the limits of this lecture. TYPHUS AND TYPHOID FEVER. 735 My object as to the treatment is to impress upon you the leading truth, that typhus is a real exanthematous disease, and has a natural course to run. No one should dream of interfering with this course when it is pass- ing through its regular and ordinary stages. The treatment of typhoid fever is not yet well settled. Like typhus it has a natural course, and about the same average duration (twenty to twenty-one days), but it is not yet certain whether the treatment should be, as in the mild cases of typhus, purely negative and defensive, or more active and aggressive. My own experience leans towards the former conclusion: I am strongly inclined to think that in mild cases the physi- cian should interfere as little as possible, should restrict himself to laxa- tives, abstain from stimulants, resort from these to cups, either dry or scarified, to the nucha, now and then, but rarely to blisters. Towards the close of the disease, a mild alterative, consisting of small doses of mercurials, such as calomel or blue pill with ipecacuanha, hastens the cleaning of the tongue, and favours the convalescence. Tonics and mild stimulants are at times necessary after the termination of slight cases. The purgative treatment of typhoid fever has attracted much notice of late years. I mean what may be termed the purely purgative treatment, consisting in the repeated administration of saline laxatives, so as to keep the bowels in a soluble state during the course of the disease. The re- sults of the treatment are certainly extremely favourable, and it is very possible that it may be the best mode of treating the disease, which differs from typhus, not only in the general symptoms, but in the very different condition of the alimentary canal. The treatment of severe cases of typhoid fever is necessarily modified by the symptoms, and you must study carefully the cases of the disease which you see, and bear in mind the pathology and general course of the disease, and then you will at least rarely commit any important errors. You will find that, on the whole, the disease requires a less stimulating practice than typhus; it is more inflammatory in its primary as well as its secondary lesions. For details, I must refer you to the work of Dr. Louis, and to the excellent memoir published by Dr. James Jackson, of Boston. In your practice you may rarely meet with typhus, but you will be sure to see cases of typhoid fever, and you should consider the two diseases as distinct, but as allied together more or less closely ;—each one of them offering numerous sub-varieties, as different from each other as a mild case of scarlatina is from a malignant one. The advantages which I en- joyed of carefully studying the pathological anatomy, and the symptoms of the two fevers, enabled me to place the question of their identity upon more settled scientific points than had yet been done ; for by reference to the writings, both of British and continental physicians, you will find that the confusion is but lately dissipated. It is true that, after the ob- servations which formed the basis of the paper which I published in 1837, were collected, but before their publication, Dr. Lombard, of Geneva, who was of course familiar with typhoid fever, stated in the Dublin Jour- nal that the two diseases were different ; the same remark I remember to have heard Professor Andral make on the authority of Dr. Alison ; and it was obvious to many persons that the description of Dr. Louis did not apply to the British typhus, but the points of resemblance and of differ- ence were not settled, that is, they were not scientifically demonstrated. The views which I have given you are gradually receiving the sanction 736 GERHARD'S CLINICAL LECTURES. of physicians. How far experience may modify them I do not know ; but it is probable that it will only add some new facts to those which we possess, without impairing their authority. The seeming discrepancy of previous statements may be perfectly reconciled with the facts, as is amply proved by Dr. Valleix, in the memoirs which he published on this subject in the Archives de Medicine, about the beginning of the year 1840. In the last edition of his work, Dr. Louis has taken up the same subject, and I am gratified to find that, far from retaining any doubts as to the patho- logy of these diseases, he fully admits that they are allied, but not iden- tical.* NOTES ON TYPHUS AND TYPHOID FEVER IN THE YEAR 1848. The subject of typhus and typhoid fever has received great attention in the United States, within a few years, from the large number of cases of typhus fever introduced in emigrant passenger ships from Great Britain. The disease has been in some of our large cities very extensively diffused, but chiefly amongst emigrants recently arrived, and a small number of native citizens who were accidentally brought into close connection with them. In all the large seaports, many thousand cases have occurred; and even in cities remote from the seaboard, the disease has extended itself, although it was mainly limited to the recently-arrived emigrants and to a few others who were brought into immediate contact with them. The large number of cases which have thus been freshly introduced directly from the British islands, have furnished us with the most convenient opportunities possible for the study of the disease, and to a great degree have diminished the difficulties which have hitherto belonged to this subject. The principal question to determine was, whether this disease was identical with the typhoid fever which is always found more or less dif- fused in different parts of the world, or was in reality a distinct affection. My attention had already been given to this subject from being called upon to treat an epidemic fever which occurred at the Blockley Hos- pital (Philadelphia) in the year 1836 ; and, from much study of the disease, I was led to conclude that it was altogether a different disorder from the typhoid fever which we had been accustomed to see here and at Paris, and that it did not differ apparently from the typhoid fever of the British islands. In this opinion my colleague, Dr. Pennock, who was also per- fectly conversant with the fever of Paris, agreed with me, and his observa- tions fully confirmed my own conclusions as to this matter. I published an account of this epidemic in the American Journal of Medical Science, in February and August, 1837, and I there stated the conclusions to which I had arrived, and noted particularly the difference in symptoras • The observations of British physicians confirm the views which I gave as to the pathology of these fevers. One of the latest writers goes over the same grounds as myself, and refers frequently to the memoirs of Dr. Valleix, without citing the papers which were the subject of his analysis; nor does he ever allude to them, except to give a garbled quotation from Dr. Valleix,—an apology, the author says, for citing American instead of British writers upon a fever which was especially prevalent in Great Britain. The observations in question, however wanting in scientific fairness, confirm the general statements as to the symptoms and causes of the continued fevers. TYPHUS AND TYPHOID FEVER. 737 and lesions between this disease and the typhoid fever of Paris. Since that time, there has been an abundant opportunity of examining the sub- ject more closely, from the continuance of this epidemic influence, which did not disappear at the Blockley Hospital for some years after its ap- pearance; while from the opportunities which have occurred of studying the symptoras and lesions of the cases introduced into this country directly from the British islands, I have been able to compare the two epidemics of fever with each other, as well as with the typhoid fever which is always raore or less present in this country. From these abundant opportunities, I have been enabled to extend my observations on this subject, and to a great extent have arrived at results more definite than those which I had already reached, because they were formed on a larger scale of observa- tion, and extended to the diseases brought in masses from Europe, as well as to those which originated in the United States. From these extended sources of observation, I have arrived at the fol- lowing conclusions as to the symptoms and character of these fevers. The typhoid fever of France is constantly met with in the United States, although it varies very much as to its relative frequency and seve- rity. It is not confined to any particular season of the year, but occurs at every period. I have, however, found that it is rather more frequent in the autumn than at any other season. In the United States it is raore frequent at the North than the South, where it becomes quite rare, espe- cially in those parts of the country at which yellow fever or other autumnal fevers are very prevalent. In the New England States, it is more frequent than in any other portion of the country, and frequently appears there as a severe epidemic, extending itself to different parts of the country. When these epidemics occur, the disease becomes more certainly conta- gious than at other times, and does not follow the ordinary law relative to the freedom from the disease which generally prevails amongst persons who have reached the middle periods of life. The typhoid fever is, then, the regular continued fever of the United States, as well as of the continent of Europe. The typhus fever of Great Britain appeared in the United States under circumstances very favourable for its study, inasmuch as it was with us almost a new disease—certainly a new one so far as regards the rigid examination of the distinctive symptoras. Although 1 call the disease the typhus fever of Britain, I do so, not because the disease is absolutely con- fined to the British islands, but because it is there much more rife than in any other country, and prevails there as the most constant form of fever. The epidemic of 1836, at Philadelphia, was evidently not of foreign origin, but originated in the city of Philadelphia, at a season of the year when very few emigrants arrive in this country, and amongst a class of persons who have very little connection with them. Still the disease is on the whole an infrequent one in the United States, while the typhoid fever is always to be met with in greater or less number of cases, just as it is in France, and presenting the same peculiar symptoras. The proper typhus fever being the constant epidemic of the British islands, and vastly more frequent than the typhoid fever which is met with there, just as it is in France, has, to a certain extent, given a strong inclination to British physicians to regard it as the only, or at least the principal form of fever, while the typhoid form was looked upon as a more ameliorated variety of it, scarcely possessing the characteristic symp- 48 738 GERHARD'S CLINICAL LECTURES. toms of a peculiar disease, but constituting little else than a new modifica- tion or variety of the regular typhus. With this view of the subject I am, however, far frora agreeing; the forms of disease are on the whole quite distinct, and do not often offer much difficulty in the diagnosis, while the pathological lesions are equally characteristic. We always find in typhoid fever of the United States, the lesions of the glands of Peyer, of the mesenteric glands, and of the spleen, which are considered in France as the pathognomonic lesions of the disease ; yvhile in typhus fever we always find the follicles of the small intestines and the mesenteric glands perfectly healthy, the spleen is often softened, but not usually to as great a degree as in the typhoid fever. The only lesion which to a certain extent seems to be common to the two diseases, is an altered con- dition of the blood ; what the nature of this alteration is, and how similar it may be in the two diseases, cannot be certainly shown, but it is evidently the immediate cause of the alteration of the spleen,and it probably gives rise to the various symptoms which are to a certain extent common to the two affections. I have never met with a case of typhus fever, or with a single exception a case (see American Journal of Medical Science, Feb., 1837), which I supposed at the time to be typhus fever, in which the lesion of the glands of Peyer was found. Cases undoubtedly are met with, although rarely, by physicians, in which a disease regarded as typhus fever during life was found to present the lesion of the glands of Peyer supposed to be characteristic of typhoid fever, but I cannot avoid thinking that in these cases one disease may have been mistaken for another, or that some of the proper symptoms of typhus fever may, during an epidemic, have been extended to cases of typhoid fever, so as to modify them to a certain degree. Of these cases 1 cannot, however, speak from my personal knowledge ; but it seems to me that this explanation is one which more easily reconciles the apparent cause of difficulty in diagnosis, than any other one. Typhus fever, which had appeared at Philadelphia in 1836, did not entirely cease for several years, but the cases were few in number and almost limited to the poorest classes of the population. In the year 1847, however, this city, like most of the seaports in the United States, received large numbers of Irish emigrants, who brought the disease with them. Some of these died at sea or recovered before reaching port, others were taken to the different quarantine establishments, and a large number, who landed in good health, were attacked by the disease soon afterwards. From these patients, a certain number of those who were thrown into im- mediate contact with them, contracted the disease. In the year 1847, a number of patients were admitted with typhus into the Pennsylvania Hos- pital : of these, nineteen cases entered the hospital labouring under typhus fever during my term of service. Of these patients, eleven were seamen, belonging to passenger ships from the British islands, on board of which were passengers labouring under typhus fever. Four were themselves emigrant passengers belonging to ships in which fever prevailed, but who were not taken with it until after they had passed quarantine. Of these nineteen, many of whom offered the disease in a severe form, seventeen recovered. Two died, both of whom were Italian searaen, belonging to the sarae ship. Four were patients who contracted the disease in Phila- delphia from other patients affected with it. Patients labouring under this disease are not comraonly admitted into TYPHUS AND TYPHOID FEVER. 739 the hospital; the fever belonging to the number of those diseases which are contagious, at least under certain circumstances. With strict atten- tion to ventilation, the contagious character of the disease is so much diminished, that it is not considered necessary to entirely exclude those labouring under it, although the number of patients was not as large as it would have been if it had not been thought desirable to restrict them to a small number. All seamen, however, labouring under the disease were admitted without hesitation, and besides them, a considerable number of other patients, who were not selected on account of the disease having assumed a grave or slight character. The patients who died with the disease both belonged to the same ship, from which we received in all four seamen, all labouring under the dis- ease in a very severe form. Of the seamen who recovered, one of them was English, the other a German. I shall now give a sketch of the two cases which proved fatal. An Italian seaman, P-------, aged 27 years, entered Sept. 20th, 1847. Arrived in ship Berlin a day or two before from Liverpool. The disease appeared in the ship a few days after leaving Liverpool. A number of cases had occurred before her arrival in port, of which several died at sea, and many others were removed to the quarantine station. Patient speaks very little English, so that no anterior history could be obtained from him ; it was known, however, that he had been ill but a few days before coming into the hospital. Present condition : skin hot, face flushed, eyes injected, much stupor, but no obvious delirium, eruption of minute red points, not elevated, covering the whole body, disappearing partially under pressure, conformation of abdomen natural, not sensitive on pressure, bowels not open since admission, tongue dry, coated, not very red, pulse 96, soft. Spts. mindereri, hot pediluvia, cold to head, sponging body, arrow-root. Sept. 22d. Feels better, rather less stupor, face flushed, intelligence perfect, pulse 92, soft, easily compressed, eruption of a darker tint, no tympanitis, no sudamina, spleen slightly enlarged, tongue dry, coated, moderately red. Treatraent continued. Sept. 24th. Skin hot, pulse 108, tongue red at tip, less coated, with some tendency to moisture, eruption of a deeper tint, does not disappear on pressure, bowels open once since yesterday, subsultus moderate. Con- tinued treatment. Ice constantly allowed to patient; swallows it with great avidity. Sept. 25th. Skin comparatively cool, sweating, pulse 112, tongue red and dry, eruption still visible, bowels open once or twice since yesterday, bladder distended with urine, which is drawn off by catheter, stupor, but no delirium. Treatment continued, with addition of 3viii. wine in 24 hours, essence of beef, carb. ammon. gr. v. every hour. Sept. 27th. Stupor increased yesterday, is now very heavy, cannot be aroused, unable to answer questions, pulse about 100, very irregular, ex- cessively feeble. Treatment directed yesterday was continued, and gvi. brandy given, and blisters applied to extremities. Died at 4 o'clock in the afternoon. Post-mortem, 20 hours after death, was made in presence of Dr. Bartlett, of Transylvania University. The examination was not extended to all the viscera, from want of time. Viscera of abdomen and thorax were, however, carefully examined. Small intestines were found perfectly 740 GERHARD'S CLINICAL LECTURES. healthy throughout their whole extent, presenting neither the slightest trace of inflammation nor ulceration. Glands of Peyer and Brunner were but moderately developed, without the slightest trace of inflamma- tion or ulceration. Mucous membrane generally was also perfectly nor- mal. Mesenteric glands natural in color and consistence. Stomach and large intestine by accident, unfortunately, were not examined, but no doubt were in a perfectly normal condition. Spleen enlarged to length of seven or eight inches, rather more soft than natural, engorged with reddish blood. Liver engorged with blood, perfectly natural consistence. Lungs con- gested with blood in posterior part. Mucous merabrane of bronchial tubes slightly reddened. Heart rather soft in consistence, containing very little coagula. This case, which was unequivocally one of typhus fever, terminated about the tenth or twelfth day after its appearance. At the admission of the patient, the usual symptoras of the disease were developed, but the disorder did not assume the character of extreme danger until about 30 hours before its termination. The examination after death, although incomplete in some respects, from accidental causes, afforded the same absence of positive lesions as is usually the case in pathological researches into this disease : the patient not apparently dying from any local inflam- mation, but, from the severe impression of the disorder upon his whole body, was perhaps less able to resist it than the natives of colder coun- tries. The treatraent was nearly similar to that used in the large number of cases that recovered. P. T----, age 29, Italian seaman, admitted September 29tb, shipmate of last patient, in Berlin. Taken ill on 24th, a week after arriving in port, with pains, cephalalgia, &c, had no chill. Condition, 29th and 30th : stupor, memory impaired, face moderately flushed, eruption of red points appearing over surface of skin, tongue red at tip—coated poste- riorly, abdomen retracted—no sensibility on pressure, skin pungent, heat, pulse 100, easily compressed, bowels opened by Seidlitz powder on adrais- sion, neutral mixture, ice, pediluvia. Diet, arrow-root, &c. Oct. 1st. Skin less hot, pulse 100, face flushed, eruption of spots abun- dant on abdomen and thorax, no sudamina, no cephalalgia, no delirium at night, much stupor. Treatraent continued, with addition of wine 3iv., in whey daily, beef-tea. Oct. 2d. Muttering delirium last night, intelligence now good, subsultus frequent, pulse 96, feeble, skin but moderately hot, eruption still abun- dant, tongue moist, coated, bowels open twice in twenty-four hours. Quinine, gr. i., every two hours, in addition to former treatment. Cold applications to head if stupor should increase, and carb. ammon., gr. v., every hour or two. Oct. 3d. Symptoms continued as they had been, carb. ammoniae, gr. v., every two hours was given, with wine, ^x., brandy, ^vi., daily. Blis- ters to back of neck and extremities. Oct. 4th. Eyes injected, suffused, face flushed, much stupor, delirium at night, subsultus, abundant eruption over skin, tongue protruded with difficulty, very dry, coated, pulse 83, feeble ; bowels also open this morn- ing after taking Seidlitz powders. Continue treatment. Wine, brandy, carb. ammon., gr. v., every hour. Quinine. Oct. 5th. Skin was cooler, face slightly flushed, eruption less distinct, slight subsultus, less stupor, but delirium at night, pulse b4, tongue dry, TYPHUS AND TYPHOID FEVER. 741 covered with a dark coat, protruded more readily than before. Treat- raent continued. Oct. 6th. Pulse very feeble, 85, still delirium at night, now very stu- pid, subsultus, with rigidity of muscles of arra, eruption still very abun- dant over the whole body. Wine increased to ^xii., carb. ammon. gr. x. every hour; other treatment continued. Oct. 7th. Skin cool, pulse 85, intelligence better, medicine taken more readily, less subsultus, less lividity of face, urine sometimes drawn off with catheter, at other times passed involuntarily in bed. Treatment continued. Oct. 8th. Skin less warm, face less flushed, less stupor, tongue raore moist, eruption very faint. Continued treatment, reducing carb. ammon. to gr. v. every hour. Oct. 9th. Skin nearly natural temperature, pulse 84, countenance more natural, intelligence clearer, but still stupor, subsultus subsided, tongue dry, red, brownish at centre, protruded with less difficulty. Oct. 11. Still stupid, pulse 84, skin cool, tongue dry, brownish at cen- tre, bowels open two or three times in last twenty-four hours, not involunta- ry. Continue treatment, increasing carb. ammon. to gr. v. every half-hour. Oct. 12th. Occasional delirium, tongue red and dry, bowels open seve- ral times last night and this morning ; discharges involuntary, pulse 92, feeble, was attacked yesterday with nausea and vomiting, it still con- tinues without being checked by blisters to the epigastrium. Ice-water, brandy and water, ess. beef, in teaspoonful doses throughout the day. Oct. 13th. Emaciation greater, complete apyrexia, no vomiting since last night. Continue treatment. Oct. 14th. Vomited this morning after drinking a quantity of water which was not allowed him ; no return of vomiting afterwards. Oct. 16th. Heavy, stupid, tongue red, dry, brownish at centre, pulse 100, feeble. Treatment continued, arrow-root allowed in addition. Oct. 19th. Intelligence perfect, no return of vomiting. Treatment continued. Oct. 20th. Sloughs have formed on sacrum and haunches, blisters on legs are suppurating, great feebleness. Treatment continued. Oct. 21st. Erysipelas developed over left eye within last two days, patient extremely feeble. Egg and wine, arrow-root. Died at half-past 4 o'clock, p.m. Examination of body twenty-four hours after death. Exterior.—Considerable emaciation, erysipelatous redness around right eye, scattered ulcerations on legs, extending vertically six inches in length. The ulcerations are in process of healing, are from three to six inches in- tervening, portions of inflamed skin intervening. Inflammations on sacrum and contiguous portion of Glutei muscles, with ulcerations ; some twelve to eighteen lines in diameter. Integuments on each side of vertebral column, from spine of scapula downwards, of a dark red cr livid hue, with occasional small ulcerations towards lower part. Thorax.—Re?irt, pale, soft; contained small coagula. Lungs mode- rately engorged, at lower portion posteriorly. Bronchial mucous mem- brane perfectly healthy. Some old adhesions on either side of chest. Abdomen—Stomach.—Minute vessels moderately injected with bright arterial blood, mucous membrane of natural thickness and consistence. Small intestines moderately distended, containing thin yellowish fluid, not injected, consistence normal, glands of Peyer and Brunnerperfectlyhealthy. Large intestines healthy throughout the whole extent, neither injected nor 742 GERHARD'S CLINICAL LECTURES. ulcerated. Liver pale, firm, structure not altered. Gall-bladder dis- tended with dark-coloured bile. Spleen slightly softened, normal in size and colour. Kidneys rather pale, perfectly healthy in appearance. This case terminated fatally on the twenty-seventh day. The disease passed through its usual course, the fever abating decidedly, eruption dis- appearing entirely, and the intelligence of the patient having nearly returned to its natural condition ; the first symptom of a decidedly unpleasant kind was the nausea and vomiting, which rendered it impossible to continue the use of stimulants in as large doses as had been previously used. The strength of patient however improved, and it became possible to resume the stimulants in some degree, but he was already so debilitated that they failed to produce the wished-for effect, and the patient seemed to die at last of exhaustion ; the ulcerations which had formed along the back and on the legs were probably a powerful cause favouring the fatal termination. The lesions, as is usual in this fever, were almost totally negative, that is, no organ presented traces of evident inflammation ; and we are, there- fore, as is usually the case in typhus fever, obliged to look for the causes of death in the alteration of the blood, and the accompanying disorders of the brain and nervous system. This result coincides precisely with the lesions of the last case, as well as with those observed in a patient who died under the care of Dr. Pepper a few days before I took charge of the wards. The disease is therefore perfectly identical, so far as the absence of lesions is concerned, with the epidemic of typhus fever which occurred in Philadelphia in the year 1836, and occasionally reappeared for several years afterwards: this epidemic I described in the American Journal for February, 1837, and gave a short sketch of it in the preceding lecture in the year 1842. In several successive years, 1838, 1839, and 1840, I met with a number of cases of the same disease in recently-arrived emi- grants, in all of whom the disease was identical, both in symptoms and lesions, with the epidemic of 1836-7. During the years 1838-9, a number of cases of typhoid fever were also observed among the recently-arrived emigrants : some of these cases, I believe, came from vessels in which the greater number of passengers suffered with the typhus now described. The distinctive characters of the two diseases were, in almost every case, perfectly well marked, so that it was almost always as easy to distinguish the two diseases by the symptoms during life, as to point out the difference in lesions after death. At the Philadelphia Hospital, typhus fever prevailed this year on an ex- tensive scale, but like the cases we have described, it was confined to emigrants and those who contracted the disease from them. In that in- stitution I have learned from Drs. Buchanan and Thomson, who were lately residents there, that the bodies which they examined were also free from any characteristic lesion. In the New York Hospital, however, I understood from some of the gentlemen in attendance this summer, that they sometimes met with the lesions of the glands of Peyer, similar to those usually observed in typhoid fever. I must confess I cannot reconcile this singular discrepancy of re- sults, except by supposing that in some rare cases the contagious principle of typhus fever may have been applied to patients who were about to be taken ill with typhoid fever, and that in this way this seeming inconsistency should have appeared. So far as my own observation however extends, in a number of examinations which must now considerably exceed one hundred, I have never met with a case in which the symptoms of typhus \ TYPHUS AND TYPHOID FEVER. 743 fever were followed by the lesions of the glands of Peyer, peculiar to the typhoid disease, if we except a single case mentioned in the paper pub- lished in 1837, which occurred when the disease was still new to us in Philadelphia, and in which there was really an error of diagnosis. The symptoms of neither of the cases which proved fatal offered any thing peculiar. Although stimulants were used more profusely in this case than in the first one, the benefit resulting from them was by no means permanent; still, had the patient retained his food and medicines so that we could have given them in as large doses as seemed to be absolutely necessary, there is little doubt but that he would have recovered. W. R.,aetat. 35 years, English seaman, shipmate of the two last patients, was adraitted 20th September. Was perfectly well when he left Lazaretto, where ship was detained ten days. Taken ill on 17th with chilliness, cephalalgia, pains in back and extremities. Took no medicine except a purge of calomel and jalap before admission. When admitted was ordered spts. mendereri, gss. every two hours, cold to head, sponging. Sept. 21st. Present condition : intelligence perfect now, but is con- scious of being delirious at times, dull, heavy, but face not flushed, eyes nearly natural, skin hot on head and central parts of body, cool on extre- mities, pulse 84, soft, tongue dry, coated, red at tip, no sensibility of the abdomen, no tympanitis, no eruption ; bowels open three times this morn- ing, not disturbed yesterday. Continued prescriptions, adding pediluvia twice a-day. Sept. 22d. Skin hot, pulse 88, less flushed, slight traces of the eruption on abdomen ; treatment continued. Sept. 24th. Eruption more distinct, extending over whole surface, pulse 84:—intermitting one beat in every 8 or 9, tongue dry, covered with yellowish brown coat; treatment continued. Sept. 25th. Mind at times bewildered, but not positively delirious, abdomen retracted, not sensitive to pressure, pulse 90 : treatment con- tinued : ice given him to chew. Sept. 26th. Wine,3vi., given in whey, during day, with essence of beef. Sept. 27th. Stupor increased yesterday, still continues, pulse 80, feeble. Discontinued acet. ammoniae. Continued wine, ess. beef: sinapisms applied to legs. Sept. 28th. Countenance better, pulse 66, tongue disposed to clean at tip and edges, skin cool, eruption nearly disappeared, few sudamina pre- sent, abdomen rather retracted, not sensitive on pressure, appetite not returning; continue wine, ess. beef, adding quinia, gr. i., every two hours. Sept. 29th. Complained only of weakness, pulse 52, feeble, bowels once open last night, once this morning, tongue cleaning. Increase wine to ^viii. Continue ess. beef, quinia. Brandy, gij. daily, egg beaten up with wine in addition. Carb. ammoniae, gr. v., wine given every two hours yesterday afternoon ; discontinued to-day. Sept. 30th. Pulse 48, feeble, increase brandy to Z'w. daily, carb. am- mon., gr. v. every hour during day. Continued former treatment. Oct. 2d. Pulse 44, tongue cleaning, carb. aramoniae to be given occa- sionally only ; other treatment continued. Oct. 5th. Pulse risen to 48, skin of natural temperature, eruption dis- appeared on 1st. ... _ , Oct. 6th. Pulse 52. From this time he continued to improve. Brandy discontinued on 11th ; wine diminished to gvi. daily ; quinia and ess. beef continued. Eggs, chicken, &c. On 14th left his bed. On 27th, after 744 GERHARD'S CLINICAL LECTURES. being up several days, pulse was examined and found to beat 64 in a minute. Was discharged on 30th.* This patient was ill about 20 days until his convalescence was fully established. His symptoms, like those of the last patients, consisted in extreme prostration, stupor, with delirium,characteristic eruption on body; the pulse was feeble and not very frequent. At the conclusion of the disease, the pulse became exceedingly slow, and was also quite irregular. Treatment consisted in the abundant use of stimulants, which he bore perfectly well, and which he still required after the entire cessation of the fever. The eruption, as in most of the cases during the present epidemic, extended over the whole body, but was less abundant than it usually was during the epidemic of 1836-7. The cases which I have just given will serve as abundant proof of the perfect identity of the form of typhus described by me as having occur- red in Philadelphia in 1836, with the British variety. The same symp- toms, the same absence of distinct lesions, and the sarae necessity for using a stimulating treatment at the conclusion of almost every case, and in the earlier periods of many of them. The treatment is always perfectly simple : the patient should be placed in a well-ventilated room, in which but few persons should be allowed to remain. He should have wine at an early period of the disease, with light animal broths and nutritious but digestible articles of diet, such as sago, arrow-root, and the like, at a much earlier period than in most febrile diseases. Brandy is sometimes neces- sary, especially for patients who are accustomed to the use of spirits when in health, but it should be allowed only when the patient is so much exhaust- ed, that wine would seem to be an insufficient stimulant. The proper medicinal articles are of comparatively little avail in checking the course of the disease, although they are very important in relieving the temporary causes of danger into which a patient may fall. In moderate cases of the disease, I merely keep the patient's bowels open, and give the ordinary neutral mixture, or the spirit of mindererus, with cold sponging to the head and sometimes over the whole surface, either with simple water or vinegar and water, or with a solution of chlorine. When there is ex- treme congestion towards the brain in the early periods of the disease, blood-letting may be borne without depression by the patient; but I almost always prefer the application of a few cups to the back of the neck : this is a safe and quite as effectual a mode of taking away blood as venesection. Dry-cupping will often quiet the restlessness of the patient, and is there- fore a valuable remedy. In more severe cases, we are obliged to use nearly the same means: wine may be given raore freely, sometimes cam- phor is a useful adjuvant, opiates are generally totally inadmissible, but sometimes, when there is much restlessness and great jactitation, a very small dose of morphia will quiet it better than any other reme'dy. Blis- ters are not so objectionable as in typhoid fever, but as they cause much irritation and restlessness, they should not be often used ; sometimes, if they are applied to the back of the neck, they diminish the delirium and do good. With this treatment the mortality in typhus fever will in general be small, but it is a disease which will give very variable results, depending as much on the character of the epidemic as upon the condition of the patients when they are attacked. * The notes of these cases were taken from my dictation by a very intelligent young phy- sician, Dr. Hutchinson of Missouri, then a member of the class. INDEX. Aberdeen Infirmary, Report of Fever in, Dr. Kilgour, 140 Abscess of the heart, case of, 344 Abuse of mercury in syphilis, 320 Acetate of lead in tympanitis, 79 in Asiatic cholera, 590 Acidity of the stomach in indigestion, 573 Acute inflammation of the heart, 644 Affections of the bones in syphilis, 296 Ague, hysterical, 601 Ague-cake, 599 treatment of, 601 Air in the alimentary canal, use of, 77 Albuminous urine in dropsy, 605 opinion on the na- ture of, 459 Alison, professor, views on the pathology of phthisis, 247 opinion as to the time of life in which phthisis supervenes, 249 Alvine discharges, peculiarities of, 622 Amaurosis, 5S5 Anatomical characters of continued fever, 59 character of the yellow fever at Gibraltar, 183 Andral, professor, opinion as to the period of life in which phthisis most fre- quently occurs, 254 on the development of tubercle, 521 Animal chemistry, Liebig's strictures on, 44 Annals of the surgical department of the Ge- neral Hospital at Hamburgh (Fricke's), extract from, 280 Anus, excoriation of, in scarlatina, 447 Apjohn, Dr., analysis of St. John Long's liniment, 212 Apoplexy, or cerebral hemorrhage, 674-679 pulmonary, remarkable case of, 232 Aretaeus, description of enlargement of the spleen, 489 Arklow, Dr. Wright's account of scarlatina in, 439 Armagh, immunity from scarlatina, 437 Armstrong's, Dr., theory of fever, 58 Arnott, Dr., reference to his elements of phy- sics, 583 Arsenic in psoriasis, 575 Arsenical solution, caution necessary in pre- scribing it, 575 Arthritis, obstinate case of, 562 with jaundice and urticaria, 553 Arthurstown, Dr. Long's letter on scarlatina in, 442 Asiatic cholera, use of acetate of lead and opium in, 590 Asthma, case of, 211 Atmospheric electricity, remarks on, by Ed. Clarke, 368 Auchenlech, Dr., letter on cholera, 593 Autenrieth, Dr., account of the state of medi- cine in Great Britain, 422 Baglivi's opinion quoted, 209 Barker and Cheyne, report on fever, quoted, 58 Barker, Dr., allusion to his paper on quinine, 51 Barrett, Dr. Joseph, case of narcotism from opium, 73 Bed-sores in fever, and their treatment, 127 Bell's paralysis, occurring in jaundice, 399 Berlin, treatment of syphilis in the hospital of, 310 Bewley, Dr., letter on scarlatina, 441 Billard on tubercles in the lungs of foetuses, 249 Brunonian school, allusion to, 422 Blake's experiments, 57 Blakiston, Dr., on influenza, 558 Blisters, advantages of, when judiciously used, 99 constitutional irritation arising from, 389 Blood in melaena, characters of, 623 the forces by which it is circulated, 399 Bones, affections of in syphilis, 296 Bonorden, Dr., publications on syphilis, 311 Bountiful, a certain Lady, her practice in fever, 65 Boxwell, Dr., letter on scarlatina, 439 Boyer's views on purulent ophthalmia quoted, 274 Brain, scrofulous inflammation of, 93 Bright's disease of the kidney, 460 kidney, remarks on, 605 British teacher of medicine, great responsibility attached to his office, 49 Bronchitis, 712 on the rales produced by, 203 chronic, use of chalybeates and eme- tics in,210 746 INDEX. Bronchitis, with dropsy, 619 Broussais's theory of fever, 58 Brown's theory of fever, 58 Brunker, Dr., letter on scarlet fever, 439 Byrne, Dr., observations on syphilitic bron- chitis, 219 Byron, Dr., letter on scarlet fever, 439 Cancer of the liver, 664 Capillary circulation, 400 Carmichael, Mr., first introduced the non- mercurial treatment of sy- philis, 277 observations on the paraple- gia following infantile re- mittent fever, 353 Carpenter, Dr., opinion as to the cause of the sensation of Thirst, 81 opinions concerning capillary circulation, 416 Caries of the bones from syphilis, 296 Carswell, Dr., opinion on the most frequent site of tubercles, 520 Cases simulating tic douloureux, 551 Catarrhal affections of the bronchial tubes, 204 Caustic, mode of applying it in chancres, 323 Cayol, professor, reference to his Lecons Orales, 493 Cemetery, Glassnevin, Interments at, during the epidemic of influenza, 465 Census committee, their statistical report of amount of deaths from typhus fever, 54 Cerebral symptoms in fever, treatment in an- ticipation of, 97 disturbance in fever, use of tartar eme- tic and opium in, 121 Chadwick, Mr., on epidemics among cattle, 55 Chalybeates in chronic bronchitis, 210 Chancres, 319 on the genital organs, 286 on the predisposition to, 291 in the throat, 293 Charite" (Hospital) at Berlin, treatment of syphilis in, 307 Cheyne and Barker, report on fever quoted, 58 Cholera, use of acetate of lead and opium in, 591 Chorea, 602 Christison, Dr., remarks on the adulteration of the hydriodate of potash, 40 on fever, 60 Chronic bronchitis, use of chalybeates in, 210 cough, 214 use of sarsaparilla and nitric acid in, 567 diarrhoea, 569 disease in fever, vomiting a symptom of, 560 laryngitis, 545 rheumatism, successful treatment of, 561 scrofulous fever, 94 variety of delirium tremens, 386 Circulation in acephalous monsters, Dr. Hous- ton's paper on this subject, 83 Circulation, on the powers which cause and re- gulate the, 399 Clarke, Dr., of Rathdrum, letter on scarlatina, from, 438 Clarke, Mr., communication on electro-magne- tism, 363 medical and atmospheric electricity, 368 Clear sound with solidified lung, 568 Clifford, Dr., of Trim, letter on scarlatina, from, 438 Clinical instruction, introductory lecture on, No. 1, 17 introductory lecture, No. 2, 26 introductory lecture, No. 3, 35 Clutterbuck, theory of fever, 58 Cold applications to the head, 392 Colds, 104 Colonies, Major Tulloch's report of the health of British troops in, 50 Condylomata, 291 Congestion of the intestines, 78 Connection between diseases of different or- gans, 480 Connor, Dr., of Carlow, letter on scarlatina, from, 442 Constitutional irritation from blisters, 389 inflammation in general, 490 Contagion, 61 Contagion of syphilis, 299 Continued nervous fever, remarks on, 171 Contraction and dilatation of the pupil in fever, 115 Contractility of efferent ducts, 193 Convalescents and fever patients, proper food for, 72 Convulsions in fever, danger of, 158 Cookson, Mr., accdunt of his attack of fever, 132 Cooper, Sir Astley, on the effects produced by tying the vertebral and carotid arteries, 117 on gonorrhoeal rheumatism, 272 Copland's dictionary, extract from, on the use of spirit of turpentine in fever with delirium and tympanitis, 120 Copland, Dr., on emetics at the commencement of fever, 104 Corrosive sublimate in syphilis, 330 Cough from worms, 216 hysteric, 217 from venereal taint, 217 occurring in the gouty habit, 219 Coup de Soleil, 117 Cowan, Dr. report on fever, 54 Croly, Dr., of Mountmellick, letter on scarla- tina, from, 443 Cruveilhier, opinions on the cause of pulmo- nary hemorrhage, 239 Cullen, Dr., theory of fever, 58 Cumming, Dr., of Armagh, letter on scarla- tina, from, 437 Debilitated heart in fever, an indication for the use of wine and stimulants, 166 INDEX. 747 Delirious patients in fever, the management of, 90 Delirium in fever, morbid appearances after, 95 Dr. Green's letter on the use of tartar emetic and opium in,165 Delirium of fever, use of tartar emetic in, 121, 131, 137, 142, 153 and convulsions in jaundice, 394 traumaticum, 389 tremens, 685 Diarrhoea, chronic, utility of persesquinitrate of iron in, 569 of phthisis, 581 Dietetic management of fever patients, 70 Difference of opinion respecting the use of mercury in syphilis, 317 Dilatation and contraction of the pupils in fever, 117 Discharges, peculiar alvine, 622 Disposition to contract syphilis, 301 Domestic remedies for feverish colds, 104 Dorpat, mercury seldom used there for syphilis, 331 Dover's powder with hydrarg. c. creta in some forms of tympanitis, 78 Drink, the proper mode of giving in fever, 72 Dropsy in acute bronchitis, 619 treatment of, 620 Ducts, contractibility of the efferent, 193 Dupuytren, Baron — mode of administering opium, 387 Dyce, Dr., report of fever in Aberdeen Infirm- ary, 140 Dysentery, 576, 695 subacute, 701 Dyspepsia, 573 Earache, preceded by rigors in fever, 558 Edinburgh—mode of clinical instruction pur- sued there, 19 Education of persons intended for the medical profession, 36 Electro-magnetism, Mr. Clarke's communica- tion on,363 Emetics at the commencement of fever, 103 and chalybeates in chronic bronchitis, 210 Endocarditis, 656 Enlargement and inflammation of the liver from scarlatina, 484 of the liver from abuse of mer- cury, 482 from disease of the heart, 486 spleen, 488 Epidemic of yellow fever in Ireland, 183 at Gibraltar, 180 of scarlet fever, 421 of influenza, 462 Epidemics, 102 Eruption from morbid poison similar to syphi- litic, 322 Erysipelas and gangrene, 489 Essential disease, fever is an, 59 Exanthematic nature of typhus—Dr. Perry's opinion, 62 Expergefacients in fever, 73 Eye, phlegmasia dolens of the, 615 Farcy, glanders, «&c, 606 Fever, general observations on, 50 account of the Russian intermittent, 200 air of the sick chamber in, 66 anatomical characters of, 59 an essential disease, 59 an exanthematous disease, 62 application of cold to the head in, 111 chronic scrofulous, 95 contagious nature of, 61 dietetic management in, 70 Dr. Armstrong's rules for wine in, 169 Dr. Stokes's researches on the state of the heart in, 166 earache preceded by rigors in, 558 emetics in the commencement of, 103 general treatment of, 69 intermittent, 196 long-continued nervous, remarks on, 171 morbid appearances after delirium in fever, in, 95 nervous, Dr. Autenrieth's account of, 427 prescriptions in, 175 proper choice of a nurse in, 65 proper food for patients labouring under, 71 protest against the use of purgative medicines in, 104 reports of mortality, in Ireland from, 54 scarlet, 421 tertiana soporosa, 200 thirst frequently depending on the state of some internal organ in, 81 treatment continued, 75 tympanitis from inattention to diet, and purging in, 76 venesection as a means of checking, 108 warm applications strongly recom- mended, 112 wine in, 167 with cerebral disturbance, use of tartar emetic and opium in, 121 yellow, 179 at Martinique, 195 Fletcher, Dr., on epidemics, 65 Formation of tubercles, 244 Fothergill, Dr., account of the " Putrid Sore Throat," 445 Fricke, Dr., communication on syphilis, 280 on the non-mercurial treatment of syphilis, 307 Froriep, Dr. Robert, observations on syphilis, 277 Fugitive swellings and pains, 494 Functional disorders of the brain, 683 Gangrene of the lungs, 710-718 and pleurisy, 221 )EX. 748 ine Gangrene from erysipelas, 492 Geoghegan, Dr., letter from, on scarlet fever, 438 Gibraltar, account of the yellow fever epide- mic there in 1828, 180 Glanders, 606 Glasnevin Cemetery, report of burials in, dur- ing the prevalence of influenza, 465 Gogerty, Dr., of Nobber, letter on scarlet fever, 441 Gonorrhoea, 263 Gonorrhoeal ophthalmia, 273 Gout, 493 affecting the lobe of the ear, 495 Gouty grinding of the teeth, 496 neuralgia of the skin, 497 ramollissement of the spinal marrow, 501 Green, Dr. R., of Youghal, letter on tartar emetic in the delirium of fever, 165 Mr., on pseudo and true syphilis, 278 Griffin, Dr., of Limerick, letter on scarlatina, 444 Gunther, Dr., communication on syphilis, 280 Guthrie, Mr., on the use of lunar caustic in purulent ophthalmia, 276 Haemoptysis, 229 remarkable instances of recovery from, 242 Hall, Dr. Marshall, theory on the circulation, 400 Hamburgh, treatment of syphilis in the hospi- tal at, 280 Hanlon, Dr., of Portarlington, letter on jaun- dice, 394 Harvey, Dr., of Pomeroy, letter on scarlatina, 442 Hastings, Dr., reference to his doctrines on the capillaries, 400 Heart, abscess of, 544 Hennen, Mr., opinions on syphilis referred to, 260 Hepatitis, chronic, from disease of the heart, 486 Hewson, Mr., opinion on cough from venereal taint, 218 Hiccup in fever, treatment of, 80 Hoarseness and loss of voice, 582 Holland, Dr., of London, on influenza, 463 of Sheffield, experiments on the circulation through the capil- laries, 420 Hoskins, Mr., on purulent ophthalmia, 261 Houston, Dr., account of an acephalous foetus, 83 observations on periostitis, 531 Howship, Mr., on the formation of bone, &c, 530 Hudson, Dr., letter on scarlatina, 439 Hunter, Mr., views on venereal referred to, 260 Hutton, Dr., case of paraplegia from irritation of urethra, 352 Huxham, Dr., description of the " Ulcerous Sore Throat," 445 Hypertrophy of the liver produced by scrofula, 482 Hypertrophy of the liver from abuse of mer- cury, 483 from scarlatina, 484 with periostitis, 481 Hypochondriacs, sleeplessness in, 390 Hysterical ague, 601 convulsions in jaundice, 399 Hysteric cough, 217 Inflammation, and the motor powers which cause and regulate the circula- tion, 399 of serous membranes, 641 of the brain (scrofulous), 94 Influenza, 462 Injections, combined with general and local means in gonorrhoea, 269 in gonorrhoea, directions for using, 267 Insidious character of the spotted fever epide- mic in Dublin, in 1834-5, 135 Intermittent fever, remarks on, 196 (Russian), 199 treatment of, 201 Intestinal inflammation with tympanitis, 78 Intestines, congestion of, 79 observations on the secretion of air from, in certain bronchitic affec- tions, 206 use of air in, 77 Introductory lecture, No. 1,17 2,26 3,35 Iritis, case of syphilitic, 564 use of turpentine in, 80 Iron, persesquinitrate of, in chronic diarrhoea, 569 Jaundice, 726 hysterical convulsions, delirium, &c, in, 399 supervention of nervous symptoms in, 394 with arthritis and urticaria, 480,553 Laryngitis, 727 (chronic), 545 Latent ulceration of the intestines, 580 Lawrence's account of yellow fever quoted, 191 Lead, acetate of, in the tympanitis of fever, ac- companied by intestinal con- gestion, 79 in Asiatic cholera, 589 Liniment, St. John Long's, formula for, 212 Lobelia, the etherial tincture of, recommended by Dr. Blakiston in influenza, 479 Louis, M., researches on yellow fever, 180 Lungs, mercury in scrofulous affections of the, 510 Malaria, Major Tulloch's report on, 50 Management of delirious patients in fever, 91 Marrow (spinal), gouty ramollissement of the, 501 Martinique, account of the yellow fever epide- mic there in 1839, 1840, 1841, 195 INDEX. 749 Mayo, Mr., observations on the state of the pupil in sleep, 88 Measles in adults and children, 635 MeUena, 623 Memorandum of Dr. Fricke's practical obser- vations on the nature and treatment of sy- philitic diseases, 294 Meningitis, acute, 665 chronic, 672 Mercury, abuse of, 319 difference of opinion respecting the use of, in the venereal disease, 316 great utility of the local application of, 562 in phagedena, Dr. Tuohill's commu- nication on this subject, 332 in scrofulous affections of the lung, 511 its supposed anti-febrile properties questioned, 129 Mobility of the sternum, a remarkable case of, 593 Mode of applying leeches when pneumonia or hepatitis supervenes on fever, 110 caustic to venereal sores, 323 Morbid appearances after delirium in fever, 95 Mortality from fever in the province of Lein- ster, 54 Motor powers which cause and regulate the circulation, 399 Muller, professor, opinions on the circulation through the capillaries, 85 Munk, Dr., communication on the use of mer- cury in scrofulous affections of the lung, 515 Narcotism, efficacy of green tea in, 73 Nervous extremities, disturbance of, giving rise to subsultus tendinum, 92 symptoms in jaundice, danger of, 394 Neuralgia, gouty, of the skin, 497 New views upon the use of tartar emetic in fever, 131 Nitric acid with sarsaparilla in chronic cough, 567 Nolan, Dr., letter on the use of opium in peri- toneal inflammation, 141 Non-mercurial treatment of syphilis, 260 Nose, bleeding from, in scarlatina, fatal case of, 448 Notes of clinical lectures delivered in 1826, on yellow fever, 192 Nurse and assistants for fever patients, proper choice of, 66 O'Beirne, Dr., plan of rapid mercurialization in scrofulous affections of the joints, 511 O'Brien, Dr., letter on scarlatina, 443 Observations on the secretion of air from the alimentary mucous membrane in certain pulmonary complaints, 206 O'Ferrall, Mr., letter on scarlatina, 434 Ophthalmia (purulent), Mr. Hoskin's observa- tions on, 264 gonorrhoeal, 271 Opium and tartar emetic, utility of, in certain forms of fever, 121 and wine in fever, 169 flagellation effectual in poisoning from, 73 with acetate of lead in cholera, 589 Oppenheim, Dr., researches on syphilis, 297 Oris cancrum, case of, with remarks, 597 Osbrey, Dr., account of the scarlatina observed at St. Mary's parochial dispensary, 450 Over-dosing with purgatives in fever, protest against, 105 Paralysis, agitans, 603 lecture on, 342 new views on this subject, 343 pathology of, 343 Paraplegia from disease of urinary organs, Mr. Stanley's cases of, 343 kidneys, Dr. Stokes's case, 350 enteritis, 346 irritation of urethra, Dr. Hut- ton's case, 352 lead, Dr. Bright's observation on, 350 poisoning by arsenic, Orfila's experiments, 350 following remittent gastric fever of infants, Mr. Carmichael's observa- tions on,353 metritis, 352 varieties of, 343 Pathology and treatment of syphilis, 276 Peculiar alvine discharges, 622 Pericarditis, 542, 650 Periostitis, 529 scrofulous, occurring in persons previously affected with chancres, importance of a correct diagnosis in such cases, 340 Peritonitis, 664 tubercular, 648 Perry, Dr., of Glasgow, on the exanthematous nature of typhus fever, 62 Phagedena, Dr. Tuohill's communication on the proper period for giving mercury in, 332 Phlebitis, 594 Phlegmasia dolens, 614 of the eye, 615 pathology of, 594 Phthisis, mortality from, as compared with other diseases, 244 pathology of, 244 pulmonalis, 705, 713-720 senilis, 579 Pirogofl's " Surgical Annals" (on venereal), 331 Pleurisy, 644 Pleuritis and gangrene of the lung, 221 Pleuro-pneumonia, 541, 577 Pneumonia, 227, 723 Poisoning from opium, flagellation effectual in, 73 Poisons capable of producing eruptions similar to syphilis, 322 750 INDEX. Predisposition to chancres, 291 Prescriptions in fever, 175 Proper choice of nurse and assistants in fever, 66 food for fever patients and convales- cents, 66 Prurigo, 548 Psoriasis, 575 Pulmonary apoplexy, 232 from syphilitic taint, 217 without haemoptysis, a remarkable case of 232 irritation connected with a gouty dia- thesis, 219 Pulse, disproportion between it and respiration, remarkable case of, 209 Pupil, Mr. Mayo on the state of, during sleep, 88 Pupil's contraction and dilatation, 116 Purgative medicines, remarks on, 384 Purulent ophthalmia, Mr. Hoskins on, 264 Quinine, sulphate of, probably first used in Ireland in ague by the author, 51 Ramollissement of the spinal marrow, from gout, 501 Recovery, remarkable instances of, from hae- moptysis, 242 Reports of the mortality from fever in Ireland, 54 on statistics of fever, Dr. Cowan's, 54 on syphilis by Dr. Roe, 260 Result of Dr. Oppenheim's inquiries on syphi- lis, 309 Rheumatism, acute, 627 chronic, 560 gonorrhoeal, 271 Ridley, Dr., letter on scarlatina, 439 Roe, Dr., report on syphilis, 2fi0 letter on scarlatina, 444 Russell, Dr., on do., 443 Russian intermittent fever, 196 Scarlet fever, 421 Dr. Connor's letter on, 442 Dr. Griffin's do., 444 Dr. Lloyd's do., 438 Dr. Long's do., 442 Dr. O'Brien's do., 443 Dr. Ridley's do., 439 Dr. Roe's do., 444 Dr. Russell's do., 443 Dr. Osbrey's account of, as ob- served at St. Mary's Dispen- sary, 450 Mr. O'Ferrall's communication, 434 Professor Porter's remarkable case of, 441 Scrofulous affections of the lung, use of mer- cury in, 511 fever (chronic), 94 inflammation of the brain, 94 Secondary syphilis, 321 Sedatives in fever, remarks on, 72 Sensation of tickling which precedes cough, 216 Sleeplessness from anxiety, grief, &c, 383 from irritation of blisters, 389 in delirium tremens, 385 in fever, 386 in hypochondriacs and hysterical patients, 390 Softening of the brain, 679 Solidified lung yielding clear sounds on per- cussion, 567 Sores (venereal), mode of applying caustic to, 323 Sore throat (venereal), 293 Spirit of turpentine in flatulent distension of the stomach accompanied with delirium, coma, &c, 119 opinion of Dr. Copland on the efficacy of this treat- ment in the above cases, 120 in iritis, 80 in tympanitis accompanied by intestinal inflamma- tion, 78 Spleen, enlargement of, 488 powder, composition of, 602 Spotted fever epidemic in Dublin in 1834-5, account of, 135 Staberoh, Dr., opinions on the treatment of syphilis, 310 Stammering, observations on, 582 suddenly stopping on the super- vention of laryngitis, a case of, 583 Stanley, Mr., observations on paralysis from disease of the urinary organs, 343 Starvation system in fever, productive of or- ganic disease, 70 State of the heart in fever as an indication for administering wine, Dr. Stokes's researches on, 166 Statistical reports on fever, by Dr. Cowan, 54 Stephenson, Mr., his own case of fever, 133 Sternum, remarkable mobility of, 593 St. John Long's liniment, 212 Stokes, Dr., observations on paralysis following enteritis, 346 protest against purging in fever, 76 on the treatment of hiccup in fever, 80 researches on the state of the heart in fever, 166 Struntz, Dr., on the non-mercurial treatment of syphilis, 307 Subsultus tendinum, sometimes from disturb- ance of the nervous extremities, 92 Superficial ulceration of the legs combined with enlarged spleen, 488 Syphilis, 260 Dr. Roe's report on, 260 Dr. Struntz's observations on the non-mercuiial treatment of, 307 on the pathology and treatment of, 276 INDEX. 751 Syphilis, treatment of at the General Surgical Hospital at Hamburgh, 280 Syphilitic eruptions, different forms of, 294 iritis, action of belladonna in, 564 Tartar emetic and opium in fever, 121 in the form of enema, advan- tages of, 91 Tertiana soporosa, case of, 200 Therapeutical principles in the treatment of syphilis, 304 Thirst in fever, best mode of allaying it, 72 frequently dependent on the state of some internal organ, 81 Thyroid gland, newly-observed affection of, 570 Tic douloureux, cases simulating, 551 Treatment in anticipation of cerebral symptoms in fever, 98 of typhus fever, 75 Tuberculous meningitis, 656 Turpentine extremely useful in the tympanitis of fever, 78 in flatulent distension of the/abdo- men accompanied by delirium and coma, 119 in iritis, 80 Tympanitis in the middle stage of fever often arises from intestinal congestion, 78 treatment, acetate of lead recom- mended, 79 Tympanitis often the consequence of inatten- tion to diet, or over-dosing with purgatives, 76 with intestinal inflammation, treat- ment of, 80 Typhus and typhoid fever, 730-736 fever, an essential disease, 59 Urticaria from eating the Otaheitan eel and certain other kinds of food, 555 with jaundice and arthritis, 553 Use and abuse of mercury in syphilis, with cases, 324 Various cautions respecting leeches and cup- ping-glasses, 110 Velpeau's method of treating sore throat, 585 Venereal sore throat, 293 Venesection as a means of checking fever, 108 Vomiting and purging at the commencement of fever, 93 considered as a symptom of fever, 560 Warm applications to the head recommended, 112 Wilde, Mr., report on fever, 54 Wine and opium in fever, 169 in fever, 166 Worms in the intestines producing cough, 217 Yellow fever in Dublin, account of, 183 Gibraltar, 179 THE END. 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