American Medical Library. 
LECTURES 
ON THE 
THEORY AND PRACTICE OF PHYSIC. 
BY WILLIAM STOKES, M. 1). 
LECTURER AT THE MEDICAL SCHOOL, PARK STREET, DUELIN *, 
PHYSICIAN TO THE MEATH HOSPITAL ; &C. &C. 
FIRST AMERICAN EDITION. 
P H I L A DELPHU: 
PUBLISHED BY A. WALDIE, 46 CARPENTER ST. 
1837. NOTICE. 
The present is the first edition of the embodied lectures of Dr. 
Stokes. They were originally published in the “ London Medical 
and Surgical Journal,” and were necessarily dispersed over several 
numbers. Detached lectures have been occasionally reprinted in 
the different medical periodicals of this country; and their excel- 
lence has been so manifest, that the particular numbers of the 
British periodical in which they first appeared have been imported 
solely on their account. The editor of the “American Medical 
Library” has consequently thought that he should be rendering a 
service to his professional brethren by issuing them in the present 
form. He is not aware of any work in which the topics treated of 
are displayed in a more attractive, and at the same time a more 
instructive, manner. The author, from his situation, has every 
opportunity for confirming or disproving his theoretical considera- 
tions by the test of practice; he is well informed on every thing 
that has been done, and is doing, in various countries; and he 
possesses, withal, powers of discrimination and exposition with 
which few are favoured. On all these accounts, his lectures will 
be found peculiarly valuable. 
ROBLEY DUNGLISON. 
Philadelphia, June 15th, 1837. 
St. A CONTENTS. 
General observations. 1 
LECTURE I. 
LECTURE II. 
General remarks on local diseases—Fixed rules for the guidance of students— 
Great importance of diagnosis—Existence of pure fever rare—Doctrine of the 
Humoralists and of the Brownists—Pathology of the digestive system. . 13 
LECTURE III. 
Pathology and treatment of diseases of the digestive system—Different forms of 
gastritis—Pathology of this disease imperfectly understood by the ancients— 
Gastritis and enteritis not always found in connection—Phenomena charac- 
terising acute gastritis—Symptoms and sympathetic relations—Diagnosis— 
Gastritis simulating other diseases. 22 
Gastritis—No one symptom decidedly indicative of the particular condition of any 
organ—Sympathetic irritation liable to terminate in organic disease—Sympa- 
thetic relations as connected with the viscera of the thorax—Treatment of 
simple acute gastritis—Antiphlogistic remedies—Purgative medicines injurious 
—Enemas and injections—Use of ice beneficial—Effervescing medicines hurtful. 31 
LECTURE IV. 
LECTURE V. 
Pathology and treatment of gastritis—Application of blisters—Emetics can be 
seldom used in acute gastritis—Heematernesis and delirium tremens compli- 
cated with gastritis—Treatment of these affections—Dyspepsia, or chronic gas- 
tritis—Hypochondriasis—Termination of chronic gastritis. ... 40 
LECTURE VI. 
Treatment of chronic gastritis—Frequent excitement of the vascular system neces- 
sary to the performance of the functions of the stomach—Local bleeding—Regi- 
men—Counter-irritation over the stomach—Treatment of Rroussais—Use of 
vegetable tonics—Oxide of bismuth—Acetate of morphia 48 
LECTURE VII. 
Friction with croton oil—Attention to diet during convalescence—Organic disease 
of the stomach—Principles of treatment—Diet and attention to the bowels— 
Duodenitis—Inflammation of the jejunum—Ileitis, complication and nature of 
—Dothinenteritis—Ulceration of the mucous membrane—Symptoms and diag- 
nosis of ileitis 5G 
LECTURE VIII. 
Diseases of the small intestines—Symptoms of ileitis—Occurrence of diarrhoea 
with fever symptomatic of this form of inflammation—Frequency and symptoms 
of the disease in children—Tabes mesenterica, treatment of. ... 64 vi 
CONTENTS. 
LECTURE IX. 
Treatment of ileitis—Advantage of leeching—Stimuli sometimes beneficial— 
Infantile remittent fever—Inflammation of the mucous membrane—Enteritis 
with diarrhoea—Effects of opium in inflammation of serous and mucous mem- 
branes—Pathology and treatment of diarrhoea and dysentery—Perforation of the 
intestine—Diseases of the large intestine 72 
Diseases of the large intestines—Treatment of diarrhoea—Apyrexial period of 
diarrhoea—Danger in suddenly arresting the discharge—Purging in phthisis— 
Dysentery—Epidemic dysentery. „ . 81 
LECTURE X. 
LECTURE XI. 
Sporadic dysentery—Nature of this disease—Treatment; mercurial, stimulating, 
antiphlogistic—Recommendation of Dr. Elliotson—Success of Dr. O’Beirne in 
the use of tobacco injections—Tympanitis, or meteorism—Windy colic, remedies 
for the cure of. 89 
LECTURE XII. 
Pathology of jaundice—Its co-existence with a flow of bile-—Case of aneurism of 
the hepatic artery—The disease, independent of mechanical construction— 
Colouring of the various parts—Effects on the milk, and humours of the eye— 
Jaundice with preservation of health—Icterus infantum 97 
LECTURE XIII. 
Jaundice from gastro-duodenitis—Researches of Broussais and Marsh on—Jaun- 
dice without hepatic inflammation—Nervous symptoms—Treatment—Yellow 
fever—Its occurrence in this country—Predominance of gastric irritation in 
warm climates—Typhus icterodes—Jaundice from biliary calculi—Different 
situations in w'hich biliary calculi may be found. 105 
LECTURE XIV. 
Diagnosis of jaundice from biliary calculi—Proof of the passage of the calculus— 
Indications of treatment—Rupture of the gall-bladder after the use of emetics— 
Spasmodic jaundice—Treatment of spasmodic jaundice—Discharges of fatty 
matter—Researches of Drs. Bright and Elliotson—Connection with malignant 
disease examined—Source of fatty matter. 114 
LECTURE XV. 
Acute and chronic hepatitis—Pathological differences—Effect of climate—General 
and local symptoms—Character of fever—Pain of shoulder—Use of pleximeter 
—Complication with jaundice—Resolution—Abscess—Various openings of the 
latter—Cicatrisation 123 
Diagnosis of the rupture of hepatic abscess—Pulmonary openings—Case of 
double opening—Puncture of the gall-bladder—Gangrene of the liver—Its con- 
nection with hepatic apoplexy—Diagnosis of distended gall-bladder—Its causes 
—Inflammation of the parietcs over the liver—Sympathy of the integuments. 131 
LECTURE XVI. 
Aneurism of the hepatic artery—Distension of the liver with bile—Treatment of 
hepatitis—Employment of mercury—Symptoms of suppuration—Dr. Graves’s 
operation for giving exit to matter in hepatic abscess—Rupture into the perito- 
neum—Chronic hepatitis—Complication with disease of the heart—Einbryonary 
state of the liver. 140 
LECTURE XVII. vii 
CONTENTS. 
Treatment of chronic hepatitis—Neuralgia of the liver succeeding hepatitis—Con- 
nection of hepatic with gastro-intestinal disease—Modes of transmission of 
disease from the mucous surface of the liver—Phlebitis of the vena porta— 
Obstruction of this vein—Case of pulmonary, hepatic, and intestinal fistulse— 
Hepatic neuralgia. 150 
LECTURE XVIII. 
LECTURE XIX. 
Gastritis, with delirium tremens—Varieties of intestinal worms—Organisation and 
origin of—Occurrence in the foetuses of various animals—Formation—Patho- 
logy of perforation of the intestines by—Worms in tumours and abscesses. 160 
Symptoms of intestinal worms—-Sympathetic irritations of—Affections of the 
nervous and respiratory symptoms—Various diseases mistaken for worms—Ex- 
citing causes of worms—Farinaceous and milk diet—Verminous fever—Treat- 
ment of worms—Specific and mechanical purgatives; calomel, turpentine, &c. 
&.c.—Remedies for each species of worms—Preventive measures. . . 169 
LECTURE XX. 
LECTURE XXI. 
Painters’ colic—Effect of metallic poisons on the nervous system—Symptoms of 
painters’ colic—Pathology of neuroses—Action of lead on the system—Abdo- 
minal and cerebral symptoms—Species of painters’ colic—Dr. Thompson’s re- 
searches on lead—Effects of in animals—Effects of on the generative system. 177 
LECTURE XXII. 
Pathology of painters’ colic—Researches on the state of the nervous and digestive 
systems—Treatment—Use of narcotics, purgatives, tobacco, &c. &c.—Treat- 
ment of paralysis from lead—Efficacy of strychnine and brucine—Colic from 
copper—Poisonous effects of mercury—Remarkable case—Affection of the re- 
spiratory muscles. . .186 
Diseases of the nervous system—Pathology of, unknown—Molecular change in 
the nervous centres—Difficulties of distinguishing arachnitis from encephalitis— 
General and partial cerebritis—Symptomatology of—Diagnosis of—Preservation 
of intellect in—Production of general symptoms by local lesion. . . . 195 
LECTURE XXIII. 
Encephalitis, diagnosis of—Preservation of function with organic disease—Vica- - 
rious action of parts—Importance of pathology to phrenology—Use of pathology 
to phrenologists—Arachnitis at the base of the brain—Symptoms of—Influence 
of age over the intellectual faculties—Opinions of Bouillaud, Serres, and Foville 
—Influence of the optic thalami and corpus striatum on the motions of the ex- 
tremities—Diagnosis of disease of the cerebellum—Connection with the gene- 
rative system—Remarkable cases of. 204 
LECTURE XXIV. 
LECTURE XXV. 
Symptoms of encephalitis—Conclusions as to contraction and paralysis—Remark- 
able cases of encephalitis—Abscesses in the brain—Sympathetic affections— 
Enteriiis simulating cerebritis—Prognosis in cerebritis—Remote neuralgia a 
symptom \ 215 
LECTURE XXVI. 
Encephalitis—Treatment of in the adult—Importance of energetic means—Dan- 
gerous effects of opening the temporal artery or jugular vein—Copious blood- 
letting from the arm—Difficulty of producing syncope—Employment of cold— Good effects from purgatives—Encephalitis caused by piles—Treatment—Bene- 
ficial effects of blisters—Mercury—Dangerous effects of emetics—Dessault’s 
treatment—Use of opium—Violent counter-irritation of coma—Application of 
boiling water—Treatment of partial encephalitis. 224 
CONTENTS. 
LECTURE XXVII. 
Analysis of symptoms of cerebritis—Inconstancy of pain—Arachnitis, pain of— 
Intermittent pain—Headache—Phenomena of the eye—State of the pupils— 
Various affections of the functions of vision—Researches of Parent and Martinet 
—Relief by convulsions—Brain considered as a secreting organ—Dangerous 
effects of opium; delirium—Phenomena of organic life—Vomiting in Hydro- 
cephalus—Sympathies of the digestive and respiratory systems—Treatment of 
hydrocephalus—Of internal remedies—Cancrum oris, treatment of. . . 342 
LECTURE XXVIII. 
Apoplexy—Cerebritis and meningitis—Definition of apoplexy—Simple or nervous 
apoplexy without disorganisation—Complicated with other diseases—Congestive 
or serous apoplexy—Dr. Abercrombie’s opinions—Apoplexy with extravasation 
—Sites of extravasation—Absorption of clot—Apoplexy in children. . . 246 
LECTURE XXIX. 
Apoplectic effusions—Curative process adopted by nature—Connection of tempera, 
ments with disposition to apoplexy—Researches of Rochoux—Periods of life 
most subject to apoplexy—Principles of diagnosis—Varieties of apoplexy— 
Connection of symptoms with pathological appearances—Rostan’s division of— 
Different symptoms of—Double effusions—Rupture into ventricles—Hemiplegia 
—Value of the suddenness of paralysis as a diagnostic examined—Symptoms of 
apoplectic effusions 254 
LECTURE XXX. 
Apoplexy from ramollissement of the brain—Supervention of apoplexy on encepha- 
litis—Inflammation round the clot—Variety of paralysis consequent on apoplexy 
—Paralysis croissde—Different forms of paralysis—Origin—Phenomena of face 
and tongue—Paralysis of the tongue—Treatment of apoplexy—Blood-letting— 
Purgatives—Lotions, beneficial effects of—Emetics, dangerous effects of—Use of 
revulsives and stimulants—Treatment of paralysis—Efficacy of strichnine—Its 
modus operandi—Brucine, its proposed employment 261 
Local treatment of paralysis—Flesh-brush, shower-bath, &c.—Application of moxa 
—Cases in which it is useful—Professor M’Namara’s plan—Acupuncture with 
galvanism—Electro-puncturation—Method of applying—Powerful action of a 
small battery—Mr. Hamilton’s observations—Value of galvanism and electricity 
—Use of, in paralysis of the muscles of the face—Paralysis from disease of the 
arterial system—Case of, by Dr. Graves—Diagnosis of this affection—Pathology 
of Pott’s gangrene—Dupuytren’s mode of treatment 271 
LECTURE XXXI. 
Paralysis from arterial disease—Singular cases of, by Rostan—Diagnosis of para- 
lysis from arterial obstruction—Magnetism, use and action of—Effect of mag- 
netism in disease—Result of trials in the Meath Hospital—Paraplegia— 
Mechanical hvperaemia—Occurrence without disease of the cord or vertebrae— 
Cases by Mr. Stanley—Effects on urine by division of the spinal cord—Ammo- 
niacal urine—Caries of the vertebra}—Diagnosis of paralysis with disease of the 
kidney—Prognosis in paraplegia. . 279 
LECTURE XXXII. 
LECTURE XXXIII. 
Sadden paralysis from abscess of the brain—Curious case of paralysis without 
effusion—Previous symptoms of—Demonstration of the cellular tissue of the 
brain—Compressibility of the brain—Inaccuracy of the opinions of Drs. CONTENTS. 
IX 
Abercrombie and Clutterbuck—Pathological states—Arachnitis without deli- 
rium—Traumatic apoplexy—Case of paralysis of the portio dura—Peculiar 
appearance of the affected side of the face—Use of the electro-puncturation— 
Bad effects from—Mechanical support of paralysed parts—Neuroses, active 
and passive—General pathology of—Principles of diagnosis—Case of neuralgic 
liver—Neurosis from moral causes 290 
Principles of treatment of neuralgic affections—Connection with organic disease— 
Neuralgia of the liver—Treatment—Hemicrania—Treatment—Use of iron, 
quinine, and opium—Endermic method of using opium—Tic douloureux— 
Opinions of Sir C. Bell—Remarkable case related by—Inflammation of frontal 
sinuses—Violent symptoms—Mr. Crampton’s treatment—Affections of the fifth 
and seventh nerves in cases of cerebral disease—Neuralgia of the side— 
Researches of Lombard and Brande on the effect of nitrate of silver—Injury to 
the skin. 300 
LECTURE XXXIV. 
LECTURE XXXV. 
Scrofula, former opinions on—White and red capillaries—Division of the system 
into red and white tissues—Vascularity of the white tissues—Dr. Graves’s views 
of the lymphatics—Analogies of lymphatics and veins—Meckel, Cruikshank, 
and Magendie’s opinions on—Relations of the circulating and nervous systems 
—Vitality of serous membranes—Reproductive power of white parts—While 
blood and white tissues more prevalent in women than men—White tissues 
more liable to cancer, &c.—Analogy of the white parts with cold-blooded ani- 
mals—Increased sensibility of white tissues—True nature of the scrofulous 
diathesis—Reference to arrest of development—Explanation of its phenomena. 311 
LECTURE XXXVI. 
Fever—General considerations on—Erroneous modes of investigation—Import- 
ance of the labours of French pathologists—-Complication of fever with local dis- 
ease—Primary and secondary fevers—Relation of, to local changes—Tendency 
to spontaneous termination—Principles of treatment—Errors of Brown and 
Broussais—Researches of MM. Gaspard and Magendie—Their pathological 
conclusions—Importance of the knowledge of secondary lesions—Effect in pre- 
venting crisis—Treatment—Humoralism and solidism. .... 323 
Intermittent fever—Definition and character of—Phenomena of the paroxysm— 
Cold stage—Internal congestions—Pathology of—Hot stage—Ague not a 
simple fever—Affections of various viscera—Theory of Broussais—Effects of 
bark, quinine, &c.—Modus operandi of. 333 
LECTURE XXXVII. 
LECTURE XXXVIII. 
Intermittent fever—Symptoms—Occasional irregularity of the paroxysms—Con- 
vulsive motions of the feetus in a pregnant woman during ague—Exciting causes 
of ague—Treatment—Complication with other diseases—Importance of careful 
investigation—Visceral lesion, how far contra-indicating the use of bark—Bark 
almost a specific in ague—Large doses of quinine in ague—Rapidity of its 
operations in some cases—Fowler’s solution of arsenic—Prussian blue—Its 
advantages 341 
LECTURE XXXIX. 
Use of quinine—Disease not a simple increase or decrease of vitality—Bark a 
specific in ague—To be given in the period of apyrexia—Large doses at con- 
siderable intervals—Arsenic followed by dyspepsia—Mercury, its effects in ague 
—Treatment during the paroxysms—Dover’s powders, heat, laudanum, carbo- 
nate of ammonia—Pressure on large arteries to arrest the cold stage—Used in 
a case of hydrophobia with temporary relief—Gastric intermittent—Endermic 
mode of using quinine—Bleeding in the cold stage—Generally with safety and 
advantage—Supervention of other diseases. 350 X 
CONTENTS? 
Continued fever—Varieties of fever inflnite—Typhus fever—Symptoms of typhus 
—Petechias, sign of typhoid character—State of the tongue various—Progress 
of the disease—Typhus produced by injection of putrid substances into the veins 
—Hemorrhage from the intestines, &c.—Opinions on fever—Prognosis—Pheno- 
mena arising from each system—Jaundice an unfavourable sign. . . 359 
LECTURE XL. 
LECTURE XLI. 
Nervous symptoms in typhus—Uncertainty of development—Opinions of Dr. 
Clutterbuck—Unfrequency of lesions of the brain in typhus—Occurrence of all 
nervous symptoms, independent of any appreciable symptoms of the brain— 
Nature and treatment of headache in fever—Delirium, researches of Louis on— 
Its treatment in early and advanced stages of fever—Pathological state of the 
brain in delirium—Use of wine and opium—Dr. Graves’s remarks on—Nature 
of adynamia—Principles of treatment of the local inflammations in fever— 
Errors of the school of Broussais on this point—Use of stimulants at certain 
stages. 367 
LECTURE XLII. 
Opium in fever—Dr. Latham’s opinion on—Symptoms for the exhibition of opium 
—Affection of the sensorium in fever—Adynamia, consequence of fever—Direct 
adynamia—Indirect adynamia—Treatment of—Stimulants in fever—Dr. Grant’s 
notions of fever—Symptoms of typhus—Catarrh of fever—Opinions of Andral, 
Louis, and Laennec—Bronchitis with fever—Increase of rttles on decrease of 
disease—Affection of the gastro-intestinal mucous surface—Symptoms of pneu- 
monia and bronchitis—Pneumonia of fever—Symptomatic affections of the 
respiratory system in fever—Sympathy between the left lung and stomach— 
Phthisis, consequent of fever. 377 
LECTURE XLIII. 
Peripneumonie des agonizans of Laennec—Congestion of the lungs from position 
—Avenbrugger’s opinions on—Precaution of Boyer—Importance of position in 
typhus—Treatment of catarrh and pneumonia in typhus—Principles of treat- 
ment—Management of excessive secretion—Employment of emetics—Use of 
sulphate of quinine and opium in injections—Typhoid pneumonia—Gastric 
symptoms in fever—Broussais’ physiological theory—Brown’s sthenia and 
asthenia—Remarks of the physiological school—Different treatments of fever. 387 
Different lesions in typhus fever—Absence of symptoms—Cases by 
Bouillaud, Andral, Louis, &c.—Andral’s arrangement of fevers—Louis’s opinion 
on the anatomical character of fever—Analogy of typhus with small-pox— 
Absence of pain in enteritis—Means for diagnosis—Variety of disease in serous 
tissues from typhus—Treatment of the digestive symptoms of typhus—Hiccup— 
Tympanitis in fever, treatment of—General treatment of fever—Conclusion. 398 
LECTURE XLIV. LECTURES 
ON THE 
THEORY AND PRACTICE OF MEDICINE. 
LECTURE I. 
GENERAL OBSERVATIONS. 
Gentlemen:—You may have often heard that the approaches 
to science are rugged and uninteresting, and some of you have 
perhaps experienced the truth of the remark. Hence the cus- 
tom of delivering an introductory lecture, in order to lay before 
the young mind, when first entering on each path of knowledge, 
the objects, the results, the attained good, and the hoped-for glory 
of the pursuit. These are to be displayed with clearness and with 
truth, yet it is obvious that much of the effect of such a lecture 
must depend on the nature of the subject and the judgment of the 
speaker ; and it is well when the exalted nature of the one is 
attainable by the capabilities of the other. Such a lecture, then, 
should be an earnest lesson on the objects, the pleasures, and the 
advantages of that science, of which the course is destined to treat; 
its history, its true mode of study, its interests, actual state, and 
future prospects, may all form legitimate subjects, and when thus 
rightly viewed, an introductory lecture, so far from being a mere 
ornamental appendage, may become a most important part of the 
course. 
With these views let us approach our subject, the theory and 
practice of medicine. Let us contemplate that study and that pro- 
fession, which, venerable by all antiquity, yet in itself is “ ever 
new.” Even in its infancy, when the world was in darkness, was 
medicine a glorious science when compared with its cotempora- 
ries, and its first professors were ennobled and exalted by its influ- 
ence. As their mantles descended through a long line of illustrious 
successors, we see medicine progressively expanding, and even 
when the night of barbarism hung gloomily over the earth, we see 
its genius triumphing over the surrounding darkness, and shining 
in the east as a beacon to the shipwrecked mind of man ; and I 2 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
trust that T shall be able to prove to you, that, in our own time, 
when the human mind has made such astonishing advances, medi- 
cine has kept pace with her sister sciences, and it is a gratifying 
reflection to think, that, among the most distinguished promoters 
of the collateral sciences, physicians have ever held a commanding 
rank, thus proving themselves foremost in knowledge, as they 
have ever been in philanthropy, in private and public charity, and 
in all good will to man. 
It is scarcely necessary to allude to the title of this course of 
lectures, further than to remark, that, however different they may 
be in name, it is yet impossible to draw the line of distinction 
between the theory and the practice of medicine. If medicine 
were merely the knowledge of a number of empirical remedies for 
particular symptoms, given without our enquiring into their mode 
of action, or any acquaintance with the dependence of one func- 
tion, or one viscus, on another, of any knowledge, in short, of physi- 
ology in the healthy or diseased state, then we might have a practice 
of medicine independent of what is called its theory. But medicine 
now holds a higher place, and much of its improvement is trace- 
able to our advances in physiological and pathological science. 
Thus to treat, or teach, the treatment of a disease, we must know 
the healthy function of the organ, or organs, the history of deve- 
lopment, the influence of other organic systems, the changes pro- 
duced by disease, and, as far as possible, the action of all external 
or internal agents on the viscera. But this is the theory of me- 
dicine. 
For example, let us suppose that we are called either to treat or 
to teach the treatment of a case of enlarged liver. Let me here 
remark, that in selecting this case I do not wish you to suppose 
that I am one of what might be called the hepatic school of medi- 
cine, in which the existence of almost every organ, except the 
liver, seems to be forgotten, and of which the creed seems to be, 
that there is but one viscus, the liver, one source of disease, biliary 
derangement, and one cure, mercury ; a creed which, though not 
enforced and defended by the sword, has lost perhaps as much of 
human life as others whose history is written in letters of blood. 
But no one can doubt the importance of the organ, and I have 
taken it to illustrate the connection between the theory and the 
practice of medicine. 
You detect an enlarged liver ; you are called to cure the dis- 
ease :— 
1st. You must be aware of the healthy state of the organ, and 
of its healthy functions, as shown by the volume, sensibility, influ- 
ence on digestion, and the healthy state of the secretion. You must 
know all these, as it is by the departure from these conditions that 
you recognise this disease at all .—But this is the theory of me- 
dicine. 
2dly, You must know the history of its development, because 
there is a period of life when the natural state of the liver is in a 
greatly enlarged condition, and this may continue even to adult GENERAL OBSERVATIONS. 
3 
life, and produce an enlarged liver, not the result of disease but 
the arrest of development, and the question will arise as to whether 
the case before you is an example of this, or of recent and actual 
disease. The whole treatment turns on this.— Yet this is the 
theory of medicine. 
3dly. You must know the influence of other organic systems. 
An enlarged liver may be produced mechanically by obstructions 
in the lungs or in the heart; it may be produced from the sympa- 
thetic irritation of a duodenitis, or be the result of original disease 
in its own structure. All these circumstances must be known and 
taken into account. If it be merely obstruction in the venae cavae 
hepaticae the ordinary treatment will not answer ; if there be duo- 
denitis we must modify our treatment, and so on. We must know 
these things ; we must know how to recognise these diseases 
before we can prescribe or practise successfully. All this is that 
part of the theory of medicine called pathology, or the physiology 
of the diseased body. 
4thly. You must know the effects of disease on the liver itself. 
Some of these are removable by art, others are totally incurable. 
You must know these in order to determine on the probability of 
their existence. 
5thly and lastly. You must know the influence of remedial 
agents on the liver and the adjacent organs. You must be fami- 
liar with the effects of stimulation of the mucous surfaces of the 
stomach and duodenum. Then, indeed, and not till then, will you 
be qualified to treat the case with judgment and success. The 
same remarks, I need scarcely add, will be found applicable to the 
diseases of each viscus in the body. 
The objects of medicine, gentlemen, are twofold; first, to cure 
disease, no matter where seated or how produced ; and secondly, 
to relieve bodily suffering in cases where a cure is impossible. Its 
great end is to prolong life, and to diminish the bodily evils which 
result from the infirmities of our nature and other circumstances. 
Some of you may ask, where then is the distinction between medi- 
cine and surgery? In truth, there is no distinction in reality, and 
there should be none in theory. The human constitution is one;— 
there is no division of it into a medical and surgical domain ; the 
same laws and the same principles of treatment apply to the cure 
of a fractured bone and the cicatrisation of an internal ulcer. 
Unlike the corporations of medicine and surgery, the supposed 
purely medical and purely surgical parts of the body live in ex- 
cellent harmony. Here, then, there is no division, no jealousy, 
no separation of interests. 
I am by no means prepared to deny that advantages may arise 
from a practitioner devoting himself to this or that branch of his 
profession ; but, if he seeks for eminence, he will first educate 
himself generally. Let him attain extended views of pathological 
medicine; let him make himself master of the actual state of the 
science, and then he will find that there is not a single fact or law 
with which he has become acquainted that will not have its bear- 4 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
ing on his particular pursuit. It is in the education of medical 
men that the ruinous effects of the division of the professions of 
medicine and surgery are most perceived: and I feel convinced 
that, of the two, the surgical student is the greater sufferer, be- 
cause his views of pathology are injured. All the great laws in 
pathology are drawn from the consideration of visceral disease; yet 
the attention of the surgical student is diverted from this, and 
directed to what, I will say, can never elevate him in the ranks of 
science. He is taught anatomy, and what is called surgical disease, 
but he is kept ignorant, by this wretched system, of the great part 
of his profession, until he comes to practise, when, if he has a mind 
fitted for observation, he will find, that for one dislocation there 
will be hundreds of visceral diseases; and he will discover what 
was concealed from him during his pupilage, that many, many 
more die of what are called medical than surgical diseases. 
During the late war, more men in the British navy died of fever 
than of all other causes—including the sword. But, I rejoice to 
say, in Dublin the exclusive system of education is fast wearing 
away, and one of the many excellences of our national school of 
medicine is the instruction in general pathology. There are few 
schools of medicine where now a more enlarged and liberal spirit 
of education exists. 
In the study of your profession, gentlemen, let me warn you not 
to allow yourselves to be misled by the idea that surgery and me- 
dicine are different in their nature. The mere surgeon, or the mere 
physician only knows half of his profession. Reckless of human 
life, he may practise the healing art as a trade, but he never can 
know it as a science. But, as there are infinitely more cases of 
what are termed medical than surgical disease, it is plain, that the 
surgeon, ignorant of medicine, will far exceed the physician igno- 
rant of surgery, in the extent of his malpractice. I have long 
observed the ruinous system which has been pursued by teachers, 
as connected with this subject. The pupil was taught to consider, 
that if he was a skilful anatomist, if he understood the routine 
surgery of an hospital, and had carefully studied certain works on 
surgery, and some obsolete books of pathology, he was thereby 
prepared, in the language of the schools, to go forth to teach and 
practise the art and mystery of medicine in general. Now, all this 
was wrong. You may be profound anatomists and be bad surgeons, 
and worse physicians; you may have by heart the writings of Pott 
and Dessault, of Hunter and Thomson, and be totally incapable of 
treating a simple or complicated fever, or a case of visceral disease. 
But it is not necessary to say more. Society demands that the 
old system of a division in education should be abolished; and, 
ere long, I even trust to see a fusion of the profession, when much 
of the present evils must cease, when medical men shall have a 
common centre, from which they will receive a common impulse; 
when their efforts shall be solely directed to the increase of medical 
science, and the political and moral exaltation of their profession; 
and last, yet not least, when the ingenuous pupil shall not be led GENERAL OBSERVATIONS. 
5 
astray; when he shall not be told by one teacher to despise this, 
and by another to neglect that part of his profession ; but, having 
the whole of the noble science of medicine thrown open to him, his 
mind, unwarped by prejudice, unfettered by fear, shall be permitted 
to take that right view of his pursuit, that alone can lead him, and 
assuredly will lead him, to the honours and success which truth 
bestows on all its votaries. 
I have said, that the exclusive system of education had singu- 
larly diminished in Dublin. Indeed, our national school has earned 
great reputation for general pathology; and, from a long and cordial 
intercourse with the class of Dublin, I will affirm, that there are 
few places where we can see such zeal, talent, and thirst for 
knowledge among the students. As an Irishman, addressing my 
own countrymen, let me congratulate you on the fame the Dublin 
School of Medicine and Surgery has now acquired, and is every 
day acquiring ; and when the strength of Irish talent, aided by the 
proper working of our unrivaled institutions, is brought into play, 
may we not anticipate a still more glorious result ? This reflection 
has often cheered me, that within the last few years there has 
been a greater stimulus infused into the science and literature of 
this country. Amid the ungenial influences of political excitement, 
and the animosities of party, how gladly should we contemplate 
the advance of what will prove an honour to our national cha- 
racter, and an advantage to mankind. It is like the growth of the 
eoral into rocks and fertile islands, though surrounded by the strife 
and waste of waters. Our scientific societies have multiplied ; our 
periodical literature, the want of which furnished so fruitful a 
theme for cavil, has been extended so as to afford a wholesome 
and vigorous supply in the varied departments of literature and 
science; and our monthly and quarterly publications are taking 
their proper place among the ranks of British journals. When we 
turn to works of a more permanent kind, we also see cause for 
satisfaction. Many most important works in anatomy, surgical 
pathology, physiological medicine, and midwifery, have lately 
issued from the Irish press; and the Irish contributions to the 
Cyclopaedia of Practical Medicine are allowed on all hands to 
give to that work no mean portion of its value. 
There are few more wholesome exercises for the mind, few so 
necessary and so useful as the comparison of the actual state of 
any science with its advance and character at a former period; 
and it is in this, most chiefly, that the value of what is called the 
history of medicine consists. We study it then, not as a matter of 
antiquarian research, of learned curiosity, but as the picture of the 
human mind, now on the right path, now misled by error, yet still 
struggling onward; as the record of a dear-bought experience, 
and a beacon to warn us of the rocks and shoals that beset its 
future progress unto truth. To analyse the actual state of medical 
science, to show you all that has been done within a little time, to 
display all old pretensions to the character of a true and thrice 
noble science, would far exhaust my capabilities and your patience. 6 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
Let it suffice to contemplate the improvement considered generally, 
and the means by which that improvement has been attained. 
It is an error too generally received, that medicine owes all its 
advances to the researches of modern times. Far be it from me to 
undervalue these, but I believe that the opinion I have alluded to 
is wrong, and is perhaps kept alive by our own vanity ; for by a 
specious deception we often take to ourselves the honours and dis- 
tinctions of the time we live in. The truth is, that medicine, like 
many other of the sister sciences, has been long steadily advancing, 
and the flippant every day remarks that the inductive system (that 
is, the observation of facts and the embodying of those conclusions 
that legitimately flow from them) has been only introduced into 
medicine in our time ; and that our predecessors in medicine put 
theory first and fact second in their medical philosophy, are “ as 
false as dicers’ oaths.” Have the authors and teachers who are 
so fond of decrying the medicine of a former day, at a time when 
hey are (perhaps innocently) making use of its facts and observa- 
tions—have they read the writings of the father of medicine? 
Have they studied that “ aureum opus” so well called from its 
lustre, its purity, and its surpassing value ? Was Avicenna a mere 
theorist? Did Morgagni observe no facts, nor truly record them, 
even at the expense of his medical reputation? Is there no induc- 
tion in Baglivi? Was Haller unacquainted with the method of 
experiment and induction ? Or is the discoverer of the circulation 
of the blood, the good, the great, the injured, but the immortal 
Harvey, forgotten ? Where do they place Boerhaave ? and shall 
the name of Sydenham go down with his ashes to oblivion ? 
The true state of the case is, that medicine, in its present 
advanced state, only represents the improvement in other branches 
of human knowledge, all of which are so intimately linked together, 
that, although their extremes be far removed, there is a point where 
all are reciprocally cause and effect; so that if we take any one of 
them, it is easy to show its intimate bearings with, and importance 
to, all the rest. We have been long advancing in medicine; and 
though I admit most fully the vast strides which have been made, 
still I must here declare my firm conviction, that the study of the 
older authors is too much neglected, and that in them you will 
find a treasury of knowledge, much of which you may think to be 
the production of modern times. 
If the writings of the ancient authors only contained a small 
portion of the information with which they abound, it would be a 
sufficient stimulus to their study; to reflect that it is in them, in 
the medical writings of the ancients, that the germs of the induc- 
tive philosophy are first to be found. It is, then, in the old regions of 
medicine that we find the fountains of that mighty river, which, for 
two thousand years, has fertilised the earth, and made man its lord. 
Had the progress of man not been retarded by the ignorance which 
is the child and servant of barbaric despotism, an earlier Newton 
might have enlightened the earth, an earlier Laplace have measured 
the heavens, or a Cuvier declared the glories of a past and present GENERAL OBSERVATIONS. 
7 
creation. The mind of man would have burst its chains, and ages 
ago have formed that holy alliance with knowledge and her first- 
born, liberty, which now is its safeguard and its glory. I repeat it, 
in the writings of Hippocrates you will find the principles of the 
inductive philosophy. A physician showed Bacon the road to 
immortality. 
We find that there is in the mind of man a tendency to reverse 
the true mode of reasoning, and to seek for a principle before it has 
observed facts, and this was the cause of the retardation of medicine, 
as well as of all other sciences. Hence the various schools, from 
Pythagoras to Cullen or Brown, in our day. But a slow, though 
sure, revolution was long going forward; and I believe that Cullen 
and Brown were even behind the actual state of medicine in their 
time. Physicians turned disgusted from the war of words and 
doubt, to seek in tangible objects the certainty which these only 
can produce; in a word, they began to follow the Baconian system 
more generally. They reverted to the instructions of Hippocrates, 
and from that period our modern improvement may date. They 
turned their attention to the examination of those changes which 
disease produces on the human body, and connected these with 
the symptoms observed during life. And what has been the result 
of this? 
1st. The accumulation of an enormous number of facts, relative 
to the changes of organs produced by disease. 
2d. The connection of a vast number of these changes with 
particular symptoms, and hence the advance in diagnosis. 
3d. The establishment of the true value of symptomatology, and 
the verification of that all-important fact, that opposite states and 
organs may produce similar symptoms. 
4th. The knowledge of the vast class of latent diseases; in other 
words, diseases which exist without influencing the phenomena of 
animal life, or, in some cases, the phenomena of both animal and 
organic life. Diseases, either without symptoms at all, or only 
with such as previously were not supposed capable of leading to 
their detection. You know that the phenomena of life are divided 
into two classes, viz. those of organic or vegetable life, such as 
nutrition, circulation, absorption, respiration, secretion. While 
those of animal life, or the life of relation {so called, from its being 
the source of our connection with surrounding bodies), are the 
senses, the phenomena of mind, and muscular motion. The one 
life seems more under the influence of the ganglionic, and the 
other under that of the cerebro-spinal system of nerves. 
As some of the junior part of the class may not have accurate 
ideas as to the meaning of symptoms, I may state that disease is 
recognised by signs and symptoms. 
By signs, we mean those mechanical alterations, produced by 
disease, in the conditions of parts, which are recognisable to the 
external senses of touch, sight, and hearing ; changes in appear- 
ance, volume, shape, resistance, peculiarities of feel, and the pro- 
duction of sounds. We may make a diagnosis by signs alone. 8 
STOKES’S THEORY AND PRACTICE OF MEDICINE.* 
Take, for example, a case of tympanitis. The abdomen is promi- 
nent, enlarged, circular, elastic, and sounding like a drum when 
struck. Thus we learn that the belly is distended by air. 
Now, symptoms are totally different; they consist in certain 
changes produced in functions ; and these functional changes are 
to be considered in a threefold manner:— 
1st. Changes in the functions of the part itself. 
2d. Changes in the phenomena of organic life. 
3d. Changes in the phenomena of animal life. 
Let us take, for example, a case of inflammation of the stomach. 
We have, first, changes in its own functions—morbid sensibility, 
vomiting, thirst, anorexia. In the next place, we have changes in 
the functions of organic life—fever, from the action on the circu- 
lating system; hurried respiration, and cough, and hiccup, from 
the action on the respiratory system ; jaundice, from its action on 
the biliary system; suppression of the secretion of the skin, 
kidneys, &c. All these, you observe, are lesions of the functions 
of organic life. 
But we may have other symptoms ; prostration, headache, deli- 
rium, convulsions ; these are lesions of the life of relation, or 
animal life. 
Now, in many cases, we have to combine these sources of 
knowledge to form a correct diagnosis. Take, for example, a case 
of hepatitis. 
The patient has had pains in the hepatic region, fever, jaundice, 
hurried breathing, tenderness. After some time he has a tumour ; 
the side dilated; the hypochondrium dull on percussion. Well, 
the signs point out an enlargement of the liver; the symptoms, 
that the cause of that enlargement was an acute hepatitis. 
In general, we may state, that signs only declare the actually 
existing mechanical condition, while symptoms, either present or 
past, point out the cause of the change, whatever it may be. Both 
must be studied together ; but you will learn more from symptoms 
without signs, than from signs without symptoms. But to return 
to the results of the improved method of investigation. 
Great light was thrown on fever in general; and it is, I believe, 
quite true, that all the advances which we have made in the know- 
ledge of fever, are due to the prosecution of pathological anatomy. 
Almost all of what we may call our general knowledge of fever, is 
due to Hippocrates ; but anatomy has revealed its effects, its com- 
plications ; and the all-important fact, that the cause of its fatality 
is often local inflammation. This knowledge, however, is not so 
new as is taught by some modern systematists. Galen (De Affect. 
Intern, c. xli.) taught, that in continual fevers bleeding and cold 
drinks were the powerful remedies. Sydenham declares that the 
ignorance of the inflammations in malignant fevers, has been more 
fatal to the human race than the invention of gunpowder. Baglivi. 
that malignant fevers often depend on a visceral inflammation, 
and Van Swieten knew the frequency of intestinal ulcerations in 
typhus. GENERAL OBSERVATIONS. 
9 
Among the direct results of pathological anatomy, it is shown 
that disease is seldom confined to one organ, or even one system, 
and thus it has utterly shaken the nosological system of Cullen 
and his predecessors, which, you know, consisted in classifying 
disease by symptoms, which were supposed to point out a certain 
and single disease. For example, the nosologists class phthisis as 
an affection of the lung; but pathological anatomy has shown, that 
in many cases it is the result of a disease invading many organs 
and systems, and that the pulmonary disease is but a link in the 
chain of morbid actions. Pathological anatomy, also, has demon- 
strated the inflammatory nature of a vast number of diseases, and 
has thus given us a key to treatment, to prevention, and to pallia- 
tion, when the disease is incurable. 
The last grand result of pathological anatomy is the discovery 
that a vast number of affections, supposed to be merely lesions of 
function, are more or less connected also with alteration of struc- 
ture. Thus many of the dyspepsias of the nosologists are proved 
to be examples of gastritis, or of other organic diseases; cases of 
asthma turn out to be chronic inflammation with emphysema; the 
palpitations may depend on organic disease which has sprung 
from a carditis, and so on. I need not now dilate on the vast 
importance of such facts to practical medicine. 
But let us now come to an all-important enquiry. Is patholo- 
gical anatomy to be considered as the basis of medicine ? or is it, 
even when combined with clinical observation, the foundation of 
all medical knowledge ? This enquiry, you will at once perceive, 
involves the question as to whether Hippocrates and his followers 
have done any thing for the science, or whether medicine is 
wholly new, an infant, and consequently a weak and imperfect 
science. Are we to despise the works of the ancients, to be igno- 
rant of them, and to allow medicine to be in its infancy ? In fact, 
if we review the history of medicine from the Hippocratic era to 
the absurdities of Hahnemann, we find that there have been two 
orders of men, one constituting what we may term the school 
founders, who made a theory, and sought to square facts to meet 
that theory ; these have only brought disgrace on medicine. The 
other class consists of the Hippocratic observers; that is, of men 
who sought for facts, who collected and pondered on these facts, 
in other words, who were Baconian philosophers. It is the labour 
of these that has really advanced medicine. Asclepiades, who 
lived in the first century of the Christian era, declared that the 
medicine of Hippocrates was a cold meditation of death. The 
celebrated Thessalus, who lived under Nero, in writing to the 
emperor, makes use of the following words :— 
“I have fpunded a new sect, which is the only true one. I 
have been forced to this, because none of the physicians who have 
preceded me have discovered any thing useful, either for the pre- 
servation of health, or for the cure of diseases, and because Hip- 
pocrates himself has put forward many dangerous maxims.” 
And what was this new doctrine ? That nature in each case 10 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
pointed out to the patient what was most fit for him, and that 
hence he should be diligently supplied with every thing that he 
fancied. 
We have next Paracelsus. He commenced his course of lectures 
at Basle, in the year 1526, by publicly burning the writings of 
Galen and Avicenna, and assured his auditors that a single hair of 
his head contained more knowledge than Hippocrates and his suc- 
cessors. He taught the cabalistic medicine, the intimate connec- 
tion between the planets and the viscera; he was a vitalist, but 
embodied his vitalism under the shape of a demon, who resided 
within the system, and which he called Archaeus. Diagnosis was 
to repose on the examinations of the stars, and not on symptoms. 
He invented the doctrine of tartar, which is the cause of all dis- 
eases, of accumulation, obstruction, and concretion ; “and I call it 
tartar,” says he, “ because it contains the oil, the spirit, and the 
salt, which burn the patient as hell does.” 
Hahnemann, the founder of the homoeopathic doctrine, may be 
quoted next as an example of these school founders; and he, like 
his predecessors, expresses himself with all that arrogance, which 
ignorance, when it pretends to learning, invariably assumes. 
Speaking of the Hippocratic medicine, he says— 
“ Since this art only consists in a gross imitation of a danger- 
ous and insufficient process, it must be admitted that the true 
medicine was not discovered until by me. It is the infallible 
oracle of the art of curing ; it is the sole mode of really curing dis- 
ease, because it reposes on an eternal and infallible law of nature.” 
And what is this mode and doctrine? We have it in four pro- 
positions, and it is hard to say which of them is most revolting to 
common sense. We are told that it is absurd to seek for the cause 
of symptoms in order to remove them; that we must cure diseases 
by the exhibition of substances which would otherwise produce 
them; that the dose is to be inconceivably small; and that there 
are three original diseases from which spring all the maladies 
which afflict mankind—syphilis, sycosis, and the itch. These are 
the fruitful causes of all diseases, epidemic, sporadic, idiopathic, 
and symptomatic. Like his predecessor in quackery and deceit, 
he, too, has is in his syphilis, sycosis, and itch, the oil, the spirit, 
and the salt, which burn the patient as hell does. Like Paracelsus, 
too, he maintains the curability of diseases, and is a disciple of the 
animal magnetism. 
Let us next see how Broussais announced his doctrine to an 
admiring world. 
“ After so many vacillations in its march, medicine at length 
follows the only path which can conduct it to truth—the observa- 
tion of the relations of man, with external modifications and the 
relations of the organs of man, one to the other” This is the 
physiological method, because it cannot be followed without study- 
ing life. 
I am more anxious to draw your attention to this doctrine, as 
Broussais may be considered as the source of the anatomical GENERAL OBSERVATIONS. 
11 
school, which, of late, was so completely the fashion—if I may use 
such a term; and it is a striking instance of the danger that 
attends the idea of our having made a discovery, to see a man 
like Broussais, than whom few have really added so much to 
medicine, falling into the same fault of arrogance and contempt 
towards his predecessors. 
At this moment, the medical world, particularly on the continent, 
are divided into two great sects. One may be called that of the 
patliologico-anatomists, the other the Hippocratists. The first 
declares that diseases are primitively local in all cases; that the 
symptoms—say in a case of fever—are only the results of a sym- 
pathetic irritation f rom some local disease, which is to be attacked 
with vigour ; that pathological anatomy is to be the foundation of 
all practice; that there is nothing approaching to a specific in 
medicine; and that nature makes little or no attempt to cure. 
Their favourite maxim is that saying of Bichat’s—“ What is 
observation, if we are ignorant of the seat of disease ?” 
This is the sentiment of an anatomist, but not of a physician ; 
and we must regret that it once escaped the author of the 
“ Researches on Life and Death,” a book of such interest and such 
beauty, as to captivate even the non-medical reader, and make the 
very name of Bichat be hallowed in our memory. Many are the 
diseases of which we know not the seat; yet in which observation 
—Hippocratic observation—is of the greatest utility. 
We know not the seat of fever, let the followers of Broussais say 
what they may to the contrary ; yet is observation of symptoms of 
no avail in fever ? Are the effects of contagion, the history and 
nature of epidemics, the termination by crisis, the results of treat- 
ment, of symptoms as connected with prognosis—is the observation 
of these useless or unnecessary ? Sydenham knew not the seat 
of variola ; yet he declared the true principles of its treatment. 
There are very many diseases on which pathological anatomy 
throws but a negative light—if I may use such a term—particu- 
larly affections of the fluids, and the neuroses. 
So much for the doctrine of the anatomical school. I beg of 
you not to misunderstand me as undervaluing pathological ana- 
tomy ; I only wish to show you its true value. I believe there 
could hardly be adduced a single fact in pathological anatomy 
that has not its distinct bearing on practical medicine. And it is 
true that the diseases whose treatment is best understood are those 
whose pathological nature are best known. Even in fever, the 
actual nature of which has not been revealed, great advantage has 
been derived from anatomical researches ; for all the advance in 
our knowledge of this Protean disease consists in ascertaining the 
number, nature, and seat, of the local inflammations which accom- 
pany or rise in the course, and complicate the disease. 
Let us, lastly, revert to the opinion of the Hippocratists. They 
admit that vast advantage has arisen from pathological anatomy; 
but they see that its light is limited within certain bounds. They 12 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
believe that great advantage is to be derived from the careful 
study of symptoms, even in cases whose pathological nature is not 
revealed by the knife. They believe that there are many diseases 
whose local origin cannot be demonstrated; for instance, fever. 
They deny that pathological anatomy is always to be our guide ; 
but admit a rational empiricism, and the use of remedies which 
may be called specifics ; and. lastly, they hold that nature, in 
many cases, makes an attempt to cure; and that the physician, in 
the words of Hippocrates, is to be the minister and interpreter of 
nature, rather than her master. 
Let us, then, combine the precepts of the founder of medicine 
with the lights of modern science. Let us take observation, and 
that observation rendered fruitful by study, for our guide; and let 
the observation equally embrace the phenomena of the living as 
well as the dead. Let us be Hippocratists in the dissecting room 
as well as at the bed-side. By comparing the practice of these two 
schools, we get more accurate ideas as to their doctrine. The 
anatomists, holding that all diseases are local, direct their whole 
attention to the discovery of the lesion, and its connection with 
symptoms. This, with their doctrine that almost all diseases are 
inflammatory, leads them to a strict general and local antiphlo- 
gistic treatment. Fever is to them symptomatic, and the supposed 
source is to be vigorously attacked in the commencement. 
Diathesis, the nature of the epidemic, and the powers of nature 
to effect a cure, are comparatively neglected. They inhibit pur- 
gatives for fear of increasing the local inflammation, and lose 
many patients for want of a timely support of the powers of life. 
They deny specificism in disease as well as in medicine, and 
are sorely puzzled to explain the extraordinary powers of bark, 
and mercury, and sulphur, and iodine. They despise the expe- 
rience of the past. 
The true Hippocratist, on the other hand, believing that we 
have not yet arrived at the knowledge of the local origin of all 
diseases, and particularly fevers, grounds his practice accordingly. 
He draws his experience from the recorded knowledge of the past, 
and his own unbiased observation. When he recognises a local 
inflammation, he meets it with judgment, taking into account the 
habit, diathesis, epidemic, constitution, and tendency to crisis. He 
trusts much to nature, and watches her operations, particularly in 
fever. He is not afraid of moderate evacuations ; the phantom of 
a local inflammation does not always haunt him; and even where 
he recognises its existence, that does not prevent him from using 
a stimulating and supporting treatment, if the general state of the 
patient requires it. He treats particular diseases by particular 
remedies, the utility of which has been proved by experience— 
such as syphilis, scrofula, intermittent fever, and so on. He uses 
the expectant medicine, which is not inactive treatment, but 
founded on the observations of the powers of nature—“ Natura 
morborum medicatrixbut he never loses the opportunity of REMARKS ON LOCAL DISEASES. 
13 
doing good, when such presents itself, remembering the first 
aphorism of his great master :— 
“Occasio prseceps.” 
I have great hopes for medicine, for I see men’s minds turning to 
the true path ; and I trust that all whom I now address will deem 
themselves as labourers in the great work. Think what a noble 
science you profess ! the only one relating to earth-born things, 
which, while it ennobles the mind of man, yet softens and expands 
his heart; whose source is all science, whose end is good to man. 
Above all things, follow truth ; nature can never deceive—see that 
you be her faithful interpreter. The great evil is, that there has 
as yet been adopted no means by which the experience of the past 
can be brought fully to bear on the actual teaching and practice of 
medicine. Too often has the physician to create his own instru- 
ments. But when all the scattered facts of medicine are collected, 
whether they be the observations on the living or the dead body, 
as old as history, or as young as to-day; when these votive tablets 
are hung up in the temple of truth, and their facts verified, com- 
pared, and classified, then, and not till then, will you see medicine 
in all her glory.' 
LECTURE II. 
General remarks on local diseases—Fixed rules for the guidance of students—Great 
importance of diagnosis—Existence of pure fever rare—Doctrine of the Humoralists 
and of the Brownists—Pathology of the digestive system. 
I commence the course by entering at once on the subject of 
particular diseases. I am aware that the common practice is to 
occupy the early part of a course on the theory and practice of 
medicine with preliminary discussions on general pathological 
subjects. To this I have strong objections. Every man who as- 
sumes to himself the office of teacher, no matter what the fact may 
be, should presume that his auditors are ignorant of the subject he 
is about to teach; if he does not he must be unjust to his class. 
Some of the class must be ignorant of the information he wishes to 
convey, and he should take it for granted that all are so. To 
commence with the consideration of general disease would argue 
that the whole class was acquainted with the subject in all its 
bearings, and capable of understanding its principles without any 
previous illustration. I think this is beginning at the wrong end. 
My plan is first to teach the facts, and then the general prin- 
ciples and conclusions to which these facts lead. It is of the 
deepest importance in the study of medicine to be able to form 
a collection of laws or fixed principles. In your professional 
career, nothing will give you so much satisfaction as having in 14 
STOKEs’s THEORY AND PRACTICE OF MEDICINE. 
your minds a number of established facts and fixed rules to bear 
on every case which comes under your cognisance. We com- 
monly hear of the uncertainty of medicine and the instability of its 
practice, it is said to have as many phases as the moon, and as 
many changes as the tide; but, after all, I think this expression is 
more general among those who know little than among those who 
know much. Those who have successfully laboured in treasuring 
up a store of deep and extensive knowledge are firmly convinced, 
that, though some cases are involved in doubt and obscurity, the 
general certainty of medicine is at present increased far beyond 
what it was in former times. No man, except one in full and 
extensive practice, earned by industry and capacity, can be aware 
of the vast improvements of modern practical medicine, and of the 
number of lives which are saved by the judicious treatment which 
the rapidly progressive improvement of medical science has intro- 
duced. Medicine is much more certain now than it was in past 
times. There are two reasons for this, one of which is, that at 
the present period diagnosis, the guide and master-key to sound 
treatment, is more certain. Here, gentlemen, is a great source of 
certainty in the practice of medicine. You will find, in the course 
of a few years, that the old saying of “doctors differ,’5 will become 
less frequently applicable, because, as the education and acquire- 
ments of medical men become more extended, diagnosis will be 
reduced to fixed rules, and difference of opinion will be very seldom 
observed. A vast number of local diseases, formerly wrapt in 
obscurity, are now detected with the most unerring certainty, and 
this certainty of diagnosis must bear on fixed principles of treat- 
ment and similarity of practice. Another vast source of increased 
certainty is the fact, now extensively established, that the element 
of a great number of diseases is the same. This is an important 
law, because the deduction from it is, that the principles of treat- 
ment are the same in these cases. The principles of treatment in 
a case of hydrocephalus and in a case of vomiting from gastritis 
may be, and often are, completely identical, because, in many cases, 
both are reducible to a common action. In the one case we have 
to deal with inflammatory action in the stomach, in the other we 
have to treat an inflammation of the membranes of the brain. The 
principle in both cases is to deplete the suffering organ and to 
diminish or remove every thing that keeps up irritation. Patholo- 
gical anatomy, too, has effected a vast deal for medicine by the 
improvements in diagnosis which it has introduced, and by re- 
ducing to one class a vast number of affections formerly supposed 
to be unanalogous and distinct. 
Before I commence entering on the consideration of the patholo- 
gy and treatment of diseases of the digestive system, it is necessary 
that I should mention another peculiarity of the mode of teaching 
the theory and practice of medicine adopted in this school. The 
ordinary way of lecturing medicine in the schools is this: the 
teacher begins by going over, at great length, the whole subject of 
fevers, and then proceeds to the consideration of the signs, symp- REMARKS ON LOCAL DISEASES. 
15 
toms, and treatment of local diseases. We reverse this mode 
here; we begin by teaching the pathology and treatment of local 
diseases, or affections of particular organs, and having studied 
these with care and attention, we then proceed to the consideration 
of fevers. In point of fact, we are thoroughly impressed with the 
truth of this splendid conclusion in medicine, that local diseases 
may be considered, as it were, the alphabet of fevers, and that to 
have a distinct and accurate conception of the whole subject of 
fever, it is essentially necessary that we should be acquainted with 
all kinds of local disease. To commence with a class which the 
teacher presumes, or should presume, to be ignorant of the phe- 
nomena of local diseases, unacquainted with the rules on which 
their diagnosis depends, and unacquainted with the principles 
which should regulate their treatment—to begin with such a class 
by entering at once on the subject of fever, would, in my opinion, 
be extremely wrong. You will read in books and hear teachers 
speak of bilious fevers, of nervous fevers, of catarrhal fevers, of 
gastric fevers, and of simple fevers. These expressions are founded 
on the fact of the complication or noncomplication of fever with 
local disease in various parts of the system. If simple fever was 
the rule, and its complication the exception, then, indeed, there 
would be some reason for pursuing the ordinary track of medical 
instruction, and we might commence by teaching the subject of 
fever, independent of local inflammation. But the truth is, that 
fever, in the simple form, is the exception, and its complication 
the rule, and that to have a correct idea of fever, in the general 
acceptation of the term, we must previously possess an intimate 
knowledge of the affections of particular organs. The progress of 
medicine has established, by the most unquestionable evidence, 
that simple fever is a matter of extremely rare occurrence, so rare, 
in fact, that you might pass through the practice of a fever hospital 
for years without meeting with a single case which you could 
say was, through its whole course, a case of pure, essential fever. 
Sooner or later its character is changed, and the complication with 
visceral disease comes on; you may take this with you as a well- 
proved fact. You will have, at some period, a complication with 
local disease in the head, or local disease in the chest, or in 
the belly, or in the circulating system, or perhaps all the great 
viscera in the body will be simultaneously affected. My expe- 
rience on this point, after having attended the fever wards of 
the Meath Hospital many years, is this, that among all the cases 
which were admitted under such circumstances, there were very 
few indeed in which I could not say that the patient had something 
more than fever. Many were admitted who presented no,indica- 
tion of disease in the head, chest, or digestive tube ; all that could 
be said of them, at the period of their admission, was, that they 
had fever ; but my experience of them is, that, in a vast majority, 
there was, during their progress, unequivocal evidence of the su- 
pervention of visceral disease. I do not go as far as the disciples 
of Broussais have gone, nor do I mean to say that all fevers are 16 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
symptomatic ; all I assert is that, at some period, most fevers are 
complicated with local disease. I admit that there is a vast number 
of symptomatic fevers, but I believe there are two which are essen- 
tially simple, typhus and intermittent. The progress of medicine 
has shown that these may exist in the simple form, and that their 
complications may be secondary ; this I believe to be the fact, but 
the almost invariable liability to complication is a point of the 
highest importance. We scarcely ever see typhus accompanied 
by symptoms of local disease ; and, with respect to intermittent, in 
ninety-nine cases out of a hundred, visceral disease of the head, 
or chest, or belly, may, and will, supervene. 
Another great fact bearing on this subject, and which patholo- 
gical anatomy has established beyond the possibility of a doubt, is, 
that in the great majority of cases having a fatal termination, death 
is caused by disease of some particular organ or organs. The old 
notion of the cause of death was, that the patient died of debility 
or exhaustion. In cholera, in tetanus, in hydrophobia, we cannot, 
to be sure, demonstrate any appreciable lesion of structure, and 
we may say, if we like, that the patient died of debility ; but this 
does not hold good in cases of fever, for on dissection you will 
generally find disease sufficient to account for death, even though 
there had been no fever at all. From these circumstances it fol- 
lows that in the management of fevers, the attention of the physi- 
cian must be directed to the local affections, or, at all events, that 
to understand fever well and treat it successfully, he must be ac- 
quainted with the nature and treatment of every form of visceral 
disease. It will be sufficient for me to call your attention to this 
fact, that there is not a single acute local disease which may not 
occur during the progress of a fever. This is a broad and general 
proposition. If you look to the nervous system you will find, in 
patients who have died of fever, traces of lesion in almost every 
part of it, inflammation or congestion in the cerebrum, in the cere- 
bellum, and in the spinal cord. If you go to the respiratory system, 
you will see all kinds of shades, and varieties of inflammatory 
action, thickening and ulceration of the bronchial membrane, hepa- 
tisation, congestion, and destruction of the parenchymatous tissue, 
effusions of lymph, serum, or pus, into the pleural cavities. As 
you proceed in your examination you will discover new lesions; 
you may see the whole lung filled with lately formed tubercular 
matter, you will meet with the destructive ravages of phthisis. 
You will find the pulmonary tissue converted into a dark and fetid 
mass by gangrene. You may see carditis, hypertrophy, inflamma- 
tion of the external or internal coverings of the heart, inflamma- 
tion of the lining membrane of the arteries, phlebitis, (a common 
occurrence in typhus fever,) and passing on to the lymphatic sys- 
tem, you will often find evident traces of inflammation in its glands 
and vessels, an occurrence which I shall be able to demonstrate to 
you when treating on the subject of gastric fever. If we go to the 
digestive system we find that disease has here taken a wider 
range ; congestions and ulcerations of the stomach and intestines, REMARKS ON LOCAL DISEASES. 
17 
morbid states of the liver, congestion and inflammation of the spleen 
or kidneys, evidence the fatal extent of local inflammation. I 
think I might safely challenge any one to point out any one single 
organ which may not become diseased during the progress of a 
typhus fever. I do not wish you to suppose that typhus is a symp- 
tomatic affection. I think we may define it, in general terms, as a 
diseased state of the whole system, in which various local diseases 
arise, modify the character of the original complaint, give it an addi- 
tional intensity, and are generally the cause of death. Go round the 
wards of an hospital during the prevalence of an epidemic fever, 
examine every patient in succession, and bring this principle to 
the test. You will see one labouring under the morbid excitement 
of high delirium; his face injected, his eyes sparkling, his carotids 
throbbing with intensity. Come next day, and you will find him 
in a state of profound coma, perfectly insensible to every thing 
around him :—two or three days afterwards he is dead. You follow 
his body to the dissecting room, and open his brain ; unequivocal 
marks of excessive congestion, inflammation of the substance of the 
brain, or of its membranes, sufficiently indicate the cause of the 
fatal termination. Here is a case of inflammation of the brain; 
you find another with cold skin, his face of a dirty hue, faintly 
tinged with red, his breathing quick and hurried, and the spitting- 
vessel by his bedside filled with adhesive mucus tinged with blood; 
you percuss his chest and find dulness over the whole surface of 
one lung; you apply the stethoscope and discover intense bron- 
chitis, hepatisation, or suppurative pneumonia. Farther on you 
see another in a state of deep prostration, with a sunken counte- 
nance, constant hiccup, and low delirium. Take down his bed- 
clothes, and you find his belly swelled, tympanitic, and tender on 
pressure; then his tongue, lips, and gums, are parched and encrusted 
with dusky sordes ; his thirst is insatiable ; he vomits, and has an 
emaciating diarrhoea. After death you find traces of an extensive 
and fatal gastro-enteritis; in others you will find exemplified the 
very climax of inflammation, and all the three great cavities are 
simultaneously affected. 
But these, you will say, are cases in which the complications 
are evident, and where an ordinary knowledge of the phenomena 
of local disease will be quite a sufficient guide. Well, here is 
another case. You will meet with instances of fever without any 
apparent local symptoms, where the patient lies in what you would 
consider a quiet state, and free from danger : nothing seems to be 
the matter with him, except that he is very weak ; he perhaps does 
not sleep at night, and his tongue is a little foul; he complains, in 
fact, of nothing but weakness and some thirst, and you think his 
fever is going on very well. Some morning or other, on coming 
to the hospital, you are astonished to see the change which has 
been wrought in him since the day before; his countenance is 
altered, his pulse can hardly be felt, and life is fast ebbing away. 
You ask the nurse about him, and she tells you that, during the 
night he suddenly complained of violent pain in his belly. On 18 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
examining him, you find distinct evidence of intense peritonitis, 
and, after death, dissection reveals the existence of a perforating 
ulcer of the intestines, of which there was apparently no sign 
during life, except fever and the unexpected occurrence of peri- 
tonitis. The frequency of the complication of local disease with 
fever, its insidious latency, and the fact, that death, in the majority 
of fever cases, is caused by visceral inflammations, all clearly point 
out the necessity of being intimately acquainted with every modi- 
fication of local disease before you proceed to the study of fevers. 
I commence with the digestive system. I am anxious to do this 
for several reasons, but for none more than this—that to the im- 
provements made in the pathology of the digestive system we owe 
much of the rapid advancement of modern practical medicine. 
Before our time the pathology of the digestive system was very 
little known, and if not quite a terra incognita in medicine, there 
existed respecting it a great deal of misconception. The schools 
were deeply tinctured with the doctrines of the Humoralists and 
the Brownists; and this had the effect of giving rise to irrational 
theories and false notions of the true state of the system in disease. 
The humoral pathologists, who sought for disease in an alteration 
of the fluids alone, neglected the study of visceral lesions ; and 
when they turned their attention to the digestive system, they only 
considered it, its secretions, and not its actual condition or the 
state of its sympathies. The liver, with them, was an organ of the 
highest importance, and the secretion of bile claimed a vast share 
of their attention. To it they gave a paramount influence, and to 
an alteration in its quantity and quality they attributed most of the 
changes which occur, not only in the digestive tube, but also in 
the whole system; and hence the great object of their practice was 
to attempt to restore its healthy condition, convinced that if this 
were once accomplished every thing would go on favourably. 
From this, too, arose the purgative plan of treatment in various 
forms of intestinal disease, a plan too often rashly pursued, even 
where there was unequivocal proof of inflammation in the diges- 
tive tube. Their sole purpose was to evacuate sordes, to produce 
a flow of healthy bile, and to eliminate depraved secretions ; and 
they did this without possessing any knowledge of local inflamma- 
tion, or of the effects of disease of the digestive system on other 
organs. The followers of Brown, on the other hand, only admitted 
disease of the digestive system in a state of intense, manifest vio- 
lence, as, for instance, ileus or violent enteritis; but, in the great 
majority of cases, they did not recognise intestinal inflammations, 
because their prominent symptom was prostration, or, to use their 
own terms, an asthenic condition of the whole system. They saw 
nothing but prostration ; they prescribed for nothing but debility; 
they gave wine instead of iced water ; ordered bark instead of local 
depletion. They exasperated the disease by stimulants; and then, 
thinking they had not gone far enough, they heightened the stimu- 
lant and doubled the debility. 
Another cause of the low state of pathology in former times was REMARKS ON LOCAL DISEASES. 
19 
the genera] neglect of dissection. The fact is, that in fever there 
were no post mortem examinations made, until very lately. Mor- 
gagni, who did so much for pathological anatomy on almost every 
other subject, did little for fever, because he was afraid to dissect 
the bodies of persons who had died of a contagious disease. This 
was the idea which prevailed among the older pathologists ; and 
hence this source of knowledge was avoided, and for many succes- 
sive centuries the state of the viscera in fever was a matter of spe- 
culation, doubt, and uncertainty. Even at the present day it is only 
done by the ardent pathologist, who cares not about filth and stench, 
and who had rather encounter the miasm of contagion than remain 
in the mists of error. Nothing is more common, I regret to say, 
even at the present time, than this :—A person says he has dis- 
sected cases of fever, and when asked whether he had examined 
the intestinal canal, he says that the intestines appeared healthy, 
but he did not make any particular inspection of them ; he only 
opened the belly, and, finding no trace of inflammation in the peri- 
toneum, he went no farther. Now nothing can be more useless 
than such an examination. If we compare the information afforded 
by an inspection of the serous membranes of the three great cavities, 
we shall find that the least is given by an examination of that of 
the abdomen. Disease of the substance of the brain is rare with- 
out affections of its investing membrane, disease of the substance of 
the lung is exceedingly rare without the occurrence of disease of 
the pleura, but you may have most extensive and fatal disease of 
the intestinal canal, without the slightest lesion of the peritoneum. 
In this point, therefore, it differs from the pleura, and from the 
arachnoid membrane. The fact of the rarity of disease of the peri- 
toneum in cases of disease affecting the parts beneath, was noticed 
by Dr. Graves and myself, in our report of the Meath Hospital, and 
also by Mr. Annesley, in his account of the diseases of India. You 
will see cases of hepatic abscess, which present a distinct tumour 
externally, and where you can detect a perceptible fluctuation ; 
and yet, if you examine these cases after death, you may not find 
any adhesions of the peritoneum, even in the situation of the ab- 
scess. You will find the mucous and muscular coats of the colon 
extensively destroyed, you will see the stomach all but perforated, 
you will meet with cases where the whole ileum is one extensive 
sheet of ulcerations, with no disease in the adjacent peritoneum. 
In entering on the consideration of diseases of the digestive 
system, we shall begin first with the mucous expansion of the sto- 
mach and intestines, and then proceed to the affections of the solid 
viscera connected with them. The mucous surface of the stomach 
and intestines is of enormous extent and extraordinary sensibility, 
possessed of innumerable and powerful sympathies; its influence 
is felt by almost every organ in the body, formed for receiving and 
elaborating every thing destined for nutrition ; its conditions, both 
in health and disease, are entitled to the deepest and most attentive 
consideration. To facilitate the study of its affections, and for the 
sake of some practical arrangement, we shall divide its diseases 20 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
into five classes, beginning with the oesophagus, or that portion of 
the digestive tube which is above the diaphragm, and then pro- 
ceeding to the stomach, duodenum, ileum, colon, and rectum. But, 
in order to give you a clear idea of diseases of the intestinal canal, 
I shall commence with diseases of the stomach ; because, if you 
consider the whole range of animal life, you will find that its func- 
tions are the most important, the stomach constituting, as it were, 
the source and fountain of life, which is nutrition, and giving by 
its existence a character to all the upper classes of animals. No 
organ possesses such remarkable sympathies as the stomach, whe- 
ther we look upon them as sympathies of organic or of animal life, 
none possesses such remarkable power and influence in modifying 
the condition of every part of the system. But, putting aside phy- 
siological reasons, let us come to practical matters. The success of 
almost every form of medical treatment, all the advantages to be 
derived from the administration of internal medicine, depend upon 
the stomach ; in fact, in whatever point of view we consider it, we 
must look upon a knowledge of the state of the stomach as the 
great key to sound and successful practice. 
It is a most useful reflection to consider the extraordinary fre- 
quency of disease in some portion of the digestive tube. It is now 
admitted by every person possessed of experience in the causes of 
mortality, that more human beings die with acute or chronic dis- 
eases of the digestive tube than with diseases of any other part of 
the system. This has been established by numerous investigations, 
and is admitted by the best pathologists ; and, indeed, I think it 
can be easily accounted for, when we call to mind how many per- 
sons die of some form of fever or other, when we look to the rava- 
ges of remittent and yellow fever, to the hundreds of thousands who 
annually perish by the various classes of fevers. Now, in almost 
every one of these cases, disease of the digestive system forms one 
of the most prominent pathological characters. Recollect, besides, 
all that die of dysentery, whether sporadic or simple, and here is 
inflammation of the colon; see, too, how many die with diarrhoea— 
here, too, there is intestinal disease; remember how many die of the 
malignant intermittent of the West Indies, in which unequivocal 
proofs of disease of the stomach and intestines have been found. 
Observe what a close connection there is between tubes mesente- 
rica, and inflammation of the mucous membrane and surface of the 
intestines ; think what a vast number of persons fall victims to the 
harassing effects of constipation and dyspepsia ; and recollect that 
there is a host of diseases in which the train of morbid phenomena 
commences in the digestive system, and then exhibits itself by 
functional alteration or organic disease of other parts. 
We recognise the presence of disease in the digestive tube, first, 
by the local phenomena and the lesion of the digestive function, 
and next, by the sympathetic relations of other parts, by the sym- 
pathies of the respiratory system, of the circulation of the skin, and 
of the nervous system. I shall enumerate the local phenomena 
and functional lesions: vomiting, anorexia, thirst, jaundice, pain, REMARKS ON LOCAL DISEASES. 
21 
tenderness on pressure, tympanitis, changes in the character and 
quality of the discharges, constipation. Here are a set of functional 
lesions and local phenomena; let us now consider the sympathetic 
relations ; these are fever, heat of skin, suppression of the cutane- 
ous secretion, suppression of the secretion of urine, morbid states 
of the tongue and pulse, pains in the chest and cough, hurried 
breathing, and palpitations of the heart. In the next place, we may 
have prostration of strength, delirium, coma, convulsions, tetanic 
spasms, and other symptoms of functional disease of the brain j 
these are all sympathies of relation. Now, in the first place, I 
have to remark, that there is a great deal of variety in the combi- 
nation of these symptoms. On what does this depend? on a variety 
of circumstances; sometimes on the intensity or extent of the in- 
flammation : sometimes on the situation of the disease ; sometimes 
on the complication of the affection; sometimes on the various 
modes and degrees of susceptibility of the individual. All these 
causes tend to produce a great variety in the disease, and an exten- 
sive modification of the sympathetic relations. For instance, in 
some cases inflammation of the stomach and intestines is so slight 
that the patient is not prevented from going about and pursuing 
his ordinary avocations; in others, on the contrary, the patients 
are struck down at once by the violence of the disease, and are 
carried off by the fever which accompanies it before the inflamma- 
tion is completely developed. It varies also according to situation; 
there is a difference between gastritis and dysentery: in the former 
we have an inactive state of the great intestine, and consequent 
constipation ; in the latter, the colon is thrown into violent action, 
and there are frequent dejections. Disease of the duodenum is 
attended with a very remarkable peculiarity, being very frequently 
complicated with jaundice ; here is a modification produced by 
situation. Again, inflammation of the ileum is attended with a 
very curious peculiarity, namely, the absence of pain. The patient 
states, that he feels unwell, he has obscure symptoms of intestinal 
disease, but it is neither dysentery nor gastritis; you investigate 
it with care and find that the ileum is in a state of inflammation. 
Yet the patient does not complain of any pain, and this is another 
peculiarity depending on situation. 
But in considering the differences which depend upon intensity, 
extent, and situation of disease of the intestinal canal, we must not 
omit those which depend upon tissue. If disease be confined to 
the mucous membrane of the intestines alone, we may have an 
extremely diffused and extensive inflammation, sufficient to destroy 
life, without any pain being complained of by the patient; it is a 
painless though fatal disease. Recollect this, extensive and fatal 
inflammation without pain. In former times the ideas of pain and 
inflammation were inseparable. Thanks to the light which patho- 
logy has shed upon modern medical science we are now acquainted 
with this seeming anomaly, and can conceive the existence of ex- 
tensive disease of mucous surfaces unaccompanied by pain. But 
let the inflammation seize on the muscular tissue, the character of 22 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the disease is instantly changed, and the pain is dreadful. Here 
is a case in which difference of tissue is to be taken into consider- 
ation. 
The phenomena and sympathetic relations of intestinal disease 
may vary also according to its complication, and here we come to 
investigate one of the most beautiful laws of the human economy, 
namely, that the more complicated a disease is the more latent will 
will be any local lesion. This is a point that should never be 
forgotten. For instance, enteritis by itself is much more easily 
recognised than when complicated with pneumonia, or with irrita- 
tion of the brain, and gastritis is but too often completely masked 
by being combined with irritation of the bronchial mucous mem- 
brane. Lastly, we have the varieties which depend on different 
degrees of susceptibility. In one person we may have only slight 
cerebral irritation, in another high excitement, in a third delirium 
and extraordinary convulsions. The variety, then, in the modifi- 
cations of disease, and the combination of sympathies, is very great, 
and is referable to the extent and the intensity of the inflammation, 
difference of situation, complication of disease, difference of tissue, 
and different degrees of susceptibility. I shall give examples of 
these at my next lecture, and then proceed to the pathology and 
treatment of gastritis. 
LECTURE III. 
Pathology and treatment of diseases of the digestive system—Different forms of gastri- 
tis—Pathology of this disease imperfectly understood by the ancients—Gastritis and 
enteritis not always found in connection—Phenomena characterising acute gastritis 
—Symptoms and sympathetic relations—Diagnosis—Gastritis simulating other dis- 
eases. 
The consideration of the pathology and treatment of diseases of 
the digestive system shall occupy our attention to-day. I shall 
commence with the study of gastritis, and to this subject I would 
entreat your undivided attention ; not that I have any thing very 
new to communicate, but because I believe that many of the state- 
ments, which are connected with this disease, will be found to rest 
on the basis of fact and truth, many of them will be found useful 
in your future practice, and this subject, I fear, is not sufficiently 
considered in the schools of medicine of this and the sister countries. 
The older authors describe gastritis as occurring under two dif- 
ferent forms, one of which they termed phlegmonous, and the other 
erysipelatous. The advanced students know the meaning of these 
terms, and that they are admitted as significant of different modifi- 
cations of the inflammatory process, but to those who are not ad- 
vanced I shall state that it is very difficult to give an accurate idea 
of these terms, so far as they are applicable to cases of internal DISEASES OF THE DIGESTIVE SYSTEM. 
23 
disease. Blit we may attempt a general definition by saying, that 
phlegmonous inflammation occurs in a good constitution, and under 
favourable circumstances, that it is an inflammation of a bold and 
distinct character, requiring and admitting of depletion, and, like 
that on the external parts, terminating in healthy suppuration, or 
adhesion. Erysipelatous inflammation is (described to be) a disease 
of a different kind, occurring in bad and debilitated constitutions, 
and under such circumstances that the same treatment, employed 
in the phlegmonous form, is more or less inadmissible ; and when 
stimulants are necessary, if not in the commencement, at least at a 
very early period of the disease. It is quite impossible to found 
any system of pathology on this division into phlegmonous and 
erysipelatous ; we are, however, sometimes obliged to make use of 
it for want of a better. The terms themselves are highly calcu- 
lated to mislead. Healthy inflammation, which is all but a con- 
tradiction in terms, may occur in a debilitated constitution, and 
erysipelatous in a strong one. The latter of these, too, is particu- 
larly erroneous, as we now know that erysipelas may occur under 
opposite circumstances. In the one case, requiring the lancet and 
leeches, and purgation ; in the other, demanding a stimulant and 
tonic treatment. In speaking of gastritis I do not intend to adopt 
this division, because it would be likely to embarrass you, and, in 
truth, it is unnecessary, as there is no difference in the (principles 
of) treatment, whatever may be the form of this inflammation. 
The proper way to consider gastritis is to look upon it as a disease, 
presenting, on the one hand, symptoms of extreme violence and 
urgent danger ; on the other, feebly shadowed out by the phe- 
nomena of ordinary and slight indigestion. Between these there 
are many shades and numberless gradations. The phlegmonous 
gastritis of the old authors implied a violent and extensive inflam- 
mation, in which all the coats of the stomach were implicated ; but, 
in treating of the subject of gastritis in these lectures, I shall only 
allude to inflammation of the mucous membrane and glandular 
apparatus of the stomach. The other tissues are sometimes en- 
gaged, but the mucous membrane, constituting the most important 
of these tissues, and forming an exquisitely delicate vasculo-nervous 
expansion, is, in the great majority of cases, the principal seat of 
inflammation, and to this I would direct your particular attention. 
The true pathology of gastritis was but very imperfectly under- 
stood by the ancients. They knew enteritis and gastritis as intense 
inflammations of the coats of the stomach and intestinal canal, ac- 
companied by violent pain and fever, but they had no conception 
of their various shades and modifications. For a knowledge of the 
true nature of gastritis, and of its numerous varieties, we are in- 
debted to modern pathology, and it is the boast of pathological 
anatomy to say, that in this instance its labours have shed a broad 
and vivid light on a class of diseases previously involved in deep 
obscurity. 
It has been stated, that it is impossible to separate the symptoms 
of gastritis from those which characterise enteritis, and the reason 24 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
given for this is, that the two affections frequently co-exist. This 
is a proposition of vast importance. It is said, that in cases where 
you have gastritis, the chances are that there is more or less of 
enteritis ; but according to this doctrine, if a man has gastritis the 
probability is that he has inflammation of some other portion of the 
intestinal canal. Broussais, in the 138th proposition, makes the 
following observations:—“Inflammation of the stomach, or, as it is 
called, gastritis, is never found except in conjunction with disease 
of the small intestine. It is better, therefore, to give it the name of 
gastro-enteritis ; and even in those cases, in which we have enteri- 
tis, we have gastritis as the irritative.” Now if this proposition is 
true, it is one of very great importance, and entitled to a large 
share of our attention, in studying the phenomena and treatment 
of inflammation affecting the digestive tube. Pathology, how- 
ever, has proved that these inflammations are not always found in 
connection. Andral gives many cases, in which disease existed 
separately in one or other portion of the intestinal canal; when it 
was found in the stomach and not in the duodenum or ileum, and 
when it was found in the ileum, but not in the duodenum or sto- 
mach. I myself have seen many examples of gastritis without 
disease of any other part of the digestive tube, and disease of va- 
rious parts of the digestive tube without the co-existence of gastric 
inflammation. But I believe the proposition is generally true, 
particularly in cases of fever, in which you have secondary in- 
flammation of the digestive tube during the course of the disease. 
When inflammation attacks the intestinal mucous surface during 
the progress of a fever, you will, in most cases, have these two 
diseases combined ; the patient generally presenting symptoms of 
gastritis, and, at the same time, symptoms of enteritis affecting the 
lower third of the ileum. 
Let us now proceed to investigate the phenomena which cha- 
racterise acute gastritis. Here I must remark, that, as an idiopathic 
disease, acute gastritis is extremely rare. This is a very curious 
circumstance. When we compare the stomach with other viscera, 
we shall find that one of the most remarkable differences between 
it and other organs is, that it is much less liable to be attacked by 
violent inflammation, as an idiopathic affection. This is an inte- 
resting fact. So rare, indeed, is the violent form of gastritis, that 
our knowledge of the symptoms which indicate intense gastric 
inflammation is principally drawn from the study of cases of acute 
gastritis caused by swallowing corrosive poisons. We very seldom 
meet with an inflammation of the stomach, presenting those decided 
characters so frequently witnessed in similar affections of other 
organs. We may attempt to explain this fact, by considering what 
the functions of the stomach are, and by recollecting that it is the 
organ of the body, whose functions require that it should be most 
frequently in a state of great vascular excitement. Every one is 
aware that the vascularity of the stomach is amazingly increased 
during the act of digestion ; but it is to be remembered that this is 
a physiological and not a pathological condition. If the stomach 25 
DISEASES OF THE DIGESTIVE SYSTEM. 
were as liable to inflammation as other organs, it could no longer 
carry on its functions with safety ; every meal would prove a 
stimulus sufficient to excite inflammation—every digestion would 
be followed by gastritis. Nature has provided against such acci- 
dents. 
Let us take a brief review of the symptoms of acute gastritis :— 
intolerable thirst, desire for cold and acidulated drinks, constant 
nausea and vomiting, pain and burning sensation of heat about the 
stomach, and fever—these are the symptoms of a violent gastritis. 
It has been stated, that in gastritis the fever is at first inflammatory 
and afterwards typhoid. If authors mean by this, that the patient 
rapidly falls into a low typhoid state, the observation is true. 
There is no form of inflammation, except that which! accompanies 
severe peritonitis, in which the typhoid state comes on so rapidly. 
Inflammations of the digestive tube differ, in general, from similar 
affections of other organs, chiefly in this—prostration rapidly su- 
persedes excitement. A patient labouring under inflammation of 
the brain will exhibit, for a long time, decided symptoms of high 
excitement, and of what has been termed the diathesis; 
acute pneumonia and inflammatory affections of other parts will 
go on for days, without prostration, and require the use of the 
lancet; but gastritis is a disease in which the inflammatory symp- 
toms, as they are called, last but for a very short time. In violent 
cases the irritation of the stomach is excessive, and every thing is 
rejected. I have seen cold water thrown up almost immediately ; 
I have seen effervescing draughts rejected the moment they were 
swallowed, and make the patient evidently worse. The epigastric 
region and the left hypochondrium are exquisitely tender on pres- 
sure, and the tenderness differs from that of peritonitis in this, that 
it is almost always localised. The patient screams with agony 
when you touch the epigastrium, but will bear pressure freely on 
the lower part of the abdomen. 
Now, with respect to the sympathetic relations of gastritis, I have 
to remark, that they are very numerous. First, as to respiration— 
it is extremely quick and hurried; the heart, also, is violently ex- 
cited ; and hence gastritis has sometimes been mistaken for pneu- 
monia and pericarditis. Sometimes we have bronchitic cough; 
the patient is restless, gets no sleep, and is extremely uneasy ; his 
skin is hot, his bowels confined, his pulse rapid and small. In the 
second stage, he is beginning to sink, his features become con- 
tracted, his skin cold and pale, his extremities sunk below the na- 
tural temperature; he now bears pressure; the vomiting is changed 
for regurgitation of every thing he swallows ; low delirium super- 
venes, and he dies. 
It is of the greatest importance to attend to the sympathetic rela- 
tions of gastritis, for this reason, that in many cases the local 
symptoms are all but wanting, and the disease is only to be known 
by its sympathetic relations. Before I enter on this subject I shall 
make one or two remarks on some symptoms which have not been 
attended to by many practitioners. One of these is an incapability 26 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
of swallowing, sometimes so great that all ingesta, whether fluid 
or solid, are rejected. This will sometimes arise from spasmodic 
stricture of the oesophagus or cardiac orifice of the stomach ; and, 
as there has been no other cause revealed, by dissection, in several 
cases in which this symptom was present, we must admit this as 
one of the causes of the dysphagia, which, on some occasions, 
attends gastritis. This symptom is most commonly accompanied 
by tightness and oppression about the praecordia. The patient, 
feeling a load or weight, as he expresses it, in this situation, thinks 
it would be relieved by vomiting, and begs his medical attendant 
to give him an emetic, which is sometimes administered, and pro- 
duces very bad effects. There is only one case in which an emetic 
can be given in gastritis, and that is, where indigestible or irri- 
tating substances in the stomach give rise to irritation, and when 
we cannot expect a favourable termination until we effect their 
removal. 
There is another most disagreeable and distressing symptom, 
generally occif|ring in cases in which there is inflammation about 
the cardiac ojfcce of the stomach—I mean hiccup. Hiccup is a 
most harassin™symptom; it does not allow the patient a moment’s 
rest; in his brief and uneasy slumbers he is conscious of it, and is 
constantly awakened by it. Now, this is also one of the results of 
gastritis, with inflammation about the cardiac orifice. I say this, 
because I have seen it in many cases, in which there was distinct 
evidence of inflammation about the cardiac orifice of the stomach; 
and, in three instances, I have verified it by dissection. I do not 
mean to say that every case of hiccup is indicative of disease of the 
cardiac orifice, but I believe it is a very frequent accompaniment. 
The case of a celebrated professor of languages was a remarkable 
example. A short time previous to his death, he came from Liver- 
pool in one of the steam packets. He was always subject to sea 
sickness ; but on this occasion he was extremely ill, and vomited 
during the entire passage or sea voyage. He complained of his 
stomach for some time, and then got hiccup, which resisted every 
kind of treatment, and continued without any abatement up to the 
time of his death. On opening the stomach, this organ was found 
in a state of intense inflammation, particularly about the cardiac 
orifice. You can see the stomach (of which a very good prepara- 
tion has been made by Dr. Houston) in the museum of the College 
of Surgeons. There was another very remarkable case in the 
Meath Hospital. A patient was admitted who had laboured under 
acute pneumonia, for which he was treated with tartar emetic, and 
the symptoms rapidly declined, but vomiting and hiccup came on, 
and the latter symptom continued until death. We opened the 
body eighteen hours after his demise, and found the lung quite 
healthy; but the stomach, and the cardiac orifice in particular, 
were, as in the case I have just mentioned, in a state of intense 
inflammation. When hiccup is the result of inflammation of the 
cardiac orifice, you will also frequently observe that the patient 
complains of pain in the lower part of the chest, along the course DISEASES OF THE DIGESTIVE SYSTEM. 
27 
of the diaphragm. These are some of the relations of gastritis, 
their connection with which is proved by their being relieved by 
draughts of cold water, leeching, and every other means calculated 
to remove inflammation of the stomach. 
We come now to consider the state of the tongue. A vast deal 
of error and misconception prevails among British practitioners on 
this subject. Nothing is more common, than from the condition of 
the tongue to form an opinion as to the state of the alimentary 
canal. For instance, whether it is in a state of inflammation, 
whether there are sordes present or not, and whether it requires 
this or that medicine. All this is behind the actual state of 
medicine, and it is melancholy to think, what a vast quantity 
of mischief is done by those practitioners who take the tongue 
as the index of an inflammatory or non-inflammatory condition 
of the intestinal canal. The schools of Abernerthy and Brous- 
sais are wrong in stating that the tongue will point out the 
state of the digestive tube. The connection between the state 
of the tongue and that of the stomach, has been lately made the 
subject of extensive clinical investigation by M. .Andral; listen 
to his sentiments on this point. From the experience of a vast 
number of cases, he declares “ that there is no constant relation 
bet wen the state of the tongue and that of the stomach.” In 
the next place he states, “that there is no modification of the 
one corresponding with any special modification of the other.” 
“ Thirdly, the stomach may be found in a certain state after death, 
with various conditions of the tongue during life.” “Fourthly, 
we may have a diseased stomach with a healthful condition 
of the tongue, and diseased appearance of the tongue with a 
healthful state of the stomach.” These are facts of the greatest 
importance. Let us now refer to Louis. In giving an account of 
the gastritis which accompanies fever, he states that in many of 
the worst cases the appearance of the tongue was natural, in fact, 
that there was not the slightest relation between the tongue and 
the stomach. It is fair, however, to observe here, that both these 
pathologists drew their information only from cases of gastritis, 
occurring in fever. But it has also been frequently observed, that 
even in idiopathic cases there is a want of correspondence between 
the condition of the tongue and stomach, and we have seen several 
instances of this in the Meath Hospital. I believe we should be 
wiong in taking the tongue alone as our guide in the treatment of 
intestinal derangement, whether existing in the stomach or any 
other portion of the tube, and this I state as the conclusion which 
I have drawn from my own experience, in gastric and enteric 
inflammation. Yet how many will you see taking the tongue as 
the unerring index of various conditions of the digestive tube? 
hundreds and thousands. It is unquestionably true, that in certain 
cases of gastritis, particular morbid appearances, as redness, dry- 
ness, pointing, and a tremulous state of the tongue, are observed, 
but what 1 wish to impress on you is, that it is necessary that these 
'phenomena should coincide with other symptoms. 1 do not wish 28 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
you to believe, that the inspection of the tongue, or the knowledge 
derived from its appearance, is useless, particularly in cases of 
fever: the state of the tongue is never to be overlooked, but you 
should understand on what principle it is to be examined. You 
should examine the tongue not so much as a guide to the know- 
ledge of local disease, but as an index of the condition of the 
general system. For instance, if, during the course of a fever, the 
appearance of this organ changes and becomes more favourable, it 
is a sign that the whole disease has taken a favourable turn, and 
vice versa. This is the proper way to look at the tongue in fever, 
not as reflecting any particular state of the intestinal canal, but as 
being indicative of some modification of the whole economy. 
Let us now consider the sympathetic relations of the nervous 
and respiratory systems in gastritis. This is a very curious and 
interesting point in the study of gastric disease. I may mention 
here, that these relations are subject to considerable variety, and 
differ according to the peculiar predisposition of the individual. If 
a person of nervous habit gets gastritis, he will be very liable to 
have sympathetic affections of some part of the nervous system; 
but if he is a person with unsound lungs, the irritation will be 
transferred to the respiratory apparatus. Can we define these irri- 
tations ? I believe the best definition we can give of them is, that 
they are affections of some organ, which are the result of sympa- 
thy ; and that they are at first functional, but afterwards become 
organic. A person of nervous habit, labouring under gastritis, will 
frequently have his head sympathetically affected; he will com- 
plain of headache, more or less intense ; toss about and get no 
sleep ; still he has no actual disease of the brain. But let the cere- 
bral irritation go on, let the pain and uneasiness and watchfulness 
continue, and he will finally get arachnitis. So, too, with respect 
to the lung; the patient has hurried breathing and cough, without 
any of the stethoscopic signs of pulmonary disease; but if these 
symptoms continue for any length of time, or if the irritation be 
severe, he will get pneumonia or bronchitis. Observe the import- 
ance of this law with reference to treatment, because it shows you 
that you cannot always expect to remove sympathetic affections 
by attacking the original source of disease; for if functional de- 
rangement, produced by sympathetic irritation, has gone so far as 
to become organic, you must direct your attention to parts which 
have been secondarily engaged, as well as to those which are pri- 
marily affected. Every one is aware of the effects of particular 
states of the stomach on the brain, and of the influence which the 
brain exercises over the stomach. Most individuals know, that by 
grief or strong mental emotion the appetite is completely removed ; 
and that after a surfeit, or from taking bad and indigestible food, a 
person will get sick headache. If this happens every day under 
ordinary circumstances, and where the original affection is so 
slight that it does not interfere with the usual avocations of the 
patient, you can readily conceive how intense the sympathetic 
irritations may be in a case of violent gastritis. The headache is DISEASES OP THE DIGESTIVE SYSTEM. 
29 
frequently intense, the patient is extremely restless, there is consi- 
derable intolerance of light, delirium, tetanic spasms, and other 
symptoms characteristic of inflammation of the brain. There are 
numerous cases on record in which these symptoms were particu- 
larly noticed, and it was supposed that the brain was in a state of 
inflammation, but on dissection there was no disease found, except 
in the mucous membrane of the stomach. There are many cases, 
too, in which medical men, not aware of the extent of these rela- 
tions, looked upon the disease as a pure cerebral affection, and di- 
rected their whole attention to the brain. They certainly succeeded 
in modifying the apparent disease, but as they took no steps to 
remove its cause, the patients generally sunk from an unsuspected 
gastritis. There is one important law with respect to inflammation 
of the stomach, which perhaps may be fairly applied to all inflam- 
matory affections of the digestive tube. When inflammation of the 
stomach or any other portion of the intestinal canal has continued 
for some time, and when the disease has attained a certain degree 
of violence, the local symptoms may subside, and the gastritis or 
enteritis will be represented by disease of some other organ, by 
symptoms of an affection of the brain or its investments, or by 
symptoms of disease of the lining membrane or parenchymatous 
tissue of the lung. I shall endeavour to explain this. Here is a 
case taken from the Clinique Medicate of Andrei. 
“ A middle-aged man, four days before his entrance into the hos- 
pital, was seized with bilious vomiting, epigastric pain, and fever. 
(Here is a certain case of gastritis.) In about twenty-four hours 
after the invasion of these symptoms, he first perceived a difficulty 
in depressing the lower jaw, and a violent trismus was established, 
which continued for the two following days ; at the end of this time 
he entered the hospital in the following state :—trismus, the head 
drawn backwards and forcibly retained in this position by the 
muscles which are inserted into the occipital region ; rigidity of all 
the extremities ; abdomen hard as a board ; intellect perfect. Not- 
withstanding the trismus, the patient could articulate with sufficient 
distinctness to give the above account of his case. From the time 
when the first tetanic symptoms appeared the vomiting and epi- 
gastric pain ceased. He died on the evening of his admission. 
On dissection no appreciable alteration of structure was found in 
the brain or spinal marrow ; the meninges of the brain were very 
slightly vascular, but those of the spinal marrow pale. The whole 
surface of the stomach presented an intense red colour, which was 
at first concealed by a thick layer of mucosities. The remainder 
of the digestive tube was perfectly healthy, and the thoracic organs 
were natural.” This may be called a case of tetanus ; and it is a 
curious fact, that when the tetanic spasms came on, the vomiting 
and other symptoms of gastritis subsided. Now this is what I 
wish to direct your attention to. A man dies with symptoms of an 
affection of the brain, the head is opened after death, there is no 
trace of cerebral disease found, but the whole surface of the sto- 
mach is discovered to be in a state of intense inflammation. That 30 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the stomach was inflamed is proved by the vomiting and epigastric 
pain which existed during life, as well as by the vascularity which 
was revealed by dissection ; and there can be no doubt that this 
condition was the result of an intense inflammation, as there was 
no other cause to produce it. 
Last year, a patient was admitted into the Meath Hospital, 
labouring under violent maniacal excitement, his eyes blood-shot, 
and his aspect ferocious. He had thirst, a dry fissured tongue, a 
quick weak pulse, and constipated bowels. There was no epigas- 
tric tenderness, no vomiting, in fact, none of the prominent symp- 
toms of gastritis complained of. On the third day the belly was 
slightly tender and tympanitic. The cerebral symptoms increased 
so as to require the use of the strait waistcoat, and continued with 
violence until a short time before death, which occurred on the 
eighth day. On dissection there was no appearance of inflamma- 
tion found in the brain or its membranes, but there was a vast 
extent of disease in the digestive tube. The splenic extremity of 
the stomach presented several patches of vascularity, and its mu- 
cous coat was softened ; the lower half of the ileum, the caecum, 
and part of the ascending colon, were in a state of intense inflam- 
mation, and dotted all over with numberless ulcerations. 
You observe of what importance the knowledge of these facts 
will be to you in practice, and how much it should become the 
object of your study, since you will thereby be able to make the 
diagnosis of gastritis from the sympathetic relations, though the 
usual symptoms are more or less absent. Even in cases of this 
kind, in which the symptoms have subsided on the appearance of 
these sympathetic irritations, the judicious practitioner will not be 
diverted from directing his attention to the source of the original 
mischief; nor will he, because the local symptoms have disap- 
peared, conclude that the disease has therefore been removed from 
the stomach. Many examples of this apparent transition of dis- 
ease are to be seen in cases of children, in which an inflammation 
of the upper part of the digestive tube frequently similates hydro- 
cephalus, and where the headache, delirium, and intolerance of 
light, are completely removed by the application of leeches to the 
epigastrium. I have seen this occur many times, and would 
entreat your particular attention to it. I believe many children 
are lost from the want of correct notions on this subject on the part 
of their medical attendants. The phenomena present in such 
cases are certainly those which characterise hydrocephalus ; but 
you should always investigate them with care, and ascertain 
whether the disease has commenced with symptoms of inflamma- 
tion of the mucous membrane, of the stomach, or bowels ; and if 
you find that it has originated in this way, and that the cerebral 
symptoms have not gone too far, direct your treatment in the first 
place to the digestive tube. It is extraordinary how rapidly all the 
symptoms of apparent cerebral disease subside under this plan of 
treatment. I must mention here to you a very remarkable case of 
enteritis, which simulated local disease of the substance of the 31 
PATHOLOGY AND TREATMENT OF GASTRITIS. 
brain. A girl who had received an injury was admitted into the 
Meath Hospital ; she was treated with purgative medicines, and 
was “ discharged cured /” In a few days afterwards she was re- 
admitted with pain in the head, and violent spasmodic contractions 
of the fore-arm, by which the fingers were bent so forcibly that 
the nails were driven into the hand. There was no thirst, vomit- 
ing, or abdominal tenderness. She died a few days after her 
admission; and on dissection the brain was found perfectly healthy, 
the viscera of the thorax were in the normal state, the stomach 
presented nothing remarkable, but the ileum was almost one sheet 
of deep and recent ulcers. The result of this case is important, 
also, in another point of view. You know that spasmodic contrac- 
tions of the upper extremtiy are believed by certain pathologists to 
point out an inflammatory softening of the optic thalamus, and its 
prolongations. Here we had the symptom, at all events, without 
the corresponding lesion. 
I shall reserve the subject of sympathetic irritations of the respi- 
ratory system until Wednesday, when I expect to be able to finish 
the pathology and treatment of gastritis. 
LECTURE IV. 
Gastritis—No one symptom decidedly indicative of the particular condition of any 
organ—Sympathetic irritation liable to terminate in organic disease—Sympathetic 
relations as connected with the viscera of the thorax—Treatment of simple acute 
gastritis—Antiphlogistic remedies—Purgative medicines injurious—Enemas and 
injections—Use of ice beneficial—Effervescing medicines hurtful. 
You recollect that at our last meeting I endeavoured to lay- 
before you some of the general facts connected with the pathology 
of gastritis, and showed you that the statement made by Broussais, 
that inflammation of the mucous membrane of the stomach is 
always accompanied by a similar affection of some part of the 
intestines, has not been confirmed by the investigations of more 
recent observers; but, on the contrary, that their experience goes 
to disprove, in various instances, the validity of this assertion. 
But, when I say that this statement has been disproved, it is only 
as taken in the general and extended sense. The fact of their fre- 
quent coexistence has been proved; the statement that they are 
always associated has been found incorrect. Another thing con- 
nected with this, which has been also established by repeated 
observation, is, that the cases in which they are commonly com- 
bined. are those in which a secondary affection of the mucous sur- 
face of the digestive tube comes on during the course of a fever; 
so that, if in fever a gastritis supervenes, you will commonly have 
enteritis ; or if the fever be complicated with enteric inflammation, 
the mucous surface of the stomach will partake in the diseased 
action. 32 
STOKES’s THEORY AND PRACTICE OF MEDICINE. 
I have described some of the more prominent symptoms of gas- 
tritis, and directed your attention not only to the ordinary symp- 
toms, as mentioned in books, but also to others which have either 
been passed over, or slightly noticed, by authors ; as, for instance, 
dysphagia, oppression and sense of constriction about the prae- 
cordia, globus, pains relieved by cold and acid drinks, &c., and 
that obstinate hiccup, which, in cases where there is reason to 
suspect gastritis, marks inflammation of the cardiac orifice of the 
stomach. I stated that hiccup alone does not pixwe the existence 
of inflammation of the cardiac orifice of the stomach, unless where 
symptoms, indicative of gastric inflammation, prevail at the same 
time. I laid before you the actual state of the case with respect to 
the value and certainty of diagnosis, as derived from an inspection 
of the tongue; and showed you that no reliance can be placed on 
it, since it has been proved that we have the most opposite condi- 
tions of the digestive tubes, accompanied by a similar condition of 
the tongue; and that there is no peculiar modification of the one, 
corresponding exactly and constantly with any peculiar modifica- 
tion of the other. The conclusion to be deduced from these facts 
is, that in the treatment of inflammatory affections of the digestive 
tube, we are not authorised, and would frequently err, in taking 
the tongue alone as our guide in practice; and you may lay down 
this as a rule, and an important one:—if we look through the 
whole range of the history of medicine, we shall scarcely be able 
to point out any symptom which, taken singly, is decidedly indica- 
tive of any one particular condition of an organ. You will find 
that this proposition is not only extensive in its scope and relations, 
but also of extreme value in its application. You will commonly 
hear persons saying, this is such a disease, for this symptom is pre- 
sent, and that is such a disease, for such a symptom is extremely 
well marked. But there is no single symptom which points out, 
with certainty, any peculiar condition ; and to arrive at a just and 
well-grounded diagnosis, you must always take the whole group 
of existing phenomena, connect the lights which they collectively 
throw upon the case, and then make a cautious decision. It may 
be objected to this that there are particular signs; as, for instance, 
the stethoscopic, which point out distinctly particular states of 
organs. It is said that gargouillement is decidedly indicative of 
a phthisical cavity, that osgopho?iy points out a particular stage of 
pleuritic effusion, and that metallic tinkling is an unequivocal 
proof of pneumothorax. This, however, is not the fact; even in 
these cases you are not authorised to depend on any sign or symp- 
tom taken alone. If you ground your decision on any individual 
sign, you will very often fail in arriving at the truth. 
I showed you that the sympathetic irritation of gastritis varied 
according to the peculiar character of the disease, and the habit 
and degree of susceptibility of the patient; that, generally speak- 
ing, the more intense the disease is, the more numerous are its 
irritations ; but that, in all cases, they are considerably modified 
by predisposition (I use this term for want of a better), the sympa- PATHOLOGY AND TREATMENT OF GASTRITIS. 
33 
thetic irritation being1 reflected on the lungs in cases where these 
organs are naturally unsound, and on the brain, where the patients 
have a tendency to disease of that organ. I endeavoured, also, to 
impress on you the fact, that these irritations are at first functional; 
but when long continued, or marked by extreme severity, they are 
very apt to terminate in organic disease. I illustrated this point 
by several examples ; I shall give a few more of this kind before I 
enter on the treatment of gastritis. 
If a patient labouring under acute gastritis has a bad cough, if 
respiration be very much hurried, and the distress of the chest 
great, and that these symptoms are overlooked or neglected, you 
will find that the cough, which was at first only a result of func- 
tional disease, will at last point out an organic affection of the lung. 
Again ; let a patient, labouring under gastritis, have severe head- 
ache, restlessness, and irritation ; suffer these symptoms to go on 
and increase in violence, and the great probability is, that they will 
terminate in arachnitis. The obvious deduction from these facts 
is, that when a sympathetic irritation has existed for some time in 
a state of considerable intensity, it is very probable that there is 
more or less of organic derangement produced, and we are not to 
expect to be able to remove it by merely attacking the original seat 
of the disease. 
The last great rule which I endeavoured to impress upon you 
was, that where these sympathetic irritations, these affections of 
the nervous, respiratory, and circulating systems, were extremely 
well marked, the ordinary local symptoms were more or less want- 
ing, but that this does not by any means imply the subsidence of 
the original disease. This is a most important law in pathology. 
In my last lecture, I entered into a detail of the sympathetic 
irritations connected with the brain and other parts of the nervous 
system; to-day we shall consider the sympathetic relations, as con- 
nected with the viscera of the thorax. If you look to the cases of 
acute gastritis, mentioned in works on toxicology, you will find 
that in cases of gastritis, produced by swallowing corrosive poisons, 
the patient has often frequent hard cough, the breathing is at first 
hurried, then becomes protracted and laborious, and that death is 
generally ushered in by tracheal rattle. The same symptoms are 
observed in cases of acute idiopathic gastritis ; hurried breathing, 
extraordinary hard and almost laryngeal cough, sometimes occur- 
ing in paroxysms, sometimes constant. For the first few days it is, 
generally speaking, dry; as it progresses, there is more or less ex- 
pectoration. At first, it is the result of sympathy; there is as yet 
no organic affection of the respiratory system, and the disease is 
purely functional; still it is of importance, and entitled to your 
particular attention, because, in consequence of the apparent 
identity of the symptoms, it is often mistaken for disease of the 
substance of the lung, or its mucous lining. The existence of a 
gastritis is frequently overlooked ; the ordinary symptoms of pain 
in the region of the stomach, tenderness on pressure, and thirst, 
are overlooked, and the sympathetic relations alone are attended 34 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
to. Observe what mischief may result from this error. The 
treatment of acute affections of the lining membrane, or paren- 
chymatous tissue of the lung, is very different from the treatment of 
a gastritis. In the one case bleeding is necessary; in the other, its 
efficacy may be doubtful, or the practice even dangerous. In one, 
tartar emetic is one of the best and most expeditious means of 
effecting a cure ; in the other, the use of antimonials has the worst 
effect. It will strike you that in such cases percussion and the 
stethoscope are of inestimable value. You are called to attend a 
patient in fever, you find he has cough, hurried breathing, and 
perhaps pain in the chest; from a consideration of the history of 
the case, and the primary symptoms, you have reason to think the 
case is one of gastritis, and you wish to know whether the symp- 
toms be purely sympathetic, or caused by organic disease of the 
lung. In such a case, a person without the knowledge of the 
stethoscope is completely helpless, and unable to decide the point. 
This, I assure you, is a very common case, and should be a strong 
inducement to the study of the stethoscope. What advantage does 
a knowledge of the stethoscope give ? It leads to the formation of 
an accurate diagnosis ; it points out either that there is no disease 
in the lung, or if there be, that it is not sufficient to account for the 
symptom, and therefore that, you should look for its cause in some 
other situation. You find a person with laboured and rapid 
breathing, perhaps fifty or sixty in a minute ; you are struck with 
the apparent lesion of the respiratory system, but on percussing the 
chest, and using the stethoscope, you find the respiration perfectly 
clear, or perhaps a slight bronchitis, insufficient to account for such 
violent symptoms. Where such phenomena are observed, you 
will often find that they are connected with a gastritis, particularly 
where there is fever, and the local signs of a gastric inflammation. 
I can tell you, from a most extensive experience, that in such cases 
you can inform the patient’s friends, that the most sudden and de- 
cided relief will be experienced from the use of iced water, and the 
application of leeches to the epigastrium. You can have hardly 
an idea of the rapidity with which all the symptoms of pulmonary 
irritation are removed by this practice. Cases of this extraordinary 
sympathetic irritation are very common in children, but you will 
also frequently meet with them in adults. 
I have been called to decide the question, whether a disease was 
pneumonia or gastritis, where there was a difference of opinion 
between two practitioners. Now, it is very easy to come to a 
proper decision in such cases. There is one point which you 
should always hold in view, and that is, the length of time the 
symptoms have lasted. If symptoms of pulmonary disease have 
been going on for four or five days, and, at the end of that time, 
you find that there is no perceptible organic disease of the lung, 
you may be certain that it is gastric irritation ; because if it were 
organic disease of the lung, it would have shown itself before that 
time, and could be detected by percussion or by the stethoscope. 
We have had many cases of these sympathetic irritations of the PATHOLOGY AND TREATMENT OF GASTRITIS. 
35 
lungs in the Meath Hospital, which recovered under the treatment 
for gastritis; and where the patients, by some excess or error in 
diet, brought on the pulmonary symptoms again, they were 
removed a second time by putting them on a low diet. Before I 
quit this subject, I wish to make one remark, by way of caution. 
When you have discovered the existence of those sympathetic 
irritations, you should not be thrown off your guard, and consider 
them only as functional affections. You should examine the next 
day and the day after, for you may find that in a very short space 
of time actual disease of the lung has taken place. You should 
be, therefore, watchful, and never omit making a daily examination; 
for if the sympathetic irritation be severe, it is very apt to run into 
actual organic disease. 
We now come to speak of the treatment of simple acute gastritis. 
Here there are three principal indications. One of these is to 
remove inflammation as speedily as possible. You cannot, as 
under other circumstances, leave this disease to nature; the organ 
affected is one of the utmost importance to life ; and if you do not 
cut it short at once, a typhoid state comes on, to which the ordinary 
and efficient means of antiphlogistic treatment are inapplicable. 
The first indication, then, is to cut short the inflammation as 
speedily as possible. The next thing is to prevent the introduction 
of any thing into the stomach which will excite the physiological 
action of that viscus. You are aware, that while the stomach is 
engaged in the process of digestion, its vascularity is very much 
increased, and that this, which in health is merely a physiological 
condition, is unaccompanied by any kind of danger. But in a state 
of disease it proves a source of violent excitement, and superadds 
very much to the existing inflammation. You must, therefore, be 
extremely cautious with respect to what enters your patient’s 
stomach, and carefully remove every thing capable of adding to 
the excitement which always attends gastritis. The third indica- 
tion in the treatment is to modify and remove the sympathetic or 
secondary irritations. 
Now I shall suppose that we have to treat a case of simple acute 
gastritis, not produced by the swallowing of corrosive poison, or 
indigestible food. Here we have a patient labouring under violent 
inflammation of one of the most important organs in the body; 
and the question is, are you to adopt the ordinary and usual mode 
of stopping inflammation by opening a vein in the arm 7 I must 
here state, that we are very much in want of a series of well- 
established facts to guide our practice on this point, and to inform 
us how far general bleeding is useful in acute inflammation of the 
stomach. At the present period, the question is by no means 
settled, and the practice is uncertain. I believe, however, that 
when we are called in at an early period of the disease, where the 
patient is young and robust, the stomach previously healthy, the 
fever high, and the pain great, we may have recourse to general 
bleeding with advantage; bearing this in mind, however, that you 
are not to expect to cut short the inflammation by the use of the 36 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
lancet. Inflammations of the mucous membrane of the stomach 
and bowels, and perhaps of the lungs, are not to be overcome at 
once by the lancet; the only cases in which you can expect to 
cut short an inflammatory attack, are those in which the paren- 
chymatous tissue of an organ, or its serous membrane, is affected. 
This is a general and important law. You will often be able to 
cut short a hepatitis or a pneumonia by a single bleeding, but you 
will not by the same means be able to repress a bronchitis or 
an inflammation of the mucous membrane of the intestines. If 
you bleed in gastritis, bleed at an early period ; not too largely, or 
with the expectation of cutting short the inflammation, but in order 
to prepare your patient for the grand agent in effecting a cure— 
local bleeding. This is the principle on which you are to employ 
the lancet. 
In the treatment of gastritis there is nothing more useful, 
nothing more decidedly efficacious, than the free and repeated 
application of leeches, whether the case be idiopathic, or produced 
by the swallowing of a corrosive poison. In this treatment of 
acute gastritis, you will frequently see, perhaps, the most striking 
instances of the rapid and decided utility of medical treatment; 
you will see the vomiting subside almost immediately, the epigastric 
pain and tenderness disappear, the cough and headache relieved, 
the fever subside, and the tongue change, after the application of 
leeches. To remove the symptoms, the best and most effectual 
means are leeches ; and these must be applied again and again, 
according to the duration and obstinacy of the symptoms. Here I 
wish to make one remark of importance. From an opinion, very 
prevalent in former times, that pain and inflammation were insepa- 
rable, the older practitioners thought that when the pain ceased 
the inflammation also ceased; and hence many of our predecessors, 
and I fear some of our cotemporaries, never think of reapplying 
leeches, no matter what the existing symptoms may be, if pain has 
been relieved by the first application. Nothing is more erroneous 
than this practice. It frequently happens that the pain and epigas- 
tric tenderness are removed by the first application of leeches, but 
the breathing is still quick, the fever high, and the thirst ardent. 
So long as these symptoms remain, the inflammation of the 
stomach is still going on. The mere subsidence of pain or tender- 
ness of the epigastrium should never prevent us from resorting to 
the application of leeches. In leeching the belly for inflammation 
of the stomach or bowels, it is a common practice to apply a 
poultice over the leech bites, with the view of getting away as 
much blood as possible. I am not inclined to approve of this 
practice. The weight of a poultice is frequently troublesome, and 
the heat produced by it disagreeable ; the patients desire cold, and 
for this purpose they will often throw off their bed-clothes, feeling 
a degree of relief from exposing the epigastrium to a stream of 
cool air. Some practitioners have applied pounded ice over the 
stomach with good effects, as we see it frequently applied to the 
head with the same results in cases of encephalitis. Again : the PATHOLOGY AND TREATMENT OF GASTRITIS. 
37 
application of poultices causes an oozing hemorrhage, the amount 
of which it is impossible to calculate, which is often hard to be 
arrested, and which, in debilitated persons and children, has the 
effect of lessening the powers of life without removing the original 
disease. It is much better to leech again and again than to do 
this. Where there is not much epigastric tenderness, you may 
apply a cupping-glass over the leech bites with advantage, as you 
can get away as much blood as you choose, and the tendency to 
after-hemorrhage from the leech bites is diminished by the applica- 
tion of the cupping-glass. In very young subjects, the tendency 
to obstinate hemorrhage from leech bites is so great, that many 
practitioners are afraid to use leeches, and I believe some children 
have been sacrificed to this fear. The best mode of managing 
this is, if the leech bites cannot be stopped by the ordinary means 
(and in very young children they seldom can), to stop them at once 
by the application of caustic. Do not lose time in trying to arrest 
the flow of blood with flour, or lint, or sitcking plaster ; wipe the 
blood off the bite with a piece of soft dry lint, plunge into it a piece 
of lunar caustic, scraped to a point, give it a turn or two, and the 
whole thing is settled; and you can generally go away with the 
agreeable consciousness of having prevented all further danger, 
and without being uneasy lest your patient should bleed to death 
in your absence. 
With respect to the management of the bowels in acute gastritis, 
a few observations will suffice. You will always have to obviate 
the effects of constipation ; both in the acute and chronic forms of 
the disease there is always more or less constipation ; in fact, the 
same condition of the bowels is generally observed in both. Now, 
if you attempt to relieve this constipation in acute gastritis, by 
administering purgatives, you will most certainly do a vast deal of 
mischief. Nothing can exceed the irritability of the stomach in 
such cases; the mildest purgatives are instantly rejected, even cold 
water, or effervescing draughts are often not retained, and a single 
pill or powder is frequently thrown up the moment it is swallowed. 
Under such circumstances, it is plain that the administration of 
purgative medicine is totally out of the question. Even though 
the stomach should retain the purgative, you purchase its opera- 
tion at too dear a price; for it invariably proves a source of violent 
exacerbation, kindling fresh inflammation in an organ already too 
much excited. In this state of things, the best thing you can 
employ to remove constipation is a purgative enema, repeating it 
according to the urgency or necessity of the case. Where there is 
no inflammation in the lower part of the intestinal canal, you may 
employ injections of a strong and stimulating nature, with the 
view not merely of opening the bowels, but also of exercising a 
powerful revulsive action. I shall mention here an interesting 
fact, proving that stimulant injections have a decided revulsive 
effect; and that their influence extends not only to other portions 
of the intestinal tube, but also to distant parts of the system. In 
South America, where, from the heat of the climate, and the preva- 38 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
lence of bilious affections, sick headache is a very common and 
distressing symptom, a common mode of cure is to throw up the 
rectum an extraordinary enema, composed of fresh capsicum, and 
other aromatic stimulants. The irritation which this produces 
acts as a very efficacious and speedy revulsive, causing the almost 
immediate removal of the cerebral symptoms. 
In those cases of gastritis, where not only purgatives, but even 
the mildest substances, are rejected, the plain common-sense rule 
is to give nothing. Where cold water is borne by the stomach, it 
may be taken in small quantities, as often as the patient requires 
it. Solid ice, too, may be given with decided benefit. There is a 
mistake which prevails with respect to the employment of ice in 
gastritis, which I wish to correct. Some persons objected to this 
use, and reason in this way:—persons who have taken a quantity 
of cold water, or ice, when heated by exercise, have been frequently 
attacked with gastritis and fever, and consequently the use of these 
substances must be attended with danger in case of gastric inflam- 
mation. This, however, is false reasoning; you need not be afraid 
to order your patient ice, ad libitum ; depend upon it, there is no 
danger in employing either ice or cold water in gastritis. There 
is nothing so grateful to the patient as ice. Let a quantity of it be 
broken into small pieces, about the size of a walnut; let your 
patient take one of these pieces, and, having held it in his mouth 
for a few moments to soften down its angles, let him swallow it 
whole. The effect produced by this on the inflamed surface of 
the stomach is exceedingly grateful, and the patient has scarcely 
swallowed one portion when he calls for another with avidity. It 
will be no harm if I should here mention to you a secret worth 
knowing. There are few things so good for that miserable sick- 
ness of the stomach, which some of you may have felt after a 
night’s jollification with a set of pleasant fellows, as a glass of ice ; 
Byron’s hock and soda-water are nothing to it. 
After the first violent symptoms of the disease have been sub- 
dued, I believe the very best thing which can be given is cold 
chicken broth. The point which we are always to keep in view 
is, to remove inflammation from the stomach, and this should regu- 
late the use of every thing taken into the stomach. I believe we 
might derive much advantage from anodyne injections in gastritis. 
I cannot say that I have ever employed them in such cases; but 
if I were to reason from their utility in other forms of abdominal 
inflammation, I should be induced to look upon them as entitled to 
some consideration. There is another point to which I will briefly 
advert. In the treatment of acute gastritis, there is nothing more 
commonly used than effervescing draughts ; yet I have frequently 
seen them produce distinct irritation of the stomach. In cases 
where gastric irritability is excessive, I would not advise you to 
give effervescing draughts, or if you do, watch their immediate 
effect; see how the first one has agreed with the stomach before 
you venture to give any more. Patients labouring under this dis- 
ease should be kept extremely quiet, as frequently a slight motion PATHOLOGY AND TREATMENT OF GASTRITIS. 
39 
brings back the vomiting. Every thing which is swallowed 
should be in small quantity; a large quantity of any substance 
frequently causes a return of the vomiting, by distending and irri- 
tating the stomach. One of the best things you can give, and the 
best way of giving it, is iced lemonade, giving a tablespoonful from 
time to time. The extremities, which are generally cold in cases 
of intestinal disease, should be swathed in warm flannel. 
I shall mention here a rule which should be carefully observed 
in the after treatment. A patient has recovered from the violent 
symptoms of the disease ; the fever, thirst, pain, epigastric tender- 
ness, and sympathetic affections, have subsided ; but he still is con- 
fined to bed, and in a state of great debility. Some patients, under 
these circumstances, have been unfortunately lost by allowing 
them to sit up in bed, or on the night chair. The nurse will some- 
times, through ignorance, suffer a patient, thus enfeebled, to risk 
his life by sitting up in bed ; sometimes, during the course of the 
night, she is overcome by sleep ; the patient has a call to empty his 
bowels : and not wishing to disturb her, attempts to get up, and is 
found, in some time afterwards, sitting on the night chair quite 
dead. This is an unfortunate termination for the physician as 
well as the patient. A German author, Hoffmann, has written a 
treatise on the danger of the erect position after acute diseases; 
and in the course of the work, which is a very interesting one, he 
cites numerous instances of its bad effects. Not very long since, a 
patient was lost in the Meath Hospital, by the nurse allowing him 
to sit up after a severe attack of enteritis. Such, also, was the 
melancholy cause of death in the case of the late Mr. Hewson, one 
of my best and earliest friends. He got a severe attack, which was 
subdued with difficulty, and his convalescence was doubtful and 
protracted. One night, in the absence of his attendant, he got up 
for the purpose of emptying his bowels, and was found, some time 
afterwards, on the night chair, nearly dead. He was immediately 
brought back to bed, and the necessary means employed to relieve 
him, but without much benefit, for he never recovered the effect 
produced on his debilitated frame. 40 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
LECTURE V. 
Pathology and treatment of gastritis—Application of blisters—Emetics can be seldom 
used in acute gastritis—Hasmatemesis and delirium tremens complicated with gas- 
tritis—Treatment of these affections—Dyspepsia, or chronic gastritis—Hypochon- 
driasis—Termination of chronic gastritis. 
There is one point connected with the treatment of gastritis 
which I have not yet touched upon—the use of blisters; and as 
this is the first time I have spoken of them, I shall make a few 
remarks on their general application. 
It is a great error to think that blistering is a matter of course in 
inflammatory diseases, or that the proper period for their applica- 
tion should not be carefully marked. It is a common idea, that if 
a blister does no good it will do no harm; that it is probable some 
benefit may result from its employment, and that you may try it 
at ail events. I need not tell you that all this is wrong, and that 
we must be guided by exact principles in this as well as in every 
other part of practical medicine. I am afraid there is a great deal 
of loose reasoning and empirical practice connected with this sub- 
ject, even at the present day. Here is the general rule by which 
you should be invariably guided. No matter what kind of disease 
you have to deal with, if it be inflammatory, blistering in the early 
stage of it is decidedly improper. I might amplify this rule, and 
say, that if the disease be inflammatory and in its early stage, or if, 
under such circumstances, the symptoms require the general or 
local abstraction of blood, blisters cannot be used with propriety. 
The truth is, that many persons take a very limited view of this 
subject; they look upon blisters as merely revulsive agents, which, 
by their action on the surface, have the property of diminishing 
visceral inflammation. This I am willing to allow is true to a 
certain extent, but there is abundant evidence to prove, that blis- 
ters have sometimes a direct stimulant effect on the suffering 
organ. That this occasionally occurs has been established by 
many facts in medicine; and I have not the slightest doubt that 
the application of a blister over an organ in a state of high inflam- 
matory excitement will certainly be productive of injurious conse- 
quences. But if you apply them at the period when stimulation is 
admissible and useful, (and there will always be such a period in 
every inflammation,) you then act on just principles, and will ge- 
nerally have the satisfaction of finding your practice successful. 
The greatest empiricism is sometimes practised in the application 
of blisters to the head in acute inflammation of the brain. You 
will see, in Mr. Porter’s admirable work on the Pathology of the 
Larynx, how strongly he is opposed to the early use of blisters in 
acute laryngitis. Dr. Cheyne, also, may, among many others, be 
quoted in support of this doctrine. 
If there is one system more than another likely to be injured by 
early blistering, it is the digestive. Broussais says that blisters 41 
PATHOLOGY AND TREATMENT OF GASTRITTS. 
should not be applied in any of the stages of acute gastro-enteritis, 
and that in the early stage their application is the very height of 
malpractice. I do not go so far as to say that they should not be 
applied in any period of the disease, for when the skin is cool, the 
pulse lessened, and the local inflammation so far reduced as not to 
require the abstraction of any more blood, I think you may employ 
them with very considerable advantage. I shall again return to 
the subject of blisters ; and will for the present merely remark, 
that blistering is almost always mismanaged, in consequence of 
persons who apply them being ignorant of their stimulating effects 
on organs. They generally allow them to remain on too long, and 
the consequence of this is often violent excitement of the organ 
over which they are applied, great constitutional irritation, stran- 
gury, and bad sores. The best mode of using them is to direct 
the person who prepares the blister to cover it with a piece of 
silver-paper before it is applied, and having put it on with the 
paper next the skin, to let it remain until a decided sense of smart- 
ing is produced, when it should be immediately removed. By 
adopting this plan, you will save yourself and your patient a great 
deal of inconvenience ; you will have no strangury, stimulation of 
the whole economy, or excessive local irritation, and the inflamed 
surface will heal kindly. The mode (too often practised) of apply- 
ing a blister sprinkled all over with an additional quantity of pow- 
dered cantharides, and leaving it on for twelve, twenty-four, or 
even thirty-six hours, particularly in the case of females, is nothing- 
better than horse doctoring. During a seven years’ experience in 
the hospital at Tours, Bretonneau, by attending to this principle, 
never had a case followed by these troublesome symptoms, and 
yet he never failed in producing the necessary degree of counter- 
irritation. The active principle of cantharides, being soluble in 
oil. exudes through the silver-paper in sufficient quantity to pro- 
duce the necessary effect on the skin, without exposing the patient 
to the risk of having too much irritation excited by the direct ap- 
plication of the blistering plaster to the cutaneous surface. 
With respect to emetics, I need not tell you that they can be very 
seldom used in acute gastritis, and that all your efforts should be 
directed to obviate and remove vomiting. But are we to interdict 
their use altogether? There are some few cases where we are 
compelled to use them; as, for instance, in cases of acute gastritis 
caused by swallowing corrosive poison, or by the irritation of indi- 
gestible food remaining in the stomach. The first step to be taken 
in a case of corrosive poisoning, is to evacuate the stomach. In the 
same way, when you are called to treat a case of gastritis produced 
by indigestible aliment, you must commence by giving an emetic. 
But even here the emetic is admissible only in the early period; 
and you should never trust to its operation for removing the gas- 
tritis altogether, unaided by other therapeutic means ; nor are you 
to conclude that because you have produced vomiting you have 
succeeded in curing the disease. The same principles apply to the 
use of purgatives in enteritis as to emetics in gastric inflammation; 
St. 4 42 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
we should never have recourse to them except where inflammation 
is kindled and kept up by the presence of irritating matter. 
There are two cases in which certain affections are complicated 
with an acute gastritis; and as these complications are not suffi- 
ciently known, and have been scarcely noticed by sytematic writers 
on gastritis, I am anxious to draw your particular attention to 
them. One of these is hcematemesis, the other that disease which 
has been termed delirium tremens. There are cases of vomiting 
of blood, which are little more than acute gastritis, in which there 
is a copious secretion of blood from the mucous surface of the sto- 
mach. Vomiting of blood may arise from various causes. It may 
be vicarious, as in the case of females, where the menstrual flux is 
suppressed ; it may be accidental, as from the rupture of a blood- 
vessel ; or it may be caused by mechanical obstruction to the 
circulation, either in the liver, spleen, heart, or lungs. But there 
is a species of gastritis, in which there is a copious vomiting of 
blood ; or there is an hsematemesis, of which the cause is gastric 
irritation. IIow are you to recognise this form of the disease?— 
The patient is vomiting blood; but then he has fever, hot skin, 
and excited pulse. Again, you will see some peculiar modification 
of the tongue; you will find ardent thirst and longing for cold 
drinks; you will observe fulness and tenderness of the epigastrium; 
you may have severe local pain ; finally, you will have all these 
symptoms occurring in a person who, previously to the attack, 
exhibited nothing capable of accounting for the heematemesis. 
Here, then, we have an haemorrhagic gastritis, very little known, 
and too often improperly treated. The ordinary practice, in such 
cases, is to give astringents. Astringents are very good and useful 
where they are clearly indicated; but there are many forms of 
disease where their routine employment is productive of a great 
deal of mischief; and I believe lives are sometimes lost by looking 
upon this affection as a simple haematemesis, and by practitioners 
contenting themselves with the use of astringents. But where you 
have the symptoms of this form of gastric irritation present, where, 
in addition to the vomiting of blood, you have fever, and thirst, 
and hot skin, and pain, and epigastric tenderness, you may be sure 
that it is a gastritis, and that the best treatment is leeches, iced 
water, and the other means recommended in the treatment of gastric 
inflammation. It may happen that, under this treatment, the vomit- 
ing of blood will not entirely subside ; but the pain, the thirst, the 
fever, and epigastric tenderness will subside, and then you can 
with propriety give astringents. The best thing you can do in the 
commencement is to leech freely, give iced lemonade, and cold 
water ; prohibit every thing purgative, stimulant, or astringent; 
and then, when you have reduced inflammation, if the haematemesis 
continues, have recourse to astringents. 
A few words now with respect to the other complication—delirium 
tremens. You have all seen cases of delirium tremens, but you 
are not, perhaps, aware that it arises under two opposite classes of 
causes. In some cases, a patient who is in the habit of taking PATHOLOGY AND TREATMENT OF GASTRITIS. 
43 
wine or spirituous liquor every day in considerable quantities, 
meets with an accident or gets an attack of fever. He is confined 
to bed, put on an antiphlogistic diet, and in place of wine or whis- 
key punch gets whey and barley-water. An attack of delirium 
tremens comes on, and symptoms of high cerebral excitement 
appear. Another person, not in the habit of frequent intoxication, 
takes to what is called a fit of drinking, and is attacked with de- 
lirium tremens. In the first case the delirium arises from a want 
of the customary stimulus, in the second from excess. In each the 
cause of the disease is different; and, consequently, with this view 
of the subject, it would be a manifest departure from sound prac- 
tice to treat both cases in the same way. Yet, I believe, this error 
is frequently committed, even by persons whose authority is high 
in the medical world, and is part of a system not yet exploded— 
the system of 'prescribing for names and not for things. The 
patient is treated for a disease which has been called delirium tre- 
mens, the present symptoms are only attended to, and the cause 
and origin of the affection are overlooked. What are the true 
principles of treatment ?—In the first variety, where the delirium 
is produced by a want of the customary stimulus, there is no doubt 
that patients have been cured by the administration of the usual 
stimulants, by giving them wine, brandy, and opium. Indeed, this 
seems to be the best mode of treating this form of the disease. But 
is it proper or admissible in the second variety, where the delirium 
is caused by an occasional excess in the use of ardent spirits ?— 
Certainly not. Yet what do we find to be the ordinary practice in 
hospitals when a patient is admitted under such circumstances?— 
A man, who has been attacked by delirium tremens after a violent 
debauch, is ordered a quantity of porter, wine, brandy, and opium; 
and the worse he gets, the more is the quantity of stimulants in- 
creased. Now this practice seems to me as ridiculous as the old 
principle of treating a case of hydrophobia with a hair of the dog 
that bit. Let us consider what the state of the case is:—A large 
quantity of stimulant liquors have been taken into the stomach, the 
mucous surface of that organ is in a state of intense irritation, the 
brain and nervous system are in a highly excited condition from 
the absorption of alcohol, or in consequence of the excessive sym- 
pathetic stimulation to which they have been subjected. Are we 
to continue this stimulation ?—I think not. What would be the 
obvious and natural result ?—Increased gastric irritation, encepha- 
litis, or inflammation of the membranes of the brain. The super- 
vention of inflammatory disease of the brain in delirium tremens is 
not understood by many practitioners, and they go on administer- 
ing stimulant after stimulant, totally unconscious that they are 
bringing on decided cerebral disease. I have witnessed the dissec- 
tions of a great many persons who died of delirium tremens, and 
one of the most common results of the dissection was, the discovery 
of unequivocal marks of inflammation in the brain and stomach. 
Broussais considers all such cases as merely examples of gastritis, 
and ridicules British practitioners for inventing a “ new disease f 44 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
but in this he is certainly wrong, for there have been several cases 
in which no distinct marks of gastric inflammation could be dis- 
covered. In all cases, however, where the delirium supervenes on 
an excessive debauch, there is more or less of gastritis; and 
though it may occasionally happen, that a patient under such 
circumstances may recover under the stimulant treatment, yet I 
am convinced that the physician will very frequently do harm by 
adopting it. 
This complication of delirium tremens with gastritis is also 
exceedingly curious in another point of view, as it illustrates how 
completely the local symptoms are placed in abeyance, and, as it 
were, lost during the prevalence of strong sympathetic irritation. 
The patient’s belly will not be tender ; the tongue may not be red; 
the symptoms present may be indicative of a mere cerebral affec- 
tion, and yet intense gastric inflammation may be going on all the 
time, and all the appearance of cerebral disease be quickly removed 
by treatment calculated to subdue a gastritis. Is this all theory? 
No ; for we have practised on this principle with the most extra- 
ordinary success in the Meath Hospital. We have seen cases of 
violent outrageous delirium subside under the application of leeches 
to the epigastrium, and iced water, without a single drop of lauda- 
num. I beg of you, if you meet with any cases of delirium tremens 
under such circumstances, to make trial of this mode of treatment, 
and record its effects, for it is important that they should be more 
extensively known. I have seen the whole train of morbid pheno- 
mena, the delirium, the sleeplessness, the excessive nervous agita- 
tion, all vanish under the application of leeches to the epigastrium. 
In some cases where after the sleeplessness and delirium were re- 
moved by this practice, and the tremours alone remained, we have 
again applied leeches to the epigastrium, and. succeeded in removing 
the tremours also. On the other hand, where a stimulant plan of 
treatment was employed, and the patients died, we have most com- 
monly found inflammation in two places, in the stomach, or in the 
brain or its membranes. The rule, then, is this—in a case of de- 
lirium tremens from the want of a customary stimulus, use the 
stimulant and opiate treatment; but when it comes on after an occa- 
sional violent debauch, such remedies must be extremely improper. 
Adopt here every thing calculated to remove gastric irritation. We 
have facts to show that most decided advantage may arise, from 
the application of leeches, even where the symptoms of gastritis 
are absent. 
We come now to consider chronic gastritis, an extremely in- 
teresting disease, whether we look upon it with reference to its 
importance, its frequency, or its Protean character. It is commonly 
called dyspepsia, and this term, loose and unlimited in its accepta- 
tion, often proves a stumbling block to the student in medicine. 
Dyspepsia, you know, means difficult digestion, a circumstance 
which may depend on many causes, but perhaps on none more 
frequently than upon chronic gastritis. In the great majority of 
dyspeptic cases, the exciting cause has been over stimulation of the PATHOLOGY AND TREATMENT OF GASTRITIS. 
45 
stomach, either from the constant excess in strong highly seasoned 
meats, or indulging in the use of exciting liquors. Persons who 
feed grossly and drink deeply, are generally the subjects of dys- 
pepsia ; by constantly stimulating the stomach they produce an 
inflammatory condition of that organ. Long continued functional 
lesion will eventually produce more or less organic disease; and 
you will find that in most cases of old dyspepsia there is more or 
less gastritis. But let us go farther, and enquire whether those 
views are borne out by the ordinary treatment of dyspeptic cases. 
When you open a book on the practice of physic, and turn to the 
article dyspepsia, one of the first things which strikes you is the 
vast number of cures for indigestion. The more incurable a disease 
is, and the less we know of its treatment, the more numerous is 
the list of remedies, and the more empirical is its treatment. Now 
the circumstance of having a great variety of u cures’’ for a disease, 
is a strong proof, either that there is no real remedy for it, or that 
its nature is very little understood. A patient afflicted with dys- 
pepsia will generally run through a variety of treatment, he will 
be ordered bark by one practitioner, mercury by another, purga- 
tives by a third; in fact, he will be subjected to every form of treat- 
ment. Now all this is proof positive that the disease is not suffi- 
ciently understood. What does pathology teach in such cases? In 
almost every instance where patients have died with symptoms of 
dyspepsia, pathological anatomy proves the stomach to be in a state 
of demonstrable disease. It appears, therefore, that, whether we 
look to the uncertainty and vacillations of treatment, or the results 
of anatomical examination, the case is still the same ; and that, 
where dyspepsia has been of considerable duration, the chance is 
that there is more or less of organic disease, and that, if we pre- 
scribe for dyspepsia neglecting this, we are very likely to do mischief. 
I do not wish you to believe that every case of dyspepsia is a case 
of gastritis. This opinion has brought disgrace on the school of 
Broussais. His disciples went too far; for whether the gastric 
derangement depended on nervous irritation, or anaemia, or disease 
of the liver, or mental emotion, they prescribed leeches and water 
diet, and thus very often brought on the disease they sought to 
cure. We may have functional disease, independent of structural 
lesion, in the stomach, as well as in any other organ ; it is no un- 
usual circumstance, and the practical physician meets with it every 
day. A great deal of confusion, however, arises from the similarity 
of the symptoms. I remember an accomplished friend of mine 
getting into disgrace with one of the members of a board of exa- 
miners on this subject. He was asked to tell the difference between 
the symptoms of chronic gastritis and dyspepsia, and in reply stated 
that he could not. For this he was nearly rejected; but, I believe, 
on a candid review of the circumstances, you will agree with me, 
that he knew more of the matter than the learned professor. In 
ninety-nine cases out of a hundred of chronic gastritis there is no 
fever, scarcely any thirst, often no fixed local pain, and this leads 
persons away from any idea of the existence of an inflammatory 46 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
condition of the stomach. What are the symptoms of a chronic 
gastritis ? pain of occasional occurrence, flatulence, acidity, swell- 
ing of the stomach, fetid eructations, sensation of heat and weight 
about the epigastrium, and perhaps vomiting. Well, these are also 
the symptoms of dyspepsia, whether it be accompanied by inflam- 
mation or not. How then, when called to a case of this kind, are 
you to determine the point ? I must mention to you here, that it 
is often hard to do this with certainty. There are two circum- 
stances, however, which you should always bear in mind, as they 
will afford you considerable assistance in coming to a correct diag- 
nosis ; first, the length of time which the disease has lasted ; 
secondly, the result of the treatment which has been employed. 
You will find, that where the disease is a chronic gastritis, that it 
has been of some duration, that it has come on in an insidious 
manner, and that it has been exasperated by the ordinary treat- 
ment for dyspepsia. Many persons think, that if you give a patient 
medicine, without regulating his diet or issuing a prohibition against 
full meals, that you can cure him, and that, as he has no fever, and 
can go about his usual business, there is no necessity for antiphlogis- 
tic regimen. But as the disease goes on, he complains of pain in the 
stomach during the process of digestion, feels uneasy after dinner, 
there is an unpleasant degree of fulness about the epigastrium, he 
also experiences a variety of disagreeable symptoms, sometimes 
being annoyed with pain in the chest, sometimes he says he feels 
it in the region of the heart, and sometimes about the cartilages of 
the eighth and ninth ribs. These symptoms subside after the 
process of digestion is completed, but during its continuance they 
harass the patient. Yery often relief is obtained by vomiting, 
and hence some persons are in the habit of throwing up their food 
for the purpose of relieving themselves, and consequently can have 
no benefit by it. In some cases digestion goes on until the food 
seems to reach a particular point, and then an acute feeling of pain 
is experienced. In these cases the gastritis is generally circum- 
scribed, and is likely to terminate in circumscribed ulceration. 
Various fluids are rejected from the stomach during the course of a 
gastritis; sometimes acid, sometimes alkaline, sometimes insipid 
and sweet, sometimes bitter and bilious. There is generally a 
degree of fulness about the stomach, and the epigastrium is tender 
on pressure, but no decided tumour, either of the pylorus, liver, or 
spleen, although the epigastrium presented that appearance of fulness 
and tension termed by the French “renitenceThe bowels, too, 
are constipated, and this is a matter worthy of your attention, for it 
sometimes unfortunately happens that the practitioner, mistaking the 
gastritis for simple constipation, goes on prescribing purgative after 
purgative, until the patient gets incurable disease of the stomach. 
I know a case of a lady who gets one stool a week by taking eight 
drops of croton oil. Some years ago she was in the enjoyment of 
excellent health; her bowels happened to get confined, and she 
was treated by a systematic practitioner with continued purgatives; 
her bowels are now completely torpid, except when they are PATHOLOGY AND TREATMENT OF GASTRITIS. 
47 
subjected to this unnatural stimulus. There are thousands of 
persons treated in this way, because practitioners look to conse- 
quences and not to causes. 
There is one remarkable difference between acute and chronic 
gastritis, which deserves your attentive consideration, as it exem- 
plifies a law applicable to all viscera under similar circumstances, 
and this is, that the sympathetic irritations are not so frequent or 
so distinct in chronic inflammation as in the acute form, and hence, 
in a case of chronic gastritis we almost never have fever, and the 
affections of the nervous respiratory or circulating systems are by 
no means so well marked. It may even go on to actual disorganis- 
ation of the stomach, and yet the patient will not complain of any 
particular symptom during its whole progress, which yon could 
set down as depending exclusively on the sympathetic irritation of 
gastritis. Some of these cases, called dyspeptic phthisis, by Dr. W. 
Philip, are most probably examples of the sympathetic irritation of 
the lungs from chronic gastritis. Another case, respecting which 
much error prevails, is what has been called hypochondriasis. 
Persons labouring under these affections are condemned to run the 
gantlet of every mode of treatment; sometimes (and fortunately for 
themselves) they are sent to travel, sometimes they are treated with 
musk and antispasmodics, then with the mineral acids, then with 
purgatives and mercurials, and lastly with bark, nitrate of silver, 
and stimulants. They go about like spectres from one practitioner 
to another, trying remedy after remedy, alternately sanguine with 
hope or saddened by disappointment, until at last they die, and, 
to the astonishment of all the doctors, the only disease found, on 
dissection, is inflammation and thickening of the mucous surface of 
the stomach. A condition, which, under these circumstances, it 
was difficult to say whether it was the original disease, or produced 
by “ fair trials'’ of a number of powerful agents. Hypochondriasis 
is not always gastritis; but it is now found that, in many cases, it 
commences and terminates with disease in the upper portion of the 
digestive tube and the assisting viscera. This you must always 
bear in mind. 
Chronic gastritis terminates in various ways. Sometimes the 
inflammation is limited to a particular spot of the stomach, and 
here we frequently discover circumscribed ulcerations. In very 
bad cases these ulcers go on perforating the various coats of the 
stomach, until at last the contents of that organ escape into the 
serous cavity of the abdomen, and the patient rapidly sinks under 
a fatal peritonitis. It does not follow however, that, in all cases of 
perforation, the contents of the stomach get into the peritoneum, 
causing death. Very often adhesions are formed, and the base of 
the ulcer is the serous covering of some other portion of the diges- 
tive system, or a false passage may be formed into the colon. One 
of the most common terminations of a chronic gastritis is. that the 
inflammation extends to other viscera; the patient gets disease of 
the liver, spleen, peritoneum, or lungs, and sinks under a compli- 
cation of disorders. It was somewhat in this way that Napoleon 48 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
died. He laboured for a considerable time under chronic disease 
of the stomach, which seems to have been overlooked by his medi- 
cal attendants, and this terminated in the extension of disease to 
various other organs. 
LECTURE YI. 
Treatment of chronic gastritis—Frequent excitement of the vascular system necessary 
to the performance of the functions of the stomach—Local bleeding—Regimen— 
Counter-irritation over the stomach—Treatment of Broussais—Use of vegetable 
tonics—Oxide of bismuth—Acetate of morphia. 
I shall begin to-day with the treatment of chronic gastritis, and 
I beg of you to bear in mind what I mentioned at my last lecture, 
that this disease, in its true and pathological meaning, is not suffi- 
ciently recognised. In general, it gets some wrong name or other; 
and as many practitioners are in the habit of prescribing for names, 
it generally meets with wrong treatment. It is called every thing 
but what it is, and its remedies are as numerous and as various as 
its appellations. By some, it is called dyspepsia, and is treated 
with bitters, astringents, and stimulants; by others, it is termed 
constipation, and treated with purgatives ; the school of Abernethy 
look upon it as an alfection of the liver, and prescribe blue pill and 
black draught; others give it the name of hypochondriasis, and 
exhaust the whole catalogue of nervous and anti-dyspeptic medi- 
cines in attemping its removal; in fact, it is called every thing but 
what it is, and the result is an unsteady and mischievous 
empiricism. 
You will recollect a fact, to which I alluded in my last lecture, 
that the physiological condition of the stomach requires that it 
should be subject to frequent excitements of its vascular tissue, and 
that this increased vascularity being the consequence of a natural 
process, digestion is, generally speaking, exempt from any kind of 
danger. If the brain or lungs were to experience an equal increase 
of vascularity, sensibility, and excitement, the consequence would 
he dangerous, or perhaps fatal, and we should have pulmonary 
and cerebral diseases produced. But though the stomach enjoys 
such a remarkable exemption from the liability to acute inflamma- 
tion, under circumstances of repeated vascular excitement, yet the 
slow, insidious, chronic gastritis, is an exceedingly common affec- 
tion. I feel convinced that many persons die of it, or of the exten- 
sive class of fatal diseases which it frequently induces. But I 
rejoice to say, that we have good reason to hope that the progres- 
sive amelioration of medical science will materially diminish the 
amount of human suffering from this cause. As physiological 
medicine advances, the number of those who die of unrecognised 
chronic visceral disease will be less and less, because diagnosis TREATMENT OF CHRONIC GASTRITIS. 
49 
will become more extended and certain, and practice more simple 
and successful. 
The first thing you should do, when called to treat a case of 
dyspepsia, is to ascertain whether it be a purely nervous disease, 
or a chronic gastritis. The majority of practitioners give them- 
selves no trouble about this matter, not recognising the fact, that 
of the number of dyspeptic persons who seek for medical advice, a 
considerable proportion are really labouring under a chronic gas- 
tritis, and forgetting, that, in consequence of long-continued func- 
tional injury, what was at first but a mere nervous derangement 
may afterwards become complicated with organic disease. You 
must also bear in mind, that the stomach is perhaps placed under 
more unfavourable circumstances for bringing about a cure than 
any other organ, because the life of the individual demands that the 
stomach, though in a state of inflammation, should still continue 
to perform its functions. In treating diseases of other organs, you 
will have the advantage of a comparative state of rest; but, in a 
case of the stomach, if you wish to preserve life, you cannot, pro- 
hibit nutriment, and, consequently, you must run the risk of keep- 
ing up these periodic vascularities which its condition requires, 
which, though harmless in health, become a source of evil when 
the stomach is diseased. The obvious deduction from this is, that 
the cure of chronic gastritis depends as much upon regimen as 
upon medical treatment, and particularly where the symptoms 
have arisen from long-continued excitement, as in the case of 
persons who live highly. Here the treatment chiefly depends on 
regulating the diet, and if your patient has sense enough to live 
sparingly for a few weeks or months, you may be able to effect a 
cure without other treatment. The great error is, that most prac- 
titioners attempt to cure the disease by specifics, and when these 
fail, they then go to the symptomatic treatment, prescribing some- 
times for acidity, sometimes for nausea, sometimes for flatulence, 
sometimes for constipation, or “the liver,” or debility. 
You should be careful in the examination of such cases, and 
should try to ascertain whether these symptoms may not depend 
upon inflammation of the stomach ; for as long as the patient is in 
this state, the less you have recourse to symptomatic or specific 
treatment the better. It is hard to mention one single medicine 
which, in this state, will not prove stimulant, and if the stomach 
be unfit for stimulants, it must be unfit for the generality of medi- 
cines. There are numbers of cases of persons labouring under 
chronic gastritis, which have been cured by strict regulation of 
diet, and by avoiding every article of food requiring strong diges- 
tive powers. We find that articles of diet vary very much in this 
respect; some are digested with ease, some with pain. We might 
express this otherwise, by saying, that some require very little 
excitement of the stomach, and others very great vascular excite- 
ment. Patients, in this irritable state of stomach, can scarcely 
bear any kind of ingesta; and when you consider the great vascu- 
larity, thickening of the mucous membrane, and tendency to 50 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
organic disease, you will be induced to think that every thing 
entering the stomach should be of the mildest kind, and not 
requiring any powerful determination of blood to that organ. 
If you continually prescribe for symptoms, neglecting or over- 
looking the real nature of the disease, giving arsenic to excite the 
system, and iron to remove anaemia, and bitter tonics to improve 
the appetite, and alkaline remedies for acidity, and carminatives to 
expel flatus, you will do no good; you may chance to give relief 
to-day, and find your patient worse to-morrow ; and at last he will 
die, and you may be disgraced. On opening the stomach, after 
death, you are astonished to find extensive ulceration, or, perhaps, 
cancerous disease. Yery often, in such cases, practitioners say 
that it is cancerous disease, and that no good can be done. But 
the thing is to be able to know, when you are called to a case, 
whether it is a case of mere nervous dyspepsia, or chronic inflam- 
mation of the stomach. Some of the best pathologists think that 
most of the cancerous affections of the stomach are, in the begin- 
ning, only chronic inflammations of that organ. 
I believe we have not yet in this country adopted the plan of 
moderate application of leeches to the epigastrium in cases of 
chronic gastritis. I have seen, in many cases, great benefit result 
from the repeated application of a small number of leeches to the 
epigastrium, at intervals of two or three days. Here is a point 
which you will find very useful in practice. You will meet with 
cases which have lasted for a long time; cases where there is 
strong evidence of organic disease, and which have resisted the 
ordinary dyspeptic treatment. You will be called frequently to 
treat these three different cases:—where the disease has been of 
long duration ; where there is distinct evidence of organic disease ; 
and where the disease has resisted the ordinary dyspeptic treat- 
ment. Here is a case of a patient labouring under what is called 
indigestion, and which has resisted the stimulant, and tonic, and 
purgative treatment. Here is one fact. In the next place, the 
disease is chronic, and the probability is that there is inflamma- 
tion, and consequently that there is chronic gastritis. Now if, in 
such a case, you omit all medicine by the mouth, apply leeches to 
the epigastrium, keep the bowels open by injections, and regulate 
the diet, you will often do a vast deal of good. I have seen, under 
this treatment, the tongue clean, the pain and tenderness of the 
epigastrium subside, the acidity, thirst, nausea, and flatulence, 
removed, the power of digestion restored, and all the symptoms for 
which alkalies, and acids, and tonics, and purgatives, were pre- 
scribed, vanish under treatment calculated to remove chronic 
inflammation of the stomach. 
What is next in importance to regulated regimen and local 
bleeding? A careful attention to the bowels, which, in chronic 
gastritis, are generally constipated, and this has a tendency to keep 
up disease in the upper part of the digestive tube. Is this to be 
obviated by introducing purgative medicine into the stomach? 
No. If you introduce strong purgative medicine by the mouth, TREATMENT OF CHRONIC GASTRITIS. 
51 
you will do a great deal of mischief. You must open the bowels 
by enemata, or, if you give medicine by the mouth, by the mildest 
laxatives in a state of great dilution. A little castor-oil, given 
every third or fourth day, or a little rhubarb, with some of the 
neutral salts, will answer in most cases. The diet, too, can be 
managed, so as to have a gently laxative effect. The use of 
injections is, however, what I principally rely on. I have seen 
many cases of gastritis cured by the total omission of all medicine 
by the mouth, by giving up every article of food which disagreed 
with the stomach, and by the use of warm water enemata. I have 
seen this treatment relieve and cure persons whose sufferings had 
lasted for years previous to its employment, and who had been 
considered by many practitioners to labour under organic disease 
of an incurable nature. It is important that you should bear this 
in mind. The old purgative and mercurial treatment of gastritis, 
I am happy to say, is rapidly declining; and British practitioners 
are now convinced that they cannot cure every form of dyspepsia 
by the old mode of treatment. I do not deny that many diseases 
of the digestive tube may be benefited by the mild use of mercury 
and laxatives, but I think I have every reasonable and scientific 
practitioner with me in condemning the unscientific routine prac- 
tice, which was followed by those who took the writings of Aber- 
nethy and Hamilton for their guide. I do not say that, where 
cases of gastric inflammation, treated after the plan of Mr. Aber- 
nethy, have proved fatal, the medicines have destroyed life; I 
merely assert that the patients died of inflammation, over which 
these medicines had no control; and the error lay in mistaking 
and overlooking the actual disease, as much as in its maltreatment. 
You will find some practitioners (they are becoming fewer in 
number every day), who seem to have but two ideas, the one a 
purgative, the other a pot full of faeces; but the connecting link— 
the gastro-enteric mucous membrane—that vast expansion, so 
complicated, so delicate, so important, seems to be totally forgotten. 
But practitioners are now beginning to see that purgatives are not 
to be employed empirically ; that they should be administered in 
many cases with great caution, and with a due attention to the 
actual condition of the alimentary canal, and that they have been 
a source of great abuse in the medical practice of these countries. 
Next to leeching, and a proper regulation of the bowels, is the 
employment of gentle and long-continued counter-irritation over 
the stomach. This may be effected by the repeated application of 
small blisters, or by the use of tartar emetic ointment. I have 
been in the habit of impressing upon the class, that the tartar 
emetic ointment used in these countries is too strong, the conse- 
quence of which is an eruption of large pustules, which are exces- 
sively painful, and often accompanied with such disturbance of 
the constitution as amounts to symptomatic fever. In fact, tartar 
emetic ointment of the ordinary strength produces so much irrita- 
tion, that few patients will submit to it long. The form which I 
recommend you to employ is the following:—Take seven drachms 52 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
of prepared lard, and, instead of a drachm of tartar emetic, which 
is the usual quantity, take half a drachm, directing, in your pre- 
scription (this is a point of importance), that it be reduced to an 
impalpable powder ; and you may add to it what will increase its 
action, one drachm of mercurial ointment. This produces a crop 
of small pustules, which give but little pain and are easily borne; 
and the counter-irritation may be kept up in this way for a con- 
siderable time, by stopping, for a few days, until the eruption fades 
away, and then renewing the friction. I have often seen the utility 
of this remedy exemplified in cases of chronic gastritis, where the 
symptoms of gastric irritation, which had subsided under the 
employment of friction with tartar emetic ointment, returned when 
it was left off, and again vanished when it was resumed. The 
case of the celebrated anatomist, Beclard, furnishes a very remark- 
able proof of the value of a well-regulated diet and repeated 
counter-irritation in the treatment of this disease. While he was 
engaged in the ardent prosecution of his professional studies he got 
an affection of the stomach, which he considered to be a chronic 
gastritis, and immediately put himself under a strict regimen, 
using, at the same time, repeated counter-irritation. He kept up 
the counter-irritant plan for a considerable length of time, for he 
found that, when he discontinued it, the gastric symptoms had a 
tendency to return. In this way he got completely rid of the dis- 
ease. Several years afterwards he died of an attack of erysipelas ; 
and, on opening his stomach, the cicatrix of an old ulcer was 
discovered in the vicinity of the pylorus, which was exactly the 
spot to which he had referred his pain during the continuance of 
his gastric affection. 
There is, perhaps, no science in which the motto, “medio tutissi- 
mus ibis” is of more extensive application than in medicine. Some 
physicians on the continent, particularly the disciples of Broussais, 
having repeatedly witnessed the advantages of strict regimen and 
local depletion in chronic gastritis, have pushed this practice too 
far. They seemed to forget that the system requires support and 
nutrition, which can be effected only through the agency of the 
stomach; they saw the evils which result from the use of stimu- 
lating food in cases of chronic gastritis; and, looking to these alone, 
they ran into the opposite extreme, the consequence of which was, 
that they kept their patients so long upon low diet that they 
actually produced the very symptoms which they wished to 
remove. The patients became dyspeptic from real debility of the 
stomach and the whole frame. You remember a general law of 
pathology to which I have alluded on a former occasion, and 
which I shall again mention, as it illustrates this point, namely, 
that opposite states of the economy may be accompanied by the 
same symptoms. Thus we observe, that palpitation may depend 
on two different causes—on a sthenic or asthenic condition—on 
the presence of too much or too little blood in the heart. Now, it 
frequently happened that patients, labouring under chronic gas- 
tritis, and who had been treated for a long time after the strict plan TREATMENT OP CHRONIC GASTRITIS. 
53 
adopted by the Broussaists, finding themselves not at all improved, 
went to other physicians who had different views, and were rapidly 
cured, by being put upon a full nutritious diet. In this way 
numerous cases, which water diet and depletion had only aggra- 
vated, were relieved, and the consequence was, that a mass of facts 
was brought forward and published, not long since, by a French 
author, against the antiphlogistic treatment of dyspepsia and 
chronic gastritis. It must be stated, however, that the cases which 
he published were chiefly those in which the depleting system had 
been carried to excess, and that they cannot, therefore, be received 
as proofs of the value of a stimulating diet in the treatment of 
chronic inflammation of the stomach. Bear this in mind ; the 
sooner you can put your patient on a nutritious diet the better will 
it be for him. It would be absurd to keep a patient for many 
months, as the Broussaists have done, on slops and gum-water. 
It will be necessary for you to feel your way and improve the diet 
gradually. Commence by giving a small quantity of mild nutri- 
tious food; if your patient bears it well, you can go on; if the 
gastric symptoms return, you can easily stop. If a small portion 
of the milder species of food rests quietly on the stomach, you may 
increase it the next day, or the day after, and thus you proceed to 
more solid and nutritious aliment, until the tone of your patient’s 
stomach regains the standard of health. Never lose sight of this 
fact, that you may have a case of dyspepsia depending on a 
chronic gastritis, in which, though you remove the inflammation 
by a strict antiphlogistic treatment, you may not by this remove 
the dyspepsia; and if you continue to leech, and blister, and starve 
your patient, after the inflammatory state he removed, you will do 
great injury. Such a patient, falling into the hands of another 
practitioner who treated him on a different systen, might be 
relieved, and his case quoted against you and your treatment, 
though this, at the commencement, was judicious and proper. 
With respect to internal remedies, the school of Broussais think 
that there is nothing required but cold water and gum. This is 
going too far. In a former lecture, I have drawn your attention to 
the fact, that in the treatment of acute inflammation there is a 
point where antiphlogistics should cease, and where tonics and 
stimulants are the most efficient means of cure. Of this fact, the 
disciples of Broussais appear to be ignorant, and they consequently 
declare against every remedy for chronic gastritis except leeches 
and cold water. Now is this right? I think not. We find that, 
in all cases of gastric inflammation, a change in medication seems 
to be useful at some period of the disease, that is, a change from 
antiphlogistics to tonics and stimulants, and 1 believe that in cases 
of chronic gastritis these remedies may be used with very great 
advantage, having, of course, premised depletion and counter- 
irritants. I believe, too, that most of the remedies, which we see 
every day unsuccessfully employed, would have acted beneficially, 
if the preparatory treatment, which I have mentioned, had been 
adopted. Among the best remedies of this kind is the oxide of 54 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
bismuth; I have seen more benefit from the use of this than of any 
other medicine, after the treatment already alluded to. Generally 
speaking, the list of internal remedies for chronic gastritis is very 
small, but after the use of antiphlogistics, you may prescribe the 
vegetable tonics and oxide of bismuth with advantage. The most 
decidedly valuable remedy, however, in the after stage of a chronic 
gastritis, is the acetate of morphia, which, I am convinced, has a 
very powerful effect in allaying chronic irritation of the stomach. 
Dr. Bardsley, of Manchester, in one of his published works, entitled 
“Hospital Facts and Observations,” adduces many cases of gastric 
irritation which were completely relieved by the use of this remedy, 
and I am perfectly satisfied of the truth of his statements. It may 
be said that Dr. Bardsley’s cases were only instances of dyspepsia. 
But, as his cases were extremely numerous, some of them of long 
standing, and the symptoms very severe, the great probability is, 
that some of them at least must have been cases of chronic gas- 
tritis. I know very few books, the perusal of which I would more 
strongly recommend to you than Dr. Bardsley’s accurate and 
instructive work. The great besetting sin of medical writers is, 
that their statements of successful practice are grounded on a very 
limited number of cases, or that, in publishing the result of their 
practical investigations, they only give their successful cases, and 
leave out those in which the treatment recommended has been 
found inefficacious. Yet this is a circumstance which should 
never be neglected. If a man declares that he has discovered a 
cure for gastritis, or dyspepsia, and brings forward one hundred 
cases in which the remedy has done good, the statement is still 
unsatisfactory and insufficient, because there may be one thousand 
cases in which it has totally failed. Unless he comes forward and 
gives both his successful and unsuccessful cases, of what value are 
his statements ? Dr. Bardsley, with the candour and good sense 
which always characterise the philosophic enquirer, gives the 
result of all his cases, forms them into tables, and then leaves his 
readers to judge for themselves. From an inspection of these 
tables, you will be convinced of the efficacy of acetate of morphia 
in the treatment of chronic gastritis. I have been in the habit of 
using it with the most gratifying results after leeching, regulating 
the diet, and paying proper attention to the state of the bowels. 
There are some forms of the disease in which it is more useful 
than others. The particular form, in which it proves most service- 
able, is where there is a copious secretion of acid from the stomach 
(that form in which all kinds of alkalies have been exhibited), 
where severe pain and constant acidity are the prominent symp- 
toms. Here I have seen the acetate of morphia act exceedingly 
well. You may begin with one twelfth of a grain, made into a 
pill with crumb of bread, or conserve of roses, twice a day; the 
next day you may order it to be taken three times, and you may 
go on in this way until you make the patient take from half a 
grain to a grain and a half in the twenty-four hours. I shall here 
mention the circumstances of a case, which I do not mean to bring TREATMENT OF CHRONIC GASTRITIS. 
55 
forward as an instance of cure, but as an illustration of the extra- 
ordinary power which acetate of morphia possesses in relieving 
gastric irritation. A gentleman of strong mind and highly culti- 
vated intellectual powers, which he kept in constant exercise, got 
a severe chronic gastritis; his appetite completely declined; he 
had frequent vomiting of sour matter ; fetid eructations ; and such 
violent pain in the stomach, that he used, when the attack came 
on, to throw himself on the ground, and roll about in a state of 
indescribable agony. He applied to various practitioners, had 
several consultations on his case, and the opinion of the most 
eminent medical men was, that he had incurable cancerous disease 
of the stomach. These symptoms continued for several years, but 
for the last two or three years they were quite intolerable. He 
had repeated cold sweats, vomited every thing he took, even cold 
water, was reduced to a skeleton, and led a life of complete torture. 
Under such circumstances he tried, for the first time, by my advice, 
the acetate of morphia. He tried it first in doses of one tenth of a 
grain three times a day, and experienced the most unexpected 
relief. On the third day all his bad symptoms were gone. He 
had no pain, no vomiting, no sweats; his spirits were raised to the 
highest state of exhilaration, and he thought himself perfectly 
cured. He went out in the greatest joy, visited all his friends, and 
told them that he had at last got rid of his tormenting malady. In 
the evening he joined a supper party, indulged very freely, and 
next morning had a violent haematemesis, to which he had been 
for some time subject. All his old symptoms again made their 
appearance. He again had recourse to the acetate of morphia, and 
again immediately experienced relief, but the vomiting of blood 
again returned, so that he discontinued the remedy. This gentle- 
man is now in the enjoyment of good health. He regulated his 
diet, left off all medicine by the mouth, used warm water injections, 
and thus recovered from his supposed cancer. 
I do not bring this case forward as an instance of the curative 
effect of acetate of morphia, but as an instance of its powerful 
effect in allaying gastric irritation. I could adduce other cases in 
proof of its value in the treatment of the after stage of chronic 
gastritis, and particularly of that form in which pain and acidity 
are the prominent symptoms; but I perceive my time has nearly 
expired. At my next lecture, I shall give some other particulars 
connected with this subject, and then proceed to the consideration 
of diseases of the small intestine. 56 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
LECTURE VII. 
Friction with croton oil—Attention to diet during convalescence—Organic disease of 
the stomach—Principles of treatment—Diet and attention to the bowels—Duodenitis 
—Inflammation of the jejunum—Ileitis, complication and nature of—Dothinenteri- 
tis—Ulceration of the mucous membrane—Symptoms and diagnosis of ileitis. 
In speaking of the employment of counter-irritation in cases of 
chronic gastritis, I forgot to mention the use of friction with croton 
oil, which has been found beneficial in many cases of chronic 
inflammation. It has been extensively used by many practitioners 
in the treatment of chronic affections of the joints, and in various 
forms of pulmonary disease; and I have employed it myself in 
some cases of chronic gastritis with benefit. I cannot say that the 
cases in which I have used it presented all the symptoms of chronic 
gastritis, but they were certainly cases of chronic gastrodynia, with 
severe local pain, nausea, and loss of appetite. It is an excellent 
counter-irritant, and gives very little pain. The mode in which I 
employ it is this—take a few drops of croton oil, five or six, for 
instance, drop them on the epigastrium, and rub them in with a 
piece of lint or bladder, interposed between your finger and the 
skin, and the next day you have an eruption of small papulae, 
which you can increase at will. There is one interesting circum- 
stance connected with the use of croton oil frictions, which you 
should be made acquainted with. The liability to produce counter- 
irritation, seems to depend upon the absorption or non-absorption 
of the croton oil; if it be absorbed it will purge, but if it be not it 
will produce counter-irritation. In cases of this kind, therefore, 
where it produces the necessary degree of irritation in the skin, the 
chances are, that it will not act disagreeably by bringing on ca- 
tharsis. I have only seen one case where there were both the 
eruption and catharsis. This was a gentleman who had lately 
suffered from dysentery in warm climates.1 
I may also mention, that, in convalescence from an attack of 
chronic gastritis, you must pay great attention to diet for a long 
time, because there is no affection of any organ in the body, in 
which an error in diet so rapidly induces a return of the original 
symptoms, as in diseases of the stomach, while each return of the 
disease renders the attack more dangerous and unmanageable, 
until at last disorganisation takes place. 
This leads me to speak of organic disease of the stomach. On 
1 There is one variety of revulsion which is effectual in removing chronic 
gastritis, and, indeed, every form of dyspepsia, at times when every other 
remedy has failed. We allude to constant change of air, society, and scene- 
ry, with exercise in the open air, such as traveling affords. Even a single 
voyage, as from one side of the Atlantic to the other, is often sufficient to 
break in upon the morbid catenation; and Dr. James Johnson remarks, em- 
phatically, that he believes every form of dyspepsia, unaccompanied by organic 
mischief, would yield to the revulsion produced by traveling two or three 
thousand miles over such a country as Switzerland.—R. D. 57 
ORGANIC DISEASE OF THE STOMACH. 
this subject I shall be very brief; the best mode of communicating 
information will be to exhibit these preparations ; you will derive 
more instruction from their inspection than from any lecture I 
could deliver. (Dr. Stokes here exhibited a number of beautiful 
preparations from the Park street museum, illustrative of various 
organic lesions of the stomach.) Here is a case, which some pa- 
thologists would call cancer, others chronic gastritis. I may 
remark here, that pathologists are divided as to what is the cause 
of cancer of the stomach, but the best informed are of opinion that, 
in those cases of gastric disorganisation which are called cancer 
or scirrhus, all that can be demonstrated by the knife is referable 
to the results of chronic inflammation. This is a different propo- 
sition from saying that chronic inflammation alone will produce 
cancer. As yet we know little of cancer; dissection of cancerous 
organs gives but scanty information ; but this seems certain, that, 
in particular conditions of the economy, an inflammation of the 
stomach will end in cancerous disease. Here is an excellent pre- 
paration of the stomach of a person who died of cancer of that 
organ. For several years before his death he had a jaundiced 
look, an emaciated appearance, frequent vomiting, and severe pain 
towards the termination of the digestive process, a circumstance 
which denotes disease of the pylorus. He also had hsematemesis. 
You see the inner surface in the vicinity of the pylorus presents 
ulcerations of the mucous membrane and thickening of the sub- 
mucous cellular tissue. The pylorus itself does not appear to be 
at all contracted, but the parts around it are in a state of extraordi- 
nary disease. Look at the preparation again, and say what could 
bitters, or acids, or alkalies, or tonics, have effected in a case of 
such extensive disease. Here is a stomach in a state of long con- 
tinued chronic inflammation, and exhibiting lesions, which some 
would designate as cancer of that organ. Now, though I do not 
know the treatment which this patient underwent, I would venture 
to say that he took plenty of the usual anti-dyspeptic medicines. 
Yet, in a vast number of cases, where enormous quantities of these 
remedies are taken daily, the stomach is in as bad a state as that 
preparation exhibits, and I feel the more strongly convinced of this, 
because I am aware that many persons die. after having gone 
through the whole routine of anti-dyspeptic practice, and, when 
they are opened after death, incurable disease of the stomach is 
discovered. Here is an example of vast cancerous disease of the 
stomach ; here is a very interesting specimen of chronic gastritis, 
chiefly representing a most remarkable and circumscribed ulcer at 
the termination of the stomach. Here you see is the ulcer, with 
raised, thickened, and introverted edges. Now, in all probability, 
this ulceration was exceedingly chronic, for you perceive nature 
has been at work with it, and has made some attempts at repara- 
tion. It is in such a case as this that patients generally refer their 
pain to a particular part of the stomach : digestion goes on without 
any pain until the food reaches a certain point, when acute pain is 
felt, and this continues until it is relieved by vomiting. The 58 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
occurrence of this symptom, after an attack of acute gastritis, would 
lead you to suspect the formation of one or more ulcers, and the 
persistence of this localised pain should induce you to persevere in 
employing every means in your power calculated to remove the 
disease. The preparation which 1 now exhibit is interesting, as it 
shows the effect of corrosive poison on the stomach. The patient, to 
whom this stomach belonged, died in consequence of swallowing 
a quantity of sulphuric acid; here you see the consequences—the 
mucous membrane is black and disorganised, exhibiting this rag- 
ged appearance. In some cases of malignant fever we have found 
the stomach presenting somewhat similar appearances; and the 
same state of the stomach is described by some writers as occur- 
ring in cases of intertropical fever. Here is a preparation which 
you should inspect; chronic gastritis with a large ulcerated patch 
in the centre of the stomach. Here is another example of extensive 
cancerous disease. 
A very few words will suffice for the state of the science on the 
subject of cancer of the stomach. It is very hard, nay, even almost 
impossible, to draw a line of distinction between the symptoms of 
cancer of the stomach and chronic gastritis, and I believe it is ad- 
mitted on all hands that the same causes give rise to both. Long 
continued irritation will, in one case, produce cancer of the sto- 
mach, in another, chronic gastritis. Again, it is admitted by many, 
that what is called cancerous ulceration of the stomach has no 
appreciable difference from ulceration in various other organs ; and 
hence some other persons have gone so far as to say that there is 
no such thing as cancer of the stomach (separately considered); 
and that all the cases adduced of it are nothing more than so many 
forms of chronic gastritis. In the present state of medicine, we 
are not, indeed, possessed of any data which would enable us to 
come to a final determination on this question. It is certainly 
impossible to determine this point; but if there be any thing pecu- 
liar in cancerous matter, similar to tubercular or melanotic matter, 
there is no reason why, under the influence of inflammation, it 
should not be developed in the stomach as well as in any other 
part of the body. But whatever views we eutertain on this subject, 
we must confess that, in the majority of cases, there is a chronic 
gastritis, and that the principles of treatment which would alleviate 
the patient’s sufferings and prolong life, are those which are calcu- 
lated to prevent the occurrence of gastric inflammation. The 
more you approximate the treatment of cancer to that of chronic 
gastritis, the greater comfort will you afford your patient, and the 
more will you prolong his existence. 
The most celebrated case on record of this affection is that of the 
Emperor Napoleon. He died with extensive ulceration of the sto- 
mach, which, of course, was called “cancerous,” and there were 
also distinct traces of disease in the liver, the mucous coat of the 
intestines, and the lungs. His disease was believed by himself to 
have originated in the stomach, and to this opinion he adhered, 
notwithstanding the results of some solemn consultations, at one of $9 
ORGANIC DISEASE OF THE STOMACH. 
which his affection was declared to be an “ obstruction of the liverf 
with a “ scorbutic dyscrasy” At another it was pronounced to 
be a “ chronic hepatitis” and a course of mercury recommended! 
When we reflect on this, and read in the account by Gaubert,- 
(which you will see in the Examen des Doctrines Medicales,) the 
regimen which was used, and the list of stimulating medicaments 
employed, you will not wonder at the words of this great man, 
when he was pressed to take more drugs, to swallow the universal 
nostrum, mercury, to which he had the greatest aversion. “ Your 
disgusting preparations are good for nothing. Medicine is a 
collection of blind prescriptions, which destroy the poor, sometimes 
succeed with the rich, but whose whole results are more injurious 
than useful to humanity.” But he got mercury, notwithstanding, 
mercury for his “digestive organs;” to “excite the liver;” to “re- 
move its obstruction,” and mercury to create bile, and purgatives 
to remove it; and tonics, and antacids, and stimulants; and he 
died in torture, and his body was opened, and the stomach was 
found “ cancerous"' 
I should not omit mentioning to you, that in those cases of 
chronic gastritis which run on to an incurable stage, the best 
treatment consists in a careful regulation of diet, in keeping the 
bowels open by enemata, or the very mildest laxatives, and in 
avoiding every thing capable of producing excitement. You will 
also derive advantage from the employment of gentle counter- 
irritation. and from the internal use of narcotics, which in such 
cases appear to have a more beneficial effect than any other class 
of remedies. With the exception of these, I do not know any 
other kind of medicine you can safely employ ? and I believe that, 
in the majority of cases, you will find that the patients have taken 
already too much medicine. Anxious for relief, and urged on by 
the hope of obtaining some remedy capable of relieving their suf- 
ferings, they have recourse to every grade of quacks, are persuaded 
to swallow every kind of drug, and are subjected to every form of 
harassing and mischievous treatment. The diet which you pre- 
scribe for such patients should be sparing but nutritive; give the 
stomach as little to do as will be consistent with the support of life 
and strength ; and you may take it as a general rule in the treat- 
ment of all chronic affections of the digestive tube, whether cancer 
of the stomach, scirrhus of the pylorus, or stricture of the intestines, 
that there are two great principles of general application—preserv- 
ing a gently open state of the bowels, and allaying inflammatory 
excitement. 
Let us now proceed to the remaining parts of the digestive 
tube, of which the next in order is the duodenum. I shall not 
dwell much to day on the subject of duodenitis ; as I shall 
revert to its consideration when speaking of jaundice, because 
inflammation of the duodenum is a common cause of jaundice, 
perhaps the most common, if we take the whole of its cases to- 
gether. You are not to suppose that I wish to inculcate the 
doctrine that jaundice is a necessary complication in duodenitis: 60 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
but it has been proved that there is an extraordinarily frequent 
coincidence between both, and that jaundice very often seems 
independent of any mechanical cause, such as an obstruction of the 
biliary ducts. So far from this, that, in some cases, particularly 
those which are produced by, or accompany, a duodenitis, we have 
intense universal jaundice at the same time that the bile is flowing 
freely into the digestive tube. 
The researches of the immortal Bichat gave the first hint which 
directed the attention of practitioners to the circumstance, that, in 
many cases where jaundice had existed during life, there was no 
obstruction or disease in the liver or biliary ducts, but that in such 
cases there was always more or less inflammation in that part of 
the digestive tube into which the bile was immediately discharged, 
and this led ultimately to the discovery of the connection which 
exists between inflammation of the duodenum and jaundice. In 
treating of the sympathies which depend upon continuity of sur- 
face, Bichat refers to the connection which exists between the 
surfaces of mucous membranes and the ducts which open on them, 
and endeavours to show that the natural mode of excitement in 
all secreting glands is a stimulus applied to the surface on which 
their ducts open. As examples of this, he instances the effect 
which food and other substances, applied to the mucous membrane 
of the mouth, have in stimulating the salivary glands ; the effect 
which stimulants, applied to the conjunctiva, or nose, have on the 
lachrymal gland, and many others. Hence Broussais concludes 
that, when the mucous surface of the duodenum is thrown into a 
state of excitement, we may have a consequent affection of the 
liver, for the duodenum bears the same relation to the liver as the 
mouth does to the parotid glands. That this is frequently the case, 
I think, is very probable. It is now established, that the cause of 
the yellowness in what has been called yellow fever, is disease of 
the upper part of the digestive tube, in which the duodenum is 
always involved ; and that the fever itself (the typhus icterodes of 
the nosologists) has been found to be greatly connected with in- 
flammation of the stomach and duodenum. During the epidemic 
of 1827, we had in the Meath Hospital a great many cases which 
bore a striking resemblance to the yellow fever of warm countries, 
and particularly in this, that they were accompanied by intense 
jaundice, and inflammation of the upper part of the digestive tube. 
You will see in the works of Rush and Lawrence, two of the best 
American writers on yellow fever, that, of the numerous bodies 
they examined, there were scarcely any in which the jaundice 
was found in connection with liver disease, but that in all cases 
there was intense inflammation of the digestive surface. I shall 
return to this subject when I come to speak of liver disease. 
With respect to the jejunum, I may state that we know very little 
of the symptoms which characterise inflammation of this part of 
the intestinal canal; and it is a curious pathological fact, that this 
portion of the tube is, of all others, the least liable to inflammation. 
In point of fact, we have no means of ascertaining what are the ORGANIC DISEASE OF THE STOMACH. 
61 
prominent symptoms of inflammation of the jejunum, because, in 
almost every case in which jejunitis has been discovered, there has 
been also extensive disease of the rest of the small intestine. We 
have cases of simple gastritis ; there have been also cases of distinct 
disease of the duodenum. We may have disease in the lower 
third of the ileum, unaccompanied by an affection of any other 
part of the tube. The same thing may occur in the case of the 
caecum, colon, or rectum, but it seldom or never occurs so far as 
the jejunum is concerned. I shall therefore pass over jejunitis, 
and proceed to draw your attention to one of the most important 
diseases to which the human subject is liable—inflammation of 
the ileum. 
Inflammation of the ileum is a most important affection, for two 
reasons ; first, in consequence of its extraordinary frequency, and, 
in the next place, of its insidious latency, the disease generally 
requiring a considerable degree of tact and experience on the part 
of the practitioner to make out its diagnosis with certainty. In 
fever, it is the most frequent of all forms of intestinal inflammation; 
and hence Broussais, finding inflammation of the ileum of such 
constant occurrence in fever, concluded that fever was only symp- 
tomatic of intestinal inflammation. Further researches have shown 
that he was mistaken, and that the inflammation of the digestive 
tube is, in many cases, secondary ; but it is still a circumstance of 
almost constant occurrence, and in many cases of fever is the cause 
of death. Now, the portions of the intestinal tube most commonly 
affected in fever are the stomach and lower part of the ileum ; 
and the frequent occurrence of this in fever is very remarkable. 
There are few cases of typhus without it. In some cases of typhus 
you will, on examination after death, be astonished to find exten- 
sive disease of the intestinal canal, which, during life, had not 
attracted any particular notice, and this you will most commonly 
find in the lower part of the ileum. So common is it, that Louis 
says that ileitis is the grand anatomical feature of typhus fever ; 
that is, had he been obliged to pitch on the lesion of same parti- 
cular organ as giving a character to typhus, he would say that it 
was ileitis. There are other diseases, too, in which inflammation 
of the ileum forms the principal complication. In the diseases of 
children, which go by the names of worm fever, remittent fever, 
and bilious fever, I believe that ileitis is generally the first affec- 
tion, and that the fevers are only symptomatic of it. It constantly 
occurs at some period or other of tabes mesenterica ; and I believe 
that in many cases it precedes the affection of the mesenteric 
glands. It is exceedingly common in phthisis. In every case of 
phthisis, where diarrhoea has lasted for some time, the probability 
is, that there is ulceration in the caecum, colon, and lower part of 
the ileum. 
Now, what is the nature of this ileitis ? This preparation, (hand- 
ing one for inspection,) which I beg of you to hand round, will 
furnish a very good illustration of the disease. Here is a portion 
of the intestine exhibiting various distinct ulcerations of different 62 
STOKES’S THEORY ANIi PRACTICE OF MEDICINE. 
sizes, occupying the situation of the mucous glands. I do not 
mean to say that the character of the disease consists in this dis- 
tinct ulceration; it is an essential disease of the mucous membrane, 
and of its glands, which exist in great numbers on the surface of 
the lower third of the ileum, and are called solitary and aggregate. 
These glands frequently take on the inflammatory condition, 
become softened, run into ulceration, and produce extraordinary- 
sympathetic irritation of the whole system. There has been lately 
a great deal of discussion with respect to the question—Whether 
disease begins in the glands or in the mucous membrane, and 
whether we can separate disease of the glands from disease of the 
mucous membrane. This has been carried to a great extent; and 
a change has been attempted to be made in the name of the disease, 
it being entitled dothinenteritis by those who say that the inflam- 
mation commences in the glands. But this I think is a mere 
refinement, and is carrying the thing too far. It is next to impos- 
sible for the glands to be affected without involving the mucous 
membrane, or for the mucous membrane to be affected without an 
extension of the disease to the glands. We sometimes, however, 
see the mucous membrane diseased without the glands being ap- 
parently engaged; but I think the glands are never engaged without 
the co-existence of disease in the mucous membrane. In this pre- 
paration you see the mucous membrane is just giving way; and 
here is an actual slough, where the mucous and submucous tunics 
have yielded to the inflammation. In the lower portion of the 
ileum we meet with an infinite variety in the size and number of 
the ulcerations: in some they are very close and numerous, in 
others there are only two or three detached ones ; in some, the 
whole circle of the intestine is destroyed ; and the ulcer is nearly 
as broad as the palm of your hand. It is interesting to consider, 
with respect to the pathology of the respiratory and digestive sys- 
tems, how it comes that ulceration of the mucous membrane is so 
much more common in the digestive apparatus than in the respi- 
ratory. For one ulceration of the bronchial mucous membrane 
from acute disease, you will have one hundred of the gastro- 
intestinal. For this peculiarity we cannot clearly account; but 
there seems to be more development in the digestive than in the 
respiratory system, and that this over-development produces a 
tendency to disease. This, perhaps, is an approximation to an 
explanation of the facts; and to this may be added, that the mucous 
membrane of the intestines is exposed to the influence of a much 
greater variety of agents. It is difficult to give an accurate idea of 
the symptoms of ileitis, as we can only arrive at a knowledge of 
it by negative evidence, or, as the French term it, u par voie 
d'exclusion.” 
In a case of gastritis and of inflammation in the upper part of 
the digestive tube, the most prominent symptoms are thirst and 
vomiting. In this affection, too, there is thirst, but it is by no 
means so urgent as in the former cases, and there is generally no 
vomiting. In a case of acute gastritis there is always a desire for ORGANIC DISEASE OF THE STOMACH. 
63 
cold drinks. In this disease there is also a desire for fluids, but 
the patient prefers them warm. Here you perceive two symptoms 
connected with the predominance of disease in the upper part of 
the digestive tube are absent—vomiting and the desire for cold 
drinks. 
Now, you are aware that, in a case of inflammation of the 
colon and rectum, the most prominent symptoms are diarrhoea, 
tenesmus, and the passing of a quantity of morbid secretions. 
These symptoms, in a case of ileitis, are either wanting, or they 
are so slight as to excite very little notice. If, then, in a case of 
intestinal disease, we abstract the characteristic symptoms of disease 
in the upper and lower part of the digestive tube from the pheno- 
mena of the existing disease ; if we find that it presents symptoms 
which do not properly belong to either the stomach, duodenum, 
colon, or rectum; we conclude that it must depend on a lesion of 
the remaining part of the canal, and we are in this way led to the 
diagnosis of ileitis. Let us enumerate the symptoms of an ileitis. 
In the first place, thirst, without a preference for cold drinks; in 
the next, absence of vomiting; again, in the early period of the 
disease there is generally a tympanitic state of the belly, and the 
patient seldom complains of pain, even in fatal cases. This is a 
point of extreme importance. There is, however, most commonly 
a degree of tenderness over the ileum, which you will be able to 
detect by an accurate examination, and this tenderness presents a 
remarkable difference from the tenderness of gastritis, both in de- 
gree and situation. It is very seldom so exquisite as in a case of 
gastritis, the patient can bear a considerable degree of pressure, 
and the tenderness, in place of being towards the epigastrium, is 
situated between the umbilicus and the crest of the ileum on the 
right side ; here pressure excites pain. The tongue in this affec- 
tion is generally of a dirty white, pointed, and red along the edges 
and tip; the pulse is quick and small, and the face is contracted. 
As to the nature of the discharges from the bowels they are ex- 
ceedingly various ; there has been as yet no diagnosis founded on 
their appearance, and in some fatal cases they have been observed 
to retain an almost perfectly healthy appearance throughout. 
What would the gentlemen who draw their diagnosis from the 
chamber-pots say in such cases ? I have seen perfectly natural 
stools in cases which immediately after have terminated fatally, 
and where, on examination after death, there was a vast extent of 
ulceration in the ileum. In addition to the symptoms just recited, 
the patient most commonly has fever, and this presents itself under 
various forms, frequently assuming the type of a simple continued 
fever ; hence, in a great many cases, the patient is merely sup- 
posed to labour under simple continued fever, and the existence of 
extensive inflammation of the ileum, is entirely overlooked. In 
other instances, there is more or less prostration, which increases 
with the progress of the disease, and the fever frequently receives 
the appellation of typhoid. Under these circumstances, the patient 
often gets bark and wine, every means is taken to support his 64 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
strength and remove the typhoid condition of the system, the 
inflammation of the intestine is exasperated by neglect and mal- 
treatment, the patient dies, and, on dissection, the ileum presents 
an enormous sheet of ulcerations. 
In cases of this kind, where the diagnosis depends as much on 
negative as on positive circumstances, it is of importance to have 
a direct sign by which we may be able to ascertain, with some 
degree of certainty, the existence of a suspected enteric inflamma- 
tion, and I think I have discovered one, which I believe has not 
been as yet noticed ; this is increased pulsation of the abdominal 
vessels. In many cases of acute inflammation of the brain, the 
increased pulsation of the carotids has been frequently remarked, 
and every one sees, that, under such circumstances, there is an 
undue excitement of these vessels, or, in other words, that there is 
a want of proportion between the action of the carotids and that of 
the arteries of the extremities. If your finger be attacked by 
paronychia the same phenomenon is observed, the artery leading to 
the inflamed finger beats much stronger than the artery of the 
corresponding one on the opposite side. From these circumstances 
I was led to conclude, that, in cases of acute inflammation of the 
digestive tube, there would be increased pulsation of the abdominal 
aorta; and on following up the investigation by examining several 
persons who had distinct and well marked intestinal inflammation, 
I found that my conclusions were well grounded. In such cases, 
I found not only a remarkable throbbing of the abdominal aorta, 
but I also discovered that this throbbing was prolonged to the fe- 
moral arteries, and that, on the other hand, there was little or no 
corresponding excitement in the arteries of the upper extremities. 
LECTURE VIII. 
Diseases of the small intestines—Symptoms of ileitis—Occurrence of diarrhoea with 
fever symptomatic of this form of inflammation—Frequency and symptoms of the 
disease in children—Tubes mesenterica, treatment of. 
At ray last lecture I was engaged in the consideration of disease 
of the small intestines : let us now resume the subject. You re- 
member I mentioned to you that most of our knowledge of the 
inflammatory affections of the small intestines refers to the ileum, 
and that, in point of fact, we know little or nothing of disease of 
the jejunum. This, however, is not of much importance, as, of all 
the parts of the digestive tube, the jejunum is the least liable to 
disease, and is seldom or never engaged without the co-existence 
of disease in the ileum or duodenum. You recollect I drew your 
attention strongly to the extreme frequency of inflammation in the 
lower third of the ileum, and the importance which it derives from DISEASES OF THE SMALL INTESTINES. 
this as well as from its insidious latency. I showed that it was 
one of the most common secondary lesions in typhus fever, and a 
frequent cause of death. This cannot be impressed too much upon 
your minds—it is a point of pathology on which the best informed 
medical men are agreed. It may also, and very often does, occur 
as a pure idiopathic affection, without being preceded or superin- 
duced by that morbid state of the whole economy to which we 
give the name of fever. I said it was extremely common in chil- 
dren ; that here it was in many instances mistaken for worms, or 
bilious, or remittent fever ; that it constantly occurred during the 
progress of tabes mesenterica, and often appeared to have the 
initiative. I alluded to the discussion which has arisen as to the 
question whether disease begins in the glands or mucous mem- 
brane, and stated that such discussions are useless, as it is impos- 
sible to separate the two affections in diagnosis or treatment, and 
practical medicine gains nothing by the distinction. 
With respect to the symptoms of ileitis, I observd that they were 
those of a general affection of the digestive tube, the phenomena 
which indicate irritation at its upper and lower part being absent. 
That if you abstract from symptoms of a general affection of the 
intestinal canal, the vomiting and desire for cold drinks which 
characterise inflammation of the upper part, and the diarrhoea and 
tenesmus which denote disease of the lower part, you will have the 
diagnostic marks of an ileitis. At our last meeting I showed you 
some preparations illustrative of this disease; I intended to have 
exhibited others of the same kind to-day, but regret that I cannot 
lay my hands on them at present. Allow me to rehearse the 
symptoms of ileitis once more. Thirst, without desire for cold 
drinks ; absence of vomiting, and of the characteristic symptoms 
of inflammation of the colon and rectum; early tympanitis, gene- 
rally on the second day of the disease ; absence of pain, but exist- 
ence of tenderness on pressure between the umbilicus and the 
crest of the ileum ; pointed tongue, of a dirty white on the upper 
surface, and red at the sides and tip; contracted features; quick, 
small pulse; fever, and, what I forgot to mention in my last lecture, 
scanty high-coloured urine, a very constant symptom, so much so 
that I have known this disease mistaken for an affection of the 
kidney, and the patient treated accordingly. I must add, that the 
patient died, that the kidney was found perfectly healthy, the 
ileum in a state of violent inflammation, and the suppression of 
urine to be referred to this cause alone. 
I drew your attention at my last lecture to the increased pulsa- 
tion of the abdominal aorta and its immediate branches, and stated 
that I looked upon this as a direct sign of abdominal inflammation. 
I do not mean to say that every case of increased action of the 
great abdominal arteries is significant of ileitis or intestinal inflam- 
mation. We see unusual pulsation of the abdominal aorta in 
hysterical females, and see it subside under the use of antispas- 
modics ; we see it in painter’s colic; we see it in cases of extreme 
emaciation ; we see it in disease of the aorta, or of some of its first 66 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
large branches. What I wish to draw your attention to is this: 
where we have this symptom in addition to other signs of inflam- 
mation of the digestive tube, it is of considerable value as a diag- 
nostic. 
You may remember I stated that ileitis, from being generally 
attended by fever of the continued type, has been frequently supposed 
to be simple continued fever, and that this was one of the conse- 
quences which resulted from the latency of the disease. Petit was 
the first who described this disease rightly. He described it under 
the name of entero-mesenteric fever, that is to say, fever depending 
on disease of the mesenteric glands and small intestine. The fol- 
lowing is an outline of his description : “ The attack comes on with 
debility, irregular fever, quick, small pulse, sunken countenance, 
perhaps some diarrhoea, a lustrous expression of the eye.” I may 
remark here that the occurrence of diarrhoea without any evi- 
dent affection of the great intestine, and accompanied by fever, is 
almost always a sign of ileitis. It too often happens that practi- 
tioners, as I before remarked, prescribe for names. In cases of 
pulmonary disease, if the patient has fever, with copious expecto- 
ration, they say he is labouring under an attack of bronchitis ; but 
in case of intestinal inflammation, accompanied by increased se- 
cretion, it is different; they merely say he has diarrhoea, and 
prescribe for it without connecting it with its proper cause. The 
general rule is, that when you have diarrhoea with fever, there is 
inflammation of the digestive tube. 
In inflammation of the ileum the patient generally lies on his 
back, and avoids motion as much as he possibly can, his skin is 
dry and harsh; he is feverish; he has thirst, but little desire for 
cold drinks; he scarcely ever vomits ; his alvine dejections are 
sometimes thin and purgative, sometimes figured and natural. 
But there is one circumstance which is of considerable importance 
in pointing out the amount of disease, even in cases where patients 
have considerable diarrhoea, and this is, that the diarrhoea is not 
sufficient to account for the extraordinary prostration. There must 
be some cause for the great reduction of vital power besides the 
mere diarrhoea, and I must state to you that there are few diseases 
which bring on such rapid prostration as inflammation of this por- 
tion of the digestive tube. In the advanced stage of this disease 
the patients have cold skin, subsultus tendinum, petechiae, involun- 
tary discharge of urine and faeces, low delirium, coma, gangrenous 
ulcerations of the back, sinking of the powers of life, effusions into 
the head and chest, in fact, all the symptoms which characterise 
the last stage of typhus. Generally speaking, the disease is more 
or less prolonged, and the patients die of exhaustion, but in some 
cases the approach of death is more sudden and formidable. Some 
of the ulcers pass deeply into the substance of the intestine, perfo- 
rate all its coats in succession, the contents of the intestine escape 
into the peritoneum, and the patient is carried off by a rapid 
peritonitis. 
Inflammation of the ileum is very frequently met with in chil- DISEASES OF THE SMALL INTESTINES. 
67 
dren, and it is most important that you should be aware of the 
extreme frequency, as well as the symptoms, of this disease, in 
those little creatures. There is one fact in pathology which seems 
not to be generally acted on—that there is a class of diseases which 
are intra-uterine, and with which a child may be born. There 
are a great many cases of this kind on record, hut still, I must 
confess, there is a great scope for investigation, and that our know- 
ledge on this subject is imperfect. I believe that any one who has 
the opportunity of dissecting a great number of still-born children, 
or of those who die immediately after birth, would, by examining 
the state of the different cavities, and publishing the results of his 
examinations, earn for himself very great reputation. It is a well 
known fact that children may be born with hydrocephalus, with 
tubercles in the lungs, with acute inflammation of the stomach ; 
nay, more, children have been known to be born with chronic 
gastritis, and with old ulcerations in the ileum and colon. When 
children happen to be born with gastro-enteric disease, they are 
puny and weak; the fact of this occurrence is generally overlooked, 
the case is considered to be one of general debility, and hence most 
of those children are lost in consequence of their medical attendants 
being ignorant of the real nature of the disease. It is a very 
curious fact, too, that where enteric disease occurs in very young 
children, it is frequently met with without any accompanying fever, 
and this is a point of great importance. Here is a fact not gene- 
rally known. A new-born infant has vomiting, swelled belly, con- 
tracted features, but at the same time he has cold skin and feeble 
pulse ; he has no distinct symptoms of fever, and a puny and feeble 
state of constitution appears to be the prominent symptom. He 
dies, and on opening the body you find distinct traces of enteric 
inflammation. The younger the child is, the less will be the 
chance of fever occurring as a sign of enteric inflammation. It 
seldom happens that this takes place after dentition, but before it is 
very common. 
Now, what are the circumstances which would enable us to re- 
cognise this disease in children who have passed the period of first 
dentition ? If you find the child vomiting, thirsty, with swelled 
belly, hot skin, a tendency to diarrhoea, and an erythematous red- 
ness about the anus, you may be sure that there is disease of the 
digestive system ; if the child is restless, and you perceive that the 
symptoms of irritation of the head are coming on, you will be more 
certain, and in such cases pathology will inform you that the dis- 
ease is chiefly in the ileum. In the advanced stage the diarrhoea is 
lessened, but the belly continues tympanitic, the child exhibits 
traces of long suffering, and the circumstance of the teeth not 
being developed gives it the appearance of premature old age, 
which cannot be mistaken by an experienced eye, and is a sign of 
long continued and extensive intestinal disease. In some cases, the 
child gets a common attack of diarrhoea ; this is neglected, but 
after going on for two or three days, symptoms of fever begin to 
appear. Here we arrive at a practical rule. Where a child has 68 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
diarrhoea, and, after labouring under this for a few days, gets an 
attack of fever, you may be almost sure that it is a case of enteritis, 
and that you will be acting wisely in treating it as such. In the 
opinion of many well-informed practitioners, that form of fever 
which has been called infantile remittent, is only an example of 
this disease. In proof of this fact, Dr. Marsh, my friend and pre- 
decessor in this school, in his paper on jaundice, makes some excel- 
lent remarks on this subject. “ There is yet one form of disease of 
very frequent occurrence, the seat of which is in the stomach and 
small intestines. That to which I allude, is the infantile remittent 
fever, or, as it is vulgarly termed, the worm fever of children. Its 
characteristic symptoms, if closely analysed, will be found all of 
them to point to the mucous surface as the original seat of morbid 
action.”—Dublin Hospital Reports, vol. iii. 
It would be well for medicine, if the valuable information con- 
veyed in Dr. Marsh’s paper was more universally diffused. I feel 
convinced that many children fall victims to malpractice under 
circumstances of this kind. A child gets symptoms of diarrhoea, 
has irregular or bad appetite, and swelled belly. The disease is 
called worm fever ; he gets a dose of calomel and jalap, and, per- 
haps, passes some worms; for, when we come to speak of worms, 
we shall find that disease of the mucous surfaces is intimately 
connected with worms, and, in the opinion of one practitioner, 
worms may be the result of enteric inflammation. Well, some 
worms are passed; the purgative is again used ; the child may 
not pass any more, or he may pass one or two in a week to en- 
courage the practice. But all the symptoms of intestinal inflam- 
mation, the diarrhoea, the tympanitis, the thirst, the fever, are 
supposed to depend upon the presence of more worms, and these 
are to be evacuated by purgative medicine; and thus the affair 
goes on, until the child falls into tabes mesenterica, or gets sympa- 
thetic inflammation of the brain, and dies of hydrocephalus. I 
regret to add, that in many cases of this kind the head alone is 
opened; a little fluid is discovered in the ventricles of the brain, 
the doctor’s diagnosis of the head is found to be correct, and all 
parties are satisfied. In cases of this kind, the early application of 
leeches to the belly, the regulation of diet, keeping the bowels 
gently open by enemata and mild counter-irritation, would have 
saved the patient. This is not mere theory; it is but a statement 
of facts, supported by the experience of practical men. 
I wish to say a few words here with respect to tabes mesenterica. 
In a course of lectures like the present, it would be impossible to 
examine, in detail, the different forms of this disease; it will be as 
much as I can do to draw your attention to the general principles 
of its pathology and treatment. The term, tabes mesenterica, is 
employed to designate that species of consumption which depends 
upon disease of the mesenteric glands. The common idea formerly 
entertained with respect to this affection, and, I believe, still to a 
great extent, is, that the disease first commences in the mucous 
glands, and from these extends to the lymphatic ganglia of the DISEASES OF THE SMALL INTESTINES. 
69 
mesentery, which, in their turn, become enlarged, thickened, and 
less pervious, so that a sufficient share of nutriment cannot be 
absorbed, the consequence of which is, that the patient dies of 
atrophy and exhaustion. With such views of the case, the prin- 
ciples of treatment consisted in employing a class of medicines 
called deobstruent, the operation of which was supposed to be 
efficacious in removing this obstruction, this deposition in the sub- 
stance of the mesenteric glands, and the enlargement by which it 
was accompanied. This was, and this, I am sorry to say, is the 
idea still entertained by many. What is the actual state of the 
science with respect to this disease ? It is found that the glands 
are certainly changed in their structure, and that they are mani- 
festly enlarged; but this is only a link in the chain of phenomena, 
for it has been proved that in the majority of cases the disease is 
ushered in by enteritis, and that the swelling of the glands is the 
result of disease, propagated along the course of the lymphatics 
from the mucous surface of the intestines to the mesenteric 
ganglia. This preparation, which I shall send round, will give 
you an idea of the actual state of the disease. Here is one of the 
glands which has been cut through; it exhibits the cheesy texture 
commonly observed in this disease, but you can perceive there are 
a number of lines running towards each of the glands ; these are 
the engorged lymphatics, which, you see. correspond with ulcers 
on the mucous surface of the small intestine. That this is the 
true pathology of the disease will appear from the following cir- 
cumstances :—First, it has been proved that the glands of the 
mesentery commonly become inflamed, enlarge, and suppurate, in 
cases of inflammation of the mucous membrane of the intestinal 
canal in the adult. A patient gets enteric inflammation and dies ; 
on dissection, we find distinct marks of disease in the intestines, 
and, in addition to this, we find the glands evidently diseased. 
Here is one fact. In the next place, it has been proved that, in a 
great many cases of tabes mesenterica, if you retrace the history of 
the disease, if you go back to its first and earliest phenomena, you 
will find that it began with the symptoms of what has been termed 
remitttent fever, or that the patient had enteritis or diarrhoea, which 
afterwards became chronic, and that then the symptoms of tabes 
mesenterica began to appear. In the third place, you will find 
that, in a vast number of cases, where a fatal termination has oc- 
curred, if you pursue your dissection, and slit up the whole of the 
ileum, you will discover numerous old ulcerations of the mucous 
membrane, and find that the lymphatics which correspond with these 
ulcerations are in a state of manifest disease. Lastly, it has been 
observed that the best treatment for tabes mesenterica is that which 
is calculated to remove enteric inflammation, and that the old treat- 
ment, founded on the principle of removing obstruction, by the use 
of alkalies, absorbents, and solvents, is erroneous and false in the 
majority of cases. So that we have proof of the origin of this 
disease in intestinal inflammation, drawn from the occurrence of 
analogous affections in the adult, from the phenomena of the disease 70 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
in its early stage, from morbid anatomy, and from treatment. I 
think there can be no doubt that, in most instances, it commences 
by intestinal inflammation. Of course a predisposition to disease 
of the glandular system will favour the occurrence. But is there 
no case in which the disease has commenced in the glands, and 
where the mucous membrane of the digestive tube is secondarily 
engaged 7 My answer to this question is, in a few cases we can- 
not prove that the disease commenced in the mucous membrane, 
and there is no reason why the glands of the mesenterica should 
not be liable to primary tuberculous or scrofulous deposition as 
well as those of any other part of the body ; but, in a vast number 
of instances, the enlargement of the mesenteric glands is secondary, 
and resembles the inflammation of the inguinal glands which re- 
sults from chancre on the penis. I would advise you to consult 
the Commentaries on Pathological Propositions by Broussais. On 
this subject, also, Dr. Mackintosh’s Practice of Physic. 
There is one thing more connected with this disease, which is of 
considerable importance, and to which I shall briefly draw your 
attention, and this is, that this inflammation of the glands of Peyer 
and Brunner, this dothinenteritis, as it has been called, is a very 
common cause of slow convalescence in fever. You will meet 
with cases of fever, which will go on to the 17th or 21st day, and 
then something like a crisis takes place; you expect that from this 
time forward the patient will get progressively better; but in the 
course of a few days you will be surprised to find no amendment, 
and that he is not gaining strength ; you feel his pulse, and find it 
quick and small, his attendant informs you that he is restless at 
night, and when you ask him how he feels, he says he has no 
particular complaint, but that he is very weak, gets no sleep at 
night, and has no appetite. Under these circumstances you are 
anxious to find out what his disease is; you enquire into the state 
of the heart, lungs, and brain ; you find no evidence of disease in 
any of these organs; you run over in your mind the symptoms 
present, the feverishness, quick pulse, want of appetite, restless- 
ness, and finding some degree of abdominal tenderness and tym- 
panitic swelling, you arrive at the conclusion that the return of 
health and strength is impeded and delayed by the existence of a 
dothinenteritis. The first person who discovered this fact was 
Dr. Cheyne. “ In these cases,” says he, “ the distress of the patient 
often bore no proportion to the danger he was in; the former was 
very little, while the latter was extreme. The disease would pro- 
ceed without violent symptoms; nay, a patient would seem to be 
recovering, although without any critical discharge ; he would 
call for full or middle diet, and for days take his food regularly. 
The only circumstance in his situation which demanded attention 
was, that he regained neither flesh nor strength, and he expressed 
no desire to leave his bed. Then, his pulse again became quick 
and his tongue dry ; and he would complain of dull pain and un- 
easinesss in his belly, attended with soreness on pressure, and a 
degree of fulness in the upper part of the abdomen. Then came DISEASES OF THE SMALL INTESTINES. 
71 
on a loose state of the bowels, and great weakness. Probably at 
the next visit the patient was lying on his back, with a pale sunken 
countenance, and a very quick pulse; his mind without energy. 
Then his stools (mucous) passed from him in bed, and the urine 
also. Perhaps a hiccup came on ; next his breathing became fre- 
quent, in which case death was at no great distance.” In all these 
cases the mucous membrane and glands were found in a state of 
decided disease. 
Now, what was the nature of this disease ? It came on as a 
secondary affection during the course of fever, became more marked 
and intense, and finally destroyed the patient. I have seen very 
many cases of this disease. I give you this as a general rule:— 
when, after the apparent termination of a fever, your patient con- 
valesces very slowly and imperfectly ; when you find that he is 
becoming weak, that his pulse is quick, his belly tympanitic, his 
thirst still present, and all this without evidence of disease in the 
respiratory, circulating, or nervous system, you may suspect 
inflammation of the mucous glands of the digestive tube, which 
may terminate in deep ulcerations; and you will not be surprised 
if your patient should be carried off by rapid peritonitis, occasioned 
by an ulceration of all the coats of the intestine. I have witnessed 
many instances of the truth of this statement. 
It has been objected to the doctrine, that infantile remittent fever 
and tabes mesenterica depend on inflammation of the mucous 
membrane of the digestive tube, because it has been found that 
purgatives are sometimes useful in the treatment of the disease; 
and those who bring forward this objection ask, “ if purgatives 
give relief, how can it be intestinal inflammation ?” Now, what 
are the real facts of the case ? These cases, which have been 
relieved by purgatives, are cases in which purgative medicine has 
been given in the early stage, and has been productive of benefit; 
or, in other words, where the disease is only just commencing, and 
where its cause is proved to be the presence of irritating matter in 
the bowels. A physician is called to a case of this kind ; he gives 
a purgative ; a quantity of offending matter is evacuated, and the 
child gets better. You should act in the very same way, and have 
recourse to purgatives whenever you have reason to suspect the 
existence of irritating or indigestible matter in the bowels. You 
are to employ purgatives on the same principle as every one em- 
ploys emetics in cases where corrosive poison has been swallowed; 
but no one is inclined to think that he will be able to cure the dis- 
ease by the continued use of emetics. But, unfortunately, persons 
do not attend to the actual state of the digestive tube ; they go on 
prescribing purgative after purgative, until the irritation, which 
was originally produced only by indigestible matter, becomes exa- 
cerbated, and terminates in ulceration of the intestinal mucous 
surface, accompanied by all the symptoms of tabes mesenterica. 
The treatment of this affection is both simple and easy, particu- 
larly when the patient applies to you at an early period. In the 
case of children, one of the first things you have to determine is, 72 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
whether you shall have recourse to the employment of purgatives 
or not. If you happen to be called in at an early period, or if the 
patient has taken no purgatives, and there is reason to suspect a 
loaded state of the bowels, you will be right in employing some 
mild laxative. You cannot commence your treatment better than 
by prescribing some mild opening medicine, particularly when you 
discover that the patient has been taking indigestible improper food. 
This plan I think both reasonable and useful. You will frequently 
meet with cases in which all the bad symptoms will disappear 
after the use of a few laxatives. Here is a point on which the fol- 
lowers of Broussais erred. They declared that the exhibition of a 
single laxative would be to endanger the patient’s life ; and that the 
only treatment which could be relied upon consisted in the use of 
leeches, low diet, and cold water. But I think there is as much 
reason in giving a laxative to remove indigestible matter from the 
bowels in a case of this kind, as there would be in giving an emetic 
in a case of gastritis produced by the presence of indigestible mat- 
ter or corrosive poison in the stomach. But if, after having evacu- 
ated the bowels, the symptoms of intestinal irritation should con- 
tinue, you are not to persist in the use of purgatives; change your 
hand, and attack the symptoms of intestinal inflammation, which 
have now decidedly commenced. 
We shall occupy ourselves, gentlemen, at our next lecture, in 
considering the treatment of this disease in the adult as well as 
children, and then go on to the disease of the large intestines. 
LECTURE IX. 
Treatment of ileitis—Advantage of leeching—Stimuli sometimes beneficial—Infantile 
remittent fever—Inflammation of the mucous membrane—Enteritis with diarrhoea— 
Effects of opium in inflammation of serous and mucous membranes—Pathology and 
treatment of diarrhoea and dysentery—Perforation of the intestine—Diseases of the 
large intestine. 
We shall be occupied to-day in considering the treatment of in- 
flammation of the mucous membrane of the small intestine. You 
may recollect that in my last lecture I spoke of the employment of 
laxatives in this disease, and mentioned that we are to employ 
laxatives in enteritis, on the same principle as emetics are used in 
cases where corrosive poison has been taken into the stomach. We 
are not to expect to be able to cure the disease by the use of laxa- 
tives, nor are we to have recourse to them in every case; we employ 
these remedies where we have decided evidence of the existence of 
offending matter in the bowels. We may meet with a case in the 
early stage, under such circumstances that the removal of the irri- 
tating matter by judicious purgation may completely relieve the 
patient, and this, I believe, is the foundation on which the super- TREATMENT OP ILEITIS. 
73 
struction of the British purgative practice in ileitis and tabes 
mesenterica was raised. It was concluded that a laxative treat- 
ment, which had on many occasions succeeded in removing the 
first symptoms of the disease, would necessarily cure it in all stages 
and cases. This, I need not tell you, is wrong. Whenever you 
give purgatives or laxatives in enteritis, bear this in mind, that the 
effect which you have to produce is to be brought about at the least 
possible risk. If you can unload the bowels with a little castor oil 
or rhubarb, or some mild neutral salt, it is much better than to 
have recourse to calomel, or scammony, or colocynth. As a ge- 
neral rule, drastic purgatives must be avoided in inflammation of 
the mucous membrane of the intestines. The school of Broussais 
committed an error, on the one hand, by never admitting the use 
of laxatives, and British practitioners have been wrong, on the 
other hand, by giving too much purgative medicine. The error 
of the latter arose from looking always upon purgatives as anti- 
phlogistics, which they are certainly, so far as they contribute to 
relieve inflammation by causing an increased secretion from the 
intestinal mucous surface. But this increase of secretion can be 
produced only by stimulating the organ to which they are applied ; 
and hence, before they can become general antiphlogistics, they 
must of necessity be local stimulants. Further; if in a case of 
inflammation of the digestive tube you prescribe a purgative, and 
it fails in causing an increase of secretion, it will add considerably 
to the existing inflammation. It is, however, of very great import- 
ance that there should be no accumulation of offending matter in 
the bowels; and hence, when yon find a degree of fulness in the 
belly, and the dejections scanty, you should always give a laxative, 
and follow it up by the administration of a narcotic. By using ene- 
mata, you can do a great deal of good, and this without any injury 
to the digestive tube; and I think they may be always employed 
with benefit in disease affecting the ileum. Recollect, gentlemen, 
what I wish to impress upon you respecting this part of the treat- 
ment is, that laxatives are to be employed in ileitis as one of the 
means of cure ; but you are not to expect that a cure by the use of 
these alone will always be a matter of constant occurrence. It is 
true that many cases presenting symptoms of enteritis, have, in the 
beginning, yielded to laxatives; but it is true, also, that horrible 
mischief has been done by their continued or indiscriminate em- 
ployment. 
A few observations now with respect to bleeding. There is in 
simple inflammation of the mucous membrane of the intestines this 
peculiarity—it very seldom happens that it is necessary to use the 
lancet. The whole class of intestinal inflammations is so generally 
accompanied, even in the early period, with marked prostration 
and a typhoid condition of the whole system, that general bleeding 
is very seldom employed. But when the disease is recent, the 
constitution vigorous, the patient young, the skin intensely hot, 
and the pain violent, (a combination of circumstances which is not 
of very common occurrence,) you may employ the lancet with 74 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
safety and with great advantage to your patient. But what I wish 
to impress upon you is this—you must not expect to cut short an 
attack of enteric inflammation by general bleeding. Over inflam- 
mations of mucous membranes in general, but particularly of the 
intestinal mucous surface, the lancet has comparatively but little 
direct power ; it is in the inflammatory affections of parenchyma- 
tous tissues and serous membranes, that we generally observe the 
most brilliant and decided effects of venesection. Neither can you, 
as in parenchymatous inflammation, bleed a second and a third 
time with benefit. In cases of inflammation affecting the mucous 
membrane of the intestinal canal, you are to look upon venesection 
as a preparatory step to leeching. Where the pain is violent, the 
fever high, the attack recent, and the constitution strong, you will 
do well to bleed; but only bleed once, and then apply leeches in 
abundance over ths suffering organ. There is nothing of more 
importance, nothing of such decided value, as bleeding by leeches 
in inflammation of the mucous membrane of the intestinal canal, 
and here we arrive at a fact, the explanation of which is involved 
in much obscurity. A patient is attacked with inflammation of the 
mucous membrane, and glands of the digestive tube, twelve or 
twenty leeches are applied to the integuments of the abdomen, and 
their application is followed by extraordinary relief. This is a 
very curious fact when we consider that between the place where 
we apply the leeches, and the tissue which is affected, there inter- 
vene skin, cellular membrane, superficial fascia, cellular membrane 
again, deep-seated fascia, muscular substance, cellular membrane 
again, two layers of peritoneum, and muscular substance enveloped 
in cellular tissue. Yet, notwithstanding this extraordinary succes- 
sion of tissues, it is an undeniable fact, that the application of a dozen 
leeches to the surface of the belly will frequently cut short an intes- 
tinal inflammation, or materially diminish its intensity. Here is a 
fact, the explanation of which is extremely difficult; and I tell you 
candidly, I cannot explain it. The school of Broussais attempt to 
explain it as follows. They state that it is a constant law of the 
economy, that there is a strong sympathy between the internal 
parts and their respective integuments, but they do not say why 
this sympathy should exist. We frequently, however, observe facts 
confirmatory of this law; you are aware that it often happens, that, 
in cases of the deep-seated muscular phlegmon mentioned by Mr. 
Crampton, in abscess of the liver, and in empyema, we have a 
swelling of the integuments, showing the existence of a sympathy 
between the integuments and the internal organs. 
In treating a case of inflammation of the small intestine, I think 
you may generally commence with the application of twelve or 
eighteen leeches over the ileo-coecal region. The ordinary result 
of this application is, that the pain and tympanitis are reduced, and 
the thirst diminished ; but the patient still has fever, and you are 
to bear in mind that the mere subsidence of pain does not imply the 
removal of the disease. We may modify the character of an ileitis 
very considerably by a single application of leeches, but we are not TREATMENT OF ILEITIS. 
75 
on that account to expect that we shall be able to remove the dis- 
ease entirely. In general it is necessary to apply them two or three 
times, lessening the number at each succeeding application, and 
taking care that they are applied in the proper place, that is mid- 
way between the umbilicus and the crest of the ileum. Many 
practitioners are afraid of employing leeches in the advanced stage 
of this affection, in consequence of the great debility which cha- 
racterises the advanced stage of this, as well as inflammation of 
every other part of the digestive tube. But though 1 am quite of 
opinion that the school of Broussais is wrong in using them at any 
period, still I think they may be employed even where the disease 
is advanced, particularly if they have not been used before, and I 
have frequently seen leeches applied with advantage as late as the 
twelfth day. I have employed them myself in the Meath Hospital 
as late as the ninth and tenth days with decided benefit. Many 
physicians on the continent are in the habit of treating inflamma- 
tion of the digestive system by the application of leeches to the anus, 
and this is said to have a very good effect, and the number of 
leeches required is smaller. In disease of the great intestine ac- 
companied by diarrhoea, tenesmus, and tormina, I think this is an 
excellent mode, but when the disease is in the upper part of the 
tube, I prefer applying them to the belly over the situation of the 
inflamed organ. 
Now with respect to internal medicines. In this disease every 
thing that is administered should be given with the view of re- 
moving irritation, and for this purpose 1 know no better preparation 
than a combination of ipecacuanha and opium, as in Dover’s 
powder. The exhibition of the compound powder of ipecacuanha 
is attended with decided advantage. You are all aware of the 
long established use of ipecacuanha and opium in diseases of the 
intestinal canal, and I think there can be no doubt that they possess 
considerable utility. With this I generally combine some mild 
mercurial; the best you can employ is the hydrarg. cum creta. 
Give two or three grains of each every second or third hour, as 
the case may be, and you may continue this for several days. 
Where there is no diarrhoea, and the bowels have a tendency to 
be constipated, it will be necessary to order, every second or third 
day, a mild laxative, a little manna, or rhubarb, or some castor 
oil; you should insist on the daily use of enemata, and if they 
answer the purpose sufficiently 1 would advise you to be sparing 
of the use of laxatives by the mouth. In addition to these reme- 
dies, I am in the habit of giving a considerable quantity of gum 
Arabic, which appears to have an extraordinary efficacy in dis- 
ease of the small intestine. I look upon it as peculiarly valuable 
in the diseases of children. The ordinary mode of prescribing it 
is to give a certain quantity of gum water. If this is insufficient, 
you should order half an ounce or an ounce of the gum to be 
dissolved in a pint or quart of water, which the patient is to use 
during the day. After the use of the hydrarg. c. creta and Dover’s 
powder, this has a decided value in the treatment of ileitis. 76 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
In this way by leeching, mild laxatives, prescribing mercury 
with chalk, and compound powder of ipecacuanha with gum water, 
your patient begins to improve. The tenderness of the epigastrium 
disappears, the tongue begins to clean, the fever diminishes, the 
thirst goes off, and appetite returns. This is the favourable termi- 
nation. When the patient is of a weak and delicate habit, it is of 
great importance to pay particular attention to supporting the 
strength, even from an early period of the disease. In such a 
case, after the first week, the physician who neglects the proper 
means of supporting his patient’s strength does wrong, and it has 
justly been remarked, that a practitioner will be right in supporting 
the general strength, at the same time that he is employing local 
antiphlogistics. It is in steering clear between these two opposite 
dangers that the judicious practitioner is seen ; he does not allow 
his patient to die of inanition, while at the same time he takes 
care to remove local inflammation. I have seen several experi- 
enced physicians prescribe leeches to the abdomen on the same day 
that they ordered the patient to have chicken broth, and even a 
little wine. There is nothing improper in this ; an inexperienced 
practitioner, who has his eye merely on the local inflammation, is 
apt to fall into the error of overlooking the constitutional debility, 
and allowing it to steal upon him. He finds very little difference 
between the appearance of his patient this day and the next, and 
thinks the slight increase of debility undeserving of any attention. 
At last his patient begins to sink visibly, he gets alarmed and has 
recourse to stimulants, but it is now too late. Besides, there are 
several articles of diet which support strength, without increasing 
inflammation ; as, for instance, chicken broth, sago, arrow-root, 
strained rice, &c. These do no harm, and they prevent the patient 
from falling into a dangerous typhoid condition. Let us look at 
this in another point of view. Suppose you are called to a child 
who is said to have had an attack of worms, or bilious derange- 
ment, or that his bowels were costive, and purgatives were given, 
that the discharges were found to be bad, and more purgatives 
were administered; or suppose you are called to a child of a weak 
scrofulous habit, who had been taking large quantities of purgative 
medicine, for what has been termed derangement of the bowels, and 
you find the little sufferer with pale, shrunken face, a black circle 
round his eyes, cold extremities, rapid faltering pulse, great thirst, 
and evident symptoms of increased cerebral excitement; the little 
arms and hands are cold as death, but the belly burning, tympanitic, 
and very sensible to pressure, and when you compare the radial 
artery with the femoral, as it turns over the pubis, you will have 
some conception of the excited condition of the abdominal vessels ; 
and in addition to this train of morbid phenomena, you find there 
is suppression of urine. Are you to attack these symptoms with 
antiphlogistic means? No; the first thing you are to do, is to 
prevent any further mischief, by totally inhibiting every kind of 
purgative medicine. You are next to consider carefully what the 
best line of treatment to be pursued is, for here you are under TREATMENT OP ILEITIS. 
77 
circumstances of difficulty, and have a great many prejudices to 
contend with. What I find generally to be most successful is this. 
I begin by taking proper steps to support the strength, ordering the 
patient to take chicken broth, arrow-root, or jelly; the extremities 
are to be wrapped up in warm flannel ; and if the patient is sink- 
ing, and has his mouth and teeth crusted with dark sordes, a little 
wine, watching its effects. If it produces sleep, if the pulse comes 
down under its use, and the fever is not increased, it will do a great 
deal of good, and you can gradually increase the quantity. Always 
bear in mind that there is a certain period in all inflammations, in 
which stimulants prove to be antiphlogistics, a circumstance which 
has been overlooked by the school of Broussais. So far with re- 
spect to constitutional treatment; but what will you do with local 
disease? The application of blisters is of decided use, nay, I have 
seen a few leeches very effective. Apply a blister to the abdomen, 
and dress it with mercurial ointment, at the same time you may 
employ frictions with mercurial ointment; you will also swathe 
the belly with flannel, so as to keep up a comfortable temperature. 
In this way you will be able to do a great deal of good. You will 
also prescribe hydrarg. c. creta, with Dover’s powder ; and if the 
bowels are confined, emollient injections. By steadily pursuing this 
plan of treatment, you will often rescue from imminent danger a case 
which would prove fatal under the purgative plan, and you will 
add greatly to your own reputation. 
There is one form of this disease in which diarrhoea is a promi- 
nent symptom, where the purging is from the very commencement. 
On this form I am anxious that you should have clear ideas. In 
cases of this kind there is a copious discharge of fluid matter from 
the bowels. In the majority of cases you may lay down this law, 
that where there is a decided irritation of any secreting organ, in- 
creased discharges from the surface of that organ give more or less 
relief. Suppose two cases of hepatitis ; in the one we have no 
secretion of bile, in the other the secretion is copious; the latter is 
certainly most favourable. Again, suppose two cases of bronchitis ; 
in one there is a copious expectoration, in the other it is extremely 
scanty; now every medical man knows that the former is more 
easily managed. The increased secretion of any organ in the 
early stage is to be looked upon as a relief to the inflammation. 
The practical inference to be deduced from this is, that we should 
be cautious in adopting any means of arresting this discharge, as 
it is one of the modes which nature employs in relieving the irri- 
tation of a suffering organ. Well, then, suppose you have a case 
of enteritis, and that on the first or second day diarrhoea sets in, 
what does the routine and systematic physician do ? He gives 
chalk mixture and opium with tincture of kino and catechu, and 
what is the consequence ? The belly becomes tympanitic; the 
pain is increased, and even peritonitis may supervene ;—this is one 
result of the increase of inflammation ; or the breathing becomes 
difficult, and the patient gets bronchitis or pneumonia. Diarrhoea 
occurring in the early period of this-disease is not to be interfered 78 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
with, except when it gets to such a height as to threaten the pa- 
tient’s life ; and where it increases his sufferings by the frequency 
of the discharges. In the first week or fortnight, when there are 
only three or four discharges, or even five in the twenty-four hours, 
I believe it is better not to interfere by prescribing direct astringents; 
but in the advanced period, when the powers of life are low, or the 
discharges very copious, then the physician comes to the assistance 
of nature with just reason, and in such cases you should always 
interfere. The best mode of managing diarrhoea of this kind is to 
employ small, frequently repeated doses of Dover’s powder, with 
anodyne injections. And here I may mention briefly, to such of 
you as have not seen them used, the best way of employing them. 
As these injections are used on a different principle from the com- 
mon, the latter being intended to empty the great intestine and be 
discharged, the former to be retained, we are constantly to make 
the basis of our anodyne injection in such a manner, that it will 
not prove stimulant from its bulk, or from any irritating substance 
it may contain. Mucilage of starch, new milk, or linseed decoc- 
tion may be used as the basis, and the quantity taken for one 
injection should never exceed three ounces. To this, for an adult, 
you add from fifteen to thirty drops of tincture of opium, for it is a 
curious fact connected with this subject, that opium given by the 
rectum has frequently been observed to exercise a much more pow- 
erful effect on the system than when an equal or even smaller 
quantity has been taken by the mouth. The rule then is, that 
when you first make trial of the remedy in this manner, feel your 
way cautiously, and if you find that your patient bears ten or 
fifteen drops, you can increase the quantity on repeating the enema. 
An eminent practitioner of this city thinks the narcotic effect of 
opium by the rectum much better marked than by the mouth, and 
I believe this to be true in many instances. I believe the adminis- 
tration of opium in this way requires a good deal of caution. I 
recollect the case of a man who had been for a considerable length 
of time in the habit of using laudanum in large quantities, and 
was, in fact, a regular opium eater. During an attack of illness 
he got an injection containing sixty drops of laudanum; this pro- 
duced, in a very short time, symptoms of decided narcotism, from 
which the patient never recovered; in fact, he died with every 
appearance of being poisoned by opium. There is another fact 
with respect to this disease which I would have you to bear in 
mind, that, under certain circumstances, inflammation of the small 
intestine will produce a remarkable tolerance of opium. This ap- 
plies not only to the advanced stage of enteritis, but also to many 
other forms of disease. Some time since I made a series of clinical 
experiments with the view of ascertaining the power which opium 
possesses in relieving inflammation, and the result has been, that 
in many cases where the powers of life are so low that we cannot 
have recourse to the lancet, or any kind of depletory measures, 
opium alone furnishes us with a powerful means of subduing 
inflammatory action. When we come to treat of peritonitis, I shall TREATMENT OF ILEITIS. 
79 
have occasion to speak of the good effects of very large doses of 
opium, particularly in that form of disease which results from 
intestinal perforation. My first trials of this remedy were in affec- 
tions of serous membranes, and to this I was led by some interest- 
ing clinical experiments made by Dr. Graves. I next, tried it in 
diseases of mucous membranes, where antiphlogistics were inad- 
missible, and here, as in the former cases, I had many proofs of its 
great efficacy. I shall state the particulars of a very remarkable 
case. A young gentleman, a pupil of mine, and a member of the 
class at Park street, of an irritable habit, was attacked with intense 
inflammation of the mucous membrane of the intestines. He had 
a high degree of fever, and his thirst was so insatiable that for two 
days he never ceased calling for drink. His pulse was weak but 
rapid ; his tongue red and pointed ; respiration very much hurried; 
but the stethoscopic signs of disease of the lung were absent. His 
belly was exceedingly tender on pressure; and he had another 
remarkable symptom—constant smacking of the lips. The case, 
as you may perceive, was one of severe gastro-enteritis, and it was 
treated in the ordinary mode, by leeches, cold water, &c., but the 
disease showed great obstinacy, and at the end of a month the pa- 
tient was evidently in a state of imminent danger. At this period 
a curious revulsion took place: the chest became engaged, and 
the patient got bronchitis. For this he was blistered, and took the 
decoct, polygalae with large doses of carbonate of ammonia, under 
the use of which he recovered. The bronchitis disappeared, but 
was almost immediately replaced by symptoms of intense gastro- 
enteric inflammation, thirst, quick pulse, tympanitis, low delirium, 
and subsultus tendinum. In the course of two or three days diar- 
rhoea come on, becoming more profuse as it advanced. The first 
day he had four discharges, the next eight, and thus it went on 
increasing until there was a constant discharge of thin fluid matter 
from the anus. The patient was quite run down, and on three 
different occasions his friends thought him dead. Having made 
an unsuccessful trial of various stimulants and astringents, I deter- 
mined to try what might be expected from large doses of opium. 
The patient was dying, and it was necessary to do something 
instantly which would be likely to arrest the diarrhoea. I ordered 
a grain of opium to be given every hour; on the first day he took 
twelve grains with apparent benefit, the next day he took six, the 
same quantity on the third day, and on the fourth the diarrhoea 
had so much diminished, and the young gentleman was so much 
better, that I thought it might be safely omitted. From this period 
my patient recovered rapidly. I would not bring forward this case 
in proof of the efficacy of opium if there were not many others of a 
similar kind ; and I have no doubt that this was a cure effected by 
the use of opium in large doses. In the treatment of this disease 
by opium, there is one simple rule, by observing which you will be 
able to avoid all difficulties, and at the same time have a criterion 
to judge of the value of the opiate treatment. If the remedy pro- 
duces the ordinary narcotic effects of such large doses on the 80 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
system, it will not do much good. You begin, therefore, cautiously; 
and if, after the first or second dose, you find that decided nar- 
cotism is produced, or at least more than you would think the 
quantity given could have brought on, give it up—it will be dan- 
gerous. liut if he bears one, two, or three grains, or if, after having 
taken six or eight grains in the twenty-four hours, he appears to 
be improving, you may then persevere in the administration of 
opium, and it will be attended with decided advantage. 
We have next to proceed to the consideration of the pathology 
and treatment of diarrhoea and dysentery; I shall, however, first 
exhibit a few preparations illustrative of the diseases of the small 
intestine. Here is a preparation of the affection called tabes me- 
setiterica. You see here various masses of those cheesy glands 
which are generally supposed to be the result of original scrofulous 
deposition ; but if you look along the folds of the intestine, you 
will see a vast number of engorged lymphatics running up directly 
to those glands, and you will perceive that these lymphatics cor- 
respond at their commencement with ulcerative disease of the 
intestinal mucous surface and glands. Here is an interesting 
preparation, exhibiting three distinct ulcers. In one of these you 
see the bright vascularity and turgescence of the areola, and the 
ulcerative process which has just begun in the centre. Close to 
this is another large ulcer, which has destroyed the texture of the 
gut down to its serous covering, through which you perceive the 
light is shining. The last is an example of perforating ulcer ; all 
the coats of the intestine have been destroyed, and on turning the 
preparation you see evident marks of peritoneal inflammation. 
This preparation also exhibits one of the modes in which an 
ulcerative perforation of the intestine may terminate. Sometimes, 
at the very moment the ulcerative process has succeeded in de- 
stroying the last coat of the intestine, inflammation of the serous 
membrane in the immediate vicinity takes place, a quantity of 
lymph is poured out, and if the matter be not in great quantity, 
and the hole not too large, the opening is closed up by the effused 
lymph, and a stop is put to further mischief. Again, by the effu- 
sion of lymph the ulcerated portion of the intestine may form an 
adhesion to another sound portion, the effused lymph does not 
permit the passage of the contents of the intestine into the perito- 
neum, but does not prevent them from getting into the sound 
portion by a continuance of the ulcerative process, and in this way 
we have another termination, in the formation of a false passage. 
Here is a good example of disease of the ccecum, here is an exam- 
ple of disease of the colon, and here is another with a vast number 
of ulcerations. Here is an interesting specimen of disease of the 
large intestine. The patient to whom it belonged died of phthisis;— 
look at it and you will see what extensive ravages have been made 
by the ulcerative process. 
We come now to take up the subject of disease of the large 
intestine, which, as I find my time nearly past, I must reserve until 
our next meeting. I shall then speak of dysentery and diarrhoea, DISEASES OF THE LARGE INTESTINES. 
81 
and shall draw your attention to some new and curious facts 
respecting the discharge of fatty matter from the bowels. In the 
last number of the Medico-Chirurgical Transactions, three separate 
papers have appeared on this subject from Dr. Elliotson, Dr. Bright, 
and Mr. Lloyd. Dr. Bright has brought forward several interesting 
facts tending to show that discharges of fatty matter may be found 
to be indicative of certain forms of disease of the digestive tube and 
the neighbouring glands. 
LECTURE X. 
Diseases of the large intestines—Treatment of diarrhoea—Apyrexial period of diarrhoea 
—Danger in suddenly arresting the discharge—Purging in phthisis—Dysentery— 
Epidemic dysentery. 
To-day we proceed to the consideration of the nature and treat- 
ment of some of the diseases of the large intestine. You will see, 
in the various systematic treatises on the practice of physic, sepa- 
rate descriptions of the aifections of this portion of the digestive 
tube, you will find diarrhoea in one chapter and dysentery in 
another, and you will observe, that a great deal of ingenuity has 
been expended in forming nosological differences between these 
affections. I fear that much of what has been written respecting 
them is rather calculated to puzzle and mislead than to inform the 
student. Viewed anatomically, there is no essential difference. 
You may for every practical purpose place them in the same class, 
and consider them as the result of the same morbid condition of 
the same part, namely, an inflammation of the lower portion of the 
digestive tube. Some persons may quarrel with the term inflam- 
mation—call it, then, irritation, if you please ; but the truth is, 
that it is a disease of the lower portion of the intestine, the results 
of which are increased sensibility and altered secretion ; and this 
description, I think, will fairly apply to one as well as the other. 
If a man has purging, with fever and pain, it is called dysentery; 
if he has purging, without pain, and without any manifest febrile 
excitement, we call it diarrhoea. But, in cases where persons have 
died, after having laboured under diarrhoea for a length of time, we 
generally find, on dissection, lesions of the mucous membrane of 
the intestinal canal, sufficient to account for death. There are 
some cases, indeed, in which the mucous surface takes on a gleety 
discharge, similar to that which follows gonorrhoea, and under 
such circumstances you will not be able to discover any distinct 
anatomical evidences of disease. These, however, are compara- 
tively rare, and bear little or no proportion to those cases which 
present distinct traces of organic lesion. 
On the subjects of diarrhoea and dysentery I shall be very brief, 
as our time is short, and every thing relating to the pathology and 82 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
treatment of these affections may be expressed in very few words. 
First, then, as to diarrhoea, which is the frequent passing1 of stools 
of a more or less watery consistence, and which may, and gene- 
rally does, occur without fever. This affection may be considered 
to arise under three different circumstances; but, in point of fact, 
every form of the disease may be referred to a single cause, as 
there is no essential difference in the actual nature of the circum- 
stances by which they are produced. A patient, for instance, 
takes a quantity of indigestible food, this produces irritation in the 
gastro-intestinal mucous surface, and diarrhoea is the consequence. 
Another is exposed to cold, or gets wet feet, the mucous membrane 
of the bowels becomes more or less inflamed, and this terminates in 
diarrhoea. Again, a patient, labouring under hectic, has profuse 
perspirations, these go off' and are replaced by frequent fluid dis- 
charges from the bowels—here, also, the result is called diarrhoea. 
All these forms are, however, referable to the same cause—irrita- 
tion of the mucous lining of the digestive tube. 
A man commits an excess at table, eats something that he cannot 
digest, and gets diarrhoea. If you happen to be called to such a 
case at an early period, your course is very plain and easy ; there 
is every chance that the affected organ has received (as yet) no 
material injury, and is attempting to relieve itself by increased 
secretion. The indication here, is to get rid of the source of irrita- 
tion as soon as possible, and this is best done by prescribing a laxa- 
tive, to remove the offending matter, and then following it up with 
an opiate. The simple rule is to relieve the intestine, and prevent 
the liability to inflammation. A mild laxative, followed by opiates 
and demulcents, keeping the patient on a low regimen for a few 
days, and in a warm temperature; this is sufficient for the manage- 
ment of the first form of diarrhoea. In point of fact, the principal 
thing which the practitioner has to do, is to watch his patient, and 
take care not to permit the inflammatory action to become 
developed. It is in such cases as these that the expectant medi- 
cine is of value. What you are to direct your attention to, is 
the state of the intestinal surface. If a patient gets an attack of 
pain, if his belly becomes tender on pressure, if he is more or less 
feverish, you may be sure there has been some mischief done. If, 
on the contrary, the diarrhoea yields to the exhibition of a mild 
laxative and light diet; if the pulse be soft, and the belly not tender, 
you have no reason to fear. But if the purging becomes more dis- 
tressing, if the pain is severe, the abdominal tenderness evident, the 
thirst and restlessness continue unabated, it is a sign that the irri- 
tation has produced something more than mere increased secretion, 
and that actual disease of the mucous tissue is setting in. We 
have now a true inflammatory diarrhoea, which may be looked 
upon altogether as an enteritis of that kind in which there is a 
copious secretion from the surface of the intestine. You observe 
this leads us at once to the principles of treatment. Here we have 
fever, pain, frequent morbid stools, thirst, and abdominal tender- 
ness. Well, then, what are you to do ? In a case where these DISEASES OF THE LARGE INTESTINES. 
83 
symptoms are so severe as to excite alarm, at once begin with 
applying leeches. Where there is merely evidence of intestinal 
irritation, caused by indigestible food, give a laxative, and follow 
it up with an opiate; where, in addition to the ordinary symptoms, 
you have fever, pain, and tenderness, never omit the application of 
leeches. Many a time have I seen cases of this kind, in which 
chalk mixture and astringents not only failed but even caused 
additional suffering, speedily and completely relieved by the appli- 
cation of a few leeches. In using leeches, too, we are not like the 
practitioners who trust to astringents, playing at the game of 
double or quits ; nor do we stop the purging by exchanging it for 
something else equally bad, or even worse, for a peritonitis or a 
bronchitis, for instance ; by removing its cause we not only check 
the diarrhoea, but we obviate any tendency to a metastasis of 
inflammation to other tissues, and our mode of cure has at once 
the merit of being successful and safe. 
A patient who has had an attack of diarrhoea should have his 
belly swathed with flannel; this should never be neglected. He 
will also experience a great deal of benefit from the use of the hip 
bath and occasional opiates. Give, also, a combination of rhubarb 
and Dover’s powders, and you will find that it will do him a great 
deal of good. This is the remedy which Rhaederen and Wrngler 
found to be of extraordinary advantage in the mucous fever, with 
diarrhoea, which ravaged parts of Germany in the last century. 
Give two or three grains of each every second or third hour, and 
increase or diminish each of the ingredients according to circum- 
stances, increasing the Dover’s powder where the indication is to 
remove pain and irritation, and increasing the rhubarb where you 
wish to produce a laxative effect. This combination forms a 
remedy of decided value in enteric inflammations; it has been 
much used in such cases by Dr. Cheyne, and I have repeatedly 
employed it in the Meath Hospital with marked advantage. You 
are also to bear in mind, that though the principle of treatment in 
this disease is to remove its cause and put a stop to the purging, 
still you are in no case authorised to give it a sudden check, by 
astringents, in the early period. I gave the reasons for this at my 
last lecture, and showed that it was based upon a general law of 
the economy. If an organ in a state of inflammation pours out 
an increased quantity of secretion, it is the mode in which nature 
attempts to give relief; and if you suddenly arrest this secretion, 
the probability is, that you will excite more inflammation in that 
organ, or cause a metastasis to other parts. This is particularly 
the case if inflammatory fever exists. You must also attend to 
your patient’s diet. Your object here is to support him on such a 
diet as will require but little digestive power, and will not produce 
large collections of faecal matter in the bowels. Jellies, arrow-root, 
chicken-broth, and mild farinaceous food, are the only things that 
can be used with safety, until the intestinal irritation has subsided. 
By pursuing this plan of treatment with steadiness and decision, 
you generally succeed in cutting short the disease. In some cases, 84 
STOKES’S TIIJEORY AND PRACTICE OF MEDICINE. 
the diarrhoea will ran on to the chronic stage, just like the gleet 
which follows gonorrhoea; and this is to be looked upon as the 
apyrexial period, in which antiphlogistic remedies are no longer 
admissible, and where you may employ stimulants and astringents 
with effect. The best way to manage this form of the disease, is 
to make your patient use warm clothing, an even temperature, 
and mild nutritious diet; to prescribe the vegetable and astringent 
tonics, the hip bath, and the occasional use of mild laxatives, 
followed by an opiate. In this way, after some time, the disease 
generally goes off, and the patient recovers his strength. But it 
may happen that this gleety discharge will continue unabated ; it 
is running the patient down, and he wants some decided remedy to 
check it. Now, the remedies which appear to have the greatest 
power in stopping this discharge, are the metallic astringents, and 
the turpentines and balsams, combined with some of the prepara- 
tions of opium. It is a curious and interesting matter to consider 
how these remedies act. They are a class of medicines which 
exercise an extraordinary influence over discharges from mucous 
surfaces, in a way we do not understand, but the effect is to arrest 
these discharges. In a case of ophthalmia, accompanied by copious 
secretion from the conjunctiva, or in a case of chronic gonorrhoea, 
we know there is nothing more beneficial than metallic astringents 
and balsams; and we are also aware of the great value which tur- 
pentine and balsam copaiva possess in checking the increased 
expectoration of a chronic bronchitis. In diarrhoea, also, they 
have the same power; they check inordinate secretion, and 
remove the morbid condition of the mucous membrane on which 
it depends, by some effect produced on the surface of that mem- 
brane, but in what manner this is accomplished we know not. In 
severe cases of this gleety discharge, one of the most certain 
remedies we can employ is acetate of lead. You will seldom have 
occasion to use this, or any of the other remedies alluded to, in the 
case of a healthy person, because the disease will seldom pass into 
this second or gleety stage ; but if it should, and that it is running 
down the patient, it behoves you to check it as soon as possible, 
consistent with safety. Give, then, the acetate of lead in free and 
repeated doses, and it is singular to remark what quantities of it 
patients under such circumstances will bear without any bad con- 
sequence ensuing. Hitherto, many persons have been afraid to 
employ it in large quantities, from fear of producing painters’ 
colic; but at present it is known that this disease is to be attributed 
to the absorption of the carbonate of lead in almost every instance, 
and that the acetate is comparatively harmless. On this point I 
can mention one interesting fact, namely, that I have been in the 
habit of using it constantly, and in considerable doses, for the last 
six years, and I cannot bring to my recollection one single instance 
of colic produced by it. One patient, in particular, who was under 
my care, took it in very considerable doses for six weeks, without 
any apparent injury. The only cases in which I have seen the 
acetate of lead act as a poison, were those in which it had been DISEASES OF THE LARGE INTESTINES. 
85 
used as an external application. Whether it be that this remedy 
is more pernicious when employed after the endermic mode, or 
whether, when applied to the skin, it attracts carbonic acid from 
the air, and is converted into a carbonate, I do not know, but of this 
I am certain, that where bad effects have followed the employment 
of the acetate of lead, they have been brought on it by its external 
use. I generally use this remedy in the form of pill, prescribing 
two grains of the acetate of lead and a quarter of a grain of opium, 
three times a day. With the same intention you may employ the 
turpentines and balsams, which have a powerful effect in checking 
mucous discharges. Dr. Pemberton, in his work on Abdominal 
Diseases, speaks very highly of the efficacy of balsam copaiva; 
and I have seen many cases where turpentine has had a great 
efficacy in arresting chronic diarrhoea. You will see, in the works 
on materia medica, some other remedies which you can employ 
with benefit in such cases, but I may mention one which is not 
generally known—the alkali of the nux vomica. Strychnine was 
first used in checking mucous discharges by a German physician, 
and afterwards by Dr. Graves in this city. The cases in which it 
proves most successful, are those in which there is a mere gleety 
discharge, a copious secretion from the mucous surface, without 
any inflammatory action whatever, or if there be, where it is so 
low as not to produce the least feverish excitement or pain. 
Cases of this kind, in which strychnine has been eminently suc- 
cessful, have been published by Dr. Graves.1 Among others, is 
that of gentleman, who had sudden calls, so that he often had not 
time to reach the close-stool. He passed a quantity of thin jelly- 
like substance, and then experienced a transient relief until another 
attack came on. This case was cured by the use of strychnine, 
one twelfth of a grain, three times a day, made into pills with 
crumb of bread or aromatic confection. 
I may mention here, that, in treating gleety diarrhoea in this 
way, one thing should be always borne in mind—it is always 
dangerous to check any copious secretion suddenly, and the 
danger consists in the liability to metastasis or new inflammation. 
Never forget this. What generally happens is, that the patient’s 
belly begins to swell, and you have ascites rapidly formed. Now, 
I have never seen a case do well in which this kind of ascites 
came on after the sudden checking of a diarrhoea; the patients all 
died. Another consequence is the rapid supervention of pulmonic 
inflammation, and here the disease is almost as bad as in the 
bowels. You will ask how this unfavourable termination may be 
avoided. The best mode is, while you are arresting the discharge 
from the bowels, to promote a determination to the surface. While 
you are using opiates, and stimulants, and astringents, employ 
general warm bathing, or the hip bath, dress the patient in flannel, 
1 Tn similar affections it has been used successfully by Professor Gedding, 
of South Carolina. We have often given it, sometimes apparently with 
success, at others not.—R. D. 86 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
and use mild diaphoretics every night. You will also do right in 
blistering the belly occasionally. In this way you will succeed in 
curing the worst cases of this chronic flux, without exposing your 
patient to the risk of new inflammation, or translation of disease 
to other organs. 
One of the most common forms of diarrhoea is the purging which 
occurs in cases of phthisis; a physician will be called to treat this 
as often as any other, and it is of importance that you should have 
correct ideas with respect to its pathology and treatment. The 
ordinary opinion is, that this kind of diarrhoea is one of the results 
of hectic fever, and many practitioners, in treating the purging of 
consumptive patients, overlook the actual condition of the intestine, 
and only take into consideration the state of the whole constitution, 
of the hectic state of which the diarrhoea is looked upon as one of 
the symptoms. The consequence of this is, that they do not pro- 
ceed on the same principles in the treatment of this as of other 
similar affections of the intestinal canal. Now, I would impress 
upon you, that you should always consider the diarrhoea of phthisis 
as depending, in almost every instance, on enteric inflammation. 
There is no fact in medicine better established than this. Persons 
think it is the hectic which produces the purgation, but I believe 
the converse of this proposition is often much nearer the truth, 
and that the constant diarrhoea often produces and keeps up the 
hectic. If you examine the digestive tube of a patient who has 
died with symptoms of phthisical diarrhoea, you will commonly 
find extensive ulcerations in the colon, coecum, and ileum. In 
some cases of consumption, where the purging has been very 
severe, the amount of disease will often be found to be quite extra- 
ordinary ; I have often seen the whole of the lower part of the tube 
one sheet of extensive ulceration. I find I have not brought up 
any specimens of the effects of phthisical diarrhoea from the 
museum, but will exhibit them at our next meeting. The prepa- 
rations before us are those which are illustrative of dysentery, but 
they will convey to you a good idea of the state of the great intes- 
tine in the diarrhoea of consumption, for the effects are nearly the 
same. Observe now, the importance of this fact, and recollect that 
in treating every case of consumption, with diarrhoea, you will 
have constantly to bear in mind this enteric complication. Recol- 
lect, also, that one of the best means of stopping it, when all other 
remedies have failed, is a blister applied over the abdomen. If the 
purging depended on hectic, this would not be the case. I could 
bring forward several cases in which every thing had been tried 
without success, when a blister was applied to the belly, and from 
the time it rose, the patients ceased to be troubled with diarrhoea, 
and continued so up to the period of death. I do not mean that 
you should in these cases proceed to attack the enteritis with the 
same vigour as you would a similar disease in the healthy subject. 
Generally speaking, I believe this form of enteritis to be incurable ; 
but it is of importance that you should be aware of this enteric 
complication in phthisis, and when you are called in to treat such DISEASES OF THE LARGE INTESTINES. 
87 
a case, you should carefully avoid prescribing any thing calculated 
to add to the existing irritation. 
Before I quit this subject, I wish to make one remark by the way 
of caution. It not unfrequently happens that a person, labouring 
under chronic diarrhoea, comes to consult a medical practitioner, 
and tells him that he has been suffering from this complaint for 
months, that he has eight or nine discharges by stool in the day, 
and that he has been under the care of five or six doctors in suc- 
cession, without any benefit. Well, you are determined to have 
your trial, too, and you commence operations by putting him on 
full doses of acetate of lead. After a week or a fortnight, he comes 
back and tells you he is not a bit the better. You then try turpen- 
tine or balsam copaiva—no use. Nitrate of silver—the same 
result. The man get stired of you in turn, and perhaps goes to a 
surgeon to ask his advice. The surgeon examines the rectum 
carefully, and finds, at a short distance from the anus, an ulcer, 
which he immediately touches with a strong solution of the nitrate 
of silver. The ulcer begins to heal, the irritation of the gut ceases, 
and the diarrhoea goes off. The surgeon is extolled to the skies, 
and the doctors disgraced for ever in the opinion of the patient. 
Now this is not an uncommon case. I have seen several instances 
of it, and I must tell you I was once mistaken in this way myself. 
These ulcers are situated close to the verge of the anus ; they 
occur chiefly in persons of broken-down constitution, and those 
who have taken a great deal of mercury. They produce irritation 
in the colon, tenesmus, griping, frequent discharges by stool, and, 
most commonly during the straining, a little blood is passed. 
During the course of last summer, I treated a soldier for this affec- 
tion, who had been discharged from the East India Company’s 
service (as was stated in his discharge) for incurable dysentery. I 
examined the rectum, and finding some ulcers close to the anus, 
had them touched with the nitrate of silver. Under this treatment 
a rapid amendment took place, and in the space of three weeks the 
man was discharged, quire cured. Now, are you to make this 
examination in every case? I believe you will act rightly in 
doing so in every case of chronic diarrhoea in the male, but the 
examination is absolutely necessary in all cases under the following 
circumstances : first, when the diarrhoea has been of long standing; 
secondly, when it has resisted a great variety of treatment; thirdly, 
when it has been combined with tenesmus and a desire of sitting 
on the night-chair after a stool has been passed, showing irritability 
of the lower part of the great intestine; and, lastly, when the 
patient’s health does not appear to be so much affected as it natu- 
rally should be, where there was long-continued disease of a large 
portion of the great intestine. A patient will come to consult you, 
who will inform you that he has had eight or ten alvine evacua- 
tions every day for the last six months, and yet he eats heartily and 
looks quite well. Under these circumstances, the cause of the 
diarrhoea will generally be found to be ulceration of limited extent 
low down the tube, and capable of being quickly and effectually 88 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
removed by a strong solution of the nitrate of silver. I shall 
recapitulate all the circumstances under which an examination is 
indispensable ; where the symptoms have been persistent, have 
resisted a variety of treatment, are accompanied by tenesmus, and 
where the injury done to the general health is not in proportion to 
the duration of the disease. I may mention here, that a medical 
friend of mine has communicated to me the particulars of another 
case of this form of diarrhcea in a soldier who was invalided on 
this account, and who experienced sudden and permanent relief 
from the application of nitrate of silver to some ulcerated spots 
which were discovered near the termination of the rectum. 
We come now to the subject of dysentery. I shall draw your 
attention briefly to the general principles of the pathology and treat- 
ment of this affection; but I do not intend to enter upon the con- 
sideration of its general history, which you will find sufficiently 
detailed in books. The first principle I have to enforce on this 
subject—and you may take it as an observation based on the 
soundest pathology—is this, that dysentery is inflammation of the 
large intestine. In some cases it is complicated with fever, and in 
others with disease in the upper portion of the digestive tube; and 
I believe that those cases which are termed epidemic dysentery, 
are those in which this disease is combined with typhus fever, or 
with an extensive affection of the small intestines—where there is 
ileitis as well as colitis. I shall not take up your time with discus- 
sions respecting epidemic dysenteries, or those of warm climates; 
it will be sufficient, for the present, to allude to that form of disease 
which is observed in this country. 
I have told you that dysentery is an inflammatory affection of the 
great intestine, and all the symptoms during life, as well as the 
phenomena revealed by dissection, tend to confirm this view of the 
subject. We often have fever, because the constitution sympathises 
with the inflammation of an important organ; we have excessive 
pain and irritation of the intestine, in consequence of its muscular 
fibres being involved in the inflammation; and we have discharges 
of morbid, purulent, and bloody secretion. You will now please 
to inspect this preparation, and hand it round. See the effects of 
dysentery—the extensive inflammation, ulceration, and sloughing, 
of the mucous membrane. Here is another preparation ; you per- 
ceive the whole surface of the colon is covered with coagulable 
lymph, which, in some cases, forms a chief part of the dejections. 
Here is a preparation which exhibits extensive sloughing of the 
mucous membrane; its tissue, you see, is quite abraded and 
destroyed. Here is a preparation of chronic dysentery, which pre- 
sents a very curious appearance; the mucous membrane is finely 
mamillated, as it were, and it is stated on the label, that the process 
of cicatrisation was going on. If you compare it with the others, 
you will find a remarkable difference. Here is another specimen 
of dysenteric destruction. 
Here, then, is a disease in which we have violent inflammation 
of the mucous membrane and submucous cellular tissue, and, in SPORADIC DYSENTERY. 
89 
severe cases, I believe, of all the coats of the great intestine, except 
the serous. Let us rehearse its symptoms briefly. Fever of an 
inflammatory or typhoid character, great pain and excessive irrita- 
bility of the great intestine, morbid discharges of purulent, bloody, 
and lymphy matter, twisting pains called tormina, and frequently 
the absence of fecal matter in the dejections. 
At my next lecture I hope I shall be able to finish this subject, 
and I shall then bring before you some remarks on constipation and 
collections of air in the great intestine, two points upon which much 
light has been lately thrown. 
LECTURE XI. 
Sporadic dysentery—Nature of this disease—Treatment; mercurial, stimulating, 
antiphlogistic—Recommendation of Dr. Elliotson—Success of Dr. O’Beirne in the 
use of tobacco injections—Tympanitis, or meteorism—Windy colic, remedies for 
the cure of. 
I drew your attention briefly, in my last lecture, to the subject of 
dysentery ; I stated that its anatomical character is now known to 
be inflammation of the great intestine, and gave it as my opinion, 
that, in many cases of the epedemic, disease of the large intestine 
occurs under one of two conditions, either as secondary to typhus 
fever, or with an extension of the inflammatory process into the 
small intestine. These circumstances should, I think, be always 
taken into consideration in cases of epidemic dysentery; but the 
ordinary sporadic dysentery of this country, which we have now 
to consider, is, generally speaking, an inflammation of the large 
intestine. The old doctrine on this subject was, that dysentery 
was the result of an irritation caused by the presence of scybafe 
in the colon ; and the indication was to attempt their removal by 
purgatives. You will find this opinion put forward in many of the 
older authors, and that the plan of treatment which they recom- 
mend is in perfect accordance with their notions of the disease. It 
is a very curious fact, however, that in this country these hard 
faecal masses, or scybalae, are very seldom met with in cases of 
dysentery. During the epedemic of dysentery, which occurred in 
Ireland in 1818, a series of clinical investigations was made on an 
extensive scale by Dr. Cheyne, who at that period had charge of 
the Hardwicke Hospital; and he states, that on a strict examina- 
tion of the discharges in a vast number of cases, no scybalae could 
be discovered; and in the sporadic cases, which we receive from 
time to time into the Meath Hospital, I have never found that the 
patients passed them. It is a great error to think that dysentery 
depends on the presence of scybalae ; the notion is now shown to 90 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
be founded on a false pathology, and the treatment which it incul- 
cates decidedly bad. You will be convinced of the latter when 
you recollect that the disease is inflammation of the great intestine, 
that its effect is to throw the muscular fibres of the gut into violent 
and painful contractions, and that the existing mischief must be 
therefore greatly increased by the exhibition of strong purgatives. 
For a knowledge of the true and scientific treatment of this disease, 
we are indebted to the light which modern pathology has shed 
upon practical medicine. We now employ purgatives with extreme 
caution, we use general or local bleeding, according to the urgency 
of the case ; and we treat the disease as an inflammatory affection 
of the lower intestine demanding active depletion. All writers are 
unanimous in recommending the employment of the lancet, in 
cases of acute inflammation ; and acute dysentery is one of those 
cases in which general bleeding seems to have the best effect. Dr. 
Cheyne states, that in this disease the most decided relief resulted 
from the use of the lancet. He says that in several cases in which 
there were excessive pain and tormina, and in which nothing was 
passed for several days but mucous and blood, as soon as venesec- 
tion had been performed, the patients became comparatively easy, 
and passed large quantities of feculent matter. He also found 
that the blood drawn was buffed and cupped; and states that his 
experience led him to conclude that this disease was best treated 
by the lancet. Dr. Mackintosh, who has had great experience in 
dysentery, says, that laxatives will act with the best effects when 
blood-letting has been premised. In fact, the utility of general 
bleeding in dysentery is established beyond any possibility of doubt; 
and those who object to the use of the lancet object to it on theo- 
retical and not on practical grounds. As a proof of this, you will 
see a great many cases in which decided relief is obtained by a 
natural hemorrhage from the bowels; and this I think ought to be 
sufficient to overcome the doubts of those who are skeptical as to 
the value of general bleeding in acute dysentery. 
Next to bleeding, the best thing you can have recourse to is the 
free application of leeches, a practice not sufficiently appreciated or 
followed in this country. I would advise you to apply leeches 
freely along the course of the colon ; and if the tenesmus be con- 
stant and distressing, round the anus also. The case in which 
the application of leeches round the anus is attended with the 
greatest relief, is that in which the tormina and tenesmus are ex- 
cessive, and in which a quantity of blood is found blended with 
each discharge. After you have applied the leeches, I would 
strongly recommend you to direct your patient to sit in a hip bath 
for some time, and you will find that he will experience great relief, 
because the bath will act as a fomentation, and promote the flow 
of blood from the leech bites. I have often seen the application of 
a dozen leeches round the anus, followed by the hip bath, attended 
with the most rapid and signal advantage in dysentery. 
Many persons are in the habit of giving small doses of some 
mild saline laxative in this affection ; of this practice I cannot SPORADIC DYSENTERY. 
91 
speak much from experience, and I think more benefit will be 
derived from the free use of demulcents, gum-water, whey, barley- 
water, and linseed tea. But the internal remedies on which we 
chiefly rely in the treatment of dysentery, are mercury and opium. 
Blue pill and Dover’s powder are an excellent combination, so are 
calomel and opium, and you may give either of these remedies 
alternately with a mild laxative, whenever you are led to suspect 
an accumulation of faecal matter in the bowels. In very bad cases 
it will be necessary to continue the mercury until the mouth is 
affected; but in the sporadic dysentery of this country you will 
very seldom be under the necessity of bringing on actual sali- 
vation. 
Permit me here, gentlemen, to make a few observations on 
mercurial aption. In treating a case of dysentery, it does not, in 
the first place, follow as a matter of course, that you will cure your 
patient by subjecting him to the full influence of mercury. You 
are not to expect that salivation will be always attended with suc- 
cess. There is another point which should never be forgotten, 
although it is one which I believe has not been sufficiently consi- 
dered. It is a common idea with respect to the administration of 
mercury in cases of local inflammation, that if you produce saliva- 
tion you do a great deal towards accomplishing a cure, and this 
is true in most cases. Many persons are of opinion that it is the 
ptyalism which carries off the disease, and hence it is that we so 
often see the principal share of a practitioner’s attention directed to 
produce salivation at all hazards. This is the history of the 
medical treatment ordinarily pursued in warm climates, where 
such vast quantities of calomel are given. Here the idea seems to 
be, that the disease is to be subdued by salivation alone, and 
accordingly the practitioner “throws in” mercury, an expression 
evidently arising from the enormous quantities given. There are 
many cases on record in which eight hundred and even one thou- 
sand grains have been given for the cure of a single local inflam- 
mation. But it is remarkable, that in several cases in which vast 
doses have been given, no ptyalism has been produced, and thus 
it frequently happens, that the practitioner goes on increasing the 
quantity, lest he should have failed in consequence of not having 
given enough. All this practice is wrong and founded on false 
notions ; and I think that when you come to practice yourselves, 
you will be inclined to adopt the opinion, that, in cases in which 
mercury has been employed in the treatment of local inflammation, 
salivation is to be looked upon more as the result of the relief of 
inflammation to a certain degree than as its primary cause. For 
instance, suppose you are called to treat a case of acute enteritis or 
hepatitis ; you give ten grains of calomel two or three times a 
day, and find that day after- day passes without any appearance 
of salivation. Another practitioner is called in, who bleeds the 
patient, and this is almost immediately followed by the appearance 
of salivation and relief. My friend, Staff-Surgeon Marshall, who 
is intimately conversant with the diseases of India, has informed 92 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
me that he has never known a case in which abscess actually 
formed in the substance of the liver, in which salivation could be 
produced ; and that when the patient became salivated, be believed 
it to be a proof that there was no inflammation of an intense cha- 
acter, or that no abscess had formed. The greater the intensity 
of the disease, the less was the chance of salivation occurring, so 
that the salivation in certain cases appears to be the result of the 
same influence which produces a relief of inflammation, and not 
the cause of that relief. When, therefore, you have given mer- 
cury in free and repeated doses for twenty-four or forty-eight 
hours, and find no sign of salivation appearing, you should be 
cautious how you proceed, because in such cases the inflammation 
may be of that intense character which will not permit the mouth 
to be affected. Under such circumstances, the use of mercury, if 
rashly persevered in, will only aggravate the disease. In many 
cases of intense pneumonia, you will find that the patient will not 
be salivated until an advanced period, when, in consequence of the 
subsidence of intense irritation, the mercury is, as it were, allowed 
to produce its effect on the salivary glands. You may also fre- 
quently observe instances of intervals between the salivation, in 
which, during the course of an inflammation, the patient’s mouth 
becomes affected by mercury; but if he gets fresh symptoms of the 
original affection the salivation disappears, and returns only when 
the new attack has been overcome by appropriate treatment. I 
think that, under these circumstances, we are authorised in consi- 
dering salivation as the effect of a certain degree of reduction of 
inflammation, and not as its cause. You will see the importance 
of these observatians when you reflect in how many cases of local 
inflammation practitioners are in the habit of trusting to calomel 
alone ; not being aware of the fact, that inflammation of an intense 
character has a powerful tendency to prevent it from acting on the 
salivary glands. Be assured of this, that if, in any acute visceral 
inflammation, after you have performed the usual depletions, you 
find an unusual resistance to the action of mercury, you may, on 
that account, form a more unfavourable prognosis. 
There is one point in the treatment of dysentery which it is 
necessary you should be acquainted with. Sometimes the symp- 
toms steal on gradually, and the patient appears to be in a condi- 
tion not at all dangerous, when, all at once, the disease explodes 
with violence, and exhibits an extraordinary intensity ; the fever 
is ardent, the tormina excruciating, the tenesmus constant and 
harassing, the dejections frequent and blended with lymph and 
blood. Such an array of threatening symptoms must be met with 
a corresponding activity. In such a case as this I would bleed, 
leech, use the hip bath, and give free doses of calomel and opium; 
and if you were to ask me to which of the internal remedies 
used I should attribute the most decided alleviating influence, 
I should say to the opium. Dr. Cheyne says, “after"the lancet, 
the best remedy I know of is opium.” He says further: if another 
epidemic, similar to that which he witnessed, occurred, he would SPORADIC DYSENTERY. 
93 
have no hesitation in giving opium, in four-grain doses, in such 
cases. 
There was a very curious circumstance connected with the his- 
tory of the epidemic dysentery of 1818—19. At one time the deaths 
happened to be extremely numerous, and every thing which the 
experience or ingenuity of Dr. Cheyne could suggest failed in 
arresting the disease, in many cases. An English physician, who 
happened to be in Dublin at that period, and was in the habit of 
visiting the hospital, proposed the administration of large doses of 
cream of tartar, stating that he had tried it on several occasions 
under similar circumstances, and was convinced of its value. As 
the cases were not succeeding which had been treated after any of 
the ordinary modes, Dr. Cheyne consented to the exhibition of the 
cream of tartar, and allowed the physician to prescribe and ad- 
minister it himself. Accordingly, he proceeded to give it in doses 
of half an ounce every fourth hour. Its first effect, generally, was 
to produce violent distress, and to aggravate all the symptoms, but, 
after three or four doses, bilious and feculent stools came away, 
and the patient experienced the most extraordinary relief. Many 
cases which had been considered desperate improved and reco- 
vered, and Dr. Cheyne expresses his conviction that many persons 
were saved by this practice, who would have been lost under the 
ordinary modes of treatment. One of the old German authors has 
also alluded to this singular efficacy of cream of tartar in the treat- 
ment of dysentery ; and from the result of Dr. Cheyne’s experi- 
ments, there can be no doubt that it is entitled to a high rank among 
the remedies usually employed. In case you should prescribe 
castor oil as a laxative, it will be necessary to combine it with 
mucilage of gum arabic and a few drops of laudanum; given alone 
it will be likely to prove too irritating, particularly during the acute 
stage. In the advanced stage much benefit will be derived from a 
combination of castor oil with tincture of opium and a small quan- 
tity of oil of turpentine. This is not at variance with the pathology 
of the disease, for there is a period in this as well as in every other 
form of inflammation, when stimulants may be used with benefit. 
Such is the treatment of the ordinary forms of acute dysentery; 
but it may happen that you will be called to a case in which you 
cannot employ these decided measures ; and here I shall mention, 
that in all local inflammations it is of the utmost importance that 
you should act with judgment and decision in the commencement. 
Every hour is precious; a single day is worth much ; and if two 
or three days are allowed to pass, and the treatment is inactive or 
indecisive, the patient too often sinks into the chronic stage, or dies. 
Whenever you happen to be called to treat a case of acute local 
inflammation, attempt to cut it short as soon as possible; it is 
much easier to cure an inflammatory attack in its commencement 
than to save the patient from the effects of it in the advanced stage. 
Now, if you should be called to a case of dysentery of some stand- 
ing, and on your arrival find the patient lying on his back, his 
skin of a pale dirty hue, his eyes sunk and without lustre, his 94 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
extremities cool, and bedewed with a clammy sweat; his pulse 
small, rapid, and feeble; his thirst ardent; his pains and tormina 
incessant; and constantly passing from his bowels a quantity of 
fluid matter, blended with depraved mucus, lymph, and blood, with 
great irritation about the anus, and if these symptoms have lasted 
for some days you may be sure there is extensive ulceration of the 
lining membrane of the large intestine. How are you to act under 
such circumstances ? The patient will not bear bleeding, or per- 
haps the application of a small number of leeches. Here your sole 
object must be to support your patient’s strength; you must give 
wine, (if the skin be cool,) strong chicken broth, beef tea, jellies, &c.; 
you must wrap your patient in flannel, and have recourse imme- 
diately to anodyne and astringent injections, and you should blister 
the abdomen, taking care to remove the blister at a proper time, 
and not leave it on so long as may add to the existing irritation. 
You may also prescribe the acetate of lead, or the sulphate of zinc 
with tincture of opium. I have seen several cases of this kind in 
the Meath Hospital, in which the administration of the sulphate of 
zinc was attended with good effects. The best mode of using it is 
to dissolve ten or twelve grains of the sulphate of zinc in six or 
eight ounces of cinnamon water, with a proportion of laudanum, 
and direct this quantity to be taken during the twenty-four hours. 
Dr. Elliotson recommends the sulphate of copper, and you can 
employ it in combination with opium. In this way, by supporting 
your patient’s strength, keeping him warm, paying attention to the 
state of his bowels, using counter-irritation, and prescribing astrin- 
gents combined with opiates, (taking care not to check the discharge 
too suddenly,) you will often succeed, even in very bad cases. 
Before I quit this subject I may observe, that Dr. O’Beirne has 
succeeded in some cases, and in others has given great relief by the 
use of tobacco injections. You can understand this when you 
reflect that tobacco acts powerfully on the general system, and pro- 
duces effects somewhat analogous to bleeding. Like general bleed- 
ing it brings on faintness, vomiting, cold skin, perspirations, and 
feeble pulse. It is also a powerful antispasmodic. and Dr. O’Bierne 
states, that its employment has been attended with the best effects 
in several very bad cases. I have not tried this remedy 
but I think it well worthy of a trial in the acute stage of dysentery, 
when there is room for an antiphlogistic treatment. In the ad- 
vanced stages, of course, it is inadmissible. 
We come now to consider the affection of the digestive tube, 
which merits a separate consideration, and this is tympanitis, or, as 
it is sometimes termed, meteorism. I shall not enter upon the ge- 
neral pathology of aeriform effusions into the abdomen ; we are not 
acquainted with that peculiar condition of parts which produces 
them, but it is now established that we may have effusions of air, 
not only into the digestive tube, but also into every part of the 
body. The term tympanitis is limited to effusion of air into the 
digestive tube, in all parts of which we may find it. We detect it 
in the stomach under two circumstances; first, as a recent and SPORADIC DYSENTERY. 
95 
transient affection, as when it comes on after swallowing indigesti- 
ble matter; secondly, in a more permanent form, as when it depends 
upon hysteria, hypochondriasis, or chronic gastritis. It may be 
also frequently seen in very young children, when there is fever- 
ishness with irritation of the digestive system. I recollect a very 
remarkable case of this kind, in which the distension was so great, 
and the pressure on the diaphragm so considerable, as to cause 
displacement of the heart upwards ;—this, I believe, has not been 
mentioned among the causes of displacement of the heart. The 
symptoms of this affection are sufficiently obvious;—a sense of 
uneasiness and distension at the region of the stomach ; when the 
effusion is in excess, a distinct tumour can be felt, and the sound 
on percussion, over the stomach, is like that of a drum. It often 
happens, also, that when the patient is shaken, a distinct sound of 
fluctuation is heard, a circumstance which more than once has 
led to the suspicion of the existence of pneumothorax, or empyema. 
There are also cases on record, in which the distension was so great 
as to cause rupture of the stomach, and effVision of its contents into 
the cavity of the peritoneum, causing intense inflammation and 
rapid death. 
The effusion of air into the intestinal tube is extremely common 
in cases of acute enteric inflammation and gastro-enteritis, after the 
disease has lasted for a few days, and, as this is a matter of consi- 
derable interest, I wish to make a few remarks upon it. It is of 
importance that you should bear in mind that this is one of the 
results of enteric inflammation, because many persons are in the 
habit of looking upon it, not as a mere symptom of another affection, 
but as a peculiar form of disease, forgetting that it may occur with, 
as well as without, inflammation. In consequence of this limited and 
imperfect view of the subject, they are in the habit of prescribing 
turpentine as a specific remedy for tympanitis. Now, I can 
say that I have seen the most dreadful effects from the administra- 
tion of turpentine in the tympanitis of acute enteric inflammation. 
The immediate effect is to produce a rapid dimunition of the tym- 
panitic swelling ; but this is purchased at too dear a rate ; for you 
will find next day that there will be a violent exacerbation of the 
existing symptoms, and the tympanitis becomes worse than before. 
You should never, therefore, interfere in this way with the tym- 
panitis of acute enteric inflammation, nor should you alter your 
practice on this account in the slightest degree, except where the 
tympanitis is so great as to interfere with the due performance of 
the function of respiration; but, in the advanced stage, after the 
twelfth or sixteen day, when the fever has abated and the tongue is 
moist, I have frequently seen great advantage result from the use of 
turpentine. But as long as the condition of your 'patient admits 
of antiphlogistic treatment, be assured that the administration of 
turpentine is hazardous. When the patient is in a low state, when 
you can no longer have recourse to bleeding or leeching, when the 
tympanitis is connected with an asthenic condition of the intestinal 
mucous membrane, then, and not till then, should you venture on 96 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the employment of turpentine. I shall return to this subject when 
we come to speak of hysteria. 
I may mention here, that the occurrence of flatus in the intestines 
sometimes gives rise to dreadful sufferings in that affection which 
has been termed windy colic. A person in the enjoyment of good 
health happens to take at his dinner or supper a quantity of indi- 
gestible food, he goes to bed without feeling any particular inconve- 
nience, but about the middle of the night he awakes with an attack 
of pain and tormina, which extend from the hypochondria to the 
umbilicus. This subsides for a short time, and then returns with 
violence, and the patient often finds that it is relieved by pressure. 
In a short time the pains get worse, and the abdomen begins to 
swell, sometimes at one point, sometimes at another, as if the air 
was confined and pent up in particular situations. The patient 
begins to suffer indescribable anguish, he has great anxiety, extreme 
prostration of strength, his face is pale, his extremities cold, a cold 
sweat breaks out all over the body, and he sits bent forwards, with 
his hands pressed on his stomach to relieve the paroxysms of pain 
which come on with increasing rapidity. In some cases there is 
distressing hiccup, in some a large quantity of aqueous urine is 
passed, in some there are loud borborygmi, and the intestines may 
become so enormously distended as to fall rapidly into a state of 
gangrene. Hippocrates has given a description of one of the forms 
of this disease, which terminates by the passage of air upwards and 
downwards, by which the patient obtains relief; this he calls dry 
cholera. This windy colic is an exceedingly violent disease: one 
of the first cases of it which I witnessed, presented such an array of 
alarming symptoms, that I thought every moment the patient would 
expire. It is, however, a disease which is generally easily managed 
if taken in time. One of the first things to be done is to apply 
heat to the abdomen by anodyne stupes, or warm flannel. Flannels 
wrung out of a decoction of popyheads, as hot as can be borne, will 
do a great deal of service, and in some cases will give complete 
relief, when assisted by the use of carminative draughts. But of all 
the remedies which I have seen, the most efficacious is an injection 
with tincture of asafoetida, turpentine, and opium. This is gene- 
rally followed by speedy relief, the pulse becomes more natural, the 
belly soft, and the excruciating agony is relieved. This is the 
mode of treatment in which I have the greatest confidence. After 
the acute symptoms are removed, it will be proper to exhibit a 
laxative, for the purpose of removing the exciting cause of the 
disease—indigestible matter; unless you get rid of this, your patient 
is liable to a return of the attack, and even to an inflammation of 
the tube itself. Be not, therefore, satisfied with merely relieving 
your patient; watch him carefully, and, by a proper treatment, 
obviate a recurrence of the symptoms, and prevent any tendency to 
inflammation.1 
1 When the flatus is pent up in the large intestine, as it often is, (the very 
term colic, indeed, indicates the common belief of old, that the colon is its 
ordinary seat,) instantaneous relief is often afforded by passing up a hollow PATHOLOGY OF JAUNDICE. 
97 
LECTURE XII. 
Pathology of jaundice—Its co-existence with a flow of bile—Case of aneurism of the 
hepatic artery—The disease, independent of mechanical construction—Colouring of 
the various parts—Effects on the milk, and humours of the eye—Jaundice with pre- 
servation of health—Icterus infantum. 
To-day we have to enter upon the consideration of a subject, the 
nature and extent of which claims for it a more than ordinary share 
of importance—I allude to that form of disease which is termed 
jaundice. I have selected this disease for our present lecture, be- 
cause I think we may look upon it as presenting a series of pheno- 
mena, which form a distinct link of connection between affections of 
the liver and the digestive tube. In the first place, jaundice, and I 
wish to impress this upon your attention, is to be regarded as a 
symptom rather than a disease sui generis, and that it is a symptom 
which occurs in many diseases of a most essentially opposite pa- 
thological character. There is nothing, for instance, more different 
than disease accompanied by acute inflammatory action, and disease 
without any inflammation at all; yet we may have perfect jaundice 
as a consequence of the one as well as the other. No diversity 
can be more complete than that which exists between the jaundice 
arising from inflammation and organic lesion of the liver, and 
that which results from simple mechanical obstruction of the 
biliary ducts. It is, therefore, to be looked upon not as a disease 
but as a symptom, and we may define it by saying, that it is a state 
in which the solids and fluids of the body are tinged more or less 
deeply with bile. Generally speaking, this presence of bile in 
fluids and solids where it should not be normally, is accompanied 
by the absence of that secretion in the place where it is naturally 
found, the digestive tube. Yet it is an interesting physiological 
fact, and one of practical importance, also, that we may have plenty 
of bile in the stools during an attack of jaundice, or that we may 
have jaundice co-existing with even a copious flow of bile. This 
is a strong proof in favour of the opinion, that some cases of jaun- 
dice have no connection or dependence on the absorption of bile 
into the system, as, in the instances to which I have alluded, there 
is no mechanical retention of bile; the biliary ducts and gall-bladder 
are open, the bile passes freely into the intestines, and yet the whole 
body is jaundiced. 
I have told you that jaundice is a symptom which is produced by 
a variety of causes—these I shall briefly enumerate. Without en- 
tering into the ultimate mode of action of these causes, and their 
bougie through the annulus of the rectum into the colon. The editor had 
the satisfaction of preserving the valuable life of an aged individual, who 
had been long honourably engaged in the service of his country, by this 
simple expedient. Injection after injection had been employed ineffectually. 
An elastic gum male catheter was passed up, the flatus was immediately 
discharged, and the pain and tympanitic distension were at once removed. 
R, D. 98 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
separate effects on the economy, it will be sufficient for my purpose 
to mention them individually. The first of these causes I take to 
be mechanical obstruction to the exit of the biliary secretion. 
Under such circumstances one of these two things is supposed to 
take place, either that the bile, which is poured into the biliary 
duct and gall-bladder, and cannot get into the duodenum, is re- 
absorbed, or, according to another opinion, that the innervation of 
the liver is injured; in other words, that the liver is paralysed and 
unable to perform its ordinary functions, and that, consequently, it 
does not separate the materials of bile from the blood. The latter 
opinion has been advanced by men of high authority in the medical 
world, but when we find, on dissection, (as is not unfrequently the 
case in jaundice,) the biliary ducts and gall-bladder distended with 
bile, we cannot infer a paralysis of the liver as the cause of the 
disease, we must attribute it to the re-absorption of bile. I have 
taken mechanical obstruction to the flow of bile as one of the causes 
of jaundice. Now, you will find this to depend, in the first place, 
upon the presence of gall stones in the biliary or common ducts. 
A biliary calculus is formed in one of these ducts, it excites violent 
irritation, spasmodic pain, and often (but not always) jaundice. At 
my next lecture I will show some specimens of this obstruction. 
In the second place, the biliary ducts may, from various causes, 
become obliterated ; they may be closed by adhesion, as the conse- 
quence of inflammation, or they may be impervious as the result of 
congenital malformation. In some cases children have been born 
without biliary ducts, in others the ducts have terminated in a mil 
de sac. A third cause of jaundice by mechanical obstruction is, 
where the flow of bile has been prevented by the pressure of 
tumours on the biliary ducts. Of this one of the most familiar 
instances is disease of the head of the pancreas, or malignant disease 
of the pylorus or duodenum. I have on a former occasion alluded 
to a case of jaundice produced by aneurism of the hepatic artery, 
one of the rarest pathological circumstances on record, and one 
which has not been hitherto described. So rare is it, that at a late 
meeting of the Academie de Medicine, that eminent pathologist, 
Cruveilhier, stated that he had never, seen a case of it. I was so 
fortunate as to meet with an instance of this uncommon form of 
disease, and will take an early opportunity of exhibiting the prepa- 
ration of it to the class. You will see by it how an aneurism of the 
hepatic artery may cause a complete obstruction to the flow of bile, 
and I shall be able to show you, that not only the trunks, but also 
the minute ramifications of the biliary ducts, are enormously dilated 
and filled with retained bile, and that these dilatations are continued 
up to the peritoneal surface of the liver, forming as it were so many 
aneurisms by dilatation of the biliary ducts themselves. The last 
cause of jaundice from mechanical obstruction, is that which de- 
pends upon the accumulation of scybalous matter in the bowels, a 
thing frequently met with in old persons. Dr. Marsh alludes to 
this form of the disease in his admirable paper on jaundice in the 
Dublin Hospital Reports, and brings forward cases in which the 99 
PATHOLOGY OF JAUNDICE. 
jaundice disappeared rapidly under treatment calculated to remove 
accumulations of hard faecal matter from the intestines. So much 
for the varieties of jaundice which depend upon mechanical ob- 
struction. Before I quit this part of the subject it will be necessary 
to allude to another form of the disease, which bears some analogy 
to those already mentioned, namely, the spasmodic jaundice. With 
respect to this variety there exists a great deal of doubt; some per- 
sons maintain that the ducts are muscular, and consequently liable 
to spasm like all other parts of the muscular system; others deny 
the existence of muscular fibres in the ducts; while a third party 
are of opinion that the spasm resides in the duodenum, and that 
the contraction of its muscular fibres is the sole obstacle to the free 
passage of bile. It is of very little consequence which of these 
opinions we adopt; the fact is, that this is a form of the disease 
which we occasionally meet with in persons of an hysterical or 
hypochondriac habit, but what is its exact seat we cannot ascertain. 
The probability is, that it is spasm of the duodenum itself. 
The next class of causes giving rise to jaundice, are those which 
are connected with acute or chronic disease of the liver, as, for 
instance, the different varieties of hepatitis and the existence of mor- 
bid growths in the substance of the liver. Here, however, it must 
be recollected that the occurrence of hepatic disease in the acute or 
chronic form does not necessarily imply the existence of jaundice ; 
in other words, there are some cases of disease of the liver in which 
bile is freely discharged into the digestive tube, others in which it 
is not, so that the non-secretion of bile and the consequent produc- 
tion of jaundice are to be looked upon as accidental complications. 
I have seen a case in which there was enormous destruction of the 
liver from suppuration, where one of the lobes was almost entirely 
converted into a bag of purulent matter, and the other extensively 
diseased, yet the patient had not the slightest tinge of jaundice. 
We are ignorant, therefore, of the cause which determines the 
production of jaundice in one case of hepatic disease, and not in 
another; the question remains to be decided by future investiga- 
tions. All we know is this, that it may occur or be absent in every 
form of acute or chronic disease of the liver. 
The third great source of this affection is disease of the mucous 
surface of the stomach and duodenum, the most important, because 
it is the most frequent, cause of jaundice. We are indebted to the 
researches of modern pathology for a correct notion of this form of 
the disease, and for the invaluable light thrown upon its treatment, 
which, up to the time of Broussais, had been extremely confused 
and empirical. Inflammation of the upper part of the digestive 
tube is an extremely frequent cause of jaundice, and this result is, 
generally speaking, independent of any mechanical obstruction of 
the gall-bladder or biliary ducts. This phenomenon may be 
explained by calling to mind the various examples of sympathetic 
irritation, and by recollecting that disease in one situation frequently 
produces disease in another, or, in other words, that we have an 
irritation of the stomach and duodenum, in which the liver sympa- 100 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
thetically partakes, and, as a consequence of this, the biliary secre- 
tion is arrested. In a former lecture, I alluded to the strong sym- 
pathy which is known to exist between mucous membranes and 
the glands whose ducts open upon their surfaces. It is supposed 
by some that the irritation existing in the duodenum may be ex- 
tended to the liver, producing paralysis of the functions of that 
organ and jaundice. It would appear, also, that the yellow fever 
of warm climates is only a variety of jaundice depending upon 
irritation of the gastro-intestinal surface. On this point the best 
pathologists seem to have made up their minds. 
The last cause of jaundice seems to consist of the sympathetic 
action of the brain upon the liver, and this is an extremely curious 
circumstance. There are numerous cases on record of persons 
who have received an injury of the brain becoming jaundiced, and 
the same affection has been repeatedly known to supervene on pow- 
erful mental emotion. Thus we find that Murat, on learning that 
his queen had assumed the sovereign power of Naples in his 
absence, fell into a violent passion, and became almost immediately 
jaundiced. The close connection which exists between the brain 
and the biliary system has been long known; it is unnecessary, 
therefore, that I should enter upon its consideration, for the purpose 
of accounting for an occurrence the nature of which must be ob- 
vious to all. You will, however, find that jaundice is, in the 
majority of cases, connected with disease of the gastro-intestinal 
surface, and that this is one of the most common causes of the 
sporadic jaundice of this country. I shall return to this subject on 
a future occasion, when we enter upon the consideration of hys- 
teria. 
Before I enter upon a description of the separate forms of jaun- 
dice, it will not be amiss to premise a few general remarks. I told 
you, at the commencement of my lecture, that we define jaundice 
by saying, it was that state in which the solids and fluids of the 
body were tinged more or less deeply with bile. Now, is this 
definition to be received without any exception ? and does it em- 
brace all the solids and all the fluids of the body? I have stated, 
that in some cases you will not be able to detect the slightest trace 
of bile in the stools. This is, hoAvever, but an apparent exception; 
it is, perhaps, because the bile is too small in quantity to be able to 
overcome the diluting power of the ingesta, or that the portion of it 
which finds its way into the digestive tube is too small to be appre- 
ciable by our senses under these circumstances. The rule of uni- 
versal colouring in this disease will not, I believe, hold good, at 
least there are certain fluids and solids which are tinged only in a 
very slight degree ; but the majority of the textures and fluids have 
been observed to be more or less distinctly coloured. For instance, 
we find the jaundiced tint appearing in bone, cartilage, muscle, in 
the cellular membrane, in the centraf portions of the teeth, but not 
in their enamel. It is doubted whether the hair is coloured or not, 
but it is the opinion of many that it is, and a professional friend of 
mine has assured me that he has had unquestionable proofs of the PATHOLOGY OF JAUNDICE. 
101 
colouring of the hair. The membranes of the brain are distinctly- 
tinged. I have seen the arachnoid and pia mater decidedly coloured 
in a case of dreadful gastro-duodenitis, to which I shall call your 
attention on a future occasion. The substance of the brain, how- 
ever, has not been found to partake in this universal discoloration. 
Frank, who is a good authority on this point, states that the sub- 
stance of the brain is never coloured, though the membranes may, 
and most commonly are. In my experience of jaundice, I have 
found the membrane distinctly coloured, but never could see any 
tinge of yellowness in the substance of the brain. I have how- 
ever observed, that when a horizontal section of the brain had been 
made in such cases, the orifices of the divided vessels, which are 
denoted by bloody points in the healthy state, seem to pour out a 
quantity of yellowish blood, but the substance of the brain appeared 
white and normal. 
With respect to the state of the fluids, you will find the blood 
distinctly coloured; the saliva also is yellow; the urine is loaded 
with bile, it stains the linen, and chemical analysis shows that a 
large proportion of the biliary secretions is blended with it. The 
perspiration is also tinged with it; and if you apply a blister you 
find the exuded serum bilious. If a person, labouring under phthisis 
or bronchitis, should happen to get an attack of jaundice, the pul- 
monary secretions will be often tinged with yellow. The mucous 
secretions from the vagina and uterus are also discoloured; but it 
is an interesting and curious fact, that the milk during lactation 
seems to escape the general impregnation with bile, and is never 
tinged. This would appear to be a beautiful provision of nature to 
prevent the child from being injured. Frank, who witnessed two 
epidemics of jaundice, one at Mayence, in 1754, and another at 
Ghent, 1742, states that he has never seen the milk tinged with 
bile. Dr. Marsh, in his paper on jaundice, mentions that in the 
case of one unfortunate female a yellow fluid was squeezed from 
the breasts after death ; but this cannot be considered as a proof of 
the existence of bile in the milk duringf life. 
In jaundice the eye almost always presents a very distinct yellow 
tinge, and yet it is a curious and interesting fact, that the patients 
very seldom complain of yellow vision. Out of several thousand 
cases of jaundice, Frank only met with five in which this symptom 
was observed. The occasional occurrence, however, of yellow 
vision in jaundice, has excited a good deal of interest; and Drs. 
Graves and Elliotson, who have turned their attention to this sub- 
ject, have made some ingenious and valuable remarks on this sin- 
gular phenomenon. Dr. Elliotson’s opinion is, that where this 
symptom is complained of, the cornea is in a state of irritation or 
inflammation, and that under these circumstances its vessels, which 
in their physiological condition are too small to allow of the passage 
of coloured fluids, become dilated, so as to carry bilious blood across 
the field of vision, and thus cause all objects to wear a yellow hue. 
To support this opinion, he brings forward the case of a jaundiced 
patient, who had a considerable degree of inflammation in one eye 102 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
but none at all in the other, and who saw objects yellow .with the 
inflamed eye, but of their natural colour with that which was free 
from inflammation. This case is, indeed, as far as it goes, extremely 
interesting; but I think it does not prove the point in question, 
namely, that the cause of jaundiced vision is irritation of the cornea, 
for it is a fact that even when the cornea is deeply tinged, yellow vision 
is not of constant occurrence, nor does it affect all persons alike. 
One person sees objects in their natural colours ; to another under 
the same circumstances every object appears to wear a yellow hue, 
and what is equally remarkable, this yellowness of vision is fre- 
quently intermittent; it is present to-day and disappears to-morrow. 
These are extremely curious facts. 
The object of Dr. Graves on this subject, in the Dublin Medical 
Journal, is to explain the cause of the absence of yellow vision in 
certain cases of jaundice. He believes that the humours of the eye 
frequently escape the jaundiced tinge, and suggests that this may 
be a beautiful provision of nature for the preservation of sight. 
From his own observations he states that the aqueous, and perhaps 
the vitreous, humours escape. But, it may be objected to this, that 
when all the fluids, the blood, saliva, serum, perspiration, &c., are 
impregnated with bile, how is it possible that the fluids of the eye 
should escape?—Does it not seem very extraordinary?—It does, 
certainly; but that it is possible seems to be established by the fol- 
lowing circumstances;—you are not to conclude, because all the 
fluids which are found to exist in the blood are filled with bile, that 
the secretions, properly so called, which do not exist in the blood, 
should be also tinged with bilious discoloration. This is the an- 
swer which Dr. Graves makes to this objection—I recollect two 
cases of malignant cancerous disease of the liver, which were some 
time ago in the Meath Hospital, and which presented symptoms of 
universal jaundice before death. In these cases we found fluids 
deeply impregnated with bile—every thing, in fact, seemed bilious 
and discoloured; and yet, you will hardly credit me when I tell 
you, that, on opening the gall-bladder, it was found to contain a 
quantity of beautiful limpid fluid, perfectly transparent, and of a 
high refractive power. Here, then, is a fact to prove that we may 
have intense general jaundice, and yet find in a sac, existing in a 
system so diseased, a quantity of fluid perfectly free from any bilious 
admixture, proving, at least, that it is possible that the humours of 
the eye may in a similar manner escape. Dr. Graves further 
remarks, that, even where the humours of the eye happen to be- 
come tinged, the alteration in the colour of objects may still escape 
the observation of the patient; because the change takes place gra- 
dually and insensibly. The patient does not think every thing he 
sees is yellow; he believes still that they are white, because the 
transition from one colour to the other has been so insensible as to 
escape his notice. This reasoning may, I think, apply to cases of 
yellow vision coming on gradually, but will not explain those in 
which it has been of sudden occurrence. The other cause which 
Dr. Graves adduces as tending to prevent a patient with a yellow PATHOLOGY OF JAUNDICE. 
103 
cornea from seeing objects of the same colour, is, the want of some 
standard of comparison to judge by. He has no means of compar- 
ing objects; and, though he sees this piece of paper, for instance, 
(yellow,) he thinks it white, because every standard he looks to, 
every other piece of paper he examines, presents the same tinge, 
Dr. Johnson states, that most of the jaundiced patients whom he 
has interrogated were sensible of the alteration in vision to a greater 
or less degree, and observes that the power of appreciating varieties 
of colour is retained, though we look through a yellow medium not 
deeply dyed, though yellow, of course, is made to enter into this 
composition. You will see this observation in the Medical Chirur- 
gical Review for October, 1833. 
I shall conclude this subject with an observation which suggests 
itself to me, and this is, that the alteration of colour and vision may 
arise from other causes than the mere jaundiced condition of the 
eye; and that it may (I believe this has not been taken notice of 
before) depend upon direct nervous influence. There are cases on 
record of patients labouring under typhus fever, who, without 
being in the slightest degree jaundiced, saw every thing yellow. 
There are also numerous instances of various colours, differing 
from the natural hues of the objects, being seen by patients in con- 
sequence of affections of the nervous system; and hence it is ex- 
tremely probable that many cases of yellow vision in jaundice may 
depend upon a functional lesion of the optic nerves. I have one 
fact to bring forward on this subject of great importance. In the 
case of jaundice from aneurism of the hepatic artery, the patient 
saw every thing intensely yellow, until a few days before death, 
when all yellow vision subsided, and he saw objects of their natural 
colour, though the jaundice continued, if possible, more intense 
than ever. In this case there was no inflammation of the eye. I 
do not think that Dr. Elliotson’s observations apply to all cases of 
this phenomenon. All that he has said is, that where the cornea is 
in a state of inflammation, there is a greater probability that there 
will be yellow vision in the affected eye or eyes; and this can be 
easily accounted for by the increased size of the vessels which the 
inflammatory process brings on. We may however conclude, that, 
in some cases, the alteration of vision may be owing to a yellow 
state of the humours of the eye, that in some it is the result of in- 
flammation, and that in some it may be fairly attributed to a lesion 
of innervation. I think that the latter statement is borne out by the 
facts that there is a want of constancy in the occurrence of this 
phenomenon, that it is often of a more or less intermittent character, 
being one day present and another day absent, and that it has been 
observed in cases where not the slightest symptom of jaundice ex- 
isted. We must also bear in mind that some of the most remark- 
able nervous systems commonly occur in jaundice, such as coma, 
&c.; and we may enquire how far the occurrence of yellow vision 
may be looked on as an indication of an excited state of the 
brain, and so lead us to measures calculated to remove impending 
danger. 104 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
Let us now return to the more immediate consideration of jaun- 
dice. One of the first diseases of children is the icterus infantumi, 
or, as it has been termed by nurses, the yellow gum. Children, 
shortly after birth, without any known cause, become suddenly 
jaundiced, and this, after continuing for some days, goes off, fre- 
quently without any treatment. This form of jaundice appears to 
depend upon some particular irritation of the intestinal canal, which 
seems to result from the circumstance of the digestive system being 
called into active exertion for the first time, and receiving a new 
stimulus from the mother’s milk. It is a curious fact, that this form 
of jaundice generally disappears spontaneously. Now, it is remark- 
able, in this as well as other cases, (when we recollect the nature of 
jaundice, and that there exists in the fluids of the body an irritating 
substance like bile,) that the effects of an admixture of the biliary- 
secretion with those fluids should not be attended with more striking 
symptoms. In some instances we shall have intense jaundice 
without any particular effect upon the economy. There is some 
itching of skin, ardour urinae, a little depression of spirits, and 
vertigo, which last for a few days and then disappear. Dr. Gre- 
gory mentions many cases of persons affected with jaundice who 
went about their ordinary business, and performed all the functions 
as if in a state of perfect health, eating, drinking, and sleeping in 
their usual manner. I have myself seen persons who laboured 
under this affection for more than a year, and yet had all that time 
their digestion good, their bowels regular, the flow of urine natural, 
and the circulatory, nervous, and respiratory systems apparently 
conformable to the standard of health. Dr. Blundell gives the 
cases of two children who lived for four months, apparently well 
fed and healthy; and, on opening their bodies, it was found that 
the biliary ducts terminated in a cul de sac, and that, consequently, 
not a drop of bile had been discharged into the intestines. Sir 
Everard Home gives a remarkable case of the total absence of the 
gall-bladder, and no passage of bile into the intestines, occurring in 
connection with a perfect state of health. These are curious facts, 
and should be borne in memory. I remember two cases of pro- 
tracted jaundice in the persons of two male servants, who were 
admitted into the Meath Hospital with symptoms of irritation in the 
upper part of the digestive tube. From this both recovered under 
an appropriate treatment, but the jaundice continued in one for 
eighteen, and in the other for sixteen months. One of them, a 
stout, well-built, and fully developed man, came into the hospital 
some time afterwards in the apparent enjoyment of perfect health, 
except that he had still the jaundiced colour. He wished to be 
taken into the hospital to get cured of his jaundice, stating that, in 
consequence of the peculiarity of his appearance, he could not get a 
place any where, and was in a very distressed condition. From 
these facts it seems fair to conclude that the symptoms of other 
affections, occurring after jaundice, are owing to some other cause 
than the bilious state of the blood. 
I find that my time is nearly expired; I cannot, therefore, enter JAUNDICE FROM GASTRO-DUODENITIS. 
105 
into the various causes of jaundice to-day; at our next meeting I 
hope I shall be able to conclude this subject, and then pass on to the 
consideration of hepatic disease. 
LECTURE XIII. 
Jaundice from gastro-duodenitis—Researches of Broussais and Marsh on—Jaundice 
without hepatic inflammation—Nervous symptoms—Treatment—Yellow fever—Its 
occurrence in this country—Predominance of gastric irritation in warm climates— 
Typhus icterodes—Jaundice from biliary calculi—Different situations in which 
biliar}7 calculi may be found. 
We commence to-day with the consideration of that form of jaun- 
dice, which, taking all its cases into account, appears to be the most 
common. The pathological expression for this form of the disease 
is, that it is inflammation of the upper portion of the digestive tube, 
or, in other words, that it is the result of a gastro-duodenitis. In 
this case, an inflammatory affection of the stomach and duodenum 
acts sympathetically on the liver, and we have jaundice occurring 
independent of hepatic inflammation or mechanical obstruction to 
the flow of bile. This variety of the disease it is important you 
should be accurately acquainted with, as it is not only exceeding 
common in temperate climates, but because I believe it is a great 
cause of mortality in warm countries, and that the yellow fever of 
the tropics is reducible, in a great measure, to this form of disease. 
In other words, that the cause of the yellowness, and many other 
of the symptoms, is to be referred to an intense irritation or inflam- 
mation of the digestive tube, with a predominance of that irritation 
in its upper portion. 
The jaundice which depends upon gastro-duodenal inflammation, 
was first accurately described by Broussais. Dr. Marsh has also 
made many valuable additions to our knowledge on this subject, in 
his paper on jaundice, published in the fifth volume of the Dublin 
Hospital Reports. You will find, too, that in a case of jaundice 
described by John Hunter, he suggests the possibility of its being 
preceded by inflammation of the duodenum. But I believe we are 
chiefly indebted to Broussais for our first correct notions of the 
pathology of this disease, and for its scientific and successful treat- 
ment. 
The disease may occur in the acute form, or it may come on in 
a slow insidious manner; but in either case, as far as my expe- 
rience goes, it is always accompanied by symptoms referable to a 
morbid state of the mucous membrane of the intestines. Dyspeptics, 
and individuals subject to diarrhoea, are liable to it; but it may 
also attack strong and healthy persons from the two following 
causes. A man is exposed to considerable heat, his body is bathed 
in perspiration, he experiences some degree of lassitude, and is very 
thirsty; in this state he takes a large draught of cold water. In a 106 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
few hours afterwards he begins to feel uneasy, and complains of 
being unwell; he gets shivering, nausea, thirst, and fever, and this 
fever and thirst, with bilious symptoms (as they are called), con- 
tinue for two or three days, when some morning, on awaking, the 
patient finds himself jaundiced. The same thing may happen as a 
consequence of error in diet. A person eats at supper a quantity of 
indigestible food, next day he has vomiting and thirst, and in a day 
or two more jaundice appears. I may remark here, that this indis- 
position of two or three days’ standing is a very curious and interest- 
ing feature in the disease, and would seem to be connected with the 
progress of disease in the mucous surface of the stomach and 
duodenum. Jaundice from gastro-duodenitis generally occurs in 
this country under two varieties. The first is an extremely mild 
disease; it comes on with very slight and transient symptoms of 
constitutional or local derangement; it seldom prevents the patient 
from pursuing his ordinary avocations, and generally disappears 
without any trouble. The second variety is an extremely severe 
and frequently a fatal disease; between this and the former there 
are numberless shades and gradations. 
Let us take a case of the more severe form of jaundice. The 
cause of this, as I have already mentioned, is often the taking a 
copious draught of cold water while the body is heated by exercise, 
or eating a quantity of indigestible food. The patient is indisposed 
for two or three days before the jaundice appears ; he lias nausea, 
vomiting, great thirst, loss of appetite; he complains of burning 
heat in the epigastrium, and there is some tenderness on pressure 
over the region of the stomach and duodenum. His tongue is foul, 
his bowels costive, his urine loaded; he has considerable prostration 
of strength, complains of vertigo and lowness of spirits, and is con- 
stantly sighing. There is always more or less febrile disturbance; 
in some cases the fever is ephemeral, and goes off in a day or two; 
in others it continues for a much longer period. When this fever 
continues beyond the second or third day, it is to be looked upon as 
an unfavourable sign, and you may expect that the case will be 
unmanageable and dangerous. There is another remarkable symp- 
tom on which I have had reason generally to found an unfavour- 
able prognosis, and this is a variation in the intensity of the 
yellowness. In some cases, you will find that to-day the counte- 
nance and skin are much less yellow, and this is always noticed by 
the patient, whose spirits are generally raised by the decline of the 
jaundiced tint, but in a day or two it becomes as deep as ever, and 
it may go on in this way, alternating from a faint to a deep tinge, 
and vice versa. This is an unfavourable symptom; it appears to 
indicate the repetition of inflammatory action in the intestinal tube, 
because each increase in the depth of the yellow tinge is accom- 
panied by an increase of the epigastric symptoms. In such cases 
as this, the patient does not, as under other circumstances, shake 
off the disease and return to his usual habits; he lies in bed, and 
though he complains of no pain, except when you make firm pres- 
sure on the epigastrium, still he is not at all improving; he tells JAUNDICE FROM GASTRO-DUODENITIS. 
107 
you he is better, but he is still languid, and his appetite does not 
return. The stools are generally clay-coloured, but this is not a 
necessary consequence of jaundice ; they are sometimes yellow, and 
1 have seen them of a perfectly healthy appearance. The pulse, in 
most cases where the fever is ephemeral, returns in a few days to 
its natural standard ; in some instances it is remarkably slow, and 
this state of pulse is to be regarded as an unfavourable symptom. 
Sometimes there is a slight degree of subsultus tendinum and 
delirium ; and I must observe that you are never to forget that the 
early supervention of nervous symptoms, in any form of this dis- 
ease, is always to be looked upon with suspicion. One of the most 
alarming complications, however, of this gastro-duodenal jaundice, 
is the occurrence of coma during its progress, a symptom to which 
the attention of the profession was tirst strongly directed by Dr. 
Marsh. He has given several cases of jaundice, characterised by 
this symptom, the majority of which resisted all the ordinary 
resources of medicine, and terminated fatally. I must confess, too, 
that I have never seen a case, in which the coma was distinctly 
established, terminate favourably. You should, therefore, when 
called to treat a case of jaundice, be always on the alert, and never 
allow any bad symptom like this to steal upon you ; and it is 
gratifying to think, that if you take this symptom in time, you will, 
in all probability, be able to overcome it. 
An extremely interesting paper on this coma, occurring in jaun- 
dice, will appear in the forthcoming number of the Dublin Medical 
and Chemical Journal, from the pen of Dr. Griffin, of Limerick. 
He gives the details of some extraordinary cases, which you will 
find well worthy of an attentive perusal. Out of four cases in one 
family, which he attended, two died, who had become comatose at 
an early period: in the other two, the affection of the brain was 
relieved by bleeding and other active measures. From this it 
would appear, that the mere supervention of coma is not necessarily 
followed by death, but that it is an exceedingly dangerous symptom 
when it comes on at an early period of the disease. It is very diffi- 
cult to give a satisfactory explanation of this. Some persons think 
that it is attributable to the action of the bile on the blood which is 
circulating in the brain. This explanation would answer very well 
if coma was a symptom of common occurrence; this, however, is not 
the case, and we must seek for some better reason. It is stated, by 
some, that coma may be one of the consequences of the close 
sympathy which exists between the brain and liver. Dr. Griffin 
draws an analogy between the effects of suppression of bile in jaun- 
dice and suppression of urine in diseases of the kidneys, and thinks 
that the affection of the brain is of common occurrence in one as 
well as in the other. This analogy, however, is incomplete, for we 
have no case of complete suppression of urine without fever and 
other violent symptoms, but we have many cases of complete sup- 
pression of bile with very slight and almost inappreciable disturb- 
ance of the economy. It is very difficult, in the present state of 
medical science, to explain the coma of jaundice; all we know is, 
25* 108 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
that it sometimes occurs, that it is a bad symptom, and must be met 
with great activity. I may mention one fact which seems to be 
strongly opposed to the analogy of Dr. Griffin. It will be proper 
to observe here, that Dr. Griffin does not advance this as an opinion, 
or advocate it as a theory; he merely offers it as a hint or sugges- 
tion, leaving it to others to decide the question. We are not, there- 
fore, in examining this analogy, reasoning against any opinion of 
his. But with respect to this matter, the fact to which I allude is 
this—one of the worst cases of coma I ever witnessed, occurred in 
a patient who had no suppression or retention of bile; the bile 
flowed freely into the intestines, the dejections were distinctly tinged 
with it, and yet this man had deep jaundice and intense coma. We 
are still in want of a number of facts on this point; it is a subject 
which affords a large field for interesting enquiry, and Dr. Griffin 
deserves great credit for the philosophical and impartial manner in 
which he has brought his cases before the medical public. 
When a patient dies of jaundice, accompanied by this comatose 
affection, you are naturally anxious to ascertain the cause of death. 
INow what you will generally find is this: on opening the head you 
examine the brain accurately, but cannot detect any lesion of its 
substance or membranes; you then go to the stomach, and discover 
there marks of vascularity; you open the duodenum, and find it in 
a state of intense inflammation. I have seen many cases of this 
disease in which the mucous membrane of the duodenum was 
highly engorged and almost black. It is said that this inflamma- 
tion extends from the duodenum along the common biliary duct to 
the liver. I am not possessed of facts to confirm this assertion, but 
I have little doubt that, in the majority of cases, the jaundice is more 
the result of a mere lesion of innervation of the liver, than proceed- 
ing from any spread of inflammation along the ducts into its sub- 
stance. Unless we can demonstrate this inflammation, it is idle to 
assume its occurrence. When you examine the liver, gall-bladder, 
and biliary ducts, you generally find them in the normal state. In 
a few cases, the ducts have been found impervious from adhesive 
mucus; you will see in John Hunter’s works a case of this kind, 
which occurred in a consumptive patient. You will find a great 
number of important facts, relating to the pathology of jaundice, in 
the commentaries upon his own pathological propositions by M. 
Broussais. I would also advise you to peruse Dr. Marsh’s excellent 
paper in the Dublin Hospital Reports. 
We come now to the diagnosis of jaundice depending upon 
gastro-duodenal inflammation. In the first place, we learn from the 
history of the case that the exciting cause has been some excitant 
of inflammation in the mucous surface, the ingestion of indigestible 
aliment, or taking cold water into the stomach while the body has 
been overheated. The next thing is the supervention of fever with 
gastric symptoms, and these being followed, in two or three days, 
by an attack of jaundice, without any of the ordinary signs of 
hepatitis. Here we have a disease excited by taking cold water 
while the body is heated, or by indigestible food, preceded by febrile JAUNDICE FROM GASTRO-DUODENITIS. 
109 
disturbance with gastric symptoms, and unaccompanied by the 
symptoms or signs of hepatitis. When this combination of circum- 
stances occurs, you make your diagnosis with great certainty, and 
set it down as jaundice depending on inflammation of the stomach 
and duodenum, and treat it accordingly. There are but two forms 
of jaundice accompanied by symptomatic fever; the one under con- 
sideration, and that which is the consequence of hepatic inflamma- 
tion, or other disease. It might be supposed that the tenderness of 
the epigastrium was caused by an affection of the liver, but by 
making an accurate examination you will be generally able to dis- 
criminate with certainty. You will find that the pain is less than 
that of acute hepatitis, that strong pressure gives pain, not in the 
region of the liver, but in that of the duodenum; you can ascertain 
by a manual examination, and by the pleximeter, that there is no 
enlargement of the liver, that there is no remarkable dulness on 
percussion at the lower part of the chest on the right side, and when 
the fever is ephemeral, this will furnish you with much valuable 
assistance towards forming a correct diagnosis. 
With respect to the treatment of this form of jaundice, in mild 
cases, where there is little or no fever (for fever is to be taken as a 
test of the severity of the disease), the patient very often gets well 
without any treatment, and the jaundice, after lasting a few days or 
weeks, goes off spontaneously. In all such cases, a regulation of 
diet, keeping the bowels open by mild laxatives, and prohibiting 
wine, spirits, and other stimulants, will be found, in general, suffi- 
cient to remove all the symptoms. I wish, however, to impress 
upon you that it is of the utmost importance to cut short this dis- 
ease as soon as possible. There is no use in letting it get ahead 
of you ; and in every case where the symptoms are in any degree 
acute, and there is a degree of fulness and tenderness over the 
epigastrium, you will be culpable, if you omit to apply leeches over 
the stomach and duodenum, and prescribe iced water, and every 
other means calculated to remove inflammation. If you allow it to 
go on to a certain length, if you allow fever to progress, and coma 
to supervene, you will not be able to manage the case so easily. 
Never, then, omit the application of leeches the moment you have 
ascertained the existence of decided inflammation. Keep your 
patient’s bowels open by enemata, or by mild saline laxatives, regu- 
late his diet carefully, prohibit all stimulants, and he will generally 
do well. 
Many persons are in the habit of prescribing mercury in this dis- 
ease. From my own experience I cannot say whether this is right 
or wrong; but I can state that I have seen a great many cases get 
well without it. But in cases where the symptoms are obstinate, 
and the stools continue white, I think you would be justified in 
giving mercury, even so far as to produce salivation. I must 
remark to you, however, that I have seen two cases in which it 
was found impossible to produce the free action of mercury in 
patients labouring under this disease. The exhibition of small 
doses of cream of tartar, two or three times a day, made into an 110 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
electuary with some mild confection, I have found to be an excellent 
remedy in the treatment of this affection. In my lecture on dysen- 
tery, I mentioned some facts which go to prove that this remedy 
seems to have great power in bringing down bilious discharges. In 
this form of jaundice I found cream of tartar extremely useful, and 
its exhibition is unattended with danger. 
Now suppose you should meet with a case in which coma appears 
as an early symptom, what should your line of treatment be ? 
Here you have to deal with a very threatening symptom, which, if 
neglected for any time, will, in all probability, bring on a fatal ter- 
mination. You should, therefore, on its first appearance, meet it 
with a corresponding activity; you should immediately have the 
head shaved, apply leeches behind the ears, blister the nape of the 
neck, and act smartly on the bowels by laxatives. It was by such 
treatment as this that Dr. Griffin saved his patients. 
I wish here to make some observations on a very remarkable 
form of gastro-duodenitis, which was almost epidemic in this country 
some years ago, at least it occurred during the existence of an 
epidemic fever, and we had at that time a great many cases of it in 
the hospital. It is a curious fact that the majority of these seemed 
to bear a distinct resemblance to the yellow fever of warm climates. 
This will appear somewhat extraordinary; but, when you have 
heard a statement of the facts, you will be inclined to think that 
these cases were nothing more or less than so many instances of 
the malignant yellow fever of the tropics. I shall read for you an 
account of the symptoms, as they were observed in numerous cases 
under the care of my colleague, Dr. Graves, and myself, in the 
Meath Hospital. 
In the great majority of cases this disease was preceded by fever; 
in fact, all the patients who exhibited this form of jaundice had been 
admitted as fever patients. After a longer or shorter period, with- 
out any premonitory indications, symptoms of intense irritation of 
the digestive tube set in, and advanced with a fatal rapidity. Most 
of the patients vomited frequently; there was great tenderness of 
the epigastrium, and over the region of the small intestine; the 
tongue became black and parched; there was a violent pain in the 
belly, and a spasmodic affection of the abdominal muscles, which 
felt hard and knotted, and to which the nurses gave the name of 
twisting of the guts, a name which singularly agreed with the 
numerous intussusceptions found along the course of the small 
intestine after death. This state of suffering continued from one to 
four hours, and then the body became all over suddenly jaundiced. 
Then came another train of symptoms. With intense and universal 
jaundice, the patients exhibited also extreme restlessness, tossing 
their arms about, and regarding their attendants with a look at once 
expressive of nervous suffering and despair. Some raved, had 
trembling and convulsive fits, and were totally unconscious of 
every thing passing around them; others preserved their intellect 
to the last, but they had depicted in their countenances an agony 
and a despair which I shall never forget. General spasms were JAUNDICE FROM GASTRO-DUODENITIS. 
frequently observed; and many, on attempting to swallow, had 
spasms like those of hydrophobia. There was great irritability of 
the stomach ; many vomited frequently, and in some cases the 
matter ejected bore an exact resemblance to coffee grounds. The 
pulse became low and fluttering, the extremities cold, the face pale 
and shrunken, and in some the nose assumed a purple colour, 
giving to the patient a truly horrible appearance. This change in 
the colour of the nose was preceded by extreme paleness ; the part, 
at first, appeared as if it had been frost-bitten. Broad patches of a 
wax-like whiteness, elevated a little above the level of the skin, and 
somewhat resembling urticaria, having the same temperature as the 
rest of the body, were found on the following day to assume a 
reddish colour; and on the third day the redness was converted 
into dark purple. The toes were affected in a similar way; and in 
some of these cases the parts so affected sloughed and were thrown 
off. There is at present in this city a woman who lost the ala of 
the nose, and one of the toes, in this manner. 
The phenomena observed on dissection were equally remarkable. 
Though the tenderness of the epigastrium was very great, there 
was no trace of peritoneal inflammation ; neither ivas there, in any 
case, inflammation of the liver, and. the gall ducts were found to 
be pervious in every instance. The mucous surface of the stomach, 
and duodenum, and ileum, were found in every case to present 
intense marks of inflammation ; there were numerous intussuscep- 
tions along the course of the ileum, and the spleen was found to be 
large, soft, and pultaceous. There was no evidence of inflammation 
of the brain; but in the ventricles, and at the base of the brain, there 
was in some cases an effusion of yellowish fluid, and the membranes 
had a faint tinge of yellowness. In one case l found a remarkably 
dry state of the arachnoid. In one severe case there was a good 
deal of a substance resembling coffee grounds in the stomach, and 
the mucous membrane was soft and disorganised. 
All the phenomena of this disease, the gastro-intestinal inflam- 
mation, the yellowness of skin, the enlargement and softening of 
the spleen, the rapid fatality and excessive prostration, seem to point 
out a strong analogy between it and the yellow fever of warm 
climates. In the writings of Rush and Lawrence, you will find 
that their description of the phenomena, observed on dissection, 
would in a great degree answer for those of the cases which I have 
detailed. I may mention here, too, that in our cases the mortality 
was severe. We lost the first sixteen cases ; and it was not until 
we fully ascertained the nature of the disease by dissection, that we 
began to save these patients. Then, by free depletions, copious 
applications of leeches to the abdomen, and the bold use of calomel 
and opium, we succeeded in a great number of cases. In some 
cases death took place in four, in others in six hours ; in a few it 
was more prolonged. There is no epidemic on record in this city 
in which the same symptoms, and the same rapid fatality, were 
observed. 
With respect to the analogy between this disease and yellow fever, 112 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
it appears that in the latter affection the yellow colour depends 
upon the presence of bile in the blood. This is one point. Again, 
from the most accurate descriptions which have been given of the 
morbid appearances of yellow fever, it appears that in the majority 
of cases the liver has been found healthy ; here is another point. In 
yellow fever, also, inflammation of the stomach, duodenum, and 
intestines, is a matter of almost universal occurrence, as you will 
find by examining the works on yellow fever. In our cases we 
had all these circumstances; we had extreme tenderness of the 
epigastrium, and inflammation of the stomach, duodenum, and 
intestines ; and in one severe case we had black vomit. All these 
circumstances, combined with the fatality, seem to prove that the 
cases which were under treatment in the Meath Hospital, during 
the epidemic of 1846-27, bore a very striking resemblance to that 
species of fever which is supposed to exist only in warm climates. 
It is probable that if yellow fever should appear in temperate coun- 
tries, it would exhibit itself in the form of gastric fever, with some 
cases only of yellowness. Indeed, it seems to be now very gene- 
rally admitted, that yellow fever has nothing peculiar in it; that it 
is the maximum of bilious or gastric fevers. We find that in pro- 
portion as we approach the warm latitudes, the digestive mucous 
membrane appears to take on a greater susceptibility of disease. 
Between the tropics it would seem as if morbid actions were chiefly 
thrown upon the viscera of the abdomen. Europeans, who have 
resided there for any length of time, acquire a yellow tinge, and 
many of them suffer from intestinal and hepatic inflammations. If 
we go northward, we find the case to be the reverse; as we approach 
the colder latitudes, we find the mucous membrane of the digestive 
tube acquires a greater degree of tone and vigour, that it is less sus- 
ceptible of disease, and can bear much greater stimulation. The 
inhabitants of warm climates use a large proportion of vegetable 
food; they seldom indulge in the use of animal food or spirits. 
The Hindoo lives on rice, the Arab on dates and milk. But, if we 
go northward, we find the natives habitually using stimulating food 
and drink with impunity ; indeed, it is wonderful to think what 
vast quantities of flesh, animal oil, and other stimulants, the 
stomach of an Esquimaux or Kamschatkan will bear without injury. 
There is no doubt that warm climates predispose to inflammatory 
affections of the digestive apparatus, and this seems to connect 
yellow fever with the ordinary form of gastro-duodenitis, accom- 
panied with jaundice, or, in other words, a little more extent, a 
greater degree of intensity, and we may have the jaundice of this 
country converted into yellow fever. And it is fair to conclude 
that the typhus icterodes of temperate countries owes its danger 
not to the mere circumstance of jaundice existing, but to the greater 
degree of secondary gastro-enteritis which has produced that jaun- 
dice. 
I shall now draw your attention to some other forms of jaundice. 
One of the most important of these is, that which arises from the 
obstruction of the biliary ducts by calculi. It would be foreign to 113 
JAUNDICE FROM GASTRO-DUODENITIS. 
my purpose to enter into any discussion with respect to the forma- 
tion of gall stones in a course of lectures like this ; I shall therefore 
refer you, for information as to their history and composition, to 
the various treatises on animal chemistry. What we have to con- 
sider at present, are the symptoms of the disease, the habit of body 
in which it is found to occur, and its mode of treatment. You see 
on the table numerous preparations of the various forms of this dis- 
ease. 
Gall stones are more commonly observed after the age of forty or 
fifty than before these periods ; they are very frequently met with 
in persons of sedentary habits, and hence women are more subject 
to them than men. They are also liable to occur in persons who 
eat highly-seasoned indigestible meats, and take little or no exer- 
cise. It is stated that in England five sixths of the cases of gall 
stones occur in females. I do not know whether this proportion 
be exact, but the fact is established that they are more common in 
females than men. Biliary calculi may be found in three different 
situations, either in the substance of the liver, or plugging up the 
biliary ducts, or filling the gall-bladder. Here is a preparation, 
exhibiting the gall-bladder almost obliterated by the pressure of a 
number of those calculi within its cavity. Here is another speci- 
men. You see the gall-bladder is contracted, and nearly filled up 
with biliary calculi; it also appears to be atrophied and reduced in 
size. Here is a remarkable specimen. You observe the gall- 
bladder, which is rather large, is completely filled with a vast cal- 
culus ; its coats are also thickened, probably the result of inflam- 
mation. Here is another preparation of the gall-bladder, contain- 
ing two moderately sized calculi. 
Gall stones, when lodged in the substance of the liver, or in the 
gall-bladder, may remain for a long time, and accumulate pro- 
digiously, without producing jaundice. This has been frequently 
proved by the fact, that on opening the bodies of persons who have 
not had during life the slightest symptom of jaundice, the gall- 
bladder has been found completely filled up with these productions. 
But when any cause determines the passage of one of these bodies 
into the ducts, and that it is too large to pass freely, then the symp- 
toms of icterus begin to make their appearance. We do not know 
what it is that produces the attempt to discharge small biliary cal- 
culi through the ducts, but it is during this process that the dread- 
ful symptoms of what has been by some called hepatic colic are 
observed, and, supervening on these, the rapid occurrence of jaun- 
dice. Under such circumstances, a train of phenomena presents 
itself, very different from that which characterises the jaundice 
depending on inflammation of the stomach and duodenum. The 
patient is suddenly attacked with violent pain in the epigastrium 
and right hypochondrium. The stomach sympathises, and we have 
nausea, cardialgia, and vomiting; the patient’s sufferings are dread- 
ful, and he refers his pain to the region of the gall-bladder. The 
abdominal muscles are thrown into spasmodic contractions, there 
are often convulsions and fainting fits, the extremities are cold, the STOKES’S THEORY AND PRACTICE OF MEDICINE. 
body is bathed in perspiration, and the pulse is often hard and con- 
tracted, but seldom accelerated. This is a very remarkable symp- 
tom. Heberden says, that the pulse not being in quickness above 
the standard of health, with a sudden attack of pain in the region 
of the epigastrium, are diagnostics of this affection. “ I have 
seen,” says he, “ a patient in this disease rolling on the floor in a 
state of violent agony, which I could not allay with nine grains of 
opium, and yet the pulse was as tranquil as if he was in a calm 
sleep.” I can confirm the truth of this observation from my own 
experience. Here are the diagnostics ; the pain is more intense 
than that which attends any form of inflammation, and yet the 
pulse is perfectly quiet; it occurs in persons not generally subject 
to spasmodic attacks; it is not preceded by constitutional symptoms; 
and is rapidly followed by jaundice, and absence of bile in the stools. 
Under these circumstances you may make a certain diagnosis. 
Sometimes a tumour is formed in the right hypochondrium, 
which rises above the edge of the liver, and gives a feeling of dis- 
tinct fluctuation, marking the situation of the distended gall- 
bladder. In such cases as these, the calculus is in the common 
duct, and the bile descends into the gall-bladder, from which it 
cannot escape, thus causing the distension of that organ. This 
may go on until the distension becomes so great as to increase the 
size of the gall-bladder to such a degree, that, in some cases, it has 
been known to contain a pint of fluid ; and cases have occurred in 
which it has burst, and effused its contents into the peritoneum, 
causing violent peritonitis and death. This termination, however, 
is fortunately of very rare occurrence. I believe that some of the 
cases in which rupture occurred, were those in which an emetic 
was given; and hence it is that many practitioners are afraid to 
give an emetic where this state of the gall-bladder has been ascer- 
tained, or is strongly suspected. 
LECTUPvE XIV. 
Diagnosis of jaundice from biliary calculi—Proof of the passage of the calculus—Indi- 
cations of treatment—Rupture of the gall-bladder after the use of emetics—Spasmo- 
dic jaundice—Treatment of spasmodic jaundice—Discharges of fatty matter— 
Researches of Drs. Bright and Elliotson—Connection with malignant disease exa- 
mined—Source of fatty matter. 
We were occupied at our last meeting, in considering the symp- 
toms of that disease in which there is a formation of what are termed 
biliary calculi; the passage of these into the common biliary duct; 
the possible strangulation of the duct for some time, and the conse- 
quent production of jaundice. I described the symptoms of this 
disease as consisting in a sudden and violent attack of pain in the 115 
JAUNDICE FROM BILIARY CALCULI. 
region of the gall-bladder, succeeded sooner or later by the pheno- 
mena of jaundice, and in the generality of cases occurring without 
fever. Between these violent attacks the patient sometimes has 
intervals of complete ease ; at other times a gnawing sensation con- 
tinues in the original situation of the pain. It is remarkable, how- 
ever, that a patient may have an interval of perfect ease between 
the fits, somewhat similar to the calm which occurs during the 
pains of labour. The occurrence of this cessation of intense suffer- 
ing has been attributed to the passing of the stone into the duode- 
num ; this, however, is by no means certain. The idea generally 
entertained upon this matter is that each attack of pain corresponds 
with the passage of a stone. How far this notion may be true I 
cannot decide; but this I shall impress upon your attention, that 
the mere subsidence of pain is no proof of the removal of the disease, 
unless bile is discharged by stool or by vomiting ; but when such 
a discharge coincides with the cessation of pain, you may be sure 
that the obstruction has been overcome for the time. I need not 
remark to you that the smaller the calculus is, the greater the facility 
with which it will be discharged. You will find in some cases that 
the efforts which nature makes to remove one of these concretions 
are quite unavailing; it lies in the gall-bladder or duct, and there 
remains impacted. Here its presence sometimes excites inflamma- 
tion, lymph is thrown out, and the duct becomes permanently 
closed; in other cases it has been found to make its way into the 
duodenum by ulcerative absorption, and is thus discharged. 
The size of biliary calculi is various. Generally speaking, their 
dimensions are similar to those which you see before you ; but there 
are many cases on record of very large ones having been discharged. 
In the twelfth number of the Medico-Chirurgical Transactions, Dr. 
Brayne gives an instance of one passed, which was three inches 
long and three and a quarter in circumference. I may however 
mention, that there is a source of doubt connected with this case. 
It is possible that the calculus in this instance was nothing more 
than one of those fatty covered secretions which are found in the 
intestinal tube, and which have nothing to do with the gall-bladder 
or its ducts. As it is my intention to return to this subject, I shall 
here only observe, that fatty matter has been frequently discharged 
in hard as well as soft masses, that it sometimes cuts like a biliary 
calculus, and that it may be difficult for a mere physiologist to dis- 
tinguish concrete masses of this kind from gall stones. 
The passage of a biliary calculus does not of necessity imply the 
the occurrence of jaundice ; if it passes without difficulty there is 
none; if it happens to become impacted, then jaundice is sure to 
follow. It is a curious fact, that of this form of jaundice cases have 
occurred in which the flow of bile into the digestive tube has been 
obstructed for more than a year, and yet a recovery took place. 
Permit me now to rehearse the diagnosis of jaundice from biliary 
calculi. Sudden and violent pain in the region of the gall ducts, 
increased by pressure, but generally unaccompanied by acceleration 
of pulse or fever, coming on in a person not subject to spasmodic 116 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
attacks, and speedily followed by jaundice. This is the diagnosis. 
In most of the cases described in books, and, I believe, in the ma- 
jority of instances, you will find the disease to exist without febrile 
symptoms; but it is also true that it may be complicated with 
febrile disturbance, and under such circumstances you should be 
apprehensive of inflammation in the biliary ducts or duodenum. 
The importance of this will appear when you come to consider the 
treatment. 
Now, suppose you are called to attend a case of this kind. A 
person of sedentary habit, who indulges in highly seasoned food and 
takes no exercise, gets a sudden attack; he lies, perhaps on the 
floor, writhing in agony; he is beginning to exhibit the yellow 
tinge of jaundice ; he refers his pain to the region of the gall-bladder; 
his pulse, however, is quiet, and he has no evident symptoms of 
fever. Here the nature of the disease is manifest, and the first thing 
you have to consider is, what are the indications of treatment. 
These are obviously threefold. The first is to guard against in- 
flammation ; for you are aware that inflammation may take place, 
and besides, the higher the irritation and (if I may so term it) the 
spasm of the gall ducts are, the greater will be the difficulty in 
passing the stone. The next thing is to allay spasmodic pain. We 
know that this pain is principally spasmodic, or nervous, because it 
is always more sudden and violent than that which attends common 
inflammatory action, and, moreover, it is commonly uncomplicated 
with symptoms of inflammation. The third indication is to adopt 
measures to favour the passage of the stone. Now these three indi- 
cations, but more particularly the second and third, are, as you may 
perceive, reducible to one form of treatment. Whatever will relieve 
pain and spasm will assist in favouring the passage of the stone. 
If, then, you happen to meet with a case of this affection in a strong 
robust constitution, where the pain is violent and is aggravated by 
pressure, and particularly where there is any sign of febrile disturb- 
ance in the system, I would advise you to bleed such a person 
immediately. Not that you have to combat actual inflammation, 
but because you have to prevent the liability to it, and because, in 
using the lancet, you are employing a most powerful antispasmodic. 
The next thing of importance, in severe cases, is the application of 
leeches over the region of the gall-bladder, and the same remarks 
apply to leeching as to venesection. Yon are not to suppose that 
the application of leeches will cure the disease; but you may be 
sure that it will assist materially in allaying spasm, and favouring 
the passage of the calculus. The bowels should be freely acted on 
by purgatives and enemata; you may give a brisk purgative by the 
mouth, and at the same time a purgative enema. After the bowels 
have been opened, the only thing which you can rely upon for 
giving relief is opium, and that in full doses. I have seen several 
patients labouring under this disease who appeared to me to be mal- 
treated. The different measures for procuring relief were certainly 
put into practice, but not in a regular or proper manner. They 
first got a dose of opium, then a purgative, and lastly were blooded. JAUNDICE FROM BILIARY CALCULI. 
117 
If you have a case of this kind to treat, bleed first, then leech, next 
employ purgatives, and when you have emptied the bowels, have 
recourse to opium. I have never employed the anodyne injection 
in this disease; but, reasoning from analogy, I am inclined to think 
that it would prove serviceable, and I am aware that it has been 
employed with effect in that form of jaundice which depends upon 
hysteria. The tobacco injection also seems to have strong claims 
to our notice, and in this disease must prove extremely useful, from 
its powerful effect in reducing spasm. 
There is a difference of opinion with respect to the employment 
of emetics. The object of their exhibition is to force the calculus 
through the ducts, by the shock given by the sudden and violent 
contraction of the abdominal muscles, and also to relieve spasm, by 
their subsequent relaxing effect. Some practitioners of high au- 
thority, however, state that this practice is not unattended with 
danger, and give cases of rupture of the gall-bladder after the exhi- 
bition of an emetic. Such an accident as this would be very likely 
to injure for ever the character of a professional man. I am sure 
the practice, in some cases at least, is dangerous. A distinguished 
medical friend of mine has related to me the particulars of a case of 
this kind, in which the exhibition of an emetic was followed by 
rupture of the gall-bladder and fatal peritonitis. In this instance 
the case was not so deplorable, so far as the patient was concerned; 
he was labouring under extensive disease of the liver, and only 
exchanged a lingering for a sudden death ; but this furnishes no 
excuse for a medical practitioner. If I were to hazard a conjecture, 
I would say that emetics can he employed with safety only in the 
early stage of the disease, when there is no obstruction from or- 
ganic disease ; for the longer the jaundice has lasted, the greater 
is the chance of obstruction from organic disease. Again, you 
should never use them where there is evidence of a distended 
gall-bladder. If you can feel the tumour formed by the distended 
gall-bladder, in the right hypochondrium, you may be sure some- 
thing has been going on for a long time, and you should be cautious 
in giving an emetic. Never use it then where you can feel a tu- 
mour in the region of the gall-bladder. If you give it at all, give it 
in the early stage, and after premising venesection, leeching, and 
the use of the tobacco injection. I had almost forgot to mention 
that very signal advantages accrue from the use of the warm hip 
bath in this disease. I have seen cases in which the most extra- 
ordinary relief was obtained by applying twelve leeches over the 
region of the gall-bladder, and then placing the patient in a hip 
bath. 
Sometimes it happens that the symptoms return again and again. 
Here you cannot repeat the venesection ; you must employ leeches, 
the hip bath, warm fomentations, opium, and every thing calculated 
to relieve pain and spasm. Watch your patient carefully, guard 
against inflammation, and if any inflammatory symptoms of the duo- 
denum arise (but this is rare) take proper measures to obviate 
them. 118 
THEORY AND PRACTICE OF MEDICINE. 
A few words now with respect to what has been termed spasmo- 
dic jaundice. This form of the disease occurs independent of 
inflammation of the stomach or duodenum, and independent of dis- 
ease of tiie ileum, brain, or liver. It appears to be an essentially 
spasmodic disease, but the situation of the spasm has not as yet been 
accurately determined. It is supposed to exist, either in the gall- 
bladder, or in the biliary ducts, or in the duodenum. If the biliary 
ducts and gall-bladder do not possess muscular fibres, we must 
place it in the duodenum; but whatever may be its seat, it presents 
the characters of a spasmodic disease. It seems to be excited by 
the same cause, and yields to the same treatment as other spasmodic 
affections. It generally occurs in hysterical females, and in hypo- 
chondriac and nervous persons, and disappears under treatment 
calculated to allay nervous excitement. Its exciting causes seem 
to be chiefly sudden and violent mental emotions, or the taking of 
a quantity of indigestible food ; and it frequently terminates by the 
discharges of flatus upwards and downwards. It resembles, in a 
certain extent, the last-mentioned form of jaundice, but differs in 
two particulars ; first, the pain is relieved by pressure, which ge- 
nerally increases it in the former species. Dr. Pemberton, in his 
Treatise on the Diseases of the Abdominal Viscera, dwells strongly 
on this point. The second peculiarity is, that in this disease the 
attack is more sudden. In the case of jaundice from gall-stones, 
the patient has some degree of pain and uneasiness before the vio- 
lent symptoms appear ; but in this form they exhibit themselves in 
a sudden and unexpected manner. The disease, too, is accom- 
panied with hysterical or convulsive symptoms, and there is some- 
times a copious flow of limpid urine. All these circumstances are 
important in forming a correct diagnosis. 
The best treatment for this spasmodic jaundice is, after acting on 
the bowels by warm purgatives, to use fetid enemata, and prescribe a 
mixture composed of ether, castor, and ammoniated tincture of 
valerian and opium, which are of the greatest use when the bowels 
have been opened. In this form, as well as that which we have 
been lately considering, the fact is, that if you expect any good 
from opium, you must not give it until the bowels have been 
opened. Opium and antispasmodics have, I am convinced, often 
lost their character for utility, from being given at a time when the 
exciting causes of disease are still present in full energy; and the 
failure of these powerful auxiliaries is to be attributed to the neglect 
of proper measures for reducing intense irritation. In the spasmo- 
dic jaundice, tobacco injections would be likely to produce bene- 
ficial effects. Generally speaking, however, you will not find it 
necessary to have recourse to such a vigorous remedy, as the 
disease is most commonly observed in delicate females, and yields 
readily to milder treatment. Indeed, it will often disappear sponta- 
neously, and without any apparent cause. 
The last form of this disease which we have to consider, is jaun- 
dice connected with an affection of the brain; and this is a very 
interesting and curious subject. I shall not, however, enter upon JAUNDICE FROM BILIARY CALCULI. 
119 
it at present, as I intend to reserve my observations on this point 
until we come to treat of diseases of the nervous system. I have 
alluded to this variety on a former occasion, and referred you to 
Dr. Marsh’s paper on jaundice in the Dublin Hospital Reports, in 
which you will find several cases of it which came on as the result 
of disease in the head. Broussais admits that it is dependent on 
and secondary to cerebral disease; but he thinks there is another 
link in the chain of connection, and that this is duodenitis. He 
believes that we have irritation, first in the brain, next in the duo- 
denum, and then jaundice. Several practitioners of great authority, 
on the other hand, assert that the cerebral affection produces jaun- 
dice at once, without the intervention of duodenal inflammation. 
In the present state of medical science we cannot determine this 
point. 
A few observations now with respect to the discharge of fatty 
matter from the bowels. The reason why I introduce the subject 
here is, because it has been frequently observed in connection with 
jaundice and disease of the upper portion of the digestive tube. In 
the last number of the Medico-Chirurgical Transactions, a great 
mass of interesting matter has been published on this subject 
by Dr. Bright, Dr. Elliotson, and Mr. Lloyd. I shall give you a 
short analysis of these papers; and I wish to impress this upon 
your recollection, that when you go into practice the study of this 
affection would form a subject worthy of your investigations ; and 
that any attempts on your part to clear up the difficulties which 
complicate this singular form of disease will be advantageous to the 
cause of science. 
Dr. Bright gives three interesting cases of this disease. In these 
the discharge was in the form of oil or semi-concrete matter-—it 
floated on the top of the faeces, and had a fetid odour. There was 
also in these three cases a remarkable similarity in the pathological 
phenomena. The first case exhibited symptoms of jaundice, dia- 
betes, enlarged liver, and discharge of fatty matter: on dissection, 
the liver, pancreas and duodenum were found diseased. The 
second presented symptoms of jaundice and disease of the liver, in 
addition to the fatty discharge; on dissection the liver was found 
healthy, but there was a similarly diseased condition of the duo- 
denum and pancreas ; there was malignant disease in both. Nearly 
the same symptoms were observed in the third case, and after death 
disease was found in the pancreas and small intestine, and the pylorus 
was in a state of extensive ulceration. In alffthere was chronic disease 
of the pancreas and duodenum terminating in jaundice, from ob- 
struction of the gall duct, and accompanied by discharges of fatty 
matter from the bowels. Here are three cases in which there is an 
extraordinary similarity in the symptoms and pathological appear- 
ances. Dr. Bright is inclined to think that these discharges may 
he connected with disease of the pylorus and duodenum, but par- 
ticularly with malignant affections of the pancreas, and gives the 
particulars of some cases, in which disease of the pancreas was sus- 
pected, and in which, from the absence of this symptom, he was 120 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
induced to give a contrary opinion, which, on dissection, turned out 
to be correct. 
Mr. Lloyd’s case resembles those detailed by Dr. Bright, inas- 
much as it presented the phenomena of jaundice with obstruction 
of the gall ducts, disease of the head of the pancreas, and contrac- 
tion of the duodenum. So that you see we have here four cases in 
which there was disease of the duodenum and disease of the pan- 
creas, together with the occurrence of jaundice. I may, however, 
mention one fact, which you should be acquainted with ; in Mr. 
Lloyd’s case the pancreatic duct was found to be obstructed by 
calculi. 
Dr. Elliotson commences his paper by alluding to that peculiar 
substance called ambergris, which is frequently washed ashore by 
the tide in several countries, and which is supposed to be a morbid 
production from the intestinal canal of the physeter macrocepha- 
lus, or spermaceti whale. The quantity found in the intestinal 
canal of this animal is said to be enormous, and instances are 
mentioned, in which this substance was found to amount to 182 lbs. 
in the body of one of these animals. Dr. Elliotson proceeds to give 
cases from the records of medicine and from his own experience, 
in which a fatty discharge took place in the human subject. Of 
this he quotes cases from Masllenbrochus and Maebius in the Ephe- 
merides, but one in particular from the works of Fabricius Hildanus, 
which I shall briefly recount. “ A pious matron of Hilden had 
been for a long time subject to severe pain in the stomach, which 
became at length much worse, when one day the pain extended all 
over the abdomen, and after very severe pain and suffering, she 
discharged about three pounds of fat, which was of a pure quality, 
had no smell, and was preserved by her for many years.” This 
woman recovered perfectly. Dr. Scott, of Howick, mentions the 
case of a servant girl who had been treated with purgatives and 
injections, under the supposition that her disease was colic, and 
who, after two or three days’ suffering, discharged a quantity of 
fatty substances, about the size of nuts, beans, and peas, which 
burned like fat when thrown into the fire; this patient also re- 
covered. Dr. Babington gives another case, which had been 
mentioned to him by Sir E. Home, in which we find that a lady 
who had been suffering, as it was supposed, from gall stones, 
happening to take castor oil draughts to open her bowels, passed a 
quantity of fatty matter. Another case is detailed by Mr. Howship, 
where a lady who had been attacked with pain, jaundice, and 
fever, passed a quantity of this substance with the subsidence of 
those symptoms. The fatty matter in this case was discharged 
after the lady had taken a pint of olive oil, upon the recommenda- 
tion of Dr. Simpson of New Malton. Dr. Turner, of St. Thomas’s 
Hospital, mentions the case of a female who laboured under an 
hysterical distension of the belly, and who passed quantities of this 
substance, specimens of which are preserved in the Hunterian 
Museum. 
Sometimes these fatty discharges are found in the concrete, some- JAUNDICE FROM BILIARY CALCULI. 
121 
times in the semi-fluid form. Dr. Elliotson mentions the case of a 
patient who had phthisis, diabetes, and discharge of fatty matter ; 
thus he was at the sam§ time passing fatty substance, large quanti- 
ties of saccharine urine, and spitting up pus and softened tubercular 
matter. Between all these, and the agonising pain which he suf- 
fered, he became in a short time completely exhausted and sank 
rapidly. The fatty matter discharged in this case was shown to 
Dr. Prout and Mr. Faraday, and Dr. Prout stated he could not 
distinguish it from human fat when heated. Tulpius is quoted by 
Dr. Elliotson as relating a case where fat ivas discharged from 
the bowels and bladder. Here is the quotation :—“ But what do 
we say of Margaret Appelmania, an innkeeper, who, in her seven- 
tieth year, passed precisely the same fat, both from the intestines 
and the bladder, and likewise without fever, emaciation, or colli- 
quative excretion. Towards the close of the disease, however, she 
did become feverish, and, in consequence, so emaciated, that death 
found her little else than a juiceless dried up corpse.” A case 
similar to this was communicated by Mr. Pearson to Dr. Elliotson. 
The symptoms were suppression of the biliary secretion, and a 
copious discharge of oil from, the bowels and bladder, which, it is 
stated, formed good soap when mixed with alkali. Dr. Prout has 
observed fatty matter passed with the urine, and considers this 
symptom as an indication of the probable supervention of malig- 
nant disease of the kidneys and bladder. The last case is from the 
Annali Universali, which is quoted by Dr. Johnson in the Medico- 
Chirurgical Review for July. In this case the patient, after fasting 
for a considerable time, took a quantity of indigestible food. On 
the evening of the same day he had an attack of vomiting ; at first 
blood was thrown up, and then he ejected this fatty substance to 
the enormous amount of thirty pounds. There was, in this 
instance, a sudden and extraordinary emaciation ; the patient was 
so reduced in the space of a few hours, that the skin hung in loose 
folds about him. He recovered in twenty days; but with great 
loss of bulk. 
Let us enquire now what is the nature of this symptom. Is this 
fatty matter a morbid secretion from the liver, from the pancreas, 
from the mucous membrane of the stomach, or from the intestines? 
There are facts to show, that in certain cases this disease cannot 
be explained by a reference to any of these circumstances. It 
seems plain, too, that Dr. Bright’s suggestion of referring it to ma- 
lignant disease of the duodenum and pancreas, and the diagnosis 
which he would seem to found upon it, cannot stand here ; for the 
symptom upon which he attempts to establish a diagnosis—a dis- 
charge of fatty matter—occurs in persons who have recovered from 
the disease. We cannot suppose that they have been labouring 
under malignant disease of the duodenum and pancreas when they 
have recovered ; and that a recovery may take place is proved by 
Dr. Elliotson’s cases. It is quite probable, however, that if the 
irritation, or whatever it be that produces this discharge, should 
continue, it may bring on fungoid and malignant disease; but that 122 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the discharge of fatty matter is significant of the actual existence o f 
such a condition is not borne out by these facts. Well, are we to 
look upon this discharge as a secretion from the liver ? I think 
we cannot, because we have seen that in Dr. Bright’s three cases 
the biliary duct was obstructed by disease of the duodenum and 
pancreas. I may mention, too, that in some cases where a dissec- 
tion was made, the liver was found perfectly healthy, and the gall- 
bladder in its normal condition, full of pure bile. Taking this and 
the foregoing fact into consideration, we have proofs that this fatty 
substance, in some cases at least, cannot come from the liver. Does 
it proceed from the pancreas ? It would more naturally come from 
the liver than the pancreas, for the liver does actually secrete a 
certain quantity of fatty matter ; but there is no substance of this 
kind found in the secretion of the pancreas, which is considered to 
bear a strong analogy to that of the salivary glands. Besides, in 
the case mentioned by Mr. Lloyd, where the duct of the pancreas 
was obstructed by calculous secretions, this fatty matter has been 
discharged; and hence we cannot, I think, refer it to the pancreas. 
Whence, then, does it come ? Is it a secretion from the surface of 
the intestines ? This is a question which it is hard to determine. 
We do not yet know, nor have we ever met with that state in 
which lesion of structure in the mucous membrane of the intestinal 
canal has been followed by a discharge of fatty matter. We have 
discharges of serum, lymph, blood, and pus, from the surface of the 
intestines, according to the nature of the disease; but we know of 
no pathological condition as the result of which fatty matter may 
be produced. Again ; cases of every known form of disease in the 
liver, pancreas, and intestinal canals, occur without this discharge 
at all. In the present state of medicine, the probability is that this 
discharge is the result of a sort of metastasis of the secretion of fat 
from the other parts of the body in which it is usually deposited, to 
the surface of the digestive tube, where it is poured out somewhat 
in the same way as in cholera; the fluids of the body are rapidly 
absorbed and eliminated by the intestinal canal. This supposition, 
without attempting to bring it forward as the true solution, fur- 
nishes us with the best explanation of the case. In the case of the 
patient who discharged this substance by stool and with the urine, 
the emaciation came on rapidly, as if all the fat of the body had 
been absorbed and carried out of the system; here, too, the fat was 
discharged from another mucous surface. In the other remarkable 
case, where a vast quantity of this substance was thrown up by 
vomiting, the emaciation was so great that the patient's skin hung 
in loose folds about him. When we reflect, too, that there is no 
recognised disease of the intestines, liver, or pancreas, to which this 
discharge can be referred, we cannot help believing that it is the 
result of a metastasis in the secretion of fat. 
The next point in this matter which we have to consider is, what 
is the best mode of treatment ? This question, I believe, cannot be 
answered at present; nor can our practice be any thing but empi- 
rical until we have more light throw upon the subject. With a ACUTE AND CHRONIC HEPATITIS. 
123 
view to increasing our knowledge, I beg of you to make this disease 
the subject of your practical investigations, and to have a look out 
for this discharge, because I believe it often occurs unnoticed, from 
our neglecting to inspect the evacuations. 
LECTURE XV. 
Acute and chronic hepatitis—Pathological differences—Effect of climate—General and 
local symptoms—Character of fever—Pain of shoulder—Use of pleximeter—Com- 
plication with jaundice—Resolution—Abscess—Various openings of the latter— 
Cicatrisation. 
I propose to-day to draw your attention to the subject of inflam- 
mation of the liver. This is the disease which you meet with in 
books under the general name of hepatitis; but it is of great im- 
portance to distinguish between acute and chronic hepatitis for 
this reason—acute hepatitis implies something specific, an organic 
change, the nature of which is well known and accurately defined; 
but chronic hepatitis implies nothing of this certainty of the nature 
of organic change, inasmuch as there is no single one of the recog- 
nised disorganisations of the liver, which may not, and have not 
occurred, with chronic hepatitis as an existing cause, or a promi- 
nent symptom. When we speak of acute hepatic inflammation, 
we speak of a disease, of which the structural lesions are sufficiently 
understood ; but when we treat of chronic hepatitis, we treat of a 
disease in which there may be a great variety of organic changes. 
Chronic irritation of the liver may in one patient be followed by 
the development of hydatids ; in another by cancer, or tubercle ; in 
a third, by hypertrophy of one or both of its elementary tissues ; in 
a fourth, by atrophy; and in a fifth, by abscess ; so that, under the 
chronic form of hepatitis, we may have many different lesions com- 
prised. Under the acute form, we have only vascularity, soften- 
ing, yellow degeneration, and suppuration. These, which are the 
ordinary results of acute hepatic inflammation, are the same as the 
results of active inflammation of other parenchymatous organs. 
It is an interesting fact, and connected with the predisposition to 
acute diseases of the abdominal viscera in warm climates, that acute 
hepatitis is much more prevalent in those countries than it is here, 
and this is particularly true with respect to the East Indies. You 
recollect, in one of my lectures, I alluded to the greater suscepti- 
bility to disease, the extraordinary nervous excitability of the 
digestive mucous membrane in warm latitudes, and hence that a 
large proportion of the diseases of those climates was characterised 
by the predominance of inflammation in the stomach and intestines. 
The same thing occurs with respect to the organs which are con- 
nected with the digestive tube ; and hence it is that diseases of the 
liver and spleen are so frequently met with between the tropics. 124 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
A very remarkable fact, bearing on this point, has been mentioned 
to me by Staff-Surgeon Blest. He states that, in the East Indies, 
hepatic disease in animals is no unusual occurrence ; that animals 
brought to India from more temperate climates are peculiarly 
subject to it; and that in them it is a common cause of death. 
He has seen many cases of hepatic abscess in dromedaries and 
horses, under these circumstances ; a fact of great interest, when 
considered with the liability to tubercle in animals brought from 
warm climates to these countries. In these countries, acute 
hepatitis in its highest degree is a rare disease; in fact, so rare, 
that it is only in our own time that any thing like a series of cases, 
by which you could compare the disease in these countries with a 
similar affection in others, have been published. A series of cases 
by Louis, and another by Dr. Graves and myself, published some 
time since, are all that we have on the subject. It is.somewhat 
extraordinary that a sort of epidemic tendency to acute hepatic 
inflammation, and the formation of abscess, occurred in the coun- 
tries about the middle of the year 1828. Up to this period, abscess 
of the liver was looked upon as a very rare disease in Ireland; a 
case of it was met with in hospital once perhaps in twelve months 
or two years ; but at the period to which I allude, almost every 
great hospital in Dublin had several cases ; and in the Meath alone 
we had a great number, out of which seven or eight proved fatal. 
We have now to consider this acute inflammation of the liver; 
and first, with respect to the symptoms. Were I lecturing on 
pathology merely, I would commence with the organic changes ; 
but as I have chiefly kept in view, during my present course, the 
practice of medicine, I shall begin by detailing the symptoms. 
You will get a good idea of the symptoms of acute hepatic inflam- 
mation by dividing them into local and general; by doing this, you 
will simplify the matter, and acquire accurate and defined notions 
of the disease. Now, the local symptoms are, pain in the region 
of the liver, tenderness over the affected organ, and a degree of 
tumefaction perceptible to the touch; pain, tenderness, swelling— 
here are the local symptoms. What are the general ? Inflamma- 
tory fever, and lesion of the digestive function; and, in addition to 
this, if the case be severe, you have functional derangement of the 
respiratory and cerebral systems. You have, then, in a case of 
acute hepatitis, the general symptoms of inflammatory fever, with 
lesion of the digestive function; and if the case be severe, of the 
respiratory and even cerebral systems, the local symptoms being 
pain, tenderness, and tumefaction. 
Now, with respect to the character of the fever which accom- 
panies this disease, it is in all cases nearly the same; and here we 
come to an interesting and curious fact. You recollect that, in 
speaking of gastro-enteric inflammation, I alluded to the nature of 
the accompanying fever, and stated that it was (commonly) of a 
low character, and that there were no local inflammations in which 
the fever was so often typhoid as in the affections of the gastro- 
intestinal surface. This, I believe, has been one great cause of the ACUTE AND CHRONIC HEPATITIS. 
125 
ignorance of medical practitioners with respect to gastric and 
enteric inflammations; they have been most commonly looked upon 
as cases of typhus, and treated accordingly. In acute hepatitis, 
however, we do not observe this typhoid prostration. Though 
closely connected with the gastro-intestinal system, the liver does 
not, in its acute inflammatory state, produce the same manifest 
depression of the vital powers. On the contrary, we have, in the 
early period of the disease in this country, high inflammatory 
fever, hot skin, and full bounding pulse; a state in which few 
would be afraid to employ the lancet with boldness. Patients 
labouring under acute inflammation of the liver, generally have 
high sympathetic fever, a full, strong, and accelerated pulse, with 
the local symptoms above described; and, in addition to these, we 
frequently observe bilious vomiting, considerable thirst, derange- 
ment of the bowels, and scanty high-coloured urine. The tume- 
faction is more or less evident, and when this is accompanied by 
severe pain, there is considerable difficulty of breathing, a circum- 
stance which sometimes occasions this disease to be mistaken for 
pleurisy. There are two remarks to be made on this subject. In 
the first place, it sometimes happens that acute inflammation of 
the liver and of the lower part of the lung occur at the same time, 
particularly where inflammation attacks the diaphragmatic surface 
of the liver. Here you frequently have an extension of the inflam- 
matory process to the corresponding surface of the pleura, or the 
two diseases co-exist from the first. Under such circumstances, 
disputes, as to which organ is engaged, are often unnecessary. 
Again, in the early period, and when the attack is acute, the 
diagnosis of inflammation of the diaphragmatic surfaces of the liver, 
or pleura, is comparatively of little consequence, as both demand 
the use of calomel and opium, leeches and the lancet; and, in the 
early stages at least, both are amenable to the same traetment. But 
it is not so in the chronic stage of either. Here the diagnosis is of 
great importance; and when I come to treat of pleuritis, I shall 
draw your attention to some researches of mine on this subject, 
which I hope have set this question at rest. 
The pain which accompanies acute hepatitis varies much in 
situation. Sometimes it is felt in the shoulder, sometimes under 
the short ribs, sometimes in the loins, and frequently in the 
epigastrium. You have all heard of pain at the top of the shoulder 
as a common symptom of liver disease ; in fact, so common as to be 
looked upon by some as a pathognomonic symptom. I believe that 
a great deal too much stress has been laid on this circumstance. It 
is now discovered, that so far from being a constant, or even a 
common, symptom, it is one which is of exceedingly rare •occur- 
rence. I have never seen a case of acute hepatitis with pain in the 
shoulder; I have sometimes observed it in chronic, but never, to 
my recollection, in acute cases. Andral states that it is very seldom 
met with; Dr. Mackintosh says the same, and, if I recollect aright, 
looks upon it as a symptom not worth enquiring about. Now, I 
have seen some medical men who considered this pain in the 126 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
shoulder as a diagnostic of such value, that if it happened to be 
absent they concluded there was no hepatic disease. The fact is, 
that it is any thing but constant. You may have it in some cases, 
particularly of chronic hepatitis, and not in others; besides, it fre- 
quenly depends upon other causes—for instance, upon pneumonia 
of the top of the right lung, or it may be caused by incipient 
phthisis, aneurism of the arteria innominata, or right subclavian 
artery, and other diseases. It is of very little consequence whether 
it be absent or present; and the only reason why I dwell upon it 
is, to show you its real value as a symptom. 
There is one remarkable circumstance connected with the pain 
of an acute hepatitis. In one case, you will find that the pain is 
very acute and constant, in another, that little or none is felt; and 
when you come to investigate the cause of this after death, it gene- 
rally happens that, in cases where the pain was violent, the inflam- 
mation existed on the surface of the liver, and in those where little 
suffering was experienced, deep in the substance of that organ. 
This is a curious fact; but it may be looked upon as an illustration 
of a general law, that if we consider inflammatory affections of the 
solid viscera, we shall find that the more superficial the inflam- 
mation the more painful it is ; and, on the other hand, the more 
deep-seated it is the more is it latent, so far as pain is concerned. 
Thus : if you take a case of inflammation of the substance or cen- 
tral parts of the brain, you will find that the disease is to be recog- 
nised often not by pain, but by the lesions of the sentient and 
locomotive powers; whereas, in inflammations of the membranes, 
on the surface of the same organ, one of the most prominent symp- 
toms is agonising headache. In the next place, go to the lung; 
take a case of deep-seated pneumonia, and contrast its almost pain- 
less character with the lancinating torture of an acute pleuro- 
pneumony. In pneunomia the pain is dull, and scarcely complained 
of; but pleuritis unaccompanied by acute suffering is extremely 
rare; in fact, where you have the signs of inflammation of the 
parenchymatous tissue of the lung, with sharp pains in the chest, 
you may very safely make the diagnosis of pleuro-pneumony. The 
same absence of pain is by no means unusual in inflammatory affec- 
tions of the mucous membrane of the intestines ; but if the inflam- 
mation should chance to extend to its peritoneal investment,, you 
will have this state rapidly exchanged for one of intense suffering. 
So it is with respect to the liver; disease on the surface of that 
organ is attended with severe pain ; but enormous destruction of its 
deep-seated parts may take place, and your patient complain merely 
of a sense of uneasiness. 
A late author on hepatic affections, Dr. Bell, who has written a 
treatise on the diseases of India, describes two forms of acute hepatic 
inflammation, which are different as to their seat and character. In 
one of these, which he terms sero-hepatitis, the disease is on the 
surface of the liver; in the other, which he terms puro-hepatitis, 
it exists in the centre. In the sero-hepatitis, he states that the 
patient is attacked with sudden pain in the region of the liver, and ACUTE AND CHRONIC HEPATITIS. 
127 
this is so severe that even the weight of the bed-clothes is insupport- 
able ; the patient cannot bear to turn or lie on his left side, from the 
pressure exerted in that position on the inflamed organ. But the 
deep-seated, or puro-hepatitis, may go on in such a latent manner, 
that the first symptoms you have of the existence of liver disease 
are those which mark the occurrence of suppuration. Neither the 
patient nor his medical attendant will have reason to suspect inflam- 
mation of the liver, until the constitutional and local symptoms of 
the suppurative process direct attention to that organ. Such are 
the statements of Dr. Bell, which I believe to be correct, as they are 
supported by the concurrent testimony of many persons who have 
practised in India, with whom I have conversed on this subject. 
Mr. Annesly makes the same assertion; and such was our expe- 
rience in the succession of cases of hepatic abscess which were 
under treatment in the Meath Hospital during the year 1828. 
The next symptom which we have to consider, is the tumefac- 
tion of the liver, and this is one of considerable importance. In 
order, however, to estimate the extent of this tumefaction with any 
degree of accuracy, you must take one preliminary step, and that 
is, to have the bowels fully evacuated. If the intestines are filled 
with feculent matter or gas, you cannot do this in a proper manner. 
A few hours before you make your examination, give the patient a 
full purgative draught, assisted, if necessary, by a strong purgative 
enema. In this way, you empty the belly of collections of feculent 
matter and aeriform fluid, and then you can with certainty and 
satisfaction ascertain the extent of the swelling. You will then be 
able (when your patient is laid in bed), perhaps, to see at once the 
extent of the tumefaction, particularly where the parietes are not 
thick or loaded with fat; at all events, you will be able to feel it 
with your hand, and in every case you can ascertain it by mediate 
percussion with the pleximeter. I do not know any more important 
adjuvant, in making out the diagnosis of an enlarged liver, than the 
use of mediate percussion. For instance, suppose you have a 
patient labouring under acute hepatitis, and that the tenderness of 
the organ is so great that he cannot allow you to make the requisite 
degree of pressure to ascertain the extent of the swelling; take the 
top of your stethoscope, apply it over the region of the liver, make 
use of light percussion, and you will find, with the greatest accu- 
racy, how far the tumefaction of the liver extends, by the dulness of 
sound heard over the inflamed organ, and exactly limited to it. In 
this way, you can make a most satisfactory examination, without 
giving your patient any pain; and this is a matter of some import- 
ance, as you will meet with many cases in which there is exquisite 
tenderness, and where the patient will not bear the slightest pres- 
sure. I would advise you, therefore, to practise this mode ; it gives 
little or no pain, it is exceedingly simple, and I have not the slightest 
doubt of its accuracy. Now, the value of this tumefaction, as a 
sign of the existence of hepatic inflammation, depends very much 
on the recent nature of the attack. If a man, who was in perfect 
health a few days back, complains of pain in his right side, and 128 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
has a tumour in that situation, it is to be presumed that this tumour 
does not depend upon the presence of a collection of fluid in the 
pleura, and, consequently, that the tumefaction is not produced by 
an empyema. Then, if, in connection with fever, and pain in the 
right side, you can ascertain the existence of a tumour in the region 
of the liver, and that it has occurred within a short space of time, 
you may be pretty sure that it is not an empyema, but an inflamed 
and enlarged liver. 
Jaundice has also been considered as a symptom of hepatic 
inflammation, but it is one which is by no means constant. Again, 
you may have most extensive hepatitis, with slight jaundice, and 
universal and intense jaundice, with trifling or no hepatitis; and, 
what is equally singular, you may have very little perceptible dis- 
ease of the liver with scanty secretion of bile; and, on the other 
hand, the liver may be burrowed with abscesses, and at the same 
time you find bilious stools, and after death the gall-bladder may 
be found filled with pure healthy bile. I thought, at one time, that 
I could explain the presence or absence of jaundice in cases of 
hepatitis, by supposing that, where it occurred, the jaundice was the 
result of inflammation of the gastro-duodenal mucous membrane ; 
and to prove this, I drew up a table of cases, of which one half 
were complicated with jaundice, and the other not. I found, how- 
ever, that in a great number of cases, where the tube was free from 
disease, the hepatitis was complicated with jaundice; and in a 
similar number of cases, where the same circumstances were 
observed, the tube was in a state of disease. So that we may have, 
as you perceive, hepatitis and jaundice, with and without disease 
of the intestinal tube; and whether we look to the cases of hepatic 
inflammation, unaccompanied or complicated with jaundice, the 
state of the gastro-intestinal mucous membrane throws, as yet, no 
light on the subject. It appears, then, that the occurrence or non- 
occurrence of gastro-duodenitis does not explain why it is, that in 
one case of hepatic inflammation jaundice is a prominent symptom, 
and in another is completely absent. 
In some cases of acute inflammation of the liver, the natural 
secretion of that organ seems to be totally annihilated. A curious 
case of this kind occurred under the care of Dr. Graves, in the 
Meath Hospital, where the slightest trace of bile did not exist in the 
gall-bladder, which was filled with a transparent mucus. In some 
instances you will find plenty of bile discharged, in others none; 
in some patients the stools are observed to be clay-coloured, or very 
faintly tinged with bile ; in others they are healthy, and natural in 
colour, as well as consistence. From our own experience, and 
from studying the series of cases published by Louis, we have come 
to the conclusion, that neither the presence nor the absence of bile 
in the stools affords any positive or useful information as to the 
different stages of this disease, its progress or termination. 
Acute hepatitis terminates in a variety of modes. It may termi- 
nate by resolution—here the organ returns to its former healthy- 
state, without any appreciable change of structure or function ; it ACUTE AND CHRONIC HEPATITIS. 
129 
may terminate by the formation of matter—here we have suppura- 
tion and abscess ; it may terminate in gangrene ; and, lastly, it may, 
without the occurrence of suppuration or gangrene, pass into 
chronic hepatitis, of which the result may be a variety of morbid 
changes in the organ itself. When the patient is so fortunate as to 
meet with the first of these terminations, the fever, pain, and tume- 
faction, gradually disappear. On making an examination with the 
pleximeter, you will find that part of the belly which was rendered 
dull by the tumefied liver becomes clear on percussion; you will 
find, also, that the dulness of the lower part of the chest, on the 
right side, is removed, the patient can breathe without any difficulty, 
and lies on the afFected side without inconvenience. But when the 
disease passes into the suppurative stage, the train of phenomena 
exhibits a marked difference. What we generally observe under 
such circumstances in this country is, that there is a change in the 
constitutional symptoms; the fever, which has been hitherto inflam- 
matory, now becomes hectic. The pulse continues quick, but is 
diminished in strength and volume ; the countenance becomes pale 
and collapsed, the patient feels languid, restless, and disposed to 
sweat, and his perspiration has a sour smell. He may also have a 
miliary eruption, and this continues for some time, with an increase 
or persistence in the size of the hepatic tumour. When these 
symptoms appear, there is every probability that matter is forming, 
or has been already formed. The patient then begins to complain 
of increased weight in the region of the liver, and in some cases the 
integuments over that organ are swollen, and slightly discoloured. 
I have observed that, in some instances, the pain concentrated itself 
in one point, and in this situation it was afterwards found that 
abscess had formed. These are the ordinary symptoms which 
usher in, or accompany, the suppurative stage of hepatic inflamma- 
tion ; but there are also cases, even in this climate, where this 
marked change of symptoms is not seen, and where abscess forms 
rapidly, and with symptoms which might be supposed to belong to 
the early period of the disease. This, however, is particularly true 
with respect to hepatic abscess in the East Indies. 
I believe I mentioned in a former lecture a very curious fact, 
namely, that it has been often found impossible to salivate persons 
labouring under hepatic abscess, so that the presence of matter or 
not, in the liver, may be determined by the circumstance of the 
patient being susceptible or not of the full effect of mercury. The 
liver, in this case, seems to illustrate that pathological law which I 
alluded to in speaking of dysentery; that the more intense an 
inflammation, the greater is the difficulty of producing ptyalism. 
My friend, Staff-Surgeon Marshall, and also Mr. Annesly, agree in 
stating, that it is exceedingly rare to find a case of hepatic abscess 
in which the salivary glands have been affected by mercury, and 
our experience of the disease in this country exactly coincides with 
their opinion. It has been also observed, that hepatic abscess may 
form in an insidious and latent manner, when it happens to be com- 
plicated with disease of other organs. This affords us an illustra- 130 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
tion of a law already laid down, that the more complicated an 
affection is, the more obscure is its character. Again, we may, as 
the result of acute hepatitis, have one or two vast cavities formed 
in the substance of the liver, or we may have a number of very 
small abscesses. I recollect a case which occurred some time ago 
near this city; the patient exhibited the symptoms, and was, in fact, 
supposed to labour under intermittent fever. After some time, death 
took place, and, on dissection, a number of small abscesses were 
found in the liver, of which, during life, there was no symptom, 
except that which I have just mentioned. 
When an hepatic abscess attains a certain magnitude, it has a 
tendency to burst and discharge its contents. If it escapes exter- 
nally, it makes its way in a great variety of directions, sometimes 
in the epigastric, sometimes in the hypochondriac, sometimes in the 
lumbar region, and there are cases on record, in which the matter 
has burst in the right axilla, by a sinuous passage beneath the integu- 
ments of the chest. When it bursts internally, it sometimes perfo- 
rates the diaphragm, and gets into the cavity of the pleura, or, what 
is more commonly the case, into the substance of the lung. The 
matter of an hepatic abscess very rarely gets into the pleural sac, 
and hence we very seldom have an empyema as the result of this 
occurrence, because the pleura being extremely liable to adhesion 
as a consequence of the inflammatory process, and the passage of 
matter being always preceded by inflammation, the opposed sur- 
faces of the pleura become glued together by coagulable lymph, 
which prevents the hepatic pus from getting into the pleura, at the 
same time that it favours its passage into the lung. The opening 
into the lung is one of ordinary occurrence; many cases of it are 
on record; and serious as the lesion may appear, it is, perhaps, one 
of the best modes in which hepatic abscess may terminate by inter- 
nal opening. Many persons have recovered after such a termina- 
tion ; and I have seen myself three cases in which it was certain, 
and a fourth in which it was probable, that the matter had been 
expectorated by the mouth, with a favourable issue. We are, then, 
as far as the records of medicine and our experience in the Meath 
Hospital go, warranted in looking on this termination as a favour- 
able one. Hepatic abscess may also open into the pericardium; but 
this is very rare, there being only one case of this kind, which is 
given by an American author. It may open into various parts of 
the intestinal canal, the stomach, duodenum, and colon; it may also 
discharge its contents into the right kidney, into the vena cava, or 
into the peritoneum, and thus cause violent peritonitis and death. 
The diagnosis of these different openings of an hepatic abscess is 
easy, and founded on the same principle, the occurrence of new and 
extraordinary symptoms, connected with the adjacent viscera, which 
were not before diseased—symptoms of a sudden discharge of pus 
from, or into, these organs. Suppose you have a case of hepatic 
abscess, and that, during the progress of the disease, the patient has 
sudden and enormous expectoration of purulent matter, without 
any preceding signs of inflammation of the lung, it is probable that HEPATIC ABSCESS. 
131 
the abscess has opened into the lung; or suppose that, during an 
attack of acute hepatic disease, your patient is all at once seized 
with nausea, and vomits a quantity of purulent matter, and, imme- 
diately after this, you perceive that the tumefaction of the liver sub- 
sides. Here the matter has been discharged into the stomach; in 
other cases you have it discharged into the duodenum or colon. 
Again, you may have instances where the matter gets into the peri- 
toneum ; here you may observe the occurrence of rapid peritonitis. 
So that, in all cases of this kind, the diagnosis is founded on the 
same principle, the occurrence of discharge of pus from, or into, 
organs which previously had been considered to be in a healthy 
state, and this coinciding with a subsidence of the original 
tumour. 
In persons who, under such circumstances, recover, it is natural 
to expect that cicatrisations should exist in the liver. Louis states 
that he has never seen this ; with respect to our cases of hepatitis, 
we can only say that the fatality of the disease has afforded us no 
opportunity of investigating this point of morbid anatomy. Mr. 
Annesly, however, in his work on the diseases of India, has given 
drawings exhibiting this appearance. I recollect one case of a man 
in the Meath Hospital, who had been a soldier in the East India 
Company’s service, and had been treated for liver disease ; this man 
died of phthisis, and, on dissection, the surface of the right lobe of 
the liver was found puckered, forming a hollow with a cartilaginous 
basis, strongly resembling what we might suppose to be the cicatrix 
of an abscess. 
LECTURE NYI. 
Diagnosis of the rupture of hepatic abscess—Pulmonary openings—Case of double 
opening—Puncture of the gall-bladder—Gangrene of the liver—Its connection with 
hepatic apoplexy—Diagnosis of distended gall-bladder—Its causes—Inflammation of 
the parietes over the liver—Sympathy of the integuments. 
I broke off at my last lecture while engaged in considering the 
phenomena of hepatic abscess, and you will recollect I spoke of the 
various modes in which these abscesses may open internally, and 
stated that the diagnosis in all cases was founded on the same prin- 
ciple, which is this—that during the prevalence of symptoms indi- 
cating the existence of suppuration of the liver, some new organ 
becomes suddenly affected, the nature of the affection being what 
would be produced by the sudden rupture of an hepatic abscess and 
and a discharge of pus into some of the neighbouring viscera, and 
this coinciding with the disappearance, more or less, of the original 
tumour. Now, when we consider the various internal openings of 
an hepatic abscess, we find that they admit of being divided into 
two classes, first, those in which the matter is effused into cavities 132 
STOKES’s THEORY AND PRACTICE OF MEDICINE. 
having- a communication with the exterior of the body, as the lung, 
digestive tube, and kidney. Here, in addition to the symptoms 
already alluded to, we have a sudden discharge of pus from the 
stomach or bowels, from the lungs, or by the urinary passages. But 
we may also have the matter discharged into shut cavities having 
no external communication, as where the contents of the abscess 
open into the peritoneum, pleura, or pericardium. You will readily 
perceive that of these two classes of openings, those in which the 
matter escapes into cavities having no communication with the 
exterior are the most unfavourable. The confined pus excites 
violent and generally fatal inflammation, and we have a dangerous 
empyema, a rapid peritoneal inflammation, or intense pericarditis. 
I stated, that of the internal openings of an hepatic abscess, one 
of the most favourable is that in which the matter is discharged 
into the right lung, and I described briefly the mechanism of this 
curious process. We are warranted, I think, in declaring this to 
be a fortunate termination, because there are many instances on 
record of persons having recovered under such circumstances. A 
very near relative of mine presented an example of this. He was 
attacked with symptoms of acute hepatitis, for which he was 
attended by some of the most eminent physicians in Dublin. His 
treatment was bold and vigorous; he had free bleeding, both gene- 
ral and local, mercury, and every other means calculated to remove 
inflammation, but all proved ineffectual. His pulse became rapid; 
he began to sweat; the hepatic tumour increased in size, and pre- 
sented a distinct sense of fluctuation ; there could be no doubt of 
the existence of suppuration in the substance of the liver. One 
morning he was suddenly seized with a violent fit of coughing, and 
during the course of the day expectorated more than a large tea- 
cupful of pus ; towards evening this increased, and on examination 
it was found that the tumour was remarkably diminished. The 
expectoration continued during the whole night, and in the morn- 
ing it was observed that there was scarcely any appearance of the 
hepatic swelling. It was singular, and tends to confirm the idea 
that the matter had been discharged into the lung, that in the erect 
position this gentleman had scarcely any expectoration, but in the 
horizontal it was always extremely copious ; a circumstance which 
you can easily understand by considering, that in the recumbent 
posture the purulent matter would find a more easy passage into 
the lung. In this case, it would appear that the communication 
between the liver and lung was very free, for I remember that on 
one occasion by making pressure over the liver, he said I was 
forcing the matter into his chest, and the pressure was followed by 
an instantaneous and copious expectoration. This frequently 
occurred. A medical friend of mine residing in Dublin, mentioned 
to me some time since the case of a large robust drayman, addicted 
to whiskey drinking, whom he attended for an attack of acute 
hepatitis. At a time when the liver was very much increased in 
size, and well-marked symptoms of suppuration present, he ob- 
served that sudden expectoration of pus took place, which conti- HEPATIC ABSCESS. 
133 
nued for several days, with manifest subsidence of the hepatic 
tumour and complete recovery. Three cases of this kind came 
under my notice in the Meath Hospital. One of the patients had 
symptoms such as I have before described as exhibiting a striking 
similarity to yellow fever, from which he recovered, and was dis- 
charged, with no other remarkable symptom but quick pulse. 
Shortly afterwards he returned, complaining of pain in the right 
hypochondrium, with rapid pulse, profuse night sweats, and a slight 
cough. At first his appearance struck me as being characteristic 
of phthisis, and under this impression I repeatedly examined the 
chest by the stethoscope and percussion, but could not detect any 
lesion. The man had only a slight cough, and this was totally 
insufficient to account for his symptoms. The nature of the case 
was soon manifest: one morning the patient stated that he felt as 
if something had given way in his chest during the night, and he 
was from that time expectorating large quantities of purulent 
matter. On examining the lower portion of the left side, I found 
that it sounded completely dull on percussion, and that the physical 
signs of an accumulation of fluid in the bronchial tubes were 
extremely distinct. That this dulness was the result of the effusion 
in question is proved by the previously healthy state of the lung. 
The very day before I had carefully examined this part of the 
chest, and found it quite healthy. There was not the slightest 
resonance of voice in this portion after the accident, because the 
tubes were so completely filled ; so that in this case the return to 
health was accompanied by increase of broncophonia, a fact that 
sets the question of the nature of the accident at rest. It may 
appear strange that in this case the puriform matter entered the left 
lung instead of the right; but this is sometimes the case, particu- 
larly when the abscess forms in the left lobe of the liver. 
I shall now draw your attention to the particulars of a case which 
I look upon as almost unique, and which derives additional interest 
from the accuracy of the diagnosis. It is of great importance that 
you should have clear ideas on the subject of hepatic abscess, for, 
though the disease is not of common occurrence in this country, 
still, if called on to pronounce an opinion on a case of this kind, 
the least difference in the quantity of your information may be of 
consequence. The patient, who was the subject of this disease, 
was admitted into the wards of the Meath Hospital in August, 1828. 
The history of his case was, that he had been labouring, some time 
previously, under obscure symptoms of an hepatic affection, accom- 
panied by slight fever and jaundice, which had gradually subsided. 
Three weeks before admission he stated that he had irregular fits 
of shivering, followed by sweating, and when he came to the hospi- 
tal he complained of sickness of stomach, but particularly of cough 
and difficulty of breathing, which were extremely harassing, and 
said that he came in chiefly to be cured of his cough. He was 
considerably emaciated, and looked pale and low, but his stools had 
a natural appearance. On considering the history of his case and 
the symptoms then present, it struck me that it was either hepatitis 134 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
with suppuration, or empyema of the right side with irritation of 
the liver. At that time I had not made my researches on the diag- 
nosis of empyema, and I must confess that I experienced a great 
deal of difficulty in determining the nature of the case. I found 
the right side considerably dilated, with dulness on percussion 
over its inferior half, but the intercostal spaces were not distended, 
and preserved their natural appearance. The case went on in this 
way for some time. Permit me to draw your attention for a mo- 
ment to this point. Dilatation of the right side may result from the 
pressure exercised upon it by a solid or by a fluid mass. If the 
mass be solid it will push the ribs outwards, but the intercostal 
spaces will still preserve their natural appearance. But if the 
protrusion of the side be the result of pressure by a fluid mass, the 
intercostal spaces will be acted on even more than the ribs, and the 
sulci, which mark their situation, will be effaced. Now, in this 
case the intercostal spaces were evident, and from this circumstance 
I determined that it was a liver disease. The patient continued 
for a fortnight without exhibiting signs of any material change, and 
then the tumour increased very much in size, but there was no ap- 
pearance of pointing. At this time the patient was visited and 
examined by a number of medical men, and all agreed that it was 
a case of deep-seated suppuration of the liver. Onder these cir- 
cumstances it was thought advisable to make an incision through 
the integuments down to the peritoneum, as recommended by Dr. 
Graves, and to keep the wound open by filling it with lint. This 
operation was performed, and the wound kept open for several 
days, but no matter came. On the sixth day the patient began to 
sink, his face became hippocratic, his extremities cold, and every 
one thought he was dying. During the course of the day it was 
observed that there was a circumscribed tumour, with a distinct 
sense of fluctuation, situated close to the wound, and towards the 
right side of the mesial line. Here is an important stage of the 
case ;—a man presenting evidence of suppuration in the liver has 
an operation performed on him to favour the exit of pus externally, 
and some time after this we find a circumscribed fluctuating tumour, 
nearly in the situation of the wound. We concluded that the hepa- 
tic abscess was pointing in that situation, and it was determined to 
pass a lancet cautiously into the tumour. This was done, but to 
our astonishment, instead of pus pure bile escaped through the 
incision. It was clear that we had mistaken a distended gall-bladder 
for an abscess, and this I need not tell you was a serious error. It 
is singular, however, that the accident was not followed by any bad 
consequences. About two hours after the operation the patient 
went to stool, and passed two large evacuations, consisting chiefly 
of a vast quantity of purulent matter. Next morning "he was 
surprisingly well, and the hepatic tumour had considerably di- 
minished. His countenance recovered its natural expression, his 
spirits were quite elated, his pulse had become tranquil, and the 
liver was manifestly returning to its ordinary dimensions. He 
began to sit up, was put upon generous diet, could walk about the HEPATIC ABSCESS. 
135 
ward, and was talking of leaving the hospital. From the period, 
however, at which the discharge of pus took place he had an obsti- 
nate diarrhoea, and though he took a great deal of nourishment he 
was still pale and emaciated. Twenty-two days after the subsi- 
dence of the tumour, another swelling began to make its appearance 
in the epigastrium, which increased daily, and it was obvious that 
another abscess was forming in the left lobe. About a fortnight 
after this he was suddenly seized with excruciating pain in the epi- 
gastrium, followed by symptoms of peritonitis. The tumour in the 
epigastrium subsided, but the patient sank in a few days of the 
peritoneal inflammation. Let me recall the circumstances of this 
case. First, we have obscure signs of the existence of abscess, then 
the sudden escape of matter from the bowels, accompanied with 
subsidence of the hepatic tumour ; in the next place a persistence 
of diarrhoea and emaciation, and, lastly, we have a new tumour in 
the epigastric region, disappearing on the supervention of symptoms 
of acute peritonitis. From a consideration of all these circum- 
stances I stated to the class that I should expect to find evidences 
of the abscess in the right lobe, which was the first affection, and I 
ventured to say, that the opening between it and the intestinal tube 
was still pervious. I was led to form this opinion from observing 
the persistence of the diarrhoea, to check which all the ordinary 
remedial means had failed. This was the first part of the diagnosis. 
In the next place I stated my belief that the gall-bladder had been 
punctured, but could not explain why the bile had not escaped into 
the peritoneum. Thirdly, I said that an abscess had formed in the 
left lobe, which had discharged its contents into the peritoneal 
cavity. All this was stated publicly, and on consideration you will 
find that there was no great difficulty in making the diagnosis. On 
dissection, we found a cavity in the right lobe with a small quantity 
of matter in it, and having a free communication with the duode- 
num. The fundus of the gall-bladder was found adhering to the 
parietal layer of the peritoneum, and the mark of a lancet wound 
in it was evident. A recent abscess was discovered in the substance 
of the left lobe of the liver, from which the matter had escaped into 
the peritoneum by a passage capable of admitting a small quill. 
Every part, therefore, of the diagnosis of this case was perfect, and 
borne out by the necroscopic appearances. You will see the 
details of this very interesting case in a paper published by Dr. 
Graves and myself, in the fifth volume of the Dublin Hospital Re- 
ports. 
This case is exceedingly interesting, because it illustrates two 
remarkable terminations of hepatic abscess: in one instance, by 
opening into a cavity which had an external communication, in the 
other, into a shut sac. The patient recovered from the first abscess, 
and would have done so effectually if the fistula had closed (no 
uncommon event); but he could scarcely have recovered from the 
second, because, where the matter escapes into the peritoneum or 
pleura, the patient almost invariably dies of acute inflammation 
of these cavities. This case derives additional interest from the 136 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
circumstance of the gall-bladder having been opened. I believe this 
is the only case on record in which an opening made into the gall- 
bladder has not been followed by fatal consequences. I might 
detail many other cases of hepatic abscess, but I must at present 
refer you to the paper already alluded to, in which we have pub- 
lished the results of our experience on the subject. 
Some authors have mentioned gangrene, or mortification of the 
liver, as one of the modes in which acute hepatic inflammation 
may terminate. It is now however agreed, that this is one of the 
rarest terminations we can meet with ; in fact, that there is hardly 
any organic disease which so seldom occurs. Mr. Annesley states, 
that in all his dissections (and these were very numerous) he never 
met with a case of gangrene of the liver. Andral, who has exa- 
mined some thousands of bodies, has only met with a single case: 
this, with another which was under the care of Dr. Graves, and 
appears to have been a genuine example of mortification of the 
liver, are almost the only cases of which I have any distinct recol- 
lection. The case under Dr. Graves was that of a patient in Sir 
Patrick Dun’s Hospital, who laboured under chronic inflammation 
of the liver, with ascites, jaundice, swelling of the lower extremi- 
ties, and an incapability of lying on the left side. After this man 
had been about eleven days in the hospital he began to complain of 
tenderness and pain of the belly ; he was next seized with vomiting, 
and threw up a large quantity of fetid matter. Soon after this he 
sank, and, on dissection, numerous marks of chronic disease were 
found in various parts of the substance of the liver ; but in the 
left lobe there was a cavity which was distinctly gangrenous, and 
had in the centre of it a large mass of slough. I think that there 
can be no doubt that in this case the disease was actual gangrene 
of the liver. I think, too, it may be very fairly doubted whether 
gangrene of the liver is the result of inflammation, properly so 
called, in any case ; and I believe it would be a very interesting 
subject for enquiry, to consider how far this disease may be the 
result of hepatic apoplexy, or effusion of blood into the substance 
of the liver. This is an accident to which the liver, as well as 
every other parenchymatous organ, is subject; and though effu- 
sions of blood into its substance are by no means so common as 
similar occurrences in the brain and lungs, still it does not enjoy 
any thing like immunity from such lesions. We have good reason 
to believe, that in many cases blood effused into the substance of 
parenchymatous organs may, under certain circumstances, either 
undergo putrefactive decomposition and form a gangrenous abscess, 
or that, although no longer circulating in its vessels and effused 
into the parenchyma of an organ, it may still retain its vitality to a 
certain extent, and, being modified by the powers of life, may give 
rise to the formation of various morbid products. In this way it is 
thought that various tumours—cancerous, steatomatous, melanotic, 
and encephaloid—may originate. I am inclined to think that this 
sometimes occurs in the brain and lungs, and it is probable that it 
may happen in the case of the liver also. Further researches, HEPATIC ABSCESS. 
137 
however, are necessary, with respect to the elucidation of this mat- 
ter, before our opinions on it can possess a higher character than 
that of verisimilitude. 
While on the subject of hepatic abscess, it will be necessary to al- 
lude to one of its occasional complications—distended gall-bladder-— 
because this may be mistaken for the pointing of an abscess, and an 
operation be performed, and that this has happened more than once 
is a positive fact. A distended gall-bladder has been mistaken for 
the tumour formed by the pointing of an hepatic abscess, an opening 
has been made into it under this supposition, bile has escaped instead 
of pus, and this getting into the cavity of the peritoneum, has given 
rise to rapid and fatal peritonitis. A remarkable case of this kind 
has been detailed with great candour by the late Mr. Todd, in one 
of the early numbers of the Dublin Hospital Reports. He was 
called suddenly to visit a girl, whom on his arrival he found to be 
in a dying state, labouring under great distension of the belly, 
almost insensible, moaning constantly with her jaw fixed, and pre- 
senting a distinct tumour in the hypochondriac region, which, from 
the history of her case, he was Jed to consider as an hepatic abscess 
pointing externally. He divided the integuments and muscles 
down to the peritoneum, and having introduced a trochar, drew off 
nearly three pints of bile, with apparent relief. Shortly afterwards 
violent peritonitis came on and the patient sank rapidly. After 
death the liver was found to be healthy, and the tumour to have 
been formed by a distended gall-bladder of enormous size. From 
this, after the operation, the bile had escaped into the peritoneum, 
causing intense and universal peritonitis. In making a diagnosis 
in such a case as this, every thing will depend upon your know- 
ledge of the history and previous symptoms. The circumstances 
which produce distension of the gall-bladder, you will find upon 
examination do not bear any distinct resemblance to those which 
precede or accompany inflammation of the substance of the liver. 
We may have it from the obstruction caused by biliary calculi, and 
here you can make a tolerably sure diagnosis. We may have it 
from disease of the duodenum, or of the head of the pancreas, or* 
from the pressure of aneurismal tumours in the vicinity. Abscess 
of the liver is generally accompanied by symptoms of inflammation 
of that organ, but distension of the gall-bladder does not present 
any corresponding train of phenomena. There may be some 
exceptions to this rule, but in making the diagnosis we must strike 
a balance of probabilities. The first part of our diagnosis then is 
this—the occurrence of a tumour in the hypochondriac region, not 
preceded or accompanied by any of the symptoms which charac- 
terise hepatic inflammation. Another important diagnostic, and 
which I think will apply in several cases, is this. In a case where 
abscess was formed in the liver, the fluctuation, which is a sign of 
the existence of fluid, is often preceded by a condition of the part 
in which there is no sign of the presence of fluid; we have first 
induration and swelling, and then the signs of fluctuation; but 
this is not the order of succession in the phenomena which charac- 
27 st. 10 138 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
terise distension of the gall-bladder. In abscess we have a hard 
tumour which gradually softens ; in case of distended gall-bladder 
we have the tumour soft and fluctuating from the commencement. 
If, then, we have a tumour in the hypochondriac region, not pre- 
ceded or accompanied by symptoms of hepatic inflammation, ac- 
companied by jaundice, with a sense of fluctuation from the begin- 
ning, and unattended by hectic, the chances are indeed very great 
that it is not an hepatic abscess, but a distended gall-bladder. 
You will perhaps be surprised, that, in treating of the diagnosis 
of distended gall-bladder, 1 do not lay any particular stress upon 
position. The reason of this is, that the situations in which a dis- 
tended gall-bladder may be felt are extremely various. First, we 
may have it appearing in different parts of the hypochondrium, 
under the cartilages of the ribs. In the next place, we may have it 
between the cartilages of the ribs and the spine of the ileum. It has 
been observed by Andral in the iliac fossa, and he has seen it in 
the epigastric region. In a case which occurred in the Meath 
Hospital, it presented itself in the epigastrium, a little to the right of 
the mesial line. Again, in severe cases you may have the whole 
of the liver filled with bile, and having a distinct fluctuating feel, 
not produced by the existence of pus in that organ, but from the 
erdargement of its ducts, which are gorged with bile. In one case 
mentioned in the Medico-Chirurgical Transactions, this curious 
circumstance occurred. So far, then, as diagnosis is concerned, 
position appears to be of very little consequence; but when we 
have this, in addition to the other circumstances mentioned, it will 
tend to give additional certainty to our diagnosis. In all cases on 
record where there was distended gall-bladder, the patient laboured 
under jaundice, except in that which I have detailed in the early 
part of this lecture ; but perhaps if our patient had lived longer, he 
would also have had jaundice. 
There is one disease more which may be, and I believe has been, 
confounded with acute hepatitis and abscess of the liver. This 
affection, which has not been sufficiently noticed by authors, is in- 
flammation and abscess of the abdominal parietes over the hepatic 
region ; and this is a very singular disease. It is sometimes trifling, 
but I have seen a patient die of it. With the original nature of this 
disease I confess that I am not at all well acquainted; nor can I 
say whether the inflammation first attacks merely external parts, or 
whether it is a primary affection of the liver, and that the external 
parts take on diseased action from sympathetic irritation. In such 
cases we frequently observe many of the symptoms of inflammation 
of the liver, as pain, tenderness, biliary derangement, foul tongue, 
and morbid stools, with a tumefied state of the integuments. After 
these symptoms have continued for some time, the tumour increases 
in size, becomes softer, and matter forms. You give exit to the 
pus by opening the abscess with a lancet, and the patient gets well. 
This occurrence I have frequently witnessed. From a considera- 
tion of all the circumstances, it strikes me that in this disease the 
first morbid action in all probability commences in the liver itself, HEPATIC ABSCESS. 
139 
and that the external inflammation is an example of the strong 
sympathy which subsists between disease of deep-seated parts and 
integuments which cover them. Of this fact you have several 
illustrative instances. In pleuritis we frequently tind the integu- 
ments of the chest remarkably tender on pressure ; and in cases of 
inflammation of the brain the integuments of the scalp have their 
sensibility much increased. The same thing occurs in hepatitis ; 
and in this disease one of the first distinct symptoms is this tender- 
ness of the superincumbent skin. Now, you can conceive that, 
if this morbid sensibility of the investing parts should increase, 
in place of having some pain and tenderness, accompanied by swell- 
ing, we may have suppurative inflammation set up in these parts ; 
and that, under such circumstances, the inflammation may leave 
the internal organ where it first existed, and be thrown upon the 
external parts in its vicinity. It strikes me that this is not unfre- 
quently the case in this curious affection. In the case of this 
disease which I have seen prove fatal, the following circumstancs 
were observed :—evident symptoms of inflammatory fever ; pain and 
tenderness in the region of the liver, followed by the appearance of 
a tumour; which became fluctuating, was opened, and a quantity of 
matter discharged with considerable relief to the patient. She left 
the hospital, but returned again in about a fortnight or three weeks, 
with an enormous tumour in the same place, which was again 
opened, and a vast quantity of purulent matter evacuated. Though 
the matter continued to flow out freely, she did not recover strength ; 
and on enquiry it was found that before her second admission she 
had spit up some blood. One day, while dressing the abscess, the 
gentleman who attended her observed that when she coughed air 
passed out through the wound, proving the existence of a fistulous 
communication with the lung. On examination after death we 
found an abscess, the base of which rested upon the peritoneal sur- 
face of the liver, without engaging its substance. From this the 
matter had made for itself a double passage, one externally, the 
other through the diaphragm and pleura into the substance of the 
lung. This was the only case in which I have seen this disease 
prove fatal; and in it death appears to have been caused by the 
extent of the disease, and by the abscess opening into the pleura 
and lung. 140 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
LECTURE XYII. 
Aneurism of the hepatic artery—Distension of the liver with bile—Treatment of he- 
patitis—Employment of mercury—Symptoms of suppuration—Dr. Graves’s operation 
for giving exit to matter in hepatic abscess—Rupture into the peritoneum—Chronic 
hepatitis—Complication with disease of the heart—Embryonary state ot' the liver. 
You may remember, in one of my past lectures I alluded to a 
case of aneurism of the hepatic artery, of which I had procured a 
preparation: to-day I shall be able to exhibit to you the morbid 
appearances in this very remarkable case. It would appear that 
aneurism of the hepatic artery is an exceedingly rare circumstance. 
At a late meeting of the Academy of Medicine of Paris, a specimen 
of aneurism of the hepatic artery was presented to the society; and 
that celebrated pathologist, Cruveilhier, stated that it was the first of 
the kind he had ever seen. I wish to bring this preparation before 
you, not merely from the interest which its rarity excites, but also 
because the disease, in this instance, produced that distended 
condition of the gall-bladder to which I drew your attention 
on a former occasion, and which, in this case, was recognised 
before death. The gall-bladder formed a distinct pyriform tumour, 
situated a little above the iliac fossa, and the patient was deeply 
jaundiced. I shall state, from recollection, what I know of the 
details of this case. The patient was brought into the Meath 
Hospital, labouring under jaundice, which he stated to be of some 
days’ standing. He was thin and weak, and when questioned 
respecting his age, he said he was thirty-five, but he appeared to 
be upwards of fifty. His habits he described as being uniformly 
temperate and regular. Some years before he had suffered from 
an attack of apoplexy, but after this had enjoyed good health, until 
the occurrence of the present illness, which began with vomiting 
of blood, and which continued for some days and then yielded to 
medical treatment. He now experienced a loss of appetite, became 
quite dyspeptic and constipated; he also began to lose flesh, and 
under these circumstances applied at a dispensary, where he got 
various remedies without any benefit. Some time after this he 
observed, on getting up one morning, that his arms and legs looked 
rather yellow ; on the following day he had a decidedly bilious 
tinge with yellow vision, and in this state he entered the Meath 
Hospital. On admission he presented symptoms of general jaun- 
dice ; the urinary secretion was deeply coloured ; the skin, eyes, 
and nails yellow; the stools white and without any trace of bile. 
On examining the abdomen, the liver was apparently greatly in- 
creased in size ; in the epigastric region there was a tumour of 
considerable dimensions ; and in the iliac fossa we observed a 
separate pyriform tumour, which could be traced up to the edge of 
the enlarged liver. I mentioned at that time to the class, that there 
was something about the case which I could not understand. The 
disease was of inconsiderable standing; the patient had, a short 
time previously, been in a state of good health, and yet, reasoning ANEURISM OP THE HEPATIC ARTERY. 
141 
from analogy, this hepatic tumour could only have occurred as the 
result of chronic disease. It must have been the consequence of 
disease more or less chronic, and yet the history of the case was at 
variance with the idea of its chronicity. After some time the 
patient got miliary eruption, then petechial spots ; he continued in 
a low and weak state, and nothing did him any good. On the 
morning of the day of his death he did not appear worse than 
usual; he answered our enquiries respecting his health in his 
ordinary manner ; in the evening he sat up in bed gasping for 
breath, with a look of extreme distress ; he then leaned back on 
his pillow and expired. 
On opening the peritoneum we found a vast quantity of blood 
effused into its cavity, and my first impression was that it was 
aneurism of the abdominal aorta. On closer inspection, the aorta 
proved healthy, and the aneurismal tumour was found to be con- 
nected with the hepatic artery ; this had ruptured close to the gall- 
bladder, and its contents had been effused into the cavity of the 
peritoneum. We now found that the cause of the jaundice had 
been the pressure which this tumour had exercised on the biliary 
ducts. In consequence of the obstruction to the flow of bile, the 
ducts of the liver were dilated to an enormous extent; some of 
them were capable of admitting the largest sized finger. This 
dilation affected not only the larger trunks, but even extended to 
their most minute ramifications, even up to the surface of the liver; 
and here we found that the biliary tubes were dilated into sacs, 
some of which were as large as a hazel-nut. When these pouches 
were punctured the bile gushed out freely. A similar condition of 
the ducts has been noticed by Mr. Lloyd as existing in connection 
with obstruction of the biliary duct, from disease of the head of the 
pancreas, in his paper on Discharges of Fatty Matter from the Bow- 
els. (See Med. Chir. Trans.) I have got the preparation of this 
singular disease before me, and I regret that in one respect it is 
defective, inasmuch as it does not show satisfactorily the condition 
of the biliary ducts. A portion of the preparation which exhibits 
this appearance I gave to Dr. Houston, the curator of the Museum 
at the College of Surgeons, and I am sure that he will give ad- 
mission to any gentleman who is anxious to examine it. This 
preparation, gentlemen, is too large to send round. It exhibits the 
hepatic artery with its aneurismal tumour, and the opening by 
which the artery communicates with the aneurismal sac. Here is 
the place in which the rupture took place, and here is the gall- 
bladder greatly extended and thickened in its coats. 
Here, then, we have a new cause of jaundice, where the disease 
is the result of the pressure of an aneurismal tumour of the hepatic 
artery—a cause which has hitherto been unnoticed by writers on 
jaundice. The great interest of this case consists in this, that dis- 
section explained the difficulty which I felt in making the diagnosis 
at first, for it showed that the hepatic tumour was formed, not by 
an hypertrophied, but by a distended and displaced liver. It 
proved that it was formed, not by a process of chronic growth, but 142 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
by the rapid formation of an aneurismal swelling and the conse- 
quent obstruction of the gall-bladder, accompanied by distension of 
the liver itself. With recent symptoms, then, we had, in this case, 
an enormously large liver, not the product of acute inflammation, 
but of distension of all the biliary ducts up to their most minute 
ramifications, and arising from mechanical obstruction. As far 
as it goes, this case appears to me to be perfectly unique. 
Let us turn now to the treatment of acute hepatitis. It is unne- 
cessary for me to say, that in all cases of acute visceral inflamma- 
tion, in the healthy subject, the first consideration is blood-letting, 
either general or local. In the early period of acute hepatitis, all 
authors have agreed in strongly recommending the use of the 
lancet; and there can be no doubt that when the disease is in its 
early stage, and the patient robust, the practitioner who omits 
employing these measures must be culpably negligent. It should 
always be borne in mind that the liver is an organ of paramount 
importance to life. There are two circumstances, also, which are 
in favour of bleeding in the case of an acute hepatitis—there is 
less chance of its being complicated with typhus fever, and general 
bleeding exercises a powerful influence over the acute inflamma- 
tions of parenchymatous organs. Hence we bleed with greater 
advantage in a case of acute hepatitis than in the inflammation of 
mucous membranes. Our first bleeding should be large, and such 
as will make a decided impression, and it will frequently be neces- 
sary to bleed a second and even a third time if the disease be very 
acute and the constitution strong, taking care to diminish the 
quantity at each successive bleeding, and to watch its effects. I 
have here to make one remark—that general bleeding is not the 
same heroic remedy, nor has it the same decided influence in ar- 
resting acute hepatic inflammation, as in checking pneumonia. 
A copious detraction of blood has, under favourable circumstances, 
often succeeded in completely removing an attack of pneumonia, 
and the patient has recovered without the employment of any other 
remedial measure ; but acute hepatitis is seldom or never cut 
short in this way. Still venesection is of the greatest importance ; 
and if it were performed merely with a view of preparing the 
patient for leeching and other depletive measures, its advantages 
would be unquestionable. I would recommend you, therefore, 
when you meet with a case of hepatitis in the early period, first to 
bleed freely, or in such a manner as to make a decided impression 
on the symptoms ; next, to empty the bowels by prescribing a pur- 
gative draught, assisted by an enema; and, lastly, to cover the 
region of the liver with leeches. You will find great advantage 
in employing your therapeutic means in this order ; for if you begin 
with leeches before you have had recourse to venesection, or the 
use of purgatives, your practice will not be so scientific, nor will 
your success be so complete. Bleeding, purgation, leeches, and 
the application of cupping glasses over the leech-bites (if necessary) 
will give you breathing time ; and, after the lapse of twelve or 
fourteen hours, you will find that all symptoms of urgent danger ANEURISM OF THE HEPATIC ARTERY. 
143 
will have passed away. During- the progress of the case, the 
remedy which I should principally rely upon is local bleeding, 
frequently repeated. If you apply thirty leeches to-day, I would not 
have you repeat them to the same amount to-morrow; but you 
might, perhaps, apply fifteen or eighteen, and the next day ten or 
twelve. By proceeding in this way you will find a great abate- 
ment in your patient’s symptoms; and I know of no circumstance 
which, taken singly, proves the value and benefit of your treat- 
ment so well as the diminution of the hepatic tumour, which you 
can acurately and satisfactorily ascertain by means of the pleximeter. 
When you find a gradual subsidence of swelling, I think you may 
be pretty sure that, even though the other symptoms exhibit little 
or no improvement, the hepatitis is on the decline, and will soon 
be removed entirely. 
You have all, I am convinced, heard a great deal of the use of 
mercury in hepatitis ; and there appears to be in the minds of most 
medical men a strong connection between mercury and all diseases 
of the liver. So far has this impression gone abroad, that to some 
practitioners it would appear perfectly heterodoxical to think of 
attempting to cure an hepatic inflammation without this accredited 
panacea. I must however confess that it is my belief that several cases 
of hepatic inflammation may be cured without it; and, if this be 
true, as I am convinced you will find by experience, it is so much 
the better for the patient. I do not mean to depreciate the value of 
this powerful remedy in making this assertion ;—it is undoubtedly 
a useful adjuvant, but it is only an adjuvant. It is decidedly second- 
ary and inferior to general and local antiphlogistics, followed by 
counter-irritation; and you should always bear in mind, that if you 
wish to bring about the full action of mercury on the system, you 
must precede its employment by means calculated to reduce the 
intensity of local inflammation. By premising general bleeding, 
leeching, and purgatives, you give the mercury an opportunity of 
exerting a decided influence on the salivary g-lands ; and in such 
cases it is that the most unequivocal advantage is derived from it; 
for, as I have observed in a former lecture, salivation appears often 
to be the result of the reduction of inflammation to a certain degree, 
and not its cause. 
In all cases of hepatitis occurring in delicate females, but parti- 
cularly in persons of low, scrofulous constitutions, endeavour to 
dispense with the use of mercury if possible. You will have con- 
siderable difficulty in divesting yourselves of early prejudices, and 
combating those of others ; but when you have an opportunity of 
acting for yourselves, I would have you make trial, and you will 
find that many cases are curable without mercury. If, after having 
regularly and carefully employed the means recommended, you 
perceive that two or three days pass without any improvement in 
your patient’s symptoms, and that the hepatic tumour remains 
undiminished, then indeed you may have recourse to mercury. 
But if you have been so fortunate as to have struck a decided blow 
in the commencement, and that the case is going on well, I would 144 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
ask, why should you expose your patient to the misery and danger 
of salivation ? I am not by any means opposed to the employment 
of mercury in cases of liver disease; on the contrary, if we compare 
inflammation of the lungs, brain, and liver, with respect to the 
power which it has over each, I believe that it is much more appli- 
cable to cases of hepatic inflammation than it is to either pneumonia 
or cerebritis. 
There is nothing more common than a complication of disease of 
the liver with disease of the upper part of the digestive tube ; and 
here you will find that calomel will frequently cause great irrita- 
tion of the bowels, vomiting, and increase of fever. Under such 
circumstances, you must omit the internal use of mercury, and have 
recourse to frictions, directing your patient to rub in a dram of 
camphorated mercurial ointment every six or eight hours until the 
gums are affected. A very good auxiliary means is to place a 
dram of the mercurial ointment in the patient’s axilla, and leave 
it there; the action of the arm will, to a certain extent, answer all 
the purposes of friction. Dr. Graves is much attached to this 
mode. Where you have employed blisters, you may cut off the 
cuticle, and dress the raw surface with mercurial ointment. This 
also will contribute materially to produce the intended effect on 
the system. With respect to blisters, the same rules are to regulate 
their application as I have mentioned before, when speaking of the 
treatment of gastro-enteritis, namely—that they are not to be used 
until active antiphlogistic treatment has been employed; for it is 
then, and then only, that the stimulus of a blister can be useful. I 
believe it is seldom necessary, or even safe, to apply a blister before 
the third or fourth day in cases of acute inflammation of the liver. 
The physician who purges to-day, and blisters to-morrow, and bleeds 
next-day, is a very injudicious practitioner indeed ; he should bleed 
first, then purge ; and having by these means reduced the symp- 
toms of active inflammation, he may proceed to the use of blisters 
with advantage. 
It is unnecessary for me to remind you that you must enjoin a 
strict antiphlogistic diet in all cases of acute hepatitis. Recollect 
the powerful influence which all dietetic stimulants exercise, not 
only over the digestive canal and general system, but also over the 
liver; bearing this in mind, you will, for the first few days, keep 
your patient on a water and slop diet, and then on mild farinacious 
food and chicken-broth. 
But suppose that after all this, after having employed all the 
resources of the science and art of medicine, your patient becomes 
gradually weaker, his face pale and expressive of much constitu- 
tional suffering, his skin flaccid and bedewed with perspiration, his 
pulse small, rapid, and compressible; that the hepatic tumour 
increases in size, and when you throw aside his bed-clothes, the 
whole of the right side appears manifestly enlarged; and, if the 
bowels are empty, you see the hepatic tumour extending far down- 
wards into the abdomen; in addition to these symptoms, suppose 
the patient has had shivering fits, not only once but repeatedly; ANEURISM OF THE HEPATIC ARTERY. 
145 
that his perspirations are profuse, and have a sour smell; that his 
tongue is dry and glazed ; that his cheeks are hollow, and some- 
times present a circumscribed flush ; and that he is low, weak, and 
restless. Under these circumstances you may be sure that suppu- 
ration is commencing, or has been already established; and the 
question is, what are you to do? You must change your hand, 
you must give up antiphlogistics, you must omit the employment 
of all measures which have a tendency to reduce strength, you 
must prescribe a light nutritious diet, and anodynes to relieve irri- 
tation. When suppuration is fully established, the next considera- 
tion is, in what direction the contents of the abscess may escape; 
and here I need not remind you that it is much better that the 
abscess should open externally, through the integuments of the 
abdomen, or into some cavity having an external communication, 
rather than into a shut sac, as in the latter case it is almost certain, 
and often immediate death. At this period of the case it will be 
proper to support your patient’s strength by allowing him wine, 
increasing the quantity if the hectic symptoms threaten to run him 
down, and taking care that his diet be nutritious and of easy 
digestion. You will also take care to relieve his sufferings, and 
irritation attendant on the disease, by the judicious employment of 
opiates. 
When after some time the tumour becomes more elevated and 
distinct, the pain concentrated in one particular part of the liver, 
and the abscess is evidently pointing towards the surface, the ques- 
tion then is, whether we shall open it and give exit to the matter, 
and how this may be best accomplished. That the contents of the 
abscess should be evacuated as speedily as possible is true, but the 
consideration is, how far it can be done with safety. Now, I beg 
your attention to this point, as it has not been sufficiently attended 
to in works on the practice of medicine. Recollect what the ana- 
tomical condition of the parts is under such circumstances, and that, 
in order to get at the matter, you have to pass through a serous 
cavity. It. is obvious that if you make an incision into the tumour 
through the peritoneum, and if this be in a state of health, and 
without any adhesions between its layers in the situation of your 
incision, you run the risk of having the contents of the abscess 
effused into the peritoneal sac, and you know that this is almost of 
necessity fatal. The condition then for success is, the circum- 
stance of adhesion taking place so as to prevent the matter from 
getting into the peritoneum. 
Well, it seems to be a very simple thing to give exit to the 
matter of an hepatic abscess which presents a distinct pointing. 
Persons will say, adhesion has formed long since, the integuments 
are swollen and painful, the matter has crossed the peritoneum and 
lies close under the skin. Here, however, is a curious fact; of all 
the serous membranes in the body the peritoneum is that which is 
least liable to general or partial adhesions, and it is well known 
with respect to hepatitis with suppuration, that you may often have 
abscess so large as to form a distinct tumour on the surface, which 146 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
shall be fluctuating, discoloured, and painful, and with all these 
conditions, so favourable to the notion of matter being actually 
under the skin, the patient dies, and on dissection we find not the 
slightest trace of adhesion. If you plunged a trochar or abscess- 
lancet into the tumour, what would be the consequence ?—death 
by peritonitis. Dr. Graves and I, in our report of the cases of 
hepatic abscess which occurred in the Meath Hospital, were the 
first who drew the attention of the profession to this interesting 
pathological fact, and, subsequently to this, Mr. Annesly, who has 
vast experience in hepatic abscess, stated that in his practice he 
found that the existence of adhesion between the layers of the peri- 
toneum in the vicinity of the abscess, even after swelling, tenderness, 
and discoloration of the integuments, is by no means a necessary 
consequence. 
It appears then to be quite certain, that the opening of an hepatic 
abscess is a matter of considerable nicety, and requiring a great deal 
of caution. The best mode of proceeding which can be adopted is, 
in my opinion, that which has been recommended by Dr. Graves, 
and which is founded on the most accurate pathological views. He 
makes an incision through the integuments, over the most promi- 
nent part of the tumour, and carries it through the cellular sub- 
stance, fat, and muscular tissue, until the peritoneum is nearly laid 
bare, and there he stops. The wound is then kept open by plug- 
ging it up with lint, and after some time the abscess bursts in this 
situation with perfect safety to the patient. This operation was 
performed under his direction, for the first time, in a case of abscess 
where there was no distinct pointing. It was the first operation of 
the kind, and every one who witnessed it waited with anxiety for 
the result. Five or six days passed away without any appearance 
of matter; but about this period the abscess began to point, shortly 
afterwards there was a large gush of matter through the wound, 
and the patient recovered perfectly in three weeks. Since that 
time the operation has been performed on two patients with success 
and safety. In the case of one patient it was performed twice at no 
very considerable interval. 
Now, I believe you are all aware that in cases of deep-seated 
collections of pus, it is of the greatest importance to remove the 
obstruction to its exit externally, and that matter will always point 
towards the place where there is the least resistance. The per- 
formance of this operation not only tends to remove the resistance, 
but also has this advantage, that the existence of irritation in the 
neighbourhood of the abscess, and immediately over the peritoneum, 
has a strong tendency to produce adhesion at this point; a circum- 
stance which I was able to verify in a fatal case, in which the 
abscess had pointed, but never burst. In this case we found on 
dissection six or seven small tumours near the surface of the liver, 
without any traces of adhesive inflammation in the peritoneum over 
them, but over the situation of the tumour, in the direction of which 
the incision had been made, there was a considerable quantity of 
organised lymph, and the two layers of the peritoneum were closely ANEURISM OF THE HEPATIC ARTERY. 
147 
adherent. That this effusion of lymph had not been accidental, is 
rendered probable by the rarity of its occurrence, from not being 
observed in other cases in which an operation had not been per- 
formed, and lastly from the success of the operation in those cases 
in which it had been employed. I would advise you, therefore, in 
all cases of hepatic abscess showing a tendency to, point, but parti- 
cularly if this pointing be distinctly towards the surface, to make an 
incision down to the peritoneum, fill up the wound with lint, and 
you will often succeed in causing the abscess to break externally, 
and without any danger to your patient. 
With respect to the bursting of an hepatic abscess into the cavity 
of the peritoneum, I have stated before to you, that it is almost 
necessarily fatal. I say almost, because I have seen two cases of 
this termination, of which one recovered completely from the 
peritonitis, and the other lived eight or nine days after the dis- 
charge of matter into the peritoneum, and on dissection it was 
found that a process of cure had been going on. The first of these 
cases was that of a young woman who had a vast chronic abscess. 
An attempt was made to make this open externally, by destroying 
the soft parts over it with caustic, but this not succeeding, a lancet 
was introduced through the eschar made by the caustic. The 
patient was immediately afterwards attacked with severe pain in 
the abdomen, and distinct symptoms of peritonitis. As she was 
very weak and emaciated, Dr. Graves, under whose care she was, 
gave her opium in full and repeated doses, allowing her the 
free use of wine and porter; no blood was drawn, no depleting 
measures of any kind used, but every thing done to support 
strength and relieve irritation. Under these circumstances (won- 
derful to relate) she recovered from the peritonitis. She after- 
wards sunk from the abscess, and on dissection we found that 
the peritoneal cavity was obliterated, just as the serous investment 
of the testicle has its opposed surfaces glued together after an ope- 
ration for the radical cure of hydrocele. In the other case, the 
patient lived eight or nine days after the occurrence of symptoms 
of peritoneal inflammation. On dissection, we found a large 
quantity of transparent lymph effused on the surface of the perito- 
neum, in the substance of which several large blood-vessels had 
been developed. 
The principles of treatment in a case of this dreadful accident is 
to support strength and remove irritation, laying aside all antiphlo- 
gistics. I am sure that, under such circumstances, the ordinary 
modes of treating peritonitis are inapplicable and useless. As I shall 
return to this subject when I come to speak of peritonitis, I shall 
here merely state, that the treatment of such a case as this is to be 
conducted upon the same principles as peritonitis, produced by rup- 
ture of the intestine, or a perforating ulcer. 
Gentlemen, I shall occupy your time briefly in treating of 
chronic hepatitis. You will find a full description of the symptoms 
of this disease in almost every book on the practice of medicine, 
and it is unnecessary for me to detain you with details of this 148 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
kind. If we are to judge from British practice, chronic hepatitis is 
a very common disease, and, if we look to the practice, it is an affec- 
tion under which half the community labour. I believe, indeed, 
that the chronic form of this disease is much more frequently 
observed in this country than the acute, but still I think it is any 
thing but a disease of universal prevalence. 
I shall not, as I said before, take up your time in stating what 
you will find in any medical work ; I shall merely mention that in 
chronic hepatitis we have generally derangement of the bowels, 
chiefly affecting the stomach and upper part of the digestive tube, 
and in addition to this we have more or less pain, tenderness, and 
swelling in the region of the liver, and often dulness of sound over 
the lower part of the right side. When we meet with this train of 
phenomena, we say that the patient has the symptoms of chronic 
hepatitis. But no one under such circumstances could undertake 
to say whether the patient will die of hypertrophy or atrophy, of 
cancer or hydatids, of tubercles, or of fatty discharge, or of any 
peculiar disease of the liver. There is another point, too, of which 
I am anxious you should be aware. Chronic hepatitis is a disease 
which has been, and is, frequently confounded with various other 
affections ;—with scirrhus of the pylorus, with chronic disease of 
the duodenum, with chronic disease of the pleura, and empyema of 
the right side. There is one circumstance which you should bear 
in mind when you are in doubt with respect to a chronic hepatitis, 
that one, two, or three of these affections may occur in connection 
with chronic inflammation of the liver. For instance, a patient 
labouring under chronic hepatitis may have also at the same time 
empyema and disease of the duodenum. I believe the subject of 
disease produced, as it is said, by contiguity in separate organs, has 
not as yet been sufficiently investigated, and that our knowledge 
on this important point is extremely scanty. 
There are two circumstances connected with this part of the 
subject, on which I shall say a few words. One common error is 
that of confounding affections of the heart with those of the liver, 
and this I regret to say is an error of very serious consequence, and 
one which is frequently observed in tbe consultations of medical 
practitioners. A patient complains of palpitations, a physician is 
called in, and pronounces the disease to be hypertrophy of the 
heart; another is called in, and gives it as his opinion that the 
liver is affected ; a third is summoned, and says that both the liver 
and heart are diseased. In such cases you should always make a 
careful examination, and weigh well the circumstances of the case 
in your mind before you venture to pronounce an opinion. In the 
first place, you are to recollect that organic disease of the heart may 
produce disease of the liver. Secondly, that disease of the liver 
(though not so often) frequently brings on morbid affections of the 
heart and nervous palpitations. Thirdly, that these affections act 
to one another reciprocally as cause and effect. If a person has 
disease of the heart, the current of the circulation through that 
organ is obstructed, and you may have disease of the liver, not as 149 
ANEURISM OF THE HEPATIC ARTERY. 
the result of any original affection of that organ, but as the effect of 
chronic obstruction to the passage of blood through the heart. 
The consequent congestion and disease of the liver may, in such a 
case, be reflected on the digestive tube, and this in turn may 
re-act on the heart. The heart sympathises then with the irritation 
of the digestive tube; we have nervous palpitations, and if these 
continue for a length of time, we have the disease of the heart 
increased. Again, suppose a patient has chronic disease of the 
liver, causing more or less obstruction to the circulation ; the heart 
begins to sympathise, palpitations commence, go on increasing, and 
finally terminate in hypertrophy of the heart. The mischief does 
not stop here; the effects of obstruction extend to the vena cava 
hepatica, this in turn re-acts on the liver, and we have in this way 
a curious train of phenomena; first liver disease, then heart disease, 
and lastly liver disease again. Let me once more impress upon 
you that, under such circumstances, you cannot be too diligent 
in making an examination, or too cautious in pronouncing an 
opinion. 
There is another thing connected with hepatic disease which you 
should be aware of. A patient, labouring under the following train 
of symptoms, comes to consult you;—he has pain in the right 
hypochondrium, loss of appetite, deranged bowels, morbid stools, a 
dirty bilious hue of countenance, and, in fact, all the symptoms of 
diseased liver. You examine the liver and find it very much 
tumefied, in fact, its size is so much increased that you would at 
once be inclined to say that it was extensively diseased. Now, 
there are some cases of great tumefaction of the liver accompanied 
with more or less of the symptoms of hepatic derangement, and yet 
in such cases you may have no disease of the liver at all, at least 
none of the ordinary forms of hepatitis: these are cases in which 
there exists, in adults, a persistence of the embryonary condition 
of the liver. If we compare the condition of this organ in the 
infant and in the adult, we find many essential points of difference. 
In the infant it is comparatively large, and, as it were, hypertro- 
phied ; it descends far below the margin of the ribs, and occupies 
a large portion of the abdominal cavity. On the other hand, if 
we examine its state in the adult, we find that it has shrunk 
beneath the short ribs, and that its size and dimensions are com- 
paratively much reduced. Now this physiological atrophy of 
the liver is a natural and healthy process. There are certain 
individuals, however, in whom\ this change does not take 'place, 
and who grow up with the liver bearing the same proportion to 
the other organs as it did in the foetal condition. This curious 
condition is one of the varieties of arrest of development, and is, in 
almost every instance, observed in those persons whose constitu- 
tions present that train of phenomena to which the term scrofula 
has been applied, and which (if I have time) I shall show you is 
explained, or at least great light is thrown upon it, by the theory 
of arrest of development. In such subjects the tumefaction of the 
liver is by no means a measure of actually existing disease. If 150 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
you were to suppose this tumefaction of the liver to be the product 
of actual recent disease, and proceed to treat the patient in the same 
way as you would treat a case of hepatitis in the healthy subject, 
you would not only do no good, but, in ail probability, a great deal 
of mischief. I know the case of a gentleman, in the enjoyment of 
good health, who has this tumefaction of the liver to a very great 
degree. He is of a thin spare habit of body, with a full, round* 
and prominent belly; he is pursuing the avocations of an active 
profession, and yet you will hardly credit me when I say that his 
liver extends below the umbilicus, and close to the anterior superior 
spine of the ileum; yet he is very active, and to all appearance a 
healthy man. You will often meet with this condition of the liver 
in children who are attacked at an early age with symptoms of 
tabes mesenterica. 
At the next lecture I hope I shall be able to finish diseases 
of the liver, and proceed to the consideration of other affections of 
the system. 
LECTURE XVIII. 
Treatment of chronic hepatitis—Neuralgia of the liver succeeding hepatitis—Connect 
tion of hepatic with gastro-intestinal disease—Modes of transmission of disease from 
the mucous surface of the liver—Phlebitis of the vena porta—Obstruction of this 
vein—Case of pulmonary, hepatic, and intestinal fistulre—Hepatic neuralgia. 
We now come to the consideration of the treatment of chronic 
hepatitis. It is of great importance, in a case of this kind, to place 
your patient under such circumstances as will ensure the full and 
favourable action of the remedies employed. The use of wine, 
spirits, and all kinds of exciting food, must be laid aside; the 
patient must not use any thing capable of producing fever during 
the process of digestion. So long as any kind of food or drink pro- 
duces uneasiness and sensations of heat and fulness, you may be 
sure that it will do more harm than good. Give him what will 
support his strength without exciting the vascular or nervous 
systems during the process of digestion. 
You must next prevail on your patient to give up the use of 
active purgatives by the mouth. This is a point which you should 
strongly and firmly insist upon, as, in consequence of the ordinary 
costive state of the bowels which accompanies chronic inflammation 
of the liver, the patient is generally in the habit of having recourse 
to those temporary and hurtful remedies. It is the same thing in 
cases of chronic hepatitis as it is in chronic gastritis; you will find 
the subjects of these diseases taking different purgatives every day. 
Break your patient of this practice, if possible ; you will have some 
difficulty in doing so, for he has been long habituated to it, and you 
must exercise all your authority in putting a stop to the pernicious 
habit. Instead of purgatives by the mouth, make him use every TREATMENT OF CHRONIC HEPATITIS. 
151 
day an emollient injection. You may, if necessary, give, occasion- 
ally, mild laxatives by the mouth, as Rocvhelle salts, manna, castor 
oil, or something equally mild, and in this way you will be able to 
secure a regular alvine discharge, once in the twenty-four hours at 
least. But where there is considerable pain and tenderness in the 
region of the liver, this plan alone will not be sufficient; you must 
apply relays of leeches, a practice which has a most admirable 
effect in chronic hepatitis. I would advise you to apply cupping- 
glasses over the leech bites ; by doing this, you get as much 
blood as you wish, and you will generally save your patient from 
the annoyance of an oozing hemorrhage. When piles exist, it will 
be useful to apply leeches to the anus, followed by the hip bath. 
But I have no hesitation in saying, that, as a general mode of reliev- 
ing hepatic disease, the application of leeches to the right hypochon- 
drium is far preferable in every point of view. You may, in the next 
place, have recourse to blisters; and I have frequently employed 
blisters, alternately with leeches, with the best results. Tartar 
emetic ointment, in the form which I have already mentioned, 
croton oil frictions, and other modes of counter-irritation, will assist 
materially in bringing about a successful termination. But these 
must be continued long, and used over an extensive surface. 
In this way, by regulating your patient’s diet, keeping his bowels 
open by enemata, or the mildest laxatives, by small and repeated 
local bleedings, with counter-irritation, you will frequently succeed 
in removing all the symptoms of chronic hepatitis without the use 
of mercury. But if, after having carefully employed all these 
measures, the symptoms manifest a degree of persistence, if your 
patient has not already taken a large quantity of mercury (which is 
not likely to be the case in this country), and if he be not of a 
scrofulous habit, I see no reason why you should not have recourse 
to mild doses of mercury. For this purpose, nothing answers better 
than to prescribe, once or twice a day, a pill composed of hydrarg. 
c. creta, blue pill, or a small quantity of calomel, combined with 
rhubarb, extract of hyosciamus, and taraxacum. It will be seldom 
necessary to bring on actual salivation ; but if the pain continues to 
be severe, the swelling undiminished, the symptoms obstinate, and 
no contra-indication existing, you may bring him under the influ- 
ence of mercury, and keep him so for a short time. The best 
mode of doing this is to direct him to rub in a dram of the cam- 
phorated mercurial ointment every day ; and if you have employed 
blisters, you can assist the frictions by dressing the blistered surface 
with mercurial ointment. 
Some practitioners are in the habit of substituting the nit.ro- 
muriatic acid for the mercurial treatment, and there appears to be 
evidence that it is an advantageous mode of practice in these cases. 
The best mode of using this remedy seems to be the endermic ; and, 
hence, bathing the feet, or sponging the right hypochondrium with 
the acid, are most recommended in chronic affections of the liver. 
As it is convenient to have a formula for making the nitro-muriatic 
solution, I shall give you the following. Take of strong nitric and 152 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
muriatic acids of each four ounces, and add to these eight ounces of 
pure water. Here you have a sixteen ounce mixture ; of this com- 
bination you may take from two to five ounces, and mix them with 
three gallons of warm water. This, I believe, is the form recom- 
mended by Mr. Annesly. Having placed this solution in a foot 
bath, or tub, you should direct your patient to keep his feet in it for 
twenty minutes or half an hour. If the bath be of proper strength, 
it will communicate to the skin a prickling sensation ; if not, you 
may increase its strength by adding an ounce or two more of your 
mixture. The same solution will answer for sponging over the 
liver. 
There is no doubt that, in certain cases of chronic hepatitis, this 
remedy has been found decidedly useful, and as its employment is 
unattended with any dangerous or disagreeable consequences, it 
has strong claims to our notice. The cases of chronic hepatitis to 
which it seems to be peculiarly adapted, are, first, those where 
mercury has been used irregularly, or for a long time without any 
benefit, and, secondly, where the patient is of a broken down con- 
stitution, and where you are anxious to dispense with the use of 
mercury, if possible. Here the intro-muriatic treatment is of 
decided value. I need scarcely remark to you that this acid fre- 
quently acts upon the system somewhat like mercury, producing 
tenderness of the gums and ptyalism. Such an effect as this, fur- 
nishes us with an example of these cases, in which we find other 
remedies, as well as mercury, producing a decided effect on the 
salivary glands, and exercising a very powerful influence over 
hepatic and syphilitic affections. An interesting fact, bearing on 
this point, is related by Mr. Cox, in his account of his residence on 
the Columbia river. Several of his party, who used a strong decoc- 
tion of the fresh sarsaparilla, were salivated. 
There is one circumstance, connected with the treatment of 
chronic hepatitis, which I believe has not been sufficiently dwelt 
on. You may have a case in which there was distinct evidence of 
chronic inflammation, and where, under the influence of judicious 
treatment, the signs of inflammation and organic derangements sub- 
sided, but where severe pain still continues to be felt in the region of 
the liver. The nature of this pain is often mistaken; it is sup- 
posed to depend upon a continuance of inflammation, while it is, 
in reality, nothing more than a mere neuralgic affection—a rem- 
nant or successor of the former disease, to which the antiphlogis- 
tic treatment is totally inapplicable. Under such circumstances, 
the patient goes from one practitioner to another, takipg different 
medicines, and submitting to repetitions of the usual modes of treat- 
ment, but with little or no benefit. Now I have seen, in several 
cases, this symptom yield completely to treatment calculated to 
remove purely neuralgic affections. In a case, lately under my 
care, of a gentleman who had been attacked with enteritis and 
hepatitis in India, and who had taken enormous doses of calomel 
“for the liver,” and of croton oil “for the bowels,” this circumstance 
occurred. When first I saw him, he was emaciated, the skin 153 
TREATMENT OF CHRONIC HEPATITIS. 
yellow, the urine high-coloured, with thirst, costive bowels, and 
great tumefaction in the region of the liver. These symptoms 
completely subsided under treatment, but a violent pain, running at 
intervals, continued obstinate. This was rapidly removed by a 
course of the carbonate of iron, and the use of the belladonna 
plaster. 
It is of great importance, in the treatment of chronic hepatitis, to 
bear in mind the state of the gastro-intestinal mucous membrane. 
You are aware that the disciples of Broussais are of opinion that 
almost all cases of hepatic inflammation are secondary to a gastro- 
enteritis ; that the first morbid action is on the surface of the intes- 
tinal tube, and that it is transmitted from this to the liver. I have 
taken a considerable share of pains in investigating this subject, and 
have examined very carefully the question as to the complication of 
hepatic inflammation with disease of the gastro-intestinal surface, 
and the conclusions to which I have come, are the following:—In 
the first place, that most cases, whether of acute or chronic inflam- 
mation of the liver, present the complication, more or less, with dis- 
ease of the intestinal mucous surface, and that in the majority of 
instances there is some degree of actual disease of the digestive 
tube. It would appear, also, from observation of different cases of 
hepatitis, that in a great many the affection of the liver has been 
secondary, and that symptoms of disease of the digestive tube have 
preceded those of hepatic irritation. But, on the other hand, we 
must admit that the hepatic affection may be primary; that the 
liver has the irritative, and that disease has been subsequently 
propagated to the gastro-intestinal mucous surface. Lastly, we 
may have hepatitis, both acute and chronic, quite independent of 
any disease of the mucous coat of the stomach and bowels. This, 
I believe, is the rarest case; still it does occur. You observe, there- 
fore, that the doctrine of the physiological school, that all hepatic 
inflammations are secondary to a gastro-enteritis, is not supported 
by the authority of facts. It is therefore wrong to say that every 
case of acute or chronic hepatitis is preceded by gastro-intestinal 
inflammation. Facts have been brought forward to show that not 
only has inflammation of the liver been observed in the simple 
state, and independent of any complication with intestinal disease, 
but that the affection of the liver has distinctly preceded the symp- 
toms of gastro-enteric disease. On the other hand, however, I am 
free to admit that these are the exceptions rather than the rule, and 
that, in the majority of cases, hepatitis is either secondary or com- 
plicated with disease of the gastro-intestinal surface. 
Now, a very interesting question comes to be considered, and 
this is, how does the disease come from the gastro-intestinal surface 
to the liver ? Pathology informs us that irritation may be trans- 
mitted from one organ to another in three different modes. First, 
sympathetically, as through the medium of the nerves. Thus, 
long-continued stimulation of the stomach is reflected upon the 
liver, the liver sympathises with the suffering organ in its vicinity, 
and finally becomes diseased itself. It is in this way that many 
st. 11 154 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
chronic affections of the liver and stomach terminate in affections 
of the neighbouring viscera and dropsy. The first mode, then, in 
which disease may come to affect the liver from the gastrointes- 
tinal surface, is by sympathetic irritation. The next mode is sup- 
posed to be the actual transmission of disease along the biliary duct 
from the duodenum to the liver. Inflammation commences in the 
duodenum; this creeps along the ducts until it reaches the liver, 
which takes on the inflammatory action in its turn. Several persons 
of high authority have supported this view of the question, and 
assert that they can actually demonstrate the passage of inflamma- 
tion along the ducts. Without denying the possibility of this, yet 
I feel convinced that it is rare. I have never been able to discover 
this mode of propagation of inflammation from the duodenum to the 
liver; and it must be remembered that, in the great majority of 
cases of duodenitis, we cannot detect inflammation in the liver or 
its appendages. The last mode by which disease may be trans- 
mitted, is the propagation of inflammation along the course of the 
veins belonging to the portal system, that is to say, there is phlebitis 
of the portal system, and the inflammation travels along the veins 
until it arrives at and attacks the liver. That this has occurred, is 
proved. But we may suppose that, in certain cases, disease of the 
liver may result from a phlebitis of the minute mesenteric veins, 
without a continuous spread of inflammation to the larger trunks ; 
just as the lung is affected in cases of phlebitis of the extremities, 
not by actual spread of inflammation, but rather, as Mr. Arnott has 
shown, by the transmission of the products of that inflammation. 
Inflammation of the portal veins is a circumstance which possesses 
great interest in a pathological and practical point of view ; it is a 
curious process, and there are some singularities connected with it 
which have a claim on our attention. In the Clinique Medicale of 
Andral, there is a ease given of a patient who, after labouring for 
some time under symptoms of fever and gastro-enteritis, was 
attacked with pain and tension in the region of the liver, followed 
by jaundice. On dissection, marks of inflammation were found in 
the stomach and ileum; there was also some disease in the colon, 
and the liver was found to be enlarged, and presenting the ordinary 
marks of inflammatory action. On a more minute examination, 
nearly all the mesenteric veins, and the trunk of the porta, were 
discovered to be in a state of intense inflammation; while, on the 
other hand, the lining membrane of the vena cava was found to be 
in its normal and healthy condition. Here we have a very remark- 
able coincidence between disease of the liver and of the portal 
system. First, the patient had fever, with gastro-enteric inflamma- 
tion, and then pain and tension in the region of the liver, followed 
by jaundice. On dissection, the mesenteric veins and the trunk of 
the porta are found inflamed; this condition extends to the liver, the 
substance of which is found tumefied, red, and friable. I believe there 
can be no doubt that disease of the liver may be brought on by dis- 
ease of the abdominal veins, particularly those of the portal system. 
It is a very curious fact, that with symptoms such as many prac- TREATMENT OF CHRONIC HEPATITIS. 
155 
titioners would not hesitate to call chronic hepatitis, we may have 
phlebitis, terminating in obliteration of the porta, and even of the 
vena cava. In such cases, nature generally makes an effort to keep 
up the venous circulation ; in consequence of the obliteration of the 
internal abdominal veins, the external ones become enlarged, and 
produce a supplementary circulation to a certain extent, and in this 
way life is prolonged. This drawing, which represents the appear- 
ance of a patient labouring under this form of disease, will give 
you some idea of the matter. You observe the patient’s belly is 
enlarged and prominent, his extremities cedematous ; and here you 
see those enormous veins passing along the surface of the belly, and 
keeping up a collateral venous circulation. In the patient, from 
whom this drawing was taken, the porta and cava were obliterated. 
These are the epigastric and other superficial abdominal veins 
which ascend to anastomose with the thoracic, intercostal, and 
axillary veins. 
I shall now relate, as briefly as possible, the particulars of this 
very remarkable case. The patient, who was the subject of it, 
laboured for more than twelve months under jaundice, accompanied 
by wasting of flesh and prostration of strength, but for the first 
eight months he had not been confined to bed. He suffered, how- 
ever, very considerably even at this period, from constant pain in 
the epigastrium and swelling of his feet. Now, in this country, we 
would be very apt, under such circumstances, to say that he was 
labouring under chronic hepatitis. At the end of the eight months 
he became bed-ridden, and the large veins, which you here see, 
began to make their appearance. Although he was wasting in 
flesh, still he had a canine appetite, and was always complaining 
that he had not enough to eat. This is an interesting fact. It has 
been observed in other cases, and tends to throw some light on the 
share the mesenteric and other abdominal veins have in the process 
of absorption. In tabes mesenterica it has been often remarked, 
that the little patients have generally enormous appetites ; and, as 
it would appear from the same cause, a deficiency of nutritious 
absorption, with this difference merely, that in the disease before us 
it is the veins that are diseased, whereas in tabes mesenterica it is 
supposed to be the lymphatics. But to return to our case. This 
patient had, as I remarked, a very voracious appetite, by indulging 
which, he brought on repeated attacks of constipation and colic. 
He then got diarrhoea and dropsy, for which he was tapped twice 
without any benefit. From observing that there was in this case 
an extraordinary supplemental circulation, leading to the inference 
that there was obstruction of the deep-seated veins ; from remem- 
bering that the appearance of the patient, and the more prominent 
symptoms, coincided with those of a former case, in which oblitera- 
tion of the porta had been discovered after death; from these cir- 
cumstances, and the remarkable voracious appetite, M. Reynaud, 
under whose care the patient was, came to the diagnosis of phlebitis 
of the portal system, extending to and affecting the liver ; and this 
diagnosis was subsequently confirmed by dissection. He was, 156 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
however, unable before death to explain one symptom which was 
present, namely, infiltration of the lower extremities. You are 
aware, that when the general venous circulation is obstructed 
either in the chest or belly, we have anasarca of the lower 
extremities, but when the obstruction affects only the portal system, 
then we have ascites as the first phenomenon. If you had two 
cases of dropsical effusion, in one of which there was, first, oedema 
of the lower extremities, in the other, first, ascites, you could thus 
determine where the primary obstruction existed. M. Reynaud 
was at a loss to account for this symptom in the present case, as he 
had not observed it before in the other case, and as the swelling of 
the feet had preceded that of the belly. On dissection, it was found 
that the right branch of the porta had been obliterated by the growth 
of a yellow substance, somewhat like the middle coat of arteries ; 
the same was found to exist in the corresponding hepatic veins, and 
the inferior cava was found obliterated to the distance of three 
inches from the left auricle. The left branch of the porta was per- 
vious, the corresponding hepatic veins much enlarged, and the 
superficial epigastric veins inosculated freely with the intercostal 
and axillary veins. 
The vena azygos was very much dilated ; and, what is extremely 
curious, a large vein was seen to arise from the union of the sub- 
peritoneal branches on the convex surface of the liver; this passed 
through the diaphragm, and emptied itself into the cava close to 
its termination. Here we have an entirely new vein. It was also 
observed, that the sub-diaphragmatic veins were much increased in 
size, and apparently varicose; these passed through the diaphragm, 
and inosculated with the pericardial and superficial thoracic veins. 
Some of them ran up and opened into the great coronary vein of 
the heart, which was as large as the crural vein. The remaining 
peculiarities of this curious case were inflammation of the duodenum 
and gall-bladder. The cavity of the latter was half filled with 
purulent fluid. 
I am fully convinced that I have seen instances of this disease, 
although I was not so fortunate as to have an opportunity of verify- 
ing the diagnosis by dissection. I have seen patients who had 
wasting of flesh, pain and tension in the region of the liver, and 
jaundice, with this singularly varicose state of the external abdo- 
minal veins ; some of them had ascites ; and I recollect distinctly, 
that in one case the appetite was very great, and the patient had a 
tendency to diarrhoea. I am satisfied that in such cases you would 
be fully justified in making the diagnosis of obstruction of the 
portal system; and if, in addition, there was infiltration of the lower 
extremities, there would be a probability that the disease had 
extended to the cava itself. 
Before I proceed to the consideration of a subject to which I have 
already alluded—hepatic neuralgia—it may not be amiss to exhibit 
some specimens of organic lesions of the liver. Here is an example 
of abscess of the liver:—you perceive the softened yellow degenera- 
tion of the substance of the organ; and here is the cavity of the 157 
abscess, in which you may observe a loose slough suspended. This 
portion which surrounds the abscess may be looked upon as a fair 
specimen of the yellow softening of the liver, before its substance 
breaks down into a purulent mass. Here is another specimen 
exhibiting the same phenomena. Here is a very curious example 
of hepatic abscess, which perforated the diaphragm, and made its 
way into the substance of the lung. I regret that the whole of this 
preparation has not been preserved. The rest of the preparations 
before me illustrate chronic disease of the liver. Here is an example 
of the disease which has been called cancer of the liver. Time will 
not permit me to enter into a detail of the pathological circumstances 
of this case. The patient was a female, who had cancer of the 
breast, scirrhus of the pylorus, and aneurism of the aorta, with this 
disease disseminated through the substance of the liver. Here is 
another preparation of what would be called by many persons pure 
cancer; the patient, a female, had cancer of the mamma. This, 
and the preparation on the other side, exhibiting a mass of white, 
firm, semi-cartilaginous substances, are examples of what has been 
called tubercle of the liver. Here is an example of the disease 
which has been termed whiskey liver, a disease which is said to be 
ordinarily found in persons who indulge in the use of ardent 
spirits. This, however, is a term which has been often abused and 
misapplied; for persons indulging in the use of whiskey may have 
every form of disease of the liver, and the appearance before you 
may be detected in the livers of persons of the most temperate habits. 
On the label of this preparation is written—“A Specimen of 
Whiskey Liver,” but this you will not mind. There is a very 
remarkable fact, however, respecting this kind of liver, verified by 
Professor Carswell, namely, that this condition of the liver is always 
accompanied with more or less ascites. I may add, that I have 
never met with this disease without ascites. 
I remember a most remarkable case of disease of the liver, which 
occurred during my stay in Edinburgh. My lamented friend and 
instructor, the late Dr. William Cullen, whose loss to pathological 
medicine was irreparable, and whose splendid attainments and high 
character justly and rapidly raised him to an elevated rank in his 
profession, brought me to see a patient. One of the most curious 
circumstances connected with this case was, that when the patient 
sat up in bed, a fluid of a serous character was poured out in con- 
siderable quantity from the anus; but while he remained in the 
horizontal posture this did not occur. The patient died shortly 
afterwards; and, on dissection, it was found that he had a gan- 
grenous abscess of the right lung, communicating with the pleural 
cavity, which contained a quantity of a sero-purulent fluid, and a 
mass of hydatids, some broken down, others perfect and entire. On 
continuing the dissection, it was found that the cavity of the pleura 
communicated with the right lobe of the liver through the diaphragm. 
In the right lobe of the liver the same kind of sero-purulent fluid, 
and a quantity of hydatids, were discovered; and, what was still 
more extraordinary, the cavity in the liver was found to communi- 
TREATMENT OF CHRONIC HEPATITIS. 158 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
cate with the colon by a distinct opening. There was, then, in 
this very remarkable case, a direct communication between the 
bronchial tubes and the colon, through the pleura and liver. We 
can thus see that, when the patient assumed the erect position, the 
fluid would immediately pour into the colon. 
As I am anxious to finish the subject of hepatic disease to-day, I 
shall now draw your attention to one of the last points connected 
with this subject, namely—neuralgia of the liver. It is a singular 
fact that a patient may labour under severe and harassing pain in 
the region of the liver; that this pain may last for months and 
years; that he may die of some other affection ; and that, on 
examination after death, we may find the liver without the slightest 
trace of disorganisation; and, also, that the organs in its vicinity 
present no appearance of any organic disease. Many cases of this 
kind have been observed; and it is the opinion of the best patholo- 
gists that they are examples of neuralgia, the seat, of pain being the 
hepatic plexus. Jt is a disease of no very unusual occurrence, and 
is often found in females of a nervous and hysteric habit. It is 
constantly mistaken for hepatitis, and there is no greater mistake 
than this, or one which is likely to entail more misery on the 
patient. The persons who are subject to this affection are, as I 
remarked before, generally of a nervous and hysteric habit; they 
complain of pain in the right side, of more or less constant occur- 
rence, and this pain, during its exacerbations, is often most excru- 
ciating. Now, this circumstance furnishes us with a sort of key to 
diagnosis ; for with this dreadful pain, and, in some cases, exquisite 
tenderness in the region of the liver, we have the skin cool, the 
pulse tranquil, no fever, no permanent derangement of the bowels, 
no tumefaction of the liver. If this were the pain of acute inflam- 
matory disease, a fatal result would be produced ; or if it belonged 
to a chronic affection, it would terminate in organic derangement; 
and yet we find it existing with a clear colour of the skin and eye, 
healthy faeces, calm pulse, and absence of swelling in the region of 
the liver. Add to this, that the disease may have lasted for a con- 
siderable time, and that it occurs in a person of hysteric and 
nervous habit. Moreover, if the patient has been treated for hepa- 
titis unsuccessfully, you may make up your mind to the diagnosis 
of hepatic neuralgia. Here is the diagnosis ; pain in the region of 
the liver, with occassional violent exacerbations, and accompanied 
by tenderness of the integuments, but without swelling, symptoms 
of fever, or abdominal derangement; the disease being of long 
standing in a person of nervous habit, and having resisted bleeding, 
mercury, and even counter-irritation, or being made worse by those 
measures. 
Now, it is no uncommon thing to see this disease mistaken for 
acute hepatitis; and I need not tell you how ruinous to the patient’s 
health such an error must be. When you are in practice, you will 
meet instances of females labouring under this affection, who have 
gone through a variety of treatment. When you recollect that the 
disease occurs generally in hysteric females, and that such persons TREATMENT OP CHRONIC HEPATITIS. 
159 
are injured by depletion, you can conceive how much mischief 
may be done by repeated bleedings and courses of mercury. Some 
of the most deplorable cases I have witnessed, were those in which 
neuralgia of the liver had been mistaken for hepatic inflammation, 
by a number of practitioners, and the patient subjected to such 
modes of treatment as gave her constitution a shock from which it 
never recovered. 
The treatment of this disease must be both general and local, but 
by no means what you would call antiphlogistic. You will have 
some difficulty in preventing the patient from getting herself 
blooded ; for though the lancet is inadmissible, yet its employment 
gives a temporary relief, and this encourages the patient to have 
recourse to it again. What I would advise you to do in this disease 
is, first to pay attention to the general condition of the patient. 
You must pursue a general anti-hysterical plan of treatment, 
remove every source of irritation and excitement, and take measures 
to improve the general health by exercise, regimen, moral improve- 
ment, and the judicious employment of tonic medicines. With 
respect to the pain, one of the most powerfld means of arresting 
and removing it, appears to be the use of the carbonate of iron in 
full doses; and this is an interesting circumstance, when we recol- 
lect the power which it possesses in removing pain in other 
nervous diseases. I would advise you to try this after having pre- 
mised the use of purgatives, and continue it for some time, for you 
will often find that it will not only cure the pain, but also improve 
your patient’s strength and appetite. While you are giving it, 
order your patient to take some mild purgative, as compound 
rhubarb pill, to prevent constipation. When you are about to pre- 
scribe a course of carbonate of iron, you should prepare your 
patient to find the stools coloured. I have known this circumstance 
taken hold of and turned to their own advantage by quacks. The 
patient is told that his complaints arise from the existence of 
morbid and dark-coloured matters in his bowels. Preparations of 
iron are given, and the black matter begins to come away, greatly 
to the credit of the empiric. After a time, the medicine is omitted, 
and some purgative substituted ; the stools become natural, and the 
trick is complete. During the paroxysms of pain, a mustard 
plaster, or anodyne stupes, and anodyne enemata, will give relief; 
and, in the intervals, I would advise you to use the belladonna 
plaster, after the following formula:—Take of extract of belladonna 
three parts, of gum ammoniac and soap plaster each one part; 
spread these on a piece of leather with an adhesive margin, and 
make the patient wear it over the region of the liver. If there be 
any tenderness over the lower dorsal vetebrse, you may apply a 
few leeches, followed by narcotic stupes, or counter-irritation. 
I have seen this hepatic neuralgia without any hysteric compli- 
cation. I remember the case of a lady who had three or four 
healthy children, and had never been subject to hysteria. This 
lady came up to Dublin to be treated for liver disease—in fact, to 
be salivated; but happening to fall into the hands of a judicious 160 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
friend of mine, who recognised the true nature of her complaint, 
she was treated with carbonate of iron, and cured effectually. I 
knew another case of a young gentleman, in whom (after being 
treated for symptoms of chronic hepatitis) this pain continued for a 
considerable time, and was at length removed by carbonate of iron, 
and the use of the belladonna plaster. 
LECTURE XIX. 
Gastritis, with delirium tremens—Varieties of intestinal worms—Organisation and 
origin of—Occurrence in the foetuses of various animals—Formation—Pathology of 
—Perforation of the intestines by—Worms in tumours and abscesses. 
You may recollect that, when treating of acute gastritis, I alluded 
to the great importance of being aware of its complication with 
delirium tremens ; and stated, that in the form of delirium tremens, 
which is the result of an excessive debauch, and where the stomach 
has been subjected to powerful stimulation, we have reason to 
believe that there is more or less of gastric inflammation. I have 
it in my power, to-day, to exhibit to you a very accurate drawing 
of the stomach of a patient who laboured under this form of disease, 
and whom I had an opportunity of examining several times before 
death. You will remember, also, I mentioned that in cases where 
symptoms of delirium tremens had arisen from excess, and not from 
a want of the customary stimulus, the ordinary routine treatment 
of giving wine, brandy, and other spirits, was extremely improper ; 
and that where it was persevered in, and the patient died, you 
commonly found, on dissection, evident marks of inflammation in 
the brain and stomach. On that occasion, too, I quoted this as an 
example of the latency of gastric symptoms when complicated with 
an affection of the nervous centre. I have now to exhibit this 
drawing, which represents the stomach of a man who died of deli- 
rium tremens, supervening on a severe debauch. This patient was 
treated entirely on the stimulant plan ; he got wine, porter, brandy, 
and opium, but their exhibition was not attended with the slightest 
benefit. Under their use his symptoms changed, and assumed a 
decided cerebral character; he had hot skin, quick pulse, great 
thirst, and general symptoms of fever, accompanied by a comatose 
condition. Previously to opening the body, I gave it as my opinion 
that the stomach would be found to exhibit marks of inflammation. 
Here is an accurate drawing of the stomach, and, from its appear- 
ance, you will be able to judge for yourselves. (Here Dr. Stokes 
exhibited the drawing to the class, representing the stomach in a 
state of intense vascularity.) Observe the generally diffused dark 
red colour of the whole organ, and the excess of inflammation 
towards its cardiac orifice. The brain, in this case, was but slightly 
vascular. INTESTINAL WORMS. 
161 
I propose to devote this day’s lecture to the consideration of an 
interesting subject in practical medicine—intestinal worms. There 
are few subjects possessing so much interest, in a physiological and 
pathological point of view, as this; and, in order to have correct 
notions, it will be necessary for you to be acquainted with the 
investigations of modern science on this subject. You are well 
aware that worms are found in most classes of animals. They 
occur in reptiles, fishes, birds, in the different classes of quadrupeds, 
and in man. In man they do not exist in such abundance, nor so 
frequently, as they do in birds and fishes. With respect to their 
places of habitation, we find them, first, in cavities which have an 
external communication, and next, in the parenchymatous sub- 
stance of organs; and we generally observe, that those which 
inhabit the cavities are different from those met with in paren- 
chymatous parts. We observe, also, that the species existing in 
the different organs and cavities are not only different in their 
nature, but that there is a difference between the worms which 
inhabit separate portions of the same organ or cavity. In one part 
of a cavity or organ we find one species, in another a different, and 
this occurs almost invariably, as if it was regulated by a fixed law 
of the economy. A peculiar species of worm, occurring in man, 
called the distoma hepaticum, is never found except in the li ver or 
gall-bladder. If this animal had been introduced from without, it 
would certainly be detected in some part of the intestinal canal, but 
this is never the case. Rudolphi states, that the strongylus 
horridus is to be met with only in the oesophagus of aquatic birds, 
and the ascaris obtusa in the stomach.of mice. 
Generally speaking, worms are of three different forms—cylin- 
drical, riband-shaped, and vesicular. Their organisation varies 
from the lowest scale, in which we can scarcely trace, as it were, 
the rudiments of an animal; beginning with the tape-worm, which 
presents little more than a cellulo-gelatinous mass, we ascend 
gradually until we arrive at a high degree of organisation, where 
we find well-developed muscles, a difference of sex, generative 
organs, and, according to some anatomists, a tolerably perfect 
nervous system. 
Now, to remove all sources of doubt and error on this interesting 
subject, and to establish proper principles of treatment, let us 
examine into the origin of these animals. I shall confine myself to 
the consideration of the origin of those worms which inhabit the 
human intestines, as they are the only species which we have to do 
with as practical physicians. 
You will at once perceive that worms must be derived from one 
of two sources ; either as introduced from without, or formed 
originally within the bodies of man and other animals. It is main- 
tained by those who are in favour of the first supposition, namely, 
that they are introduced from without, that similar animals are to 
be found in the external world, and that they are introduced either 
in the form of ova, or in a state of perfect development, with the 
food or drink, or by the respiration of the animal. Observe, this 162 
STOKES’S THEORY AND PRACTJCE OF MEDICINE. 
doctrine is founded on the validity of the assertion as to whether 
animals similar to intestinal worms are to be met with in external 
nature. Linnaeus states, that he found the tape-worm, and the 
small ascarides, a species now called oxyuris vermicular is, in a 
marsh in Lapland; but Muller, a much more accurate helmintho- 
logist, has since shown, most satisfactorily, that Linnaeus was com- 
pletely mistaken, and that those he had observed are never found 
to exist within any animal whatever. There are many observa- 
tions on record similar to those of Linnaeus ; but as they were 
made at a time when natural history was in its infancy, and as they 
have been disproved by the researches of modern zoologists, I shall 
not notice them. I believe there is no well-authenticated instance 
on record of tape-worms, lumbrici, or ascarides, being found living 
in any situation external to the animal body. Every one of you 
have seen worms in the intestinal canal, or recently discharged by 
stool or vomiting ; but I will venture to say that not one has ever 
observed them in any article of food, in earth, or in water. 
Bremser, who is a high authority, makes a very pertinent remark 
on this subject. “We find,” says he, “all animals most abundant 
in that situation which has been assigned to them by nature. Now, 
if these animals were accidentally introduced from without, we 
ought to find them more abundant in the earth, water, &c.; but 
the contrary we have seen to be the fact.” 
But it is contended that these animals may have been introduced 
from without, and that in consequence of a change in situation, 
nutriment, and other circumstances, their forms may be altered; 
and it is argued, in support of this hypothesis, that external cir- 
cumstances will and have been observed to change the forms of 
plants and animals in a very remarkable degree. In addition to 
this, it may be said that an alteration in the nature of its food may 
even produce an actual change in the function of the animal. It 
is a singular fact that neuter bees may be made prolific by chang- 
ing their food ; it is shown that when a queen bee dies or is lost, the 
neuter bees take a grub of their own species in place of her, and, by 
feeding it in a particular manner, it becomes capable of laying eggs. 
Now, supposing that intestinal worms are introduced in the form 
of ova into the human body, there is no reason why this sudden, 
remarkable, and complete change should take place. We see 
nothing similar to it in nature. The plant which springs from 
any particular seed will resemble that from which it derives its 
origin; the egg of any particular bird, no matter in what way it 
may be hatched, will produce an organised being similar to its 
parent. The form and character of the animal are given during 
the act of generation, and remain unchanged. Again, admitting 
that a difference in circumstances and nutrition might produce a 
total change in form, it should be in our power to demonstrate the 
individual in the process of transition; we should find those animals 
in a state half between what they were and what they are, and this 
state we should observe of very frequent occurrence. No such 
thing, however, has been ever demonstrated. Out of a vast INTESTINAL WORMS. 
163 
number, Bremser did not find a single one in any stage of trans- 
ition, nor has it been demonstrated by any zoologist. He also 
states expressly, that after having diligently examined fifteen thou- 
sand specimens of worms in the cabinet at Vienna, he never was 
for one moment at a loss to say which were intestinal worms and 
which were not. If there was any such transition, it would have 
been discovered, but no such thing has ever been observed. 
It appears, then, obvious that there is no direct evidence to prove 
that these animals have been introduced into the body from with- 
out, either in the form of ova, or in a state of perfect development. 
We have nothing, then, I think, but to come to the other conclu- 
sion, that they originate within the body, and this seems to be the 
opinion of the best physiologists and pathologists. This doctrine 
appears to be almost brought to a demonstration by the following 
facts. First, it appears that the worms which have been found in 
man and animals have a peculiar structure and organisation, differ- 
ing materially from that of the worms which inhabit the external 
world. This is a point admitted by almost every modern writer 
on natural history. In the next place, we find that the worms of 
certain animals present peculiarities differing from those of the same 
species in others. Thus the bothriocephalus and taenia solium, in 
man, differ from those of other animals. You are not, however, to 
conclude from this that every animal has its peculiar worms, for 
such is not the case. Thus the lumbricus and small ascarides of 
man are found to exist in various animals, both carnivorous and 
graminivorous. 
It appears obvious, that if worms were introduced from without, 
we should not find peculiar worms in the bodies of certain animals; 
yet taking a certain number of different animals, living on the same 
food and in the same situation, we find a difference in the nature of 
the worms which are met with in the bodies of each. Another 
important fact is, that worms are to be found not only in the intes- 
tinal canal, but in almost every part of the body. We find them in 
the cellular tissue, in the liver, gall-bladder, lungs, and trachea; 
in the brain, heart, kidneys, and spleen. They have been met 
with in the air-bladders of fishes ; and Treutter states that he has 
found the polystoma pinguicola in the ovaries of a woman which 
were steatomatous, and the strongylus in an aneurism of the mesen- 
teric artery of the horse. These animals have been observed in 
the anterior chamber of the eye in birds and horses, and there are 
innumerable examples of their occurrence in situations equally 
strange and anomalous. Another circumstance already mentioned, 
and which must be coupled with the fact just alluded to, is that 
there are certain species of worms which occur only in the same 
organs, and are never met with in any other situation. 
Now, observe the importance of these facts—we find that worms 
not only exist in the digestive tube, and parts having an external 
communication, but also in the very substance of deep-seated 
viscera, and that the worms which are found in the various cavities 
and organs are peculiar to them. In one case, we find a worm in 164 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the digesti ve tube, in another in the brain, in a third in the liver, in 
a fourth in the pulmonary apparatus, but no one has ever been able 
to demonstrate the trajet of a worm from one of these cavities or 
organs to another. It would be ideal and absurd to say, in the case 
of worms found in the substance of viscera, that they had been 
introduced from without, or came from the intestinal canal. The 
distoma hepaticus, which is found in the liver and gall-bladder, 
might be supposed to arrive at those situations by passing along 
the ductus communis choledochus; but in the various cases in 
which it has been found, it has never been detected in the intestinal 
canal; and this, I think, would not have been the case, if the 
digestive tube had been its original situation. One of the most 
important facts which have been stated is, that certain forms of 
these animals are found invariably in certain situations; and this 
has been observed not only in man, and other animals of the class 
mammalia, but also in reptiles and fishes. In man, we generally 
find the lumbricus inhabiting the stomach and small intestine, the 
tricocephalus in the caecum, and the small oxyuris, or thread-worm, 
in the rectum. The preparation before me exhibits a specimen of 
the rarest form of worms which inhabit the intestinal canal, the 
tricocephalus. Here is the caecum filled with these singular worms. 
The males are distinguished from the females by the whirl of the 
tail. If these little animals, or the oxyuris, had been introduced 
from without, we should expect to find them in various parts of 
the intestinal canal ; but we find, on the contrary, that their situa- 
tion is separate and distinct. 
Lastly, intestinal worms have been found in the foetus, both of 
man and other animals. Kerkring describes a foetus, the intes- 
tinal canal of which contained a vast quantity of small worms; and 
another of six months, in whose stomach a large lumbricus was 
found. Rudolphi, Blumenbach, and others of nearly equal autho- 
rity, have recorded abundance of examples of worms existing in the 
foetuses of various quadrupeds, and also in those of birds which 
had just broken the shell. Those who are obstinately attached to 
the doctrine that worms are introduced from without, have gone so 
far as to assert, that the ova of the worms have been transmitted at 
the moment of generation, a doctrine so absurd that it is unneces- 
sary for me to enter into any refutation of it. 
With respect, then, to the formation of worms in animals, we 
cannot help coming to the conclusion that they are originally 
formed within the body, and that, in fact, there is an original gene- 
ration of these animals, the result of one organisation taking place 
within another—the production, in fact, of a distinct being. This 
idea does not appear so difficult of conception when you recollect 
that circumstances analogous to it are extremely familiar and of 
almost constant occurrence. There is not much more difficulty in 
conceiving the formation of a living worm within the body than 
there is of conceiving the organisation of a portion of lymph thrown 
out upon the surface of a serous membrane. What occurs in both 
cases is, that, under the influence of the vital principle of the original INTESTINAL WORMS. 
165 
animal, a portion of matter, previously inorganic, assumes the pro- 
perties of life, presents distinct traces of organisation, vascularity, 
and sensibility. The only difference between them is, that in one 
case the organised mass remains adherent to the matrix, and in the 
other it is cast off, and forms a separate being. In the present 
state of our knowledge, all speculation on the mechanism of the 
formation of worms must of necessity be nothing more than mere 
hypothesis. The idea which Bremser entertained on this subject 
is, that intestinal worms are formed by the presence of semi-assimi- 
lated nutritious matter in the digestive tube. Food, taken into the 
system under ordinary circumstances, is converted into a substance 
fitted for the purposes of absorption and nutrition; but when the 
process is not perfected, it is not taken up by the absorbents, and is 
then, according to Bremser, converted into an animal substance. 
This appears to be but a crude idea, unsupported by any facts ; and 
it would be more philosophical to say that we know nothing about 
the matter. Besides, worms occur in various parts of the body as 
well as the digestive tube ; and to suppose the presence of unassimi- 
lated matter in such situations would be only supposing an 
absurdity. Bremser brings forward, in support of his theory, that 
worms are of very frequent occurrence in cases where the assimi- 
lating powers are weak or deranged, and says that nothing is more 
common than to meet with an abundance of these animals in 
scrofulous persons, in those who have great appetites and bad diges- 
tion, and in children labouring under disease of the mesenteric 
glands. On the other hand, there are abundant instances of worms 
existing without the slightest apparent injury to the general health. 
In certain countries almost all the inhabitants have worms. But I 
believe all that we can affirm on this subject is this, that they are 
not introduced from without, and that they are formed within the 
body by a process, the nature of which is exceedingly obscure. 
Now, to come to the pathology of this subject, can we connect 
the formation of intestinal worms with any known pathological 
condition of the intestinal canal? This is a question of no ordinary 
importance ; for if we were able to connect their formation with an 
inflammatory or any other state of the digestive tube, it would 
furnish us with a key to correct and successful treatment. The 
school of Broussais are of opinion that worms are the result of an 
acute or chronic inflammation of the gastro-intestinal surface. 
This doctrine is by no means supported by the evidence of facts, 
for it has been established that worms are found to exist not only 
in connection with every possible pathological condition of the 
intestinal canal, but also where the tube presented the appearance 
of perfect health. We cannot, then, safely affirm that intestinal 
worms are connected with an inflammatory or non-inflammatory 
condition of the digestive tube. Andral states that he has found 
them in all conditions of the intestine, whether red or pale, dry or 
covered with mucus. They are most commonly, he says, enveloped 
in a quantity of mucus, and there is some redness in the place 
where they are lodged; but this appears to be rather the effect of 166 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
their presence than the cause. I believe it to be the fact, that 
persons in excellent health, and with the intestinal canal in the 
normal state, may have worms. Dogs, who are killed while in a 
state of apparently perfect health, are often found to have a large 
quantity of tape-worm in their intestines. It is idle and hypothetic 
to say, that the formation of worms depends upon an inflammatory 
or non-inflammatory, an asthenic or sthenic condition of the digestive 
tube; their formation is owing to some modification of the vital 
power, the nature of which is unknown. I again repeat, that 
nothing can be stronger against the supposition that worms depend 
upon inflammation than the fact of their being observed in consi-- 
derable quantities in healthy individuals. 
A very curious point, connected with this subject, is the question 
of perforation of the intestines by worms. This question, which is 
an interesting one in many points of view, has been lately the sub- 
ject of medico-legal discussion, and therefore demands a share of 
our attention. Of the different kinds of intestinal worms, the only 
one which is supposed to be capable of perforating the coats of the 
digestive tube, and escaping into the peritoneum, or some adjoining 
organ, is the lumbricus, which is remarkable for its vigour, and for 
the sharp and pointed shape of its head and tail. Many of the 
most eminent pathologists of modern times, and, among the rest, 
Andral, Rudolphi, and Carswell, are of opinion that these worms 
are totally incapable of perforating the intestinal tunics. Andral 
states that there is no well-authenticated instance of this occurrence 
on record; and Rudolphi declares that they have no apparatus for 
effecting a passage through any continuous tissue. On the other 
side of the question, however, there are some curious facts and 
cases given, which, supposing that worms are incapable of perfo- 
rating, are very difficult to explain. Dr. Fischer, of Vienna, gives 
the case of a female, in whom the following circumstances were 
observed on dissection. Two circular orifices were found in the 
colon, communicating with the cavity of the peritoneum; in one of 
these openings a worm was discovered, one half of which lay in 
the peritoneal sac, the other in the intestine. No other worms 
were found in the digestive tube; but a second worm, like the 
former, was found in the peritoneum. Here we have a very 
remarkable coincidence of perforation of a portion of the gut, with 
the existence of one worm in the cavity of the peritoneum, and 
another of a similar description, as it would appear, in the act of 
making its way in the same direction. These circumstances, 
together with the existence of a double perforation, seem to be in 
favour of the idea that the openings had been made by the corre- 
sponding worms. Another case is mentioned in the Elements of 
Pathological Anatomy, by Andral, and he quotes the case, not as 
one of perforation merely, but to show that the symptoms of effu- 
sion of matter into the peritoneum may, under certain circum- 
stances, be nearly latent. The subject of this case, a young man, 
labouring under phthisis, had a tumour near the umbilicus, which 
increased rapidly in size and presented a distinct fluctuation. INTESTINAL WORMS. 
167 
Soon afterwards, the integuments grave way, and a large quantity 
of matter was discharged, together with a lumbricus. During the 
progress of this disease, there was some tympanitis, but little or no 
pain had been complained of. On dissection, there was a consider- 
able number of worms, and a quantity of matter, found in the peri- 
toneum, and a perforation in the arch of the colon, corresponding 
with the extravasated matter. Bremser gives a curious instance of 
this kind, as occurring in a species of fish. In this case, the fish 
died ; and it would appear, says Bremser, that the worm, finding 
some extraordinary change had taken place, was determined to 
take a peep and see what was the matter, for it had perforated not 
only the intestinal tube, but actually made a passage for itself 
through the whole body of the fish, until it reached the water in 
which it had been lying. Here, finding that its world extended no 
further, it stopped, and began to make its way back again to its 
original situation by a new opening, so that when it was observed 
by Bremser, the two ends were in the intestinal tube of the fish, 
and the middle portion external. This, however, does not resolve 
the question, as to whether lumbrici are capable of perforating the 
intestinal canal or not. My own impression on the subject is, that 
we have not, as yet, any distinct and unquestionable evidence of 
these worms being possessed of any perforating power ; but it is a 
fact, that there are a great many cases on record of worms being 
discharged in considerable quantities from openings in the intestinal 
tube, and where it would appear that the openings had been formed, 
not so much by the action of the worms themselves, as in con- 
sequence of their exciting an irritation in some portion of the 
intestine, followed by inflammation, ulceration, and escape of the 
contents of the tube into the peritoneum. There are many in- 
stances of this kiud. An interesting case is mentioned of a female, 
who was attacked with pain in the groin, followed by the appear- 
ance of a tumour, which she was directed to poultice by her medi- 
cal attendant. After some time, the integuments gave way, a 
quantity of matter was discharged, followed by a large lumbricus, 
and during the progress of the case about one hundred of these 
animals were discharged through the opening. This is a well- 
authenticated case. Another case is mentioned of a patient who 
had been subject to constipation and violent attacks of colic. A 
tumour began to appear in the right hypochondrium, followed by 
pointing and ulceration of the integuments, and a discharge of 
matter. A number of worms (I believe twenty-four) were dis- 
charged through the opening, which remained pervious, and the 
patient lived for many years afterwards with an artificial anus. 
This case appears to be not an example of direct perforation from 
worms, but of the accumulation of a mass of these animals in a 
particular portion of the intestine, giving rise to irritation, which 
terminates in ulcerative absorption of its tunics, and escape of its 
contents. Inflammation is set up in some part of the intestine, this 
goes on until the coats are all destroyed, and the matter and worms 
escape into the peritoneal cavity; but if adhesion should prevent 168 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
this, an opening will be formed in some part of the integuments 
covering the belly. In both cases, the opening is produced not by 
an exertion of the worms, but by an ulcerative and vital process. 
In support of this view, it has been observed that worms have come 
out through these apertures not head foremost; the centre portion 
appears first, and you can draw it out like a loop. Such cases as 
the foregoing, then, cannot be fairly given as cases of perforation 
from worms, but as cases in which these animals, acting somewhat 
like foreign bodies, produced irritation, inflammation, and ulcerative 
absorption. There is a very curious case on record, of a patient 
labouring under abscess of the liver, which burst externally, and a 
lumbricus was discharged with the matter. The patient died; and, 
on dissection, it was found that the cavity of the abscess had a 
communication with the stomach, through which it was conceived 
that the lumbricus had got into the liver. 
The worms which inhabit the intestinal canal in man are the 
following:—first, the lumbricus, or common round worm; next, 
we have the tape-worm, of which two varieties have been described; 
thirdly, we have the very curious worm, of which there is a speci- 
men before me—it inhabits the caecum, and is called tricocephalus; 
lastly, we have the thread-worm, to which the name of oxyuris 
vermicularis has been lately given. The lumbricus generally 
inhabits some portion of the small intestine, but is also frequently 
found in the stomach. Persons have often vomited them, and they 
have been known to have crept out by the mouth. They have 
been found also in the pharynx, oesophagus, and large intestine. 
There is an interesting case mentioned by Andral, of a child who, 
in a state of apparently good health, was suddenly seized with 
symptoms of suffocation, and died. On dissection, it was found 
that a large lumbricus, which had come up from the stomach, had, 
when it arrived at the glottis, turned into its orifice, and, by irritat- 
ing the larynx, produced spasmodic closure of that organ, and suf- 
focation. 
The lumbricus presents very marked appearances of an advanced 
state of development. The male has a peculiarly formed penis; 
the female has her generative organs well developed; and both 
have an extensive alimentary canal. The tricocephalus is about 
an inch in length, terminating in a point; the sexes are different, 
and the male is distinguished from the female by the circular whirl 
of his tail—it is always found in the caecum. The small thread- 
worms, with which you are all acquainted, are almost exclusively 
found in the rectum. These worms are found in vast numbers in 
some children ; and it is said that the quantities of them which are 
discharged by the West Indian negroes are extraordinary. 
The tenia, or tape-worm, is generally found in the small intes- 
tine ; but it has also been observed in the stomach, colon, and 
rectum. The length to which this animal sometimes attains is 
almost incredible. Bremser mentions a case in which a tape-worm 
one hundred and fifty feet in length was discharged by stool 
Another case is given, in which the tenia had the enormous length SYMPTOMS OF INTESTINAL WORMS. 
169 
of three hundred feet. I have myself seen a large wash-hand basin 
filled by a mass of tape-worm, discharged after a strong dose of 
castor oil and turpentine. Still more extraordinary instances are 
recorded. Thus, in the Copenhagen Transactions, we read of a 
tape-worm eight hundred ells in length. But, in all probability, 
there has been an error in these measurements, and many worms 
have been taken for one. This is rendered probable by the fact 
observed by Robinus, who found in the body of a man, who had 
before death discharged fragments of tape-worm, a tape-worm 
extending from the pylorus to within six inches of the anus. The 
length of this single worm was scarcely thirty feet. One interesting 
circumstance connected with this animal is, that it is inferior in its 
organisation to every other species of worm. It appears to be 
nearly a simple, homogeneous, cellulo-gelatinous mass, without 
any division of sexes, and without a nervous system, or generative 
organs. It is said, also, to occur principally in persons whose 
powers of life are low; and if this be the case, as I believe it is in 
many instances, it furnishes us with a very curious and interesting 
fact. The other better developed kinds are found in persons of 
healthy, good constitutions; but the tape-worms, though sometimes 
met with in such persons, are generally found to occur in persons 
of low and weak diathesis. Here we see a curious connection 
between the product and the producing cause. 
With respect to the exciting causes of worms, a vast number of 
circumstances have been mentioned by authors, as giving rise to 
their formation. Foul air, low, damp situations, bad diet, the con- 
stant use of milk, cheese, sugar, vegetables, have been reckoned 
among their exciting causes. I believe we are not well acquainted 
with these causes. They appear often to be connected with some 
morbid influence produced upon the system by bad diet, and other 
circumstances; but what the nature of this influence is, we know 
not. 
LECTURE XX. 
Symptoms of intestinal worms—Sympathetic irritations—Affections of the nervous 
and respiratory systems—Various diseases mistaken for worms—Exciting causes 
of worms—Farinaceous and milk diet—Verminous fever—Treatment of worms— 
Specific and mechanical purgatives; calomel, turpentine, &c. &c.—Remedies for 
each species of worms—Preventive measures. 
Let us proceed with the consideration of intestinal worms. At 
my last lecture you will recollect that I spoke of the different kinds 
of worms, and stated that there was a difference between the worms 
which are found in various parts of the body; that I examined the 
question as to the origin of these animals, and came to the conclu- 
sion that they are formed originally within the bodies of man and 170 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
other animals. I mentioned the various kinds of worms which 
inhabit the digestive tube in man, and examined at some length 
the question of perforation of the intestinal canal by lumbrici. We 
come now to the investigation of the symptoms. 
With respect to the symptoms of worms, it is a singular fact, 
that we have not one single pathognomic sign of their existence, 
except the circumstance of their being occasionally passed by 
stool, or vomited; almost all their symptoms are referable to irrita- 
tion of the gastro-intestinal surface, and its sympathetic relations. 
Persons, who are much subject to worms in these countries, are 
generally of a pale complexion, with a bluish circle round the 
eyes; the belly is more or less prominent, and there are various 
signs of irritation of the digestive tube, with itching at the nose 
and anus; headache; foul breath and tongue; irregular and some- 
times canine appetite, nausea, hiccup, borborygmi, tenesmus, diar- 
rhoea, and constipation. Though the patients take abundance of 
nutriment, they are generally thin and pale; and in such cases 
there is either one or two very large worms, or a great number of 
smaller ones, or their presence is complicated with disease of the 
intestinal canal. Such persons are also observed to be of an indo- 
lent and languid habit; they have perspirations, disturbed sleep, 
with grinding of the teeth, and irregularity of pulse. 
The sympathetic irritations produced by worms are numerous 
and extraordinary. The genital organs may be excited, and we 
may have priapism and seminal emissions in the male, and irrita- 
tion amounting to nymphomania in the female. There is a very 
singular case on record of a female, aged seventy, being seized 
with a violent attack of nymphomania from this cause. The 
nervous affections produced by worms are so Protean and so 
numerous, that it would be almost impossible to detail them; in 
fact, there is not a single nervous disorder which may not be simu- 
lated by the sympathetic irritation of worms. Epilepsy, hysteria, 
convulsions, dilatation of the pupil, amaurosis, symptoms of hydro- 
cephalus, and even mania, are among the affections of the nerv- 
ous centres or their immediate connections, which, in repeated 
instances, have been found to depend on the presence of worms. 
Kraus gives an extraordinary case of a man, who, at a very 
advanced age, became subject from this cause to fits of continued 
and inordinate laughter. 
There is another case on record of convulsions depending on 
worms, which, like those from the bite of the tarantula, are said 
to have been soothed and relieved by music. Hufeland, in his 
journal, mentions a case of yellow vision from the same cause; 
and there are several instances of aphonia and mania on record, 
which have yielded to treatment which had removed intestinal 
worms. A case is mentioned of a person who got violent spasmo- 
dic action of the muscles of the eye, producing inversion of that 
organ to such a degree that the eyeball appeared to be nothing 
more than a mass of red flesh. A case is recorded by Serres, in 
which the symptoms strongly resemble those of hydrophobia; and SYMPTOMS OF INTESTINAL WORMS. 
171 
it is probable that some of the cases of hydrophobia, said to have 
been treated successfully, were nothing more than this extraordi- 
nary irritation of the nervous system produced by worms. I saw, 
myself, a case in which two eminent physicians made the diagnosis 
of hydrocephalus; it was that of a child, who was certainly, to all 
appearance, labouring under cerebral disease—for he had convul- 
sions, coma, and dilated pupils. It was remarkable, however, in 
this case, that the treatment directed to the head, though early and 
well applied, proved totally inefficacious. A large dose of calomel 
was given, and some lumbrici passed; in the space of two or three 
hours there was an evident improvement, and the child quickly 
recovered. 
During the course of practice I have met with several examples 
of affections of the respiratory organs, depending upon the irrita- 
tion of worms. This affection has been long known. I recollect 
the case of a boy who was brought to me with an extraordinary 
affection of the chest. He was of a gross habit of body, of a flabby 
scrofulous appearance, and labouring under disease of the elbow- 
joint ; but his chief complaint was, that he passed the night in 
great distress from incessant cough and wheezing. On examining 
the chest, I found the respiration healthy, and no other symptom 
of pulmonary derangement except a very slight bronchitic rale. 
On expressing my opinion of the case to the mother, she said that 
he was easy during the day, but that his condition was very differ- 
ent at night. To ascertain the truth, I took the child into the 
hospital, and found that her statement was substantially correct ; 
for, from four o’clock in the afternoon until next morning, he was 
in a state of perfect orthopncea, with loud, ringing, incessant cough. 
During the rest of the day he was free from cough, and tolerably 
quiet. The case was treated with calomel and ipecacuanha, tartar 
emetic, and other similar remedies, but the disease was rather exas- 
perated than improved. The boy had swelled belly and constipa- 
tion, and for this he was ordered to take a dose of turpentine and 
castor oil. He passed some worms with relief to the existing 
symptoms; and from the consideration of this, and the failure of 
the treatment for bronchitis, we were determined to persevere in 
the use of anthelmintic medicines, and for this purpose put the 
child on syrup of couhage, to be followed by castor oil draughts. 
He passed vast quantities of thread worms in the course of a few 
days, and when they had been all removed the cough disappeared 
altogether; but, as long as any of them remained, the symptoms 
of pulmonary irritation continued. There could be no doubt that 
this was a case of intermittent bronchial irritation from worms, for 
their evacuation was immediately followed by a complete cessation 
of cough and dyspnoea. I have also, since the foregoing, met with 
many other instances of a similar description. A young girl came 
into the Meath Hospital with chronic bronchitis, and some degree 
of hepatisation at the lower part of the left lung. Having heard 
from her friends that she was extremely subject to worms, I deter- 
mined to try what would result from the use of anthelmintic 172 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
medicines, and put her on the syrup of couhage with aloetic pills. 
Under this treatment the cough was quickly removed, and the 
lower portion of the lung recovered its permeability. Here it was 
remarkable, that not only irritation of the bronchial mucous mem- 
brane, but even solidification of the lung, were cured by treatment 
calculated to remove worms. Mr. Ramsay, in his paper published 
in the Medico-Chirurgical Transactions, gives several cases of 
haemoptysis from this cause. 1 think I have seen several cases of 
phthisis, where the original source of pulmonary irritation seemed 
to be the existence of intestinal worms. 
Let me here, however, remind you that we should be cautious 
in attributing too much to worms as the causes of morbid symp- 
toms. There are several reasons why you should be on your guard 
in this respect, one of the most obvious of which is this: it does 
not follow, in the first place, that the symptoms in any particular 
case are produced by worms; because the same cause, which may 
have predisposed to the formation of worms, may have produced 
the symptoms in question, and there may be merely a coincidence 
of worms and of these symptoms. Even if we look to the results 
of treatment, there is a great deal of doubt and difficulty. There 
are many cases on record which are described as cases of epilepsy 
from worms, and where all the symptoms have subsided under the 
use of anthelmintic medicines. In many of these cases we find 
the medicine chiefly employed has been oil of turpentine, and I 
need not tell you that this is an excellent remedy in many cases of 
epilepsy totally uncomplicated with worms. The results of such 
cases do not necessarily prove that worms were the source of irri- 
tation. Again, immense injury is frequently done to children in 
persisting in the anthelmintic treatment for the supposed existence 
of worms. Recollect, the prominent phenomena of worms in the 
intestines are irritations of the digestive system and of other func- 
tions. Now, it is very well known that these symptoms may occur 
with or without worms. If, then, you have a case where these 
phenomena are present without the co-existence of worms—and if, 
under a mistaken impression, you treat it with anthelmintic medi- 
cines—you inflict a double injury: you exasperate the original 
disease by the drastic and irritating medicines which are ordinarily 
used for the removal of worms, and you do an indirect injury by 
neglecting to adopt proper means of treatment. There is nothing 
more common than to see children labouring under some irritation 
of the digestive tube, which is mistaken for worms, purged again 
and again, until they get incurable enteritis or tabes mesenterica. 
When a child has foul tongue and breath, picking of the nose, 
diarrhoea, and turbid urine, it is a common notion that he is labour- 
ing under worms. If he gets feverish, it is said to be worm-fever, 
and the anthelmintic treatment is pursued with unabated vigour. 
Now, I believe that a great majority of such cases are, in reality, 
disease of the mucous surface of the intestine, and that the conse- 
quent feverishness is dependent on this state. Another reason why 
you should be cautious is this: in persons of an hypochondriac SYMPTOMS OP INTESTINAL WORMS. 
173 
habit, there is nothing more injurious than their getting the idea 
that they have a worm in their bowels. When once this notion 
gets into the head of an hypochondriac, it is generally impossible 
to eradicate it. Some of the most melancholy and fixed cases of 
hypochondriacism are produced in this way; every symptom is 
attributed to the worm; the patient is in a state of constant feverisn 
anxiety about it; he talks of nothing else, and is constantly taking 
medicines to expel it, to the great detriment of his general health 
and with a manifest exacerbation of his symptoms. Medical men 
should be extremely cautious on this point. The patient is perhaps 
a female of hypochondriac and nervous habit; she has gnawing 
sensations about the epigastrium, which she supposes to depend 
upon the presence of a worm, and an injudicious practitioner 
favours the notion. He gives her various medicines to expel the 
worm; no worm is passed; she becomes more anxious, takes more 
medicine, and gets weak and emaciated. She then begins to think 
that all the nutritious matter in her body is going to support the 
worm, falls into a desponding state, and continues for the rest of 
her life an incurable hypochondriac. 
We come now to consider the exciting causes of worms. On 
this subject I believe our knowledge is very scanty and inaccurate. 
The following, however, are generally looked upon as remote 
causes:—foul air, residence in damp and unhealthy situations, 
sedentary habits and want of wholesome exercise, over-feeding, 
the constant use of certain articles of diet—as farinaceous sub- 
stances, milk, cheese, sugar, &c. An eminent authority (Bremser) 
asserts, as I have already stated, that unabsorbed chyle in the 
digestive tube constitutes the most fertile source of worms. It is a 
common idea, that poor diet has a strong tendency to give rise to 
the formation of these animals, but it has been frequently observed 
that worms are met with in persons who are by no means in want 
of nourishment; and it is said, that, in cases where nutrition has 
been diminished in man and other animals, the worms die. If this 
be the case, it would appear that, so far from being the exciting 
causes of worms, poor diet rather tends to favour their removal. 
Uncooked vegetables and fruits are also reckoned among the causes 
of worms, but I believe this arises from the mistaken notion that 
the ova of intestinal worms occur in vegetables, and, being taken 
with them into the stomach, are there developed, or even changed 
in their organisation—a position which we have already proved to 
have no foundation in truth. Persons who live principally on 
vegetable food have not been observed to labour under worms in a 
comparatively greater degree than those who use an animal diet. 
It is said that the Swiss, who consume a great deal of vegetables, 
are very subject to worms; but other nations, who live in a similar 
way, have not been remarkable for the same liability. 
Worms have been stated to be occasionally epidemic. It is not 
very easy to determine this point, but it has been remarked that, at 
particular periods, these animals have been more than usually fre- 
quent and numerous. Many authors have described an epidemic 174 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
of what has been called verminous fever; that is to say, fever of a 
gastric or bilious character accompanied by worms in quantity. It 
is hard to say what the nature of this fever really was, and whether 
it might or might not be fever with irritation of the digestive appa- 
ratus, one of the consequences of which was a discharge of worms 
already existing. That worms are endemic, is a proposition very 
easily conceived; for we see it illustrated by the extraordinary 
prevalence of these animals in sheep which are kept in low, damp 
pastures. In such situations worms are met with in great abun- 
dance in the liver and other parts of these animals. 
It would appear from the following remarkable case, detailed by 
Bremser, that the use of milk and farinaceous food predisposes to 
the formation of intestinal worms. This gentleman, who was phy- 
sician to a monastery, and had ample opportunity of studying the 
habits of its inmates, was called to visit one of the oldest of the 
monks, who was said to be labouring under great derangement of 
the digestive system. On enquiry, he found that the patient had 
lived for sixty years in excellent health, using animal food, which, 
however, he had been latterly induced to change for farinaceous 
diet and milk. For a few days this agreed tolerably well with him, 
and then he began to be tormented with colicky pains, flatulence, 
sour eructations, and other distressing symptoms. His physician 
gave him some purgative medicine, and he passed a large quantity 
of tape-worm with relief: the treatment was persevered in, his 
former mode of living resumed, and he recovered quickly. This 
case bears strongly against the fanciful hypothesis that the ova of 
worms are transmitted in the act of generation ; for how could it 
be possible that the ovum of this tape-worm, transmitted in this 
manner, could remain undeveloped in the system for the space of 
sixty years ? This case derives additional interest from the fact of 
a change to a farinaceous diet being apparently connected with the 
formation of worms. 
Another remarkable case is given by the same author. The 
patient was a married female who had twelve children—six boys 
and six girls. This woman observed, that whenever she was preg- 
nant of a girl she had a great longing for milk and farinaceous food, 
and lived on these articles of diet almost exclusively. After living 
in this way for some time, she uniformly got an attack of worms ; 
and this, as well as the longing for vegetables, coincided with the 
birth of a female child so invariably, that she was able to tell with 
certainty whether the child she carried was a male or a female. 
This is a singular and well authenticated fact. 
We come now to the treatment of worms. Generally speaking, 
this is extremely simple—the principles of treatment in the various 
kinds of intestinal worms being nearly the same. Simple as they 
are, however, some persons entertain false notions respecting them. 
They appear to think that all they have to do is to evacuate the 
worms; and, having accomplished this, they rest satisfied, and take 
no steps to prevent their recurrence. But the mere evacuation of 
worms is no proof of a cure; to effect this you must prevent their SYMPTOMS OF INTESTINAL WORMS. 
175 
return. From what you have learned with respect to their exciting 
causes, you will be able to give such directions as to the patient’s 
mode of living as will obviate their recurrence ; and, with regard 
to the means to be adopted for removing them, we may divide them 
into the following:—We have, in the first place, what is called the 
mechanical treatment; next, the specific ; and, lastly, the purgative 
treatment. The first and last are nearly connected. For instance, 
purgatives appear to act in the same way as mechanical anthel- 
mintics, by irritating the mucous surface of the intestine and the 
worm, and thus causing its dislodgment and expulsion. 
Among the principal mechanical anthelmintics are filings of tin, 
couhage, powdered charcoal, and crude mercury; among the spe- 
cific are a variety of substances, most of which have a strong and 
peculiar smell. This is a very curious fact. Valerian, asafoetida, 
camphor, ether, and other odorous substances, have been found to 
be anthelmintic; and the Geoffraea inermis, which has been em- 
ployed for this purpose, is remarkable for its strong, unpleasant 
odour. The same thing may be said of tobacco, the oil of cheno- 
podium or wormseed, garlic, artemisia absinthium, and many 
others. With respect to purgatives, there is not one in the whole 
list, particularly those of the drastic kind, which may not be looked 
upon as an anthelmintic. 
It is the opinion of the most eminent men, that the thread-worm 
is the most difficult to expel, because they are generated with an 
extraordinary rapidity, and accumulate in a very short space of 
time. You are satisfied of their existence, have seen them in the 
alvine discharges, and the patient has all the ordinary symptoms. 
Well, what is the best way of getting rid of them? You shall 
commence by the exhibition of a mercurial. It is difficult to ex- 
plain why it is that mercury has such an effect in removing these 
worms, but the experience of the best practitioners can be adduced 
in proof of its efficacy. The statements of Dr. Latham, of London, 
and of many practitioners in this country and on the continent, go 
to prove this. In whatever way it acts, mercury appears to be a 
powerful anthelmintic; and it is a fact, that these worms have been 
expelled where it was given in very small doses, and not sufficient 
to operate as a purgative. The best plan is, first, to give a mercu- 
rial purgative, and then to have recourse to the mechanical treat- 
ment—giving, with this view, the syrup of couhage, one of the 
most efficacious of this class. It is a remedy which is easily man- 
aged, and will do no harm; for, though it produces violent itching 
when applied to the cutaneous surface, it produces very little 
sensible effect on the intestinal mucous membrane. The form 
which I employ is the following:—Take of the hairs of the doli- 
chos pruriens one scruple, syrup of orange-peel an ounce; of this 
an electuary or syrup is to be made, of which you may give a child 
a tea-spoonful three times a day. This is the remedy on which the 
West Indian practitioners, who have frequently to treat this affection 
in the negroes, place the greatest reliance; and you will find that, 
if you employ it, a vast number of worms will be often passed. It 176 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
should be continued for two or three days, and then a purgative 
must be given, after the operation of which it may be again resumed 
if necessary. An excellent adjuvant to this is the use of aloetic 
injections, composed of two parts of milk and one of the decoction 
of aloes. In this way you will be able to remove a vast quantity of 
these little animals from the rectum. It has also been observed, 
that injections of cold fresh or salt water have a great power in 
promoting their expulsion. Bremser mentions, that, in cases where 
these worms pass from the rectum into the vagina in females, and 
excite irritation, there is nothing so effectual in destroying them as 
injections of cold water and vinegar. This you should bear in 
mind. You should also remember, in the case of administration of 
syrup of couhage, to give strict orders not to let any of it drop on 
the child’s skin, as it would excite a great deal of irritation. You 
should forewarn the attendants of its effects on the skin ; and if any 
of it should be spilled on the hands, neck, or face, the best thing is 
to wipe and wash the part well, and then rub it with a little almond 
oil. 
For the expulsion of lumbrici there is nothing so successful as 
the ordinary purgative treatment. A bolus, composed of calomel, 
rhubarb, and jalap, will answer this purpose extremely well; you 
may also use the syrup of couhage with much advantage. Brem- 
ser gives a formula for an electuary, which I have not tried, but 
have no doubt of its value, for it appears to combine all the qualities 
of a good vermifuge electuary. It is made as follows:—Take of 
the seeds of santonicum, and of the flowers and leaves of tansy, 
reduced to powder, each half an ounce. Here you have two anthel- 
mintics of the specific kind. Add to these two drams of powdered 
valerian: here is another. You then combine with these two drams 
of sulphate of potass and a dram and a half of jalap: these are 
purgatives. You then make them up into an electuary with syrup 
of squill, which is also an anthelmintic of the specific kind. Of 
this electuary two or three tea-spoonsful are to be taken during the 
course of a day. Bremser states that this combination is of great 
value, particularly against lumbrici and tape-worm. 
The treatment of tape-worm is not difficult. All the specific and 
mechanical anthelmintics are useful in promoting its expulsion, but 
there is nothing which appears to have such a powerful effect as 
full doses of turpentine and castor oil. This constitutes the best 
remedy we possess against the tsenia; but, if you wish to get rid of 
it entirely, you must give the turpentine in full doses. You will 
frequently be astonished at the vast quantities of this worm which 
will be passed. When you give turpentine, it is safer to order a 
full dose of it; for, if it be given in small quantities, it is very apt 
to irritate the urinary organs. Half an ounce of turpentine, with 
the same quantity of castor oil, form an efficacious though very 
disagreeable draught. You may, however, obviate its nauseous- 
ness by the addition of a small quantity of camphorated tincture of 
opium and mucilage of gum arabic. The celebrated empyreumatic 
oil of Chabert is, in my mind, nothing more than a modification of painters’ colic. 
177 
the turpentine. This is the remedy which Bremser looks upon as 
most efficacious against the tape-worm. You have all, I presume, 
heard of the animal oil of Dippel—the oil which is produced by 
the distillation of bones or hart’s-horn shavings. To one part of 
this are added three parts of turpentine ; these are left to combine 
for four days and then distilled; the first three parts of oil which 
come over are called the empyreumatic oil of Chabert. It is an 
exceedingly nauseous remedy, has a most disgusting smell, and is 
seldom used in this country. Bremser recommends it to be taken 
in doses of a tea-spoonful three times a day. Some persons who 
have tried it have assured me that it is extremely difficult to be 
taken, and that it excites a train of most disagreeable abdominal 
sensations. Bremser, however, thinks highly of it; he is in the 
habit of directing his patients to take it for three or four successive 
days, then to omit for a day or two, and then to return to it again; 
and he says that it not only succeeds in evacuating the worm, but 
also in preventing its return. In addition to this, he recommends 
the use of a fortifying tincture, which I think very useful in worm 
cases. It is a combination of one of the salts of iron with a pre- 
paration of aloes. If you take equal parts of the muriated tincture 
of iron and tincture of aloes, you will have a remedy somewhat 
similar to the strengthening tincture of Bremser. Twenty drops 
of this mixture, taken three or four times a day, will prevent the 
recurrence of worms. 
In our next lecture, I shall take up the subject of painters’ colic, 
and some other affections connected with the viscera of the abdo- 
men, and then pass on to the consideration of thoracic diseases. 
LECTURE XXL 
Painters’ colic—Effect of metallic poisons on the nervous system—Symptoms of 
painters’ colic—Pathology of neuroses—Action of lead on the system—Abdominal 
and cerebral symptoms—Species of painters’ colic—Dr. Thompson’s researches on 
lead—Effects of in animals—Effects of on the generative system. 
A great deal of our time has been already occupied with the dis- 
eases of the digestive system—in fact, much more than I originally 
intended; the only apology I have to make for this, is the deep 
and paramount importance of the subject. Before I quit this part 
of the course, there are yet one or two subjects to which I shall 
briefly allude, namely, peritonitis and painters’ colic. With respect 
to the first of these diseases, I shall say but very little; the ordinary 
form of peritonitis is a disease so well known, and so fully treated 
of in books, that it would be only a waste of time for me to go over 
it; and with respect to peritonitis from perforation, all the original 178 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
information I could communicate on this part of the subject, may- 
be seen in one of my published clinical lectures, and in the article 
on Peritonitis from Perforation, in the London Cyclopaedia of 
Practical Medicine. The ordinary form of peritonitis has been 
described in this work by Dr. M‘Adam, the disease from perforation 
by myself. I shall therefore pass over this subject, and proceed to 
the consideration of a very interesting disease—painters’ colic. 
This disease is called painters’ colic, from the circumstance of 
house-painters being extremely liable to it from coming into fre- 
quent contact with the poison of lead. Its synonyms are numerous, 
dry colic, Saturnine colic, rachialgia metallica, Devonshire colic, 
&c., &c. 
Painters’ colic is an example of the effects of a metallic poison 
on the nervous system. There are certain metals which produce 
a powerful effect on the system, not by means of their corrosive 
properties, or by any direct action on the surface to which they are 
applied, but by a peculiar impression made upon the nervous 
system. Thus we find that mercury, under certain circumstances, 
will give rise to a very singular nervous disease ; arsenic may be 
introduced into the system in such a way as to produce symptoms 
of nervous lesion; copper exercises a similar morbid influence, 
and the effects of lead are universally known. I do not mean to 
say that all these metals produce similar effects on the economy, 
for this is not the case; but there is one point of agreement between 
them, that all may produce symptoms which are called nervous or 
neurotic, and the diseases thus produced are classed among the 
neuroses. What is the meaning of this term neurosis ? A lesion 
of nervous function., more or less complete, occurring independ- 
ently of any demonstrable organic change. A neurosis, then, is 
an alteration in the functions of the nerves of organic and animal 
life, the nature of which alteration we cannot understand, neither 
can it be demonstrated by the knife, nor by any examination of the 
state of the nervous tissue. In other words, a person will die with 
the symptoms of a neurosis; and when you come to examine the 
body, you will be unable to detect, in the minute ramifications of 
the nerves, the trunks, or the nervous centres, any appreciable 
lesion. 
Diseases of this description have been divided into two classes— 
active and passive neuroses. Active neuroses signify an increase 
or exaltation in the nervous function ; passive neuroses are those in 
which there is a diminution of nervous energy ; in both, there is an 
absence of perceptible organic change. Take, for instance, an 
example from the nerves of animal life: a case of convulsions, 
independent of organic disease, is an example of the active neurosis; 
a case of paralysis, under similar circumstances, is an example of 
the passive. In the former, there is an exaltation of the nervous 
function, Avhich is reflected upon the muscular system; in the 
latter, there is a diminution, producing a partial or total loss of the 
power of motion. It has been asserted, by eminent physiologists, 
that passive neurosis can only exist in the organs of the life of painters’ colic. 
179 
relation, because the functions of the ganglionic system, which 
presides over organic life, cease only at the death of the individual. 
But there may be such a thing as semi-paralysis of the organs to 
which the ganglionic nerves are distributed; and hence we may 
have passive neuroses of the system of organic as well as of animal 
life. We get a good idea of these neurotic affections, by taking 
some of the most remarkable instances of this kind. Hydrophobia 
is a remarkable instance of excessive lesion of the nervous function, 
without any known organic change; so is tetanus, and so are some 
forms of apoplexy, convulsions, and mania. Here we have violent 
irritations of the nervous system, in which there is no perceptible 
organic change; and where the only information we derive from 
pathological anatomy is of a negative character, telling us what 
these diseases are not, and leaving us, as to their actual nature, as 
much in the dark as ever. We find by dissection that hydrophobia, 
and tetanus, and hysteria, and convulsions, and apoplexy, are not 
caused by inflammation of the brain or spinal marrow, and that is 
all. Hydrophobia, tetanus, convulsions, and hysteria, are instances 
of active neurosis; paralysis and apoplexy, without any known 
cerebral disease, are looked upon as examples of the passive kind, 
because they present either a diminution or abolition of the nervous 
function. 
In the present state of medical science, we must admit this 
division of the affections of the nervous system into diseases with 
and without perceptible organic lesion. I grant that it is very diffi- 
cult, when we come to consider alterations in the functions of parts, 
to conceive how such changes could be effected without molecular 
alteration, or that the brain could be deranged in its functions, 
without some change of this kind. We are, however, compelled to 
consider such functional alterations of the nerves as changes with 
which we are unable to connect any process of hardening, or soft- 
ening, or anomia, or congestion, or, in fact, any known pathological 
condition. Rostan is of opinion that all diseases are organic ; that 
is to say, that they are produced by some molecular change, and 
this, he says, should be the basis of medicine. Unfortunately for 
medicine, it has been given so many bases, that it sometimes knows 
not what leg to stand on. 
But to return to our subject. Painters’ colic is an example of a 
neurosis, that is to say, it is a lesion of the nervous function, uncon- 
nected with any known pathological alteration. It presents, com- 
monly, two periods—the first exhibiting the phenomena of active, 
the second of passive, neurosis ; or, in other words, the signs of 
exaltation of the nervous function precede those of depression. In 
the majority of cases, we find the first stage of this affection charac- 
terised by violent spasm, pain and convulsions, symptoms indicative 
of active nervous lesion; whereas in the second stage we have 
paralysis, the diagnostic mark of the passive kind. This is the 
order in which the phenomena of painters’ colic are generally met 
with, but in some cases the first stage is either very imperfectly 
shadowed out, or even entirely wanting; the paralysis comes on in 180 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
an insidious manner, and without being ushered in by any symp- 
toms of exaltation of the nervous function. 
In this country, the most common victims to this disease are 
painters, who are much in the habit of working in white lead, and 
when you are connected with the management of any public 
medical institution (as I hope you will all be), you will often have 
to treat cases of this description. In Dublin, and all large cities, it 
is an exceedingly common affection, and the patients are for the 
most part house-painters. Next to these, the persons who are most 
subject to it are plumbers, and those who are employed in the melt- 
ing of lead. 
When the poisonous particles of lead enter the system in a highly 
volatilised state, its morbid effects are more certain and extensive. 
Every house-painter will tell you that the kind of work which is 
most likely to produce a deleterious effect, is painting “ the dead 
white,” or, as it has been termed, statuary white. In doing this, 
they use white lead combined with a large proportion of the oil of 
turpentine; and, in order to produce the intended effect, they are in 
the habit of excluding the air as much as possible. By means of 
the turpentine and the warm temperature of a close room, the lead 
is volatilised, and, in this state, appears to have an extraordinary 
power of impregnating the system. Some of the very worst cases 
of painters’ colic are produced in this way. Painting in the open 
air, even where the same preparation is employed, is comparatively 
harmless. A poor fellow, who was for a considerable time under 
my care, assured me that he had escaped for twenty years, and was 
convinced that he would have enjoyed a much longer immunity, 
had he not been put to work at the statuary white in a close room. 
With respect to plumbers, it is now ascertained that this disease 
is of comparatively rare occurrence among them; and the reason 
of this is, that they generally work in the open air, or in well ven- 
tilated apartments, and have now but little to do with the actual 
manufacture of lead. The kind of lead which they generally use, 
sheet and pipe lead, is furnished from the manufactories, and their 
occupation principally consists in the moulding and soldering of 
it. We very seldom now see a plumber labouring under colic. 
Painters’ colic may be observed under a great variety of forms ; 
but, for the convenience of studying the disease, we may divide 
these varieties into four classes. In the first, we have the pheno- 
mena of simple colic, without any obvious or marked symptoms of 
bilious, gastric, or cerebral derangement. In the second variety, 
the disease assumes a more decided character ; the colic is compli- 
cated with symptoms of fever of a gastric character, the pain in the 
belly is more acute, the constipation more obstinate; there is pain 
and difficulty in going to stool, nausea and vomiting, with occa- 
sional headache, dyspnoea, and sense of constriction about the prae- 
cordia; the belly is hard and retracted, and there is often pain in 
passing urine. In the third variety we have a more formidable 
array of symptoms. The functions of the brain and spinal marrow 
are deranged; there are wandering pains in the extremities; and painters’ colic. 
181 
the patient has frequent attacks of violent convulsions, resembling 
those of epilepsy. He also labours under the abdominal symptoms, 
but in this stage they are not so well marked, or so distinct, as in 
the former; the lesions of the functions of the cerebro-spinal system 
begin now to exhibit a greater degree of preponderance, and claim 
the principal share of the attention of a symptomatologist. In the 
fourth variety there is paralysis, without being preceded by the 
ordinary symptoms of abdominal or cerebral derangement. A 
medical friend of mine met with a case of this kind not long since. 
He was called to visit a child who had lost the use of his limbs. 
He went, and found the child lying in bed perfectly quiet and easy, 
his intellect sound, and his spirits good, but labouring under com- 
plete paralysis of all his limbs. He enquired minutely into the 
history of the case, and made a most scrutinising examination, but, 
from all he could see or learn, there was not the slightest ground to 
suspect disease of the brain or spinal cord. There had never been 
any symptoms of colic. He was puzzled with the case, and tried 
one thing after another without benefit. At length he found out 
that the child’s father was a painter by trade, and this led him to 
suspect that the symptoms might have some connection with the 
poison of lead. He enquired; and was told by the mother, that a 
quantity of white paint had latterly been kept in the room, and that 
it was impossible to keep the child from it. He instantly had the 
paint removed, a free current of air admitted into the room, and by 
the use of purgatives, assisted by stimulating frictions, the child 
recovered. 
The following is the order of symptoms generally observed in 
this disease. First, we have the precursory, denoted by pain and 
sensation of weight about the epigastrium; a weak, small pulse; 
general languor and weakness of the muscular system; want of 
appetite ; cold, clammy skin; a tremulous and coated tongue. At 
this period there is sometimes diarrhoea. Then comes some excit- 
ing cause, exposure to cold or wet, excess in eating or drinking, 
and the disease sets in with more or less intensity. The patient is 
attacked with dreadful pain in the belly, which differs from the 
pain of inflammation in this, that, so far from being increased by 
pressure, it is in most cases relieved. In fact, so decided is the 
relief produced in this way, that there is a case on record in which 
the patient used to get the greatest ease by making one of his 
fellow-workmen stand upon his belly. This relief from pressure 
is very generally observed in colicky affections. Indeed, so general 
is it, that you will hear it frequently stated, that all cases of colic 
are relieved by pressure. This, however, is not invariably true} 
for I have seen cases where the patients could not bear pressure, 
and where it required a careful examination to distinguish the 
symptoms from those of inflammation. The pain is of a twisting 
kind, and felt about the umbilicus; and, in connection with this, 
there is scanty urine, with more or less pain in passing it, obstinate 
constipation, and a tense, hard, retracted state of the belly, from the 
violent contraction of its muscles. The upper portion of the belly 182 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
is sometimes more retracted than the lower, and the pulsations of 
the abdominal aorta are unusually distinct. The pain remits, and 
then becomes exacerbated, and the patient’s countenance is expres- 
sive of acute suffering. In that form of the disease where there is 
a complication of gastric or bilious symptoms, the patient has a 
semi-jaundiced look, a hot, moist skin, quick pulse, foul tongue, 
vomiting, hiccup, thirst, and epigastric tenderness. 
In the third form, the chief force of the poison seems to be directed 
against the brain and spinal cord. There is vertigo, headache, 
stupor, and sometimes delirium; the patient has fits resembling 
those of epilepsy, but of longer duration, and violent convulsions, 
which sometimes continue with unabated intensity for twelve, or 
even twenty-four hours. You will see those unfortunate creatures 
rolling and twisting in every form, sometimes doubled forwards, 
sometimes in a state of perfect opisthotonos, sometimes moving 
their limbs with the convulsive action of an epileptic, and foaming 
at the mouth. In addition to this, it is stated, in the descriptions of 
this disease, that the patient loses his sight, and becomes amaurotic; 
this I can confirm, for I have seen it more than once. It is a 
curious fact, too, that this blindness may come on before the other 
cerebral symptoms are developed. I recollect a case in which one 
of the first symptoms was blindness. The patient happened one 
evening to be indulging himself in whiskey punch, and was in a 
fair way of getting comfortably drunk, when, unfortunately, he 
found that all of a sudden he could neither see single nor double. 
He groped about in a very disconsolate state for his glass, but not 
finding it, and finding, at the same time, that he had lost his sight, 
he came to the hospital next morning, and shortly after his admis- 
sion, had a violent attack of convulsion. In cases of this kind, I 
have generally found the pupils contracted. The patients toss 
about in bed, and are frequently found lying with their heads turned 
towards the foot of the bed. In some cases, the breathing has been 
stertorous for a length of time, and the head fixed, but the fingers 
and hands were flexible. I have seen cases in which the coma dis- 
appeared, and was followed by perfect blindness, lasting for two or 
three days, and then yielding to treatment. 
These symptoms, striking and extraordinary as they are, do not 
seem to depend on the same state of the brain as cases of other dis- 
eases which are accompanied by sanguineous determination to that 
organ. The reason I make this assertion is, that many of the most 
violent nervous symptoms, including profound coma, subside under 
the use of a stimulant treatment. I think we may look upon these 
symptoms as similar to what are termed the symptoms of the 
nervous apoplexy of the ancients. A case of this kind, which 
occurred in the Meath Hospital, is deserving of notice, from the 
singular effect produced by treatment. The patient was in a state 
of profound coma, but the head was cool, and the arteries had no 
inordinate pulsation. If this was a case which presented the other 
symptoms of apoplexy, I would have prescribed bleeding, leeches, 
and cold applications. But I reasoned thus—Here is a case in painters’ colic. 
183 
which there is no evidence of the existence of inflammatory action. 
Opium has been found to relieve the abdominal symptoms of the 
disease—may it not also relieve the cerebral ? I ordered the 
patient to have a free dose of laudanum in camphor mixture. In 
a few hours he awoke, sat up in his bed, and next morning we 
found the symptoms of coma had completely disappeared. In two 
other cases of a similar kind, I have given opium and carbonate of 
ammonia with the most favourable result. 
Dr. Clutterbuck mentions a peculiar symptom of this disease— 
a kind of gouty inflammation attacking the great toe, and followed 
by relief. I have not seen this. He states that the first joint of the 
great toe becomes red, hot, painful, and swollen, and that this 
remits by day and returns again at night. I have never seen this, 
nor have I ever seen those hard tubercles on the tendons in various 
parts of the body, which some authors have described. 
After these symptoms, vve come to a new class, namely, the pas- 
sive, characterised by paralysis of ihe muscles of animal life. It is 
remarkable that this paralysis seems to be principally a paralysis of 
motion, and that the power of sensation is seldom or never impaired. 
Generally speaking, the upper are more subject to paralysis than 
the lower extremities, and the right than the left arm. The latter 
circumstance is explained by assuming that the direct influence of 
the poison is more applied to the right arm. The paralysis of the 
arm is also frequently partial; the extensors lose their power, but 
the flexors do not in so great a degree. You will see a patient with 
his arm hanging by his side as if it were dead, but if you give him 
any thing to hold lie can grasp it firmly. I have known painters 
continuing to work with a semi-paralysed arm. There is also an 
atrophied condition of the affected part; and this sometimes comes 
on with such rapidity, that, in the space of a week or ten days, the 
affected limb will be scarcely half as bulky as the corresponding 
one. We cannot account for this remarkable emaciation on the 
principle of loss of motion alone, for the short space of time in 
which it occurs, in many instances, is opposed to our entertaining 
such an opinion, and we must look for some other explanation. 
On this point, science affords us no satisfactory information. 
This disease, notwithstanding all its terrible array of symptoms, 
is very seldom fatal. Hence the uncertainty which long prevailed 
as to its pathological nature. In the great majority of cases, where 
a dissection was made, the patients died of some other disease, 
which either occurred during its course, or had preceded it. All 
that appears to be established at present is, that there is no known 
organic change of the nervous system connected with this disease; 
that it occurs in all its forms without the co-existence of organic 
lesion, and that its exciting cause is the poison of lead. 
It was formerly supposed that all the preparations of lead, whether 
applied externally, or used internally, were capable of producing 
colic, but this doctrine is at present considered very questionable. 
It was thought that metallic lead, and all its salts, were capable of 
causing the disease ; but the morbid influence of this metal is now 184 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
restricted by the best chemists and pathologists chiefly to its 
carbonate. This opinion, I believe, was first put forward by Dr. 
A. T. Thomson, the author of the London Dispensatory, in an 
interesting paper published by him in the tenth volume of the 
Medico-Chirurgical Transactions. The object of this paper is to 
prove that, of all the preparations of lead employed in pharmaceu- 
tical and other purposes, the carbonate is that which is chiefly 
poisonous, and that the acetate and sub-acetate are comparatively 
harmless. 
You have all, I am convinced, heard of cases of colic produced 
by the external use of the acetate of lead, and you will see some 
cases in proof of this opinion in Darwin’s Zoonomia, and other 
writings. There is a case on record of a woman, who having 
poulticed her ankle with this preparation, for the cure of a sprain, 
got colic and fell into a state of marasmus. I knew of a deplorable 
case of burn affecting the abdominal integuments, which was treated 
with a solution of the acetate of lead. After using it for a fortnight 
or more, symptoms of colic came on, which not being recognised, 
the lead wash was continued, and the woman died in great agony. 
Dr. Thomson explains all this in a very satisfactory way. He 
shows that the solution of acetate of lead, when exposed to the air, 
attracts a quantity of carbonic acid, and is thus converted into a 
carbonate; of this I have very little doubt, for you will find that, 
by exposing a solution of the acetate of lead to the full influence of 
the air, the carbonate will gradually be deposited in the shape of a 
white powder. In the same way we can understand why it is that a 
solution of the acetate of lead, added to fermenting poultices, may 
be converted into a carbonate by the carbonic acid which is evolved. 
It is also a fact, that the acetate can be used internally for a long 
time without producing any thing like deleterious effects. I have 
given it for weeks together in full doses, without its having been 
ever followed by colic, or any symptoms characteristic of the 
absorption of a poisonous matter. There are cases on record where 
as much as six drams of this salt have been taken internally with- 
out producing any sensible morbid effect. As far as my experience 
goes, all those cases, in which the medical use of the acetate of lead 
has been attended with disagreeable symptoms, were cases in which 
it had been used as an external application. There were two cases 
in the Meath Hospital in which this medicine was used externally, 
in which colic, and other indications of poisonous absorption, took 
place, but not a single one in which its internal employment had 
been injurious. An excellent practical rule is laid down by Dr. 
Thomson, that, where you wish to employ the acetate of lead inter- 
nally, you should take care to combine it with diluted acetic acid. 
Of the two combinations of lead with acetic acid, the sub-acetate is 
most liable to be decomposed and converted into a carbonate, so 
that, if you prevent this by mixing with the sub-acetate, or acetate, 
a certain quantity of distilled vinegar, there will be little or no 
chance of unpleasant symptoms being produced, even where the 
medicine is given in very considerable doses. We are, therefore, painters’ colic. 
185 
I think, justified in concluding that it is the carbonate of lead which 
is productive of poisonous effects ; and that where bad symptoms 
have resulted from the use of the acetate, it was in consequence of 
its being converted into a carbonate. I must, however, remark, 
that it has not been sufficiently proved, as yet, that the use of the 
acetate is perfectly safe. 
It is an interesting fact, that many of the lower classes of animals 
are subject to this disease. Burserius was one of the first authors 
who directed the attention of medical men to this singular occur- 
rence. I have got from my father an abstract of some observations 
made by him on this subject, during a visit to the lead hills in 
Scotland. He found that, in the pastures among these hills, and in 
their immediate vicinity, cows, horses, sheep, dogs, and even poul- 
try, were subject to colic from lead. The symptoms, also, in these 
animals were observed by him to bear a very close analogy to those 
of the human subject. Thus, for instance, in cows there was obsti- 
nate constipation with suppression of urine; the poor animals seemed 
to suffer from violent twisting pain in the belly, and sometimes were 
thrown into a state of furious excitement, running wildly across the 
country. He learned, also, that during that period it was calculated 
that at least one tenth of the cows in this situation had died of the 
effects of the poisonous absorption of lead. One of the most ordi- 
nary precursory symptoms, was the animal becoming what is called 
hide-bound; this was followed by obstinate costiveness, and there 
was much apparent suffering, with panting, starting, and slavering 
from the mouth. Where the cerebral symptoms were most promi- 
nent, the signs of abdominal irritation were by no means distinct; 
and this, as I have remarked, is the case in the human subject. In 
some, who had the head affected, and ran wildly through the coun- 
try, the secretion of milk was stopped ; and this accords, too, with 
the effect of lead on the human female. Another remarkable cir- 
cumstance is, that animals living in the vicinity of these lead hills 
have exceedingly difficult labours. Sheep are subject to epileptic 
convulsions and paralysis ; dogs have the head principally affected, 
they run across the country slavering at the mouth, as if in a state 
of hydrophobia, but they do not bite, and are in all respects perfectly 
harmless. In barn-door fowl, the generative function was injured, 
and the hens reared or brought there ceased to lay eggs. 
There is one fact, mentioned in these observations, which tends 
to confirm the opinion of Dr. A. T. Thomson, that the poisonous 
effects of lead are produced chiefly by the carbonate. A distance of 
very few miles from the valley, renders animals quite free from any 
liability to the disease ; but if they should happen to stray into the 
immediate neighbourhood, and particularly into a portion of low 
ground, flooded during the winter months by a river which runs 
along the valley from the mines, and which, in all probability, 
leaves behind an efflorescence of the carbonate of lead, they are 
very liable to be affected with colic. It is said, also, that the poison 
is produced by the volatilisation of lead in the smelting houses, the 
vapours of which are carried down the valley and through the 186 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
neighbouring parts. Be this as it may, the Gaelic name of the 
valley signifies, the poisonous vale; and, as it is very probable that 
this name had been given in consequence of the deleterious qualities 
of the place long before the establishment of lead works, it tends 
strongly to favour the opinion that it is the water which contains 
the poison. 
The mode of cure employed by the shepherds in this place, is to 
give strong purgative injections, and remove the cattle from the 
influence of the poison, by sending them to new and healthy 
pastures. In this way they frequently recover ; and if we look to 
the cause of the disease, its symptoms, or mode of cure, we shall 
observe a striking analogy between it and the colic from lead in the 
human subject. I shall conclude this subject at my next lecture, 
and then go on to diseases of the chest. 
LECTURE XXII. 
Pathology of painters’ colic—Researches on the state of the nervous and digestive sys- 
terns—Treatment—Use of narcotics, purgatives, tobacco, &c. &c.—Treatment of 
paralysis from lead—Efficacy of strychnine and brucine—Colic from copper—Poi- 
sonous effects of mercury—Remarkable case—Affection of the respiratory muscles. 
We were occupied at our last lecture in considering the symp- 
toms of painters’ colic. I mentioned that it occurs under a variety 
of forms; that the symptoms are to be attributed to a lesion of 
nervous function independent of any known organic change; and 
that the same disease may be seen in animals which have been 
exposed to the poison of lead. There are some other facts con- 
nected with this disease, which should not be passed over, and 
which I am anxious to lay before you previously to entering upon 
the treatment. 
You will recollect that I introduced the subject by stating that 
painters’ colic belonged to the class neuroses, and that I endea- 
voured to show that this implied a lesion of function of any part or 
viscus of the body, frequently characterised by the most decided 
departure from the natural condition, and yet unaccompanied by 
perceptible organic change. I said, also, that it was hard to sup- 
pose the existence of great functional alteration, without any mole- 
cular change; but that, in the present state of science, we are 
compelled, for the want of a better term, to call these affections 
neuroses, in contradistinction to diseases in which there is organic 
lesion visible. To illustrate this point, take an example from two 
different cases. In one case of what is called dyspepsia, we have 
inflammatory, or, at least, sub-inflammatory derangement of the 
stomach : here the disease is traceable to organic change; in another 
we have symptoms of nearly the same character, and yet there is 
no organic lesion. Painters’ colic comes under the latter head; painters’ colic. 
187 
we observe symptoms of excessive functional lesion, but dissection 
does not exhibit any organic change. Pathological anatomy tells 
us what it is not, and we arrive merely at a negative knowledge of 
its nature. We have decided proofs of extraordinary lesions of the 
nervous system, and yet, when we come to the post mortem exa- 
mination, we cannot find any visible change to account for these 
striking phenomena. 
The old pathologists maintained that spasm of the intestines 
was the principal cause of the disease, and attributed the symptoms 
to their contraction. This opinion appears to have some founda- 
tion, when we consider the violent symptoms of colic which accom- 
pany this affection. Dubois de Rochfort has mentioned, that in 
such cases he has found intussusception of the intestines. De 
Haen says that contractions of the colon are very common ; and 
several authors make the same assertion. The results of more 
modern observation, however, are against these opinions. I have 
told you already, that in consequence of this disease seldom or 
never proving fatal, there is a degree of doubt attached to its pa- 
thology ; but it is an interesting fact, that where death from other 
causes has occurred during the existence of painters’ colic, the 
digestive tube has been found either in its healthy state, or with a 
few detached spots of vascularity, without any decided inflamma- 
tory character, and totally insufficient to account for the symptoms. 
This, which is all that pathological anatomy reveals, may be consi- 
dered as purely accidental, and only of occasional occurrence, so 
that we are compelled to look upon the disease as one in which 
there is great lesion of function without any organic alteration. 
In the hospital of La Charite, at Paris, a vast number of cases of 
painters’ colic have been treated. In the space of eight years five 
hundred cases of this description have been admitted ; out of these, 
five died while labouring under the disease; and the following is 
an abstract of the appearances observed on dissection. In the first 
case, there was rupture of an aneurism of the abdominal aorta, and 
the patient sank from loss of blood. On examination, the digestive 
tube was found in the natural and healthy condition—there was 
neither vascularity nor contraction. The subject of the second 
case died of apoplexy. The whole intestinal canal was found 
healthy, and, contrary to the doctrines of the school of Broussais, 
there was neither congestion nor vascularity. In the third case, 
the patient had fits of an epileptic character, in one of which he 
expired. The colon exhibited a slight degree of redness, but quite 
insufficient to explain the symptoms during life. In the fourth, the 
cause of death was the same, and, on dissection, the tube was found 
healthy. Another patient, after recovering from the symptoms of 
painters’ colic, got a sudden attack of asphyxia and died. His body 
was examined, but there was no trace of disease in the colon or 
any other part of the intestinal canal. Here we have five cases in 
which there was either no disease at all in the digestive tube, or, 
if there was any, the amount was quite insufficient to account for 
the symptoms. Louis, in a memoir which he has published, on 188 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
sudden and unexpected deaths, gives a case of this disease where 
death occurred suddenly on the eighth day. The intestines were 
found to be in a healthy condition. Martinet gives two cases of 
persons who died of the cerebral symptoms while labouring under 
this disease: here, also, the tube was in the normal state. Thus 
we have eight cases with dissections detailed by various authors, 
all men of high professional celebrity, having no theory to support, 
and all agreeing in the statement that there is little or no appreci- 
able lesion of the digestive tube ; that in the majority of cases it is 
in a state of health; that no contraction exists; and that such 
morbid appearances as have been found must be looked on as 
accidental. 
There is one interesting circumstance in these cases which 
deserves to be noticed. With the exception of the first and fifth 
cases, all the patients presented that form of the disease in which 
the functions of the brain are decidedly injured. Here it seems 
probable that the cause of death was excessive irritation of the 
nervous system. Now, in the observations I made on the cases 
which were treated at the Meath Hospital, you will recollect I 
stated that where the cerebral symptoms were predominant the 
abdominal were more or less indistinct and latent, and that the 
cause of indistinctness, or even total absence, of these might he 
owing to the force of the disease being thrown upon the brain and 
spinal cord. Such was the case in the instances above recited, and 
such we have also seen to be the result in the case of those animals 
of an inferior order that have been exposed to the poison of lead. 
How far the predominance of cerebral excitement may explain the 
want of appearances of disease in the digestive tube may be a 
subject of consideration. 
What is the state of science with respect to the brain and spinal 
marrow ? Allow me here to call to your recollection the symptoms 
of functional derangement of the nervous centres, the coma, the 
violent convulsions, the amaurosis, the deafness, the delirium, the 
paralysis. All these are violent symptoms, and you would natu- 
rally expect to find them connected with some sensible alteration, 
some congestion, or inflammation, or ramollissement. But nothing 
of this kind can be discovered. In all the cases where death 
occurred under such circumstances, at La Charite, with the excep- 
tion of some slight appearances of cerebral lesion in the second, 
there was no perceptible disease in the brain or spinal cord. The 
membranes and substance of the brain presented their normal con- 
dition ; there was little or no fluid in the ventricles; the spinal cord 
was healthy and natural in consistence and colour, and there was 
no effusion into its sheath. All these circumstances led to the 
conclusion that painters’ colic is essentially a neurosis. Observe, 
too, how interesting it is to connect the circumstance of the absence 
of organic change with the singular fact which I mentioned in my 
last lecture, that the comatose symptoms of this affection may be 
treated with stimulants and opiates. Where we have coma with 
congestion of the brain, opium has the effect of increasing the painters’ colic. 
189 
symptoms ; here it was found to have a contrary effect. So that 
our experience and the results of pathological anatomy, as far as 
they go, appear to square exactly. We see, then, that painters’ 
colic is not inflammation of the intestines, or of the brain, or of the 
spinal cord, and this information, though of a negative character, 
possesses considerable value in a practical point of view. I do not 
know any cases of what have been termed neuroses, in which the 
bearings of pathological research on practice are so extensive and 
so satisfactory. 
It is a fortunate circumstance that this disease is seldom fatal, 
and it is some consolation to think that, although the patient’s suf- 
ferings are dreadful and often protracted, there is little danger of 
life, and that the complaint is almost always amenable to judicious 
treatment. I have been for some years in the habit of treating it in 
a routine way, and can speak from experience of its success—of 
course this treatment is to be modified by circumstances. Suppose 
a patient applied to you with violent pain about the navel, a hard 
and retracted state of the abdomen, obstinate costiveness, and the 
other symptoms which characterise an attack of painters’ colic; 
the first thing I would advise you to do is to prescribe a full opiate. 
Many persons would object to this, and say that there is constipa- 
tion enough already, and that opening the bowels would be much 
more likely to give relief. But opium does not here add to the 
constipation ; indeed, so far from doing this, it sometimes acts as a 
laxative. At all events, it is a remedy which is perfectly unobjec- 
tionable. Give, then, in the first place, a full opiate, it will have 
the effect of relieving the patient’s sufferings, and will enable you 
to gain time for the employment of other means. The next thing 
is to place the patient in a hip bath, and keep him in it as long as 
possible. Do not neglect this, for I know of nothing that gives 
more decided relief. I have often seen cases where the patient was 
quite easy while he remained in the bath, but experienced a return 
of the pain as soon as he left it. If you have no means of procur- 
ing a bath in this way ; the next best thing is to have recourse to 
emollient stupes containing some narcotic, after the manner first 
introduced by my colleague, Dr. Graves. One of the best of this 
kind is the tobacco stupe; if you cannot get this you may employ 
poppy-heads for the same purpose. The tobacco stupe is much 
better than the tobacco injection, because its effect can be more 
easily regulated, but in violent cases I am in the habit of combining 
both, employing the stupe during the paroxysms of pain, and throw- 
ing up a tobacco enema every four or six hours, until a decided 
impression has been made on the symptoms. In the success which 
has attended my distinguished friend Dr. O’Beirne’s treatment of 
tetanus by the use of tobacco we see an analogous effect. In this 
way you will succeed in giving relief; you should also prescribe a 
brisk cathartic, and this you may do without any fear of injuring 
the patient, or exciting intestinal inflammation. The insensibility of 
the intestines to the stimulus of even powerful purgatives is a cu- 
rious feature in this disease, and bears strongly against the idea of 190 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
its being connected with any inflammatory condition of the tube. 
In the Hospital La Charite the treatment is routine; it consists of 
an emeto-purgative plan, which is continued day after day until 
the symptoms yield. The purgatives we employ in the Meath 
Hospital is croton oil, combined with castor oil and mucilage, or 
given in the form of pill. When the bowels have been freely acted 
on, the case generally goes on well. After the bowels have been 
opened, we continue the employment of the hip bath, the narcotic 
stupes, and anodyne injections, taking care at the same time to 
persevere in the use of purgatives. 
Andral makes a good remark on this point:—“ Here (says he) 
are cases in which, from some peculiar alteration in the state of 
innervation, the mucous surface of the bowels is rendered less sen- 
sible than in its ordinary condition, and can bear freely the stimulus 
of powerful purgatives. May not this condition also occur in other 
states of the economy ? We are, therefore, led to conclude that 
purgatives are not, in all cases, direct stimulants.” 
Painters’ colic has been treated in Paris by bleeding and leech- 
ing, but this has not been found so successful as the ordinary pur- 
gative plan. I have never seen a case in which general bleeding 
seemed to be called for except one, and this was a most violent 
case which had resisted the ordinary means of treatment for forty- 
eight hours. I recommended bleeding from its well known anti- 
spasmodic power ; a quantity of blood was taken, and soon after 
the purgatives began to act, and the patient got relief. With respect 
to leeches, I have employed them only in those cases which are 
accompanied with symptoms of fever and gastric irritation; where 
there is quick pulse, hot skin, foul tongue, thirst, vomiting, and 
epigastric tenderness. In such cases I have applied leeches, but 
my experience of them is, that the relief afforded is by no means so 
great, or so decided, as in cases of intestinal inflammation, and it is 
a mode of treatment which I do not by any means rely upon for 
removing the disease. 
After the violent symptoms have been subdued, the next thing 
you have to consider is, whether there is any paralytic affection, 
and how this is to be treated. If the disease be severe or of consi- 
derable duration, you may look for paralysis of one or both of the 
upper extremities with a good' deal of certainty. This part of the 
subject, I believe, more properly belongs to the consideration of 
nervous affections, but, as I have gone so far into the treatment of 
painters’ colic, I may as well give the whole together. The paraly- 
sis which follows this disease is different from that which is the 
result of apoplexy; it is a neurosis of the passive kind, and to be 
treated as such. The patient, some time after the occurrence of the 
usual symptoms of colic from lead, begins to complain of weakness 
in his arm, he feels some difficulty in extending his fingers or 
raising his hand to his head, and then the symptoms become more 
marked. The arm and fore-arm become rapidly atrophied, the 
paralysis principally affects the extensors, while the flexors retain a 
considerable share of power, the fingers are bent, and the arm hangs painters’ colic. 
191 
by the side. Here the first thing you should do is to adopt the 
treatment recommended by Dr. Pemberton in his work on Abdomi- 
nal Diseases, namely, to apply a splint to the inside of the fore-arm 
and hand, so as to counteract the preponderating influence of the 
flexors. Apply a splint to the fore-arm, wrap it up in flannel, and 
make the patient keep it supported by a sling. In this way you 
establish a kind of balance between the antagonist muscles, and 
place the extensors under favourable circumstances for bringing 
about a cure. If the patient has both arms affected, which is some- 
times the case, change the splint from one arm to the other every 
second day, and continue this alteration until the cure is com- 
pleted. 
You will next have recourse to the use of strychnine, one of the 
best remedies we possess in cases where the paralysis does not de- 
pend upon organic disease of the brain. This is a remedy which 
is given with good effects even in cases of paralysis from apoplexy, 
where there is reason to suppose that absorption of the clot has 
taken place. In a case of apoplexy, it can be employed only after 
some time and where depletive measures have been sedulously put 
in force, but in a paralysis of this description you may begin with 
it at once. Commence with the exhibition of one twelfth of a grain 
of strychnine two or three times a day, and go on increasing the 
dose gradually, until a grain, or even a grain and a half, is taken 
in the twenty-four hours. To ensure the exact division of this 
powerful drug, you should direct a grain of it to be dissolved in a 
few drops of alcohol, and then made into pills of an equal size with 
crumb of bread or conserve of roses. In this way you will succeed 
in bringing back the lost power of the muscles of the fore-arm and 
restoring its nutritive functions. I may mention here, that the 
atrophy of the paralysed limb, which occurs in this disease, cannot 
be accounted for by supposing that it is produced by want of 
exercise ; the emaciation is so rapid (sometimes taking place in ten 
days or a fortnight) that we can only attribute it to some unknown 
lesion of innervation. 
If the use of strychnine be followed by severe muscular twitches, 
pain in the head, or convulsions, you must omit it for some time, 
and then, when these effects have completely subsided, it may be 
resumed if necessary. You should also bear in mind that this 
remedy is one of those medicines which have been termed accumu- 
lative, that is to say, a patient may be taking it for a considerable 
time without any perceptible symptom, and then its effects explode 
suddenly, the quantity which has been accumulating in the system 
manifesting itself at once by symptoms of great intensity. Here 
you omit it immediately, and with a view of relieving the existing 
symptoms, prescribe a draught, composed of camphor mixture, 
ammonia, and opium. This has generally the effect of calming 
the nervous excitement, and you will seldom have any more trouble 
on this account. En passant, I would advise you, whenever you 
employ strychnine in private practice, to inform your patient of the 
occurrence of such symptoms, and tell him that there is no cause 192 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
for alarm. Instead of strychnine, some of the continental practi- 
tioners are in the habit of prescribing brucine, and it is stated with 
considerable advantage. I have tried it in two or three cases 
without much apparent benefit, and I am inclined to think that it 
is decidedly inferior to strychnine. In France, however, it has 
been very largely employed, and has the reputation of being a 
remedy of considerable value in the treatment of paralysis. It has 
one advantage at least over strychnine, it can be much more easily 
divided and regulated, so far as respects the quantity given, as it 
is a much weaker preparation than strychnine, one grain of which 
is equivalent to six grains of brucine. 
In addition to these measures, I have seen much benefit result 
from the application of blisters and frictions, with stimulating lini- 
ments to the spine. It is also of importance to remove the clothes 
in which the patients have worked; they are frequently charged, 
saturated with lead, and have a considerable tendency to keep up 
the disease. I have often seen an attack of painter’s colic reappear 
so shortly after leaving hospital, and without any evident exposure 
that I could only attribute it to the circumstance of their garments 
being saturated with the lead. 
In the foregoing plan of treatment there is nothing new; it is, in 
fact, a routine practice, but it is one which is borne out by the results 
of pathology, and which, from long experience, I can strongly 
recommend. I may also remind you that the plan of treatment 
followed in the hospital of La Charite, which has more cases of 
this disease than any similar institution in Paris, is completely 
routine. 
Other metals besides lead, as, for instance, copper, produce effects 
somewhat analogous. Copper is said to produce salivation, colic, 
and vomiting. Brass-founders are liable to these symptoms, as 
also other persons employed in the manufacture of copper. I have 
not seen the disease, but it is said to be analogous to lead-poisoning, 
so far as colic is concerned; in other respects the symptoms differ. 
The convulsions are not so violent, nor is the paralysis or coma 
so frequent; there is often considerable fever, thirst, difficulty of 
respiration, prascordial anxiety, diarrhoea, and prostration of strength, 
so that it comes much nearer to ordinary intestinal inflammation 
with fever, than painters’ colic. Yet it is a curious fact, that, not- 
withstanding all this array of symptoms so closely bordering on 
inflammation, it has been found in Paris, where several cases of this 
disease have been seen, that it is amenable to the same treatment 
as painters’ colic, and that, under the use of purgatives, the fever, 
thirst, diarrhoea, and tenesmus subside. 
Mercury, under certain circumstances, will produce a most 
extraordinary affection, on which I shall here make a few observa- 
tions. The disease is not of very frequent occurrence, but it is of 
importance in practice to be able to recognise and treat it properly. 
It is a proposition well known to almost every one, that many 
bad effects have resulted from the abuse of mercury; and I need 
not tell you how many persons are injured by the empirical painters’ colic. 
193 
employment of this potent drug on all occasions and in all consti- 
tutions. It is a common opinion that mercury acts principally on 
the capillary and absorbent systems, but there can be no doubt that 
it also acts upon the nerves, and that in a very remarkable manner. 
I have seen cases where the constant use of calomel has produced 
a marked derangement of the nervous system, manifested by great 
irritability, tremors, hysterical excitement, and hypochondriasis. 
You will see in the various works on Toxicology an account of the 
effects produced by mercury on persons employed in quicksilver 
mines, and on tradesmen, such as looking-glass manufacturers and 
others, who come in contact with mercury. I shall read for you 
the notes of a remarkable case of this kind, which was some time 
back under treatment in the Meath Hospital. It may be called a 
form of the paralysis agitans from the effects of mercury. Similar 
cases have been described. 
A man, aged forty-six, was admitted into one of our medical 
wards in October, 1833. He stated, that from the time he was 
eight years of age he had been employed in a looking-glass manu- 
factory, and that his occupation principally consisted in what is 
technically termed the silvering of mirrors. In this process the 
operator’s right hand is repeatedly immersed in a vessel filled with 
mercury, while the left fixes a sheet of tin-foil, on which the metal 
is rubbed. Artisans while thus engaged are in the habit of using 
a muffle, which covers the mouth and nostrils. This the patient 
said he had never used, because he found that those who were in 
the habit of wearing it did not enjoy better health. For thirty 
years he continued to enjoy tolerable health, with the exception of 
some bleeding from the gums, with shooting pains and a sense of 
formication in various parts of the body, accompanied by a slight 
loss of power in the hands, which came on at various times, and 
was generally relieved by the use of ardent spirits. He had been 
frequently salivated, and when admitted had lost nearly all his 
teeth. The mode in which he lost them was this, gum-boils formed 
close to the roots of the teeth, which soon, after dropped out, and 
in this way the local inflammation subsided. About three years 
ago, he had an attack similar to that for which he had been admit- 
ted ; he went into the hospital and was put under an active anti- 
phlogistic treatment with relief. From that time up to the period 
of his admission, he had enjoyed tolerable health, except that the 
sight of the right eye was considerably impaired, and that his 
memory was slightly affected. He forgot the names of persons 
and places, and was frequently at a loss in endeavouring to recol- 
lect the persons to whom he had lent his tools. On being brought 
into the hospital he presented an extraordinary specimen of human 
suffering, and I was at first unable to give his complaint a name, 
the case being the first of the kind I had seen. It exhibited the 
phenomena of a violent spasmodic affection ; it was different from 
tetanus, or hydrophobia, or hysteria, but it bore some faint analogy 
to chorea. The head, arms, and fingers, particularly on the left 
side, presented a succession of quick, convulsive, jerking motions. 194 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
The angles of the mouth were retracted, the eyebrows twitching, 
the head constantly thrown back, but the agitation scarcely raised 
the arms. The nostrils were spasmodically dilated. The sterno- 
mastoid, trapezius, scaleni, diaphragm, and the abdominal muscles 
were similarly affected. Their contractions were short, rapid, and 
painful. From the constant hiccup with which the spasms of the 
diaphragm were attended, and the jerking motions of the tongue, 
his speech was interrupted and indistinct. He was occasionally free 
from spasms altogether, but whenever he transmitted volition to any 
part of the muscular system, it became instantly affected. When 
he endeavoured to raise his foot from the ground, it quivered and 
fell quite powerless and useless. Whenever he attempted to carry 
a vessel to his lips he generally overshot the mark, carrying the 
vessel towards his ear, nose, or forehead, and spilling its contents 
over his face or neck, so that it was a common saying among the 
patients in the wards, that he did not know the way to his mouth. 
But if the vessel was applied to his lips by another person, he could 
swallow easily. A sudden blast of cold air, the application of a 
cold hand to the skin, or the abrupt entrance of any person into the 
wards brought on an attack of spasms. The muscles of the left 
hand and of the left side were affected much more than those of 
the right. The mental powers were not impaired, the patient was 
intelligent, and seemed anxious to communicate the particulars 
of his case. During the whole course of the disease he retained a 
full power over the urinary discharge and defecation. There was 
some slight tenderness on pressure over the fourth and fifth dorsal 
vertebrae, but the rest of the spine exhibited no increase of sensi- 
bility. His skin was cool and dry, his pulse quick, weak, and 
small, his bowels inclined to be costive, but easily moved by laxa- 
tives. Here we see a marked difference between this affection and 
painters’ colic. 
The treatment adopted in this case was very simple. Leeches 
were applied to the tender part of the spine, the patient was placed 
in a warm bath, and got some laxative medicine, followed by 
an opiate. He was also ordered to have a large flannel shirt, and 
to be placed in a warm comfortable bed. He passed the night 
tolerably well, and next day appeared to be much improved. I 
shall not continue the daily reports of this case, but shall merely 
mention, that after a few days a great improvement took place. 
The spasms of the left side continued, though much less severe. 
Those of the purely voluntary muscles on the right ceased, while 
the spasms continued in the respiratory muscles on this side. We 
found that all the muscles of the face which have been called 
respiratory by Sir C. Bell, the platysma, scaleni, pectoral, and 
intercostal muscles, and the diaphragm, were thrown into violent 
spasms, while the purely voluntary muscles remained in a state 
of perfect quiescence. I am not aware that this circumstance has 
been observed in any other case. As far as it goes, it tends to 
corroborate the views of Sir C. Bell. In the treatment of this case 
we employed narcotic frictions, particularly those composed of DISEASES OF THE NERVOUS SYSTEM. 
195 
the extract of belladonna, to the spine with considerable benefit. 
The patient was cured by very simple means, and at little ex- 
pense to his constitution. 
LECTURE XXIII. 
Diseases of the nervous system—Pathology of, unknown—Molecular change in the 
nervous centres—Difficulties of distinguishing arachnitis from encephalitis—Gene- 
ral and partial cerebritis—Symptomatology of—Diagnosis of—Preservation of intel- 
lect in—Production of general symptoms by local lesion. 
To-day we commence the consideration of the diseases of the 
nervous system, and here let me remark, that, even on the very 
threshold, we have to encounter several difficulties ; some depend- 
ing upon the great obscurity of the symptoms—some upon the 
want of correspondence between the symptoms and known organic 
changes, and some upon the necessarily imperfect nature of our 
classification of nervous affections. Many persons are in the habit 
of taking a limited view of the nervous system. They suppose 
that, when we speak of its diseases, we merely allude to affections 
of the brain and spinal cord; but the truth is that the nervous sys- 
tem, so far as regards organisation, is universal; and there is evi- 
dence to show that, even in parts and tissues which present no 
appearance of nerves or nervous communication, there resides a 
nervous power, either inherent in their organisation or derived 
from external sources, and by the latter mode, of nervous irradia- 
tion from surrounding tissues, has the sensibility of serous mem- 
branes been supposed capable of explanation. But there can be 
little doubt that even these tissues present nervous expansions, 
though of an infinite delicacy. They are, we know, supplied with 
white vessels, and doubtless have nerves corresponding to their 
vessels in size and function—nerves, insensible to us in health, but, 
when inflammation elevates the organ in the scale, capable of 
transmitting the most exquisite pain to the centre of perception. It 
seems, also, to be highly probable that nervous disease may com- 
mence not only in an affection of the brain or spinal marrow, but 
also in a similar condition of any part of the system. Again, if 
we admit the nervous system to be the governing and directing 
portion of the whole body, it is likely that some modification of 
that government precedes the alterations which take place in the 
circulatory and nutritive functions of other parts. Thus, in all 
diseases it may be laid down as a general rule, that there is an 
affection of the nervous system, either local or general; or, in other 
words, that there is no disease which we could name, which does 
not present signs of an affection of the nervous system, either quoad 
the suffering organ itself, or of an affection more general and dif- 
fused. If we take, for instance, a case of gastritis or hepatitis, we 196 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
find a lesion of function in the nerves of the respective organs, 
which, in certain cases, seems local; bat, if the inflammation be 
intense and the fever high, we have superadded to this a sympa- 
thetic affection of the brain or spinal cord. The same thing applies 
to all forms of local disease; for in all there is an affection of the 
nerves, either confined to the suffering organ, or extending to the 
whole system. 
In reviewing the phenomena of nervous diseases, we find them 
presenting several varieties depending upon certain circumstances. 
In the first place, they vary according to the seat of the disease. 
We find that the signs and symptoms of affections of the cerebro- 
spinal system differ very considerably from those which character- 
ise diseases of the sympathetic nerves. Again, if we take any 
part of the nervous system, and examine its diseases, we find that 
here also there is a source of variation connected with the peculiar 
part affected. Thus, if we take the cerebro-spinal system, we find 
that disease of one part of it differs most essentially in symptoms 
from disease of another: we may have enormous and fatal disease 
of the spine without the slightest injury of the intellectual powers, 
but we seldom have disease of the brain, particularly of the surface, 
without a more or less appreciable lesion of the phenomena of the 
mind. To follow up this point, suppose we take the diseases of the 
brain itself, as compared with each other; we find that their symp- 
toms vary according to the locality, so that, whether we look to 
physiology or pathology, we must consider the brain as consisting 
of several distinct parts, and not as an inseparable whole. It is 
admitted, by many writers of high authority, that there is a differ- 
ence between the symptoms of disease affecting the periphery, and 
disease affecting the central parts of the brain; and there is reason 
to believe that we may be able, in many cases, to diagnosticate 
affections not only of the centre and periphery of the cerebrum, 
but even of other parts of the organ. 
The same variety occurs with respect to the effects of diseases 
of the nervous centres. In some instances we have, as the result 
of disease of the brain, a loss of muscular power, or of sensation, 
in different parts of the body—sometimes affecting the face, some- 
times one side, or even both; and these paralyses may be single or 
variously combined. It appears, then, that the component parts of 
the nervous system, by being to a certain extent separate and dis- 
tinct, furnish a very extensive source of variety in the phenomena 
of nervous affections. 
Lastly, we have the varieties which depend upon the nature of 
the lesion. We generally observe an obvious difference between 
cases of nervous disease, accompanied by some known change in 
the injured part, and cases in which no such change can be demon- 
strated. Thus, for instance, we know the symptoms of apoplexy, 
and that, in the majority of cases, it is a disease connected with 
some perceptible change in the circulation of the brain—as exces- 
sive distension of its vessels, or an effusion of blood on its surface 
or into its substance. We also have some idea of the nature of DISEASES OF THE NERVOUS SYSTEM. 
197 
inflammation of the brain; we know that its substance becomes at 
first red, then begins to soften, and finally is converted into a pulpy 
mass. Now, there are a number of symptoms which are so often 
and so constantly connected with peculiar organic changes, that, 
the symptoms being known, we can make a tolerably correct guess 
at the nature of the alteration, or vice versa. 
On the other hand, however, we have a large and important 
catalogue of nervous affections, in which the symptoms give but 
very unsatisfactory information as to the real nature of the disease, 
and to the elucidation of which the painful and long-continued 
investigations of the pathological anatomist have hitherto been 
directed in vain. Of the actual nature of a numerous, complex, 
and interesting class of diseases—the neuroses—we know nothing. 
All we can say of them is, that they are examples of lesions of 
function in various parts of the nervous system, presenting no trace 
of structural alteration appreciable by our senses. It is a startling 
fact, and one which must be a source of gloomy reflection to the 
pathologist, that many of the diseases of the nervous system, which 
present the most violent symptoms, are those in which there is the 
least perceptible organic alteration. Every man who has seen a 
case of hydrophobia, or tetanus, or mania, or epilepsy, has witnessed 
a train of extraordinary and horrible symptoms, infinitely worse 
than those which are seen to accompany even great organic altera- 
tions of the brain. 
Here, then, is a singular fact: that there is a part of the system 
presenting a series of diseases under this extraordinary law, that 
the most violent and frequently fatal symptoms are accompanied by 
the least perceptible organic alteration. Now, what is the nature of 
these neuroses ? To give you a familiar illustration, let us take a 
case of tetanus or hydrophobia as an example. Here we have a 
train of symptoms exhibiting the most frightful irritation of the 
nervous system; and yet, when we come after death to examine, 
with eager curiosity, the cause of all these appalling phenomena, 
what do we find?—nothing. There is no unequivocal, no con- 
stant, no prominent alteration of any part of the nervous system, to 
throw light upon the obscurity of our opinions, and enable us to 
fix the nature or locality of the disease. We lay aside the knife in 
despair, and bitter indeed is the consciousness of our ignorance. 
Two opinions have been entertained by pathologists with respect 
to those singular affections: one, that they are examples of some 
peculiar modification of the nervous influence, independent of any 
organic change. In other words, the pathologists who entertain 
this opinion hold, that the principle of life may be altered in its 
phenomena, and admit of modifications, independent of any mole- 
cular change. The supporters of this doctrine reason thus:—In 
the phenomena of neuroses we have a train of extraordinary and 
violent symptoms unconnected with organic change. Now, it is 
quite unphilosophical to say that there is organic change when we 
cannot see or demonstrate it; and, on the other hand, it is not 
absurd to suppose that we may have lesions or peculiar modifica- 198 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
tions of the nervous principle, without any organic alteration. The 
other opinion is, that in the neuroses there is some organic change, 
the nature of which cannot be ascertained, in consequence of our 
limited powers of detecting elementary changes. In whatever light 
we view this question, it appears to be surrounded with difficulties. 
No one can deny that neuroses are very different from organic dis- 
eases of parts. If we compare them with that class which is most 
familiar to us—the inflammatory affections—we find a remarkable 
difference. In the first place, the neuroses may be brought on by 
causes not reckoned among those commonly capable of exciting 
inflammation. In the next place, their invasion is sudden, and 
their progress rapid; they arrive at their acme in a very short 
period of time, and subside rapidly. These are characters which 
do not belong to the ordinary forms of organic disease. Again, we 
often observe the utmost intensity of nervous pain without the co- 
existence of swelling, redness, or heat of the part affected. We 
find, too, that they are not to be subdued by the antiphlogistic plan ; 
on the contrary, several of them are either relieved or cured by an 
exactly opposite line of practice; and many cases, which would 
appear to demand the lancet, are known by long experience to be 
most benefited by stimulants. Lastly, the most accurate and well 
conducted investigations of pathological anatomy have failed in 
demonstrating the slightest organic change in these cases—at least, 
where changes are found, these are neither constant, competent, 
nor commensurate with symptoms ; so that, whether we compare 
the information we derive from symptoms, or the result of patholo- 
gical anatomy, we find a great difference between neuroses and 
organic diseases. It may be said, that, though they are not inflam- 
matory affections, they have some resemblance to them. This, 
however, is only a gratuitous supposition; for, even in the very 
worst cases, they present nothing analogous to the results of inflam- 
mation, and the brain and spinal cord are as free from perceptible 
organic change, in the majority of cases of fatal tetanus and hydro- 
phobia, as they would be in nervous affections of a slight and 
transient character. 
You must have been already convinced that it is difficult to form 
any clear or definite notion of the nature of neuroses; indeed, the 
only thing we can say of them is, what they are not. When we 
reflect on nervous phenomena, and consider how occult, how mys- 
terious, the properties of those organs which give rise to them are, 
we are struck with astonishment at the discrepancy between cause 
and effect. No medical man has ever witnessed a case of confirmed 
tetanus or hydrophobia, without being oppressed with a conviction 
of the imperfect and limited state of our knowledge of nervous 
disease. 
It may be very possible, that in these neuroses the change, though 
so slight as to escape our means of detection, does absolutely occur; 
and yet such is the nature of nervous phenomena, that we must 
admit that great and extraordinary effects are produced by very 
slight causes. Do we see any thing like this in nature?—any DISEASES OP THE NERVOUS SYSTEM. 
199 
remarkable alterations in properties depending upon apparently 
slight causes? We do—we see extraordinary changes taking place 
in the characters of various inorganic substances, (to which I need 
not particularly allude,) and there is no reason why the same thing 
should not occur in organic structures. On considering the doc- 
trine of Isomerism, I should be inclined to think that it throws 
some light on this obscure subject. In chemistry, it is a well-known 
though singular law, that the properties of two bodies may be essen- 
tially different at the same time that their respective component 
elements are, as far as our knowledge goes, identically the same; 
and the change, whatever it may be, appears to result, not from the 
abstraction or removal of any of the component atoms, but from 
their peculiar juxta-position. Now, it being admitted in chemistry 
that many bodies having the same constitution possess totally differ- 
ent properties, and this difference being explained by the different 
position of their elements, it does not seem strange if the same thing 
should take place in the phenomena of organised beings; and, if 
this be the case, we have a key towards elucidating the nature of 
these neuroses, and can conceive how an analogous change—a dif- 
ference in the arrangement of the molecules of the component parts 
of the nerves, or their centres—may produce new modifications of 
their properties, without making any distinct change in their nature, 
or adding or abstracting a single organic molecule. I am much 
inclined to adopt the opinion of those who think that, in the neu- 
roses, a peculiar organic change actually takes place, though we 
cannot demonstrate its existence; because, to reason on the pheno- 
mena of animal life, independently of organisation, is to plunge 
blindly into hypothesis, and retrace the errors of an antiquated and 
exploded school. 
In treating of the diseases of the nervous system, I regret that 
time will not permit me to enter into the subject as fully as I could 
wish ; all that I hope to be able to accomplish is, to give a sketch 
of some of the more prominent affections. The arrangement I pur- 
pose to adopt is the following:—1st, I shall treat of local inflamma- 
tions of the brain ; 2d, of general inflammations of that organ; 
3d, of mere sanguineous congestion or hyperaemia of the brain; 
4th, of apoplexy; and 5th, of the various forms of paralysis. 
In taking up the subject of cerebral inflammation, I beg leave to 
observe, in limine, that the brain may be attacked by general or 
local inflammation ; and further, that it may, as stated in books, be 
inflamed in its membranes or in its substance, or in both together. 
A great deal has been written to show that we can distinguish, dur- 
ing life, between inflammation of the substance and of the mem- 
branes of the brain. On this point, I believe, we may come to this 
conclusion—that inflammation of the membranes of the brain, or 
arachnitis, may be distinguished from some cases of local inflam- 
mation of the cerebral substance, but that it cannot, in the present 
state of our knowledge, be distinguished from general inflammation 
of the brain. We can, in most instances, make a distinction between 
local disease of the brain and arachnitis ; but, when the whole 200 
STOKES’S THEORY AND PRACTICE OP' MEDICINE. 
substance of that organ is affected, our means of diagnosis fail. 
This, however, is not so much to be regretted, as the distinction is 
of very little consequence, so far as treatment is concerned. Here 
we arrive at the knowledge of a principle highly consolatory in the 
practice of medicine; namely, that in many acute cases where the 
diagnosis between two diseases of neighbouring parts is difficult or 
impossible, it is also, so far as regards immediate treatment, un- 
necessary. 
If we enquire what are the symptoms of membranous inflamma- 
tion of the brain, as laid down in books, we shall find them to be 
the following: pain, delirium, convulsions, alteration of sensibility, 
and coma. These are the symptoms which are generally given as 
characteristic of arachnitis; and it is quite true that they are ob- 
served in many cases of the kind. But the person must be dull 
indeed who thinks that such symptoms imply nothing more than 
an inflammatory affection of the membranes of the brain. Take, 
for instance, one of the most prominent symptoms—delirium; what 
does this imply?—that the portion of the brain which discharges 
the functions of intelligence or mind has been injured, and is ren- 
dered incapable of performing its office. No one will venture to 
assert that the membranes of the brain are the organs of thought, 
and that the delirium proceeds from their morbid condition: such 
a notion as this could not be entertained for a moment. What then 
are we to suppose? One of these two things—either that there 
must be inflammation of the substance as well as of the membranes, 
or that the substance of the brain must be affected in a neurotic 
manner without any actual inflammation. As far as delirium is 
concerned, it appears to me to be quite impossible to distinguish 
between inflammation of the brain generally, and of its membranes. 
The same rule applies to the other symptoms—convulsions, altera- 
tion of sensibility, and coma. I repeat, that all we can say on this 
subject is, that, in such cases, there is either inflammation of the 
substance as well as the membranes of the brain, or that, with the 
membranous inflammation, there is a neurotic condition of the sub- 
stance of the brain. Yet who, in such cases, can affirm with cer- 
tainty that the symptoms of derangement of the substance of the 
brain are merely neurotic, when inflammation is admitted to exist 
within the cranium, and when we know that the two inflammations 
commonly co-exist? 
The fact of delirium occurring so frequently in inflammation of 
the membranes of the brain, is of considerable importance, as show- 
ing, not that membranes of the brain have any thing to do with 
intelligence, but as supporting the opinions of those who believe 
the periphery of the brain to be the seat of the intellectual facul- 
ties ; and here is a fact which, as far as it goes, is in favour of the 
doctrines of phrenology. If we compare those cases of cerebral 
disease, in which there is delirium, with those in which it does not 
occur, we shall find that it is most common in cases where disease 
attacks the periphery of the brain, as in arachnitis. The cases in 
which we observe great lesions of the brain without delirium are DISEASES OF THE NERVOUS SYSTEM. 
201 
generally cases of deep-seated inflammation of a local nature, or 
inflammation of those portions of the brain which the phrenolo- 
gists consider not to be subservient to the production of mental 
phenomena. This fact, also, would seem to confirm the truth of 
the opinion of the difference in function between the medullary 
and cortical parts of the brain. It is supposed that the cortical 
part of the brain is the organ of intelligence, while the medullary 
portion performs a different function. It is, however, a curious 
fact, that in delirium the inflammation is generally confined to the 
surface of the brain, and that, in cases of deep-seated inflammation, 
the most important symptoms are those which are derived from the 
sympathetic affections of the muscular system. 
Partial encephalitis may be either primary or secondary. An 
example of the latter is that inflammation of the substance of the 
brain which supervenes on apoplectic effusion, tumours, or cancer. 
What we generally observe, in a case of this kind, is more an alter- 
ation in the functions of the muscular system, and less of the intel- 
lect. This alteration consists at first in an apparent increase of 
innervation in certain muscles of the body, and we generally find 
that one of the earliest symptoms of local encephalitis is the occur- 
rence of pain in some of the muscles of the extremities. This is a 
curious fact, but one which is well established. In partial ence- 
phalitis there is often but little, or even no pain in the head: and 
the only warning have of the approach of cerebral disease is 
the occurrence of pain in the extremities, followed by rigidity. 
Here are the two most prominent symptoms of the disease—pain in 
the muscles of the extremities, and then rigidity. Further, we have 
alternate spasms and relaxations of the muscles, in which, however, 
the power of the flexor muscles ultimately prevails; so that, if the 
disease be in the fore-arm, it may become permanently flexed on 
the arm, and the contraction of the fingers is sometimes so great as 
to drive the nails into the flesh. If it affects the leg, the heel may 
be pressed against the buttock sometimes so forcibly as to form a 
sore. As the case proceeds, the limb becomes more fixed in its new 
position, and every attempt to extend it causes pain. During the 
prevalence of these symptoms, it frequently happens that the patient 
does not feel pain in the head, or any diminution of intellectual 
power. The absence of pain in the part affected may be accounted 
for by recollecting that it is a general law, that all inflammatory 
affections of deep-seated parts are, to a certain extent, of a compara- 
tively painless character; and we may account for the non-exist- 
ence of any lesion of the mind, by remembering that the disease is 
partial, and confined to a portion of the brain which appears to 
have little or no connection with the intellectual functions. In 
cases of this kind, when the muscles of the face are affected, the 
phenomena are interesting, from their being (in the first stage) the 
reverse of those of apoplexy. The face is drawn from the affected 
side, and the tongue pushed, by the opposite half of the genio-hyo- 
glossus muscle, to the affected side. This is the spastic stage, when 
complete disorganisation has not yet occurred. But when this STOKES’S THEORY AND PRACTICE OP MEDICINE. 
happens, then the phenomena of the face are like those of apoplexy, 
because the opposite muscles, which were in a spasmodic, are now 
in a paralysed state ; so that the face is drawn to the affected side, 
and the tongue pushed from it, by the healthy action of muscles 
which are deprived of their antagonists. 
I mentioned before that delirium may not occur during the course 
of a partial encephalitis ; and I gave, as a reason for this, the cir- 
cumstance of the disease being of small extent, and confined to 
parts of the brain which do not discharge any of the functions of 
mind. Another explanation has been given, drawn from the con- 
sideration of the double nature of the brain. It is thought that, 
where disease exists in one part of the brain, sanity may be still 
preserved in consequence of the healthy condition of the corre- 
sponding part; but where disease attacks both hemispheres together, 
as in a case of arachnitis, then there is a distinct lesion of the men- 
tal faculties. 
The next stage of partial encephalitis is that in which the dis- 
eased portion of the brain breaks down, softens, and is converted 
into purulent matter. This stage is marked by a new train of 
symptoms. The first stage is characterised by pain occurring in 
the muscles of the face, or of the extremities of either side, and 
followed by great rigidity. The second stage is of a different cha- 
racter ; the rigidity and spasm of the muscles diminish, and are 
succeeded by a paralytic and flaccid state of these organs. Volun- 
tary motion on the affected side now becomes impossible, the organ 
on which it depends being destroyed. Now let us, for sake of 
arrangement, call the first, or spastic condition, the convulsive 
paralysis, and the second, the paralysis with resolution. In the 
first, or convulsive stage, the brain is affected in the first degree; it 
is labouring under irritation or actual inflammation, and the disease 
still holds out a tolerably fair prospect of relief or cure. But in the 
second stage a cure is impossible, and hence it is a matter of the 
greatest importance to commence our operations at an early period ; 
and, by having recourse to prompt and active treatment, give the 
patient every chance for a cure. 
In the partial inflammation of the substance of the brain, sen- 
sation is variously altered. In some cases motion is lost, while 
sensation remains intact; in others, sensation is partially or wholly 
abolished. In many instances the intellectual powers remain in all 
their integrity, or but little impaired, even after the occurrence of 
symptoms which mark the softening down of the substance of the 
brain, and its conversion into purulent matter. In a few there is, 
during the first stage of the disease, a slight alteration in the state 
of the intellect, marked by a certain degree of excitement or exalta- 
tion of the mental faculties, and this, on the supervention of the 
second stage, is exchanged for a state of depression. In fact, the 
morbid phenomena of the mind and of the muscular system, where 
they co-exist, appear to be regulated by the same laws. Where the 
disease is extensive, you can easily observe the injury of the mental 
faculties which accompanies the second stage ; the patient answers 203 
DISEASES OF THE NERVOUS SYSTEM. 
slowly when questioned; his memory is weak, and his counte- 
nance has a stupid expression. But cases, even of extensive local 
suppuration, have been described by various authors, in which 
there was no lesion of the intellectual functions observed. These, 
however, generally admit of an explanation. Thus, in the cases 
recorded by Lallemand, the abscesses were situated in the cerebel- 
lum, pons Varolii, and other parts which are not supposed to have 
any connection with the phenomena of mind. There are several 
well-authenticated cases of extensive disease, not only of these 
parts, but even of the substance of the hemispheres, occurring 
without any appreciable lesion of the intellect. Thus, Mr. O’Hal- 
loran gives the case of a man, who, after an injury which destroyed 
a large portion of the frontal bone, had extensive suppuration of the 
brain, and lost an enormous quantity of the substance of one of the 
hemispheres, and yet preserved his intellect entire up to the moment 
of his dissolution. There is some difficulty in explaining this. It 
is an opinion entertained by some physiologists, that when one 
hemisphere is diseased its functions are discharged by the other; 
and that, the brain being a double organ, disease of one side does 
not impair the functions of the other. But, in answer to this, it 
may be urged that there are many cases on record in which disease 
of a single hemisphere has produced great alterations of intellect. 
The supporters of the former opinion attempt to explain such cases 
in this way. They state, that in the majority of such cases there 
was, besides the local encephalitis, inflammation of the arachnoid 
membrane, and that the lesion of intellect was not so much the 
effect of local disease of the brain as the result of its complication 
with an arachnitis engaging the whole periphery of the organ. In 
the next place, they explain the fact of a general affection of the 
brain arising from local disease, as depending in most cases on the 
pressure which the tumefied state of the diseased portion necessarily 
makes on the sound hemisphere ; and they state that this pressure 
must be very considerable, as the brain, being confined within a 
bony cavity, has no power of expanding itself. Now, it is a most 
interesting fact, in support of this view, that, in a great number of 
the cases of loss of brain with preservation of intellect all through 
the case, an extensive opening existed in the bones of the skull, so 
as to permit of expansion in the diseased hemisphere, and prevent 
the pressure being exercised on the opposite one. This point 
appears to be borne out by the result of Mr. O’Halloran’s cases, and 
by many other examples. Lastly, in every acute case of local 
inflammation of the brain, two causes having a tendency to produce 
symptoms exist. One of these is the local disease which gives rise 
to those phenomena of motion and sensation which we observe on 
the opposite side of the body; the other is the determination of 
blood to the whole brain, the result of the irritation of that disease. 
—“ If hi, stimulus ibi humorum affiuxusf 204 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
LECTURE XXIY. 
Encephalitis, diagnosis of—Preservation of function with organic disease—Vicarious 
action of parts—Importance of pathology to prenology—Use of pathology to phreno- 
logists—Arachnitis at the base of the brain—Symptoms of—Influence of age over 
the intellectual faculties—Opinions of Bouillaud, Serres, and Foville—Influence of 
the optic thalaini and corpus striatum on the motions of the extremities—Diagnosis 
of disease of the cerebellum—Connection with the generative system—Remarkable 
cases of. 
We were occupied at our last lecture in considering1 some of the 
phenomena of partial encephalitis, by which is generally meant, a 
localised inflammation of the deep-seated parts of the brain; because 
superficial inflammation of the cerebral substance is very rarely 
partial. I endeavoured to show that the diagnosis of this local 
encephalitis was to be drawn, in a great measure, from the occur- 
rence of pain and muscular affections of one side of the body ; in 
other words, that the phenomena of this disease were partial, so as 
to give us at once a distinction between general and partial inflam- 
mation of the brain. In cases of general inflammation, we have 
convulsions of both sides—delirium and coma; in the partial form 
these symptoms are absent until complication takes place. Thus 
the supervention of delirium, or of convulsions on both sides, in a 
case where previously the signs of only partial encephalitis existed, 
would point out, in all probability, an extension of disease to the 
opposite hemisphere. I also endeavoured to point out the different 
modes in which partial encephalitis might be accompanied with 
symptoms of a general character, or affecting both sides ; that there 
might be a co-existing inflammation of the membranes; or that the 
pressure of the diseased on the healthy hemisphere of the brain 
might be the cause of the complication. I stated, that some of the 
most remarkable cases of extensive destruction of the brain, without 
perceptible injury of the mental powers, were those in which a 
traumatic opening in the skull gave full scope to the swollen parts, 
and obviated the effects of pressure on the sound hemisphere. I 
also observed that, in cases of local affections of the head, there are 
two causes which have a tendency to produce general symptoms. 
One of these is the cause which determines the pain and muscular 
affection of the opposite side; the other is the general determination 
of blood to the head ; so that we may have cases in which the actual 
inflammation is limited to a part of one hemisphere, and yet, from 
the general determination of blood to the head, we may have coma 
and general symptoms. 
To return again to the interesting consideration of great loss of 
cerebral substance with preservation of intellect, I have to remark, 
that this circumstance is one which some persons might quote 
against the opinion that the brain was the organ of intelligence; 
and I believe this fact has been laid hold of by the opponents of 
phrenology, and put forward as a powerful argument against the 
truth of its doctrines. Thus, for instance, in the case of Mr. 
O’Halloran’s patient, who lost a large portion of one hemisphere, ENCEPHALITIS. 
205 
and yet, with all this mischief, the powers of the intellect remained 
unimpaired; it would not seem strange if a person should say, here 
is vast destruction of substance without any lesion of intelligence; 
how then can the brain be considered as the organ of thought? 
But let us look at this matter in its true point of view. In the first 
place, it is to be remembered that cases like this are rare—that they 
are to be considered as the exception and not as the rule. I have 
already shown you, that it is a law in pathology that lesion of 
structure and lesion of function are not always commensurate. 
This law applies to the brain as well as to all the other organs. 
To say that the brain was not the organ of intelligence, because in 
cases of extensive cerebral disease that intelligence was preserved, 
is false reasoning. A man will digest with a cancerous stomach ; 
is it to be argued from this that the stomach is not the organ of 
digestion ? I have seen the liver completely burrowed by abscesses, 
yet the gall-bladder was full of healthy bile. I have seen one lung 
completely obliterated, and yet the respirations only sixteen in the 
minute, and the face without lividity. What do these facts prove ? 
Not that the health of organs is of no consequence, but that with 
great disease there may be little injury of function. 
By reference to the original laws of organisation, we may (in 
some cases at least) arrive at an explanation of this fact. You 
know that organs are primitively double; and we find, that though 
the fusion at the median line is produced by development, yet that 
the symmetrical halves still, to a certain degree, preserve their 
individuality. Thus we see how the laws of organisation affect 
the phenomena of disease, and recognise a provision, acting from 
the first moment of existence, against the accidents of far distant 
disease. 
Now, admitting that the brain is the organ of thought, we may 
suppose that, as in case of partial obstruction of the lung from 
inflammation, the remainder of the organ takes on an increased 
action, so as to supply the place of that which has been injured or 
destroyed. We know that if one lung be hepatised. the other takes 
on its functions, and carries on the process of respiration for a time. 
That this is the case, is shown, first, by life being continued, and, 
secondly, by the stethoscope, which informs us that the respiration 
of the lung, which has a double duty thrown upon it, is remarkably 
intense, proving the force of its action ; and it has been further 
established, that the lung which thus takes on a supplemental action 
may become enlarged and hypertrophied. May not this also occur 
in the brain ? There is no reason why such a pathological pheno- 
menon, occurring in one viscus, may not also take place in another. 
But the opponents of phrenology say, supposing the organ of causa- 
tion to be destroyed, how can the person continue to reason ? It 
strikes me that the only way in which we can account for this is, 
by supposing that other parts of the brain take on the functions of 
those which have been injured or destroyed. Nor is there any 
thing extraordinary or anomalous in such a supposition. We see, 
almost every day, examples of this kind. We see that in certain 206 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
diseased states of the liver, accompanied by suppression of its secre- 
tion, its functions are assumed by other parts, and bile continues to 
be separated from the blood by the kidneys, salivary glands, and by 
the cutaneous exhalants. Here is a remarkable case, in which the 
glands and other parts take on the performance of a function totally 
different from that in which they are ordinarily employed. We 
find, also, that when the urinary organs are obstructed, urine, or its 
principles, are discovered in parts of the system where we should 
not at all expect them. Thus we have a very remarkable case 
detailed in the American Journal of the Medical Sciences, in which 
we find that a young female, who laboured under paralysis of the 
urinary organs, discharged urea from almost every part of the body, 
even from the ears. Neither is there any thing very extraordinary 
in this. In several instances of suppression of the menstrual dis- 
charge, do we not see a vicarious secretion taking place from the 
surfaces of parts the most distant, and unconnected with the uterine 
system? It is a well-established law, that when the functions of 
organs are suspended or destroyed, other parts will often take on 
the action of the injured viscus. Now, supposing that a portion of 
the brain is to be looked upon as the organ of causation, and such 
portion is injured or destroyed, there is no reason why the remain- 
ing sound portion of brain should not take on, at least to a certain 
extent, in addition to its own, the functions of that part which has 
been injured. If, independently of any phrenological views, we 
admit the brain to be the organ of thought, there is no reason why 
we should not admit that the loss of intellectual power, produced by 
lesion of one part, may not be supplied by an increase of activity in 
the remaining portions. It is only by a supposition of this kind 
that we can account for the preservation of the integrity of mind in 
many cases of disease of the brain. If we admit the phrenological 
doctrines, we can suppose that when one organ is injured, another 
may take on an additional function, and in this way preserve the 
integrity of the intellect; so that, whether we reason from phreno- 
logy or not, the continuance of soundness of mind, in cases of 
injury of the brain, can be understood when you come to contrast 
it with other analogous pathological facts. I again repeat, that it 
is not more extraordinary that, in case of local injury of the brain, 
the sound parts should take on a supplemental action, than that bile 
should be eliminated by the salivary glands, skin, and kidneys, or 
that the principles of urine should be discharged from almost every 
part of the system, or that a vicarious discharge from the roots of 
the hair should supply the place of the uterine secretion. 
On this subject, one point should be always borne in mind, viz., 
that we may be wrong in saying that a patient is quite sane, while 
he is still an invalid and in bed. Unless we can show that after 
his recovery, and in his various intercourse with the world, he pre- 
serves his original intelligence, it would be wrong to assert that 
there has been absolutely no lesion of intellect consequent on the 
affection of the brain. While lying at ease in bed, and unaffected 
by any moral stimuli, he may seem to possess a sound condition of mind; he may put out his tongue, or stretch forth his hand, when 
requested; he may give an accurate account of his symptoms, and 
answer all the ordinary medical interrogatories with precision. 
But you are not, from this, to conclude that he is perfectly sane. 
Many persons, under these circumstances, have died in bed, and 
appeared to preserve their intellect to the last; but in such cases, 
the test of sanity, intercourse with the world, could not be fairly 
applied, and hence I think that there are not sufficient grounds to 
pronounce a decided opinion as to the real condition of the intellect 
in such cases. 
Before I quit this part of the subject, I wish to make a few 
remarks on the doctrines of phrenology. There can be no doubt 
that the principles of phrenology are founded on truth, and, of 
course, highly deserving of your attention, as likely, at some future 
period, when properly cultivated, to exercise a great influence over 
medical practice. The great error of the phrenologists of the pre- 
sent day, consists in throwing overboard the results of pathological 
anatomy. If a pathological fact is brought forward, as appearing 
to bear against the validity of their opinions, they immediately 
exclaim, “we dont recognise any fact or principle drawn from dis- 
ease ; our science has to do with the healthy, and not the morbid, 
condition of the brain.” Now, this is altogether absurd. Phreno- 
logy, if true, is nothing but the physiology of the brain, and patho- 
logy is nothing but the physiology of disease. Phrenology must 
be tested by disease as well as by health, and if it does not stand the 
test of pathology, it is wrong. If phrenology be a science founded 
on truth, if it is a true physiology of the brain, or of that portion of 
it connected with mental phenomena, one of two results should 
obtain—either that it should be confirmed by pathology, or that the 
difficulties, which pathology presents, should be explicable in a 
manner consistent with the science. The phrenologists, in my 
mind, are doing a direct injury to the cause of their science, by 
their unnecessary and ill-timed hostility to pathology. It is idle to 
say, as they do, that theirs is the science of health, and that it is 
unfair to apply to it the test of disease. From pathology is drawn 
a host of facts, from which the doctrines they profess derive their 
principal support. The mere phrenologist, who understands not 
and despises pathology, is nothing better than a charlatan, and pro- 
fesses a science which he does not comprehend. If he would recol- 
lect that the brain in a state of health is most, and in a state of 
disease least, adapted to the purposes of thought, he would see that 
this is one of the strongest arguments in favour of his doctrine, that 
the brain is the organ of mind. The more healthy it is, the fitter it 
is to discharge the functions of intellect, and vice versa ; yet phreno- 
logists are so absurd as to think that pathology has nothing to do 
with their science. 
But besides confirming the doctrine that the brain is the organ of 
thought, there are innumerable facts drawn from pathology, which 
have a tendency to prove that particular parts of the brain are the 
organs of peculiar phenomena. We see an injury of one part of 
ENCEPHALITIS. 208 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the brain, accompanied by a train of symptoms indicating some 
peculiar lesion of mind; we see an affection of another part, 
attended by a different class of phenomena. Here pathology, the 
science which phrenologists reject and despise, goes to establish the 
ground-work of their doctrines, that the brain consists of a congeries 
of parts, haying each a separate and distinct function. We find, for 
instance, that disease of one portion of the brain affects the intellect; 
of another, the generative organs ; of a third, the muscular system. 
What does this prove but that the brain is not a simple organ, but 
composed of a congeries of parts, each of which governs a different 
part of the system, or ministers to a peculiar purpose ? Now, what 
is this but what the phrenologists themselves wish to prove ? 
Further, the professors of phrenology have placed all their 
organs on the surface of the brain, and for this they have been 
loudly censured. Phrenology, it is urged, knows, or professes to 
know, nothing about the central parts of the brain, which must be 
equally important with the superficial, and have confined their 
investigations to the surface alone. Now it is a curious fact, that 
the pathology which they deny, in this instance, furnishes the best 
reply to this objection. I mentioned at my last lecture, that if we 
examine the symptom of delirium, we find that it characterises the 
inflammation of the periphery, and is commonly wanting in that of 
the deep-seated portions. In other words, mental alienation is the 
characteristic of the disease of that portion of the brain where the 
phrenologists have placed the intellectual organs. Here is a strong 
fact in favour of the doctrines of phrenology, derived from that 
science which the mere phrenologist throws overboard and despises. 
Again, according to the researches of some celebrated French 
pathologists, there are a number of facts to show that there is a 
remarkable difference between the symptoms of arachnitis of the 
convexity and of the base of the brain. This conclusion, which, 
after a most careful series of investigations, was adopted by them, 
is borne out by the results of my experience, and appears to me to 
be established on the basis of truth. They have discovered that 
arachnitis of the convexity of the brain is a disease characterised 
by prominent and violent symptoms, early and marked delirium, 
intense pain, watchfulness, and irritability. We have first delirium, 
pain, and sleeplessness, and then coma. But in arachnitis of the 
base of the brain, the symptoms are of a more latent and insidious 
character ; there is some pain, and the coma is profound, but there 
is often no delirium. What an important fact for the supporters of 
phrenology is this, and how strikingly does it prove their absurdity 
in rejecting the lights derived from pathology ! Here we find the 
remarkable fact, that inflammation of the arachnoid, investing the 
base of the brain to which the phrenologists attach, comparatively, 
no importance, is commonly unattended with any lesion of the 
intellectual powers, while the same inflammation on the convexity 
is almost constantly accompanied by symptoms of distinct mental 
alienation. 
It is objected to the phrenologists that they know little or nothing 209 
of the central parts of the brain; that though these parts may be 
fairly considered to be of as much importance as any others, still 
they do not admit them to be organs of intellect. Now, what does 
pathology teach on this subject'/ It shows that we may have most 
extensive local disease of the central parts of the brain—that we 
may have inflammation, suppuration, abscess, and apoplexy, with- 
out the slightest trace of delirium. Indeed, there can be no doubt 
that the central portions of the brain have functions very different 
from those on the surface. They appear more connected with 
another function of animal life, muscular motion and sensation. 
Then let us examine the phenomena of old age. Every one is 
familiar with the fact, that when a man arrives at an extreme age, 
he generally experiences a marked decay of intellectual power, and 
falls into a state of second childhood. Does pathology throw any 
light upon this circumstance ? It does. From a series of ingenious 
and accurate investigations, conducted by two continental patholo- 
gists, Cauzevielh and Desmoulins, it has been found that a kind of 
atrophy of the brain takes place in very old persons. According to 
the researches of Desmoulins, it appears that, in persons who have 
passed the age of seventy, the specific gravity of the brain becomes 
from a twentieth to a fifteenth less than that of the adult. It has 
also been proved that this atrophy of the brain is connected with 
old age, and not, as it might be thought, with general emaciation of 
the body; for in cases of chronic emaciation from disease in adults, 
the brain is the last part which is found to atrophy; and it has been 
suggested that this may explain the continuance of mental powers, 
during the ravages of chronic disease; and also the nervous irrita- 
bility of patients after acute diseases, in which emaciation has taken 
place. 
I might bring forward many other facts to show that phrenology 
is indebted to pathology for some of the strongest arguments in its 
favour; and I think that those phrenologists who neglect its study, 
or deny its applicability, are doing a serious injury to the doctrines 
they seek to establish. The misfortune is, that very few medical 
men have turned their attention to the subject; and that, with few 
exceptions, its supporters and teachers have been persons possess- 
ing scarcely any physiological, and no pathological, knowledge. 
Phrenology will never be established as a science until it gets into 
hands of scientific medical men, who, to a profound knowledge of 
physiology, have added all the light derived from pathological 
research. To give you an instance of the mode of reasoning of 
the non-medical phrenologists. In their drawing-room exhibitions, 
they appeal with triumph to the different forms of the skull in the 
carnivorous and graminivorous animals, with respect to the develop- 
ment of destructiveness ; and all are horrified at the bump on the 
tiger’s skull. But, as Sir H. Davy well observes, this very protu- 
berance is a part of the general apparatus of the jaw, which requires 
a more powerful insertion for its muscles in all beasts of prey. 
Phrenology, as generally taught, may answer well for the class of 
dilettantis and blue-stockings, or for the purposes of humbug and 
ENCEPHALITIS. 210 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
flattery; but its parent was anatomy, its nurse physiology, and its 
perfection must be sought for in medicine. The mass of inconse- 
quential reasoning, of special pleading, and of “false facts” with 
which its professors have encumbered it, must be swept away, and 
we shall then, I have no doubt, recognise it as the greatest discovery 
in the science of the moral and physical nature of man that has 
ever been made. I feel happy, however, in thinking that, of late, 
the science has been taken up on its true grounds, in Paris, London, 
and Dublin. Vimont’s splendid work on Comparative Phrenology 
will form an era in the science. In London, Dr. Elliotson has 
directed the energies of his powerful mind to the subject; and in 
Dublin we have a Phrenological Society, of which Dr. Marsh is 
the president, and my colleague, Dr. Evanson, the secretary; and, 
under such auspices, much is to be expected. 
Having drawn your attention to the ordinary symptoms of local 
encephalitis, our next enquiry is, how far we can diagnosticate the 
actual seat of disease from phenomena observed during the life of 
the patient. Do not suppose, for a moment, that this part of the 
subject is undeserving of your attention, in the strongest sense of 
the word. Recollect that the more accurate and extensive is diag- 
nosis, the more certain and available is the practice of medicine. 
On this subject, matters are not altered to the same extent as in the 
cases of chest or abdominal diseases. In our knowledge of the two 
latter, we have made vast strides within the last few years; but in 
cerebral affections, though much has been effected, much still 
remains to be done; and it is not improbable that some of the 
opinions on this subject, still promulgated in schools, require 
correction. If we examine the various cases of cerebral disease on 
record, we find that in some the paralysis was complete, and that 
sensation and muscular motion became, as it were, annihilated. In 
other cases, the muscular system alone appeared to suffer ; while in 
a third class we find that sensibility is destroyed, while the power 
of motion remains intact. Again, in some we have complete 
hemiplegia, in others the paralysis is but partial; in some the affec- 
tion is slight and transient, in others it is incurable and permanent. 
The result of all this would appear to imply that there are different 
states and seats of cerebral disease, producing different modifications 
of nervous phenomena. It has been taught, that a paralysis of the 
organs of speech points out a lesion of the anterior lobes of the 
brain, and there are many cases on record in support of this 
opinion. Here is a pathological statement strongly in favour of the 
doctrines of phrenology. But, on the other hand, it must be con- 
fessed that there are numerous cases on record of lesion of the 
powers of speech, independent of any affection of the anterior lobe ; 
and hence, as far as the diagnosis of lesion of the anterior lobe, 
derived from loss of speech, is concerned, we cannot make up our 
minds. You are aware that the phrenologists place the organ of 
language in the anterior inferior part of the brain. Now, when an 
affection of this portion of the brain is found to coincide with the 
loss of speech, it is all very well; but the difficulty is to account ENCEPHALITIS. 
211 
for those cases of loss of speech in which there is no appreciable 
lesion of the substance of the anterior lobe. In investigation on 
this point, however, you must bear the following distinction care- 
fully in mind. The organ of language of the phrenologists is not 
properly the organ of the power of speech, but that by which, as it 
were, thought is converted into language. A man, from paralysis 
of his tongue, might be incapable of speaking; and such a case, 
existing without lesion of the anterior lobes, might be most unfairly 
quoted against the phrenologists. Again, paralysis of the upper 
extremities has been connected with disease of the optic thalami, 
and posterior lobes of the brain. It is the opinion of Bouillaud, 
Serres, and others, that the optic thalami regulate the motions of 
the upper extremities; and it is a fact, that in many instances of 
paralysis of the upper extremities, disease has been found in these 
parts. We might term the following a synthetic case, illustrative 
of the doctrine:—“ A soldier was wounded in the right shoulder 
with a lance, in consequence of which, he got an aneurism of the 
axillary artery, for which an operation was performed. At the 
moment the ligature was tightened, he experienced exquisite pain 
in the situation of the ligature, which extended to the brachial 
plexus; this continued until the next day, and then ceased. On 
the fourth or fifth day the pain returned with increased violence, 
and continued until the seventh day, when it became intolerable. 
He was blooded, but without any good effect, he then became 
comatose ; his head was drawn backwards; he had alternations of 
stupor and excitement, and soon after expired. On dissection, the 
ligature was found to embrace some of the principal branches of 
the brachial plexus, and there was an abscess in the posterior lobe 
of the brain, extending to the optic thalamus.” Here we have a 
case of injury of the upper extremity, and that portion of the brain 
which is supposed to govern it was found in a state of manifest 
disease. Serres gives, also, the details of some experiments in sup- 
port of this opinion. On removing the posterior part of the right 
hemisphere of the brain in a dog, he found that the left anterior 
extremity became paralytic; he prolonged his incisions into the 
corresponding portion of the opposite hemisphere, and found that 
the right extremity became paralysed. In another dog he plunged 
a bistoury into the posterior part of the right lobe, and found that 
the left anterior extremity became affected with convulsive motions. 
He then introduced into the wound a few drops of nitric acid, so as 
to produce inflammation of that portion of the brain, and observed 
that the convulsions of the left fore-foot became more violent; in 
fact, that the animal had all the symptoms of a local inflammation 
of the brain, namely, convulsions, rigidity, and then paralysis. 
Rolando has performed a series of experiments with the same view, 
and his conclusions are exactly those of Serres. So that if we con- 
nect the results of these experiments with some facts drawn from 
pathology, we might conclude that the optic thalami, and posterior 
lobes of the brain, have a very important share in regulating the 
muscular motions of the upper extremity. I may here state, that, 212 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
ill this city, a case of a female occurred, who got an attack of severe 
pain in the left hand and fingers, which became afterwards con- 
tracted ; and she had, in addition to this, alternate flexions and 
extensions of the fore-arm, followed by resolution and paralysis. 
On dissection, there was an abscess found in the right optic thala- 
mus ; the rest of the brain was healthy. 
With respect to those cases in which there is paralysis of one of 
the lower extremities, it has been taught that it arises from disease 
of the corpus striatum. On the anterior lobe the following case is 
given by Serres. “ A woman, forty years of age, had an attack of 
apoplexy, from which she recovered with the left leg in a state of 
complete paralysis, and the left arm admitting of a slight degree of 
motion.” Here was a case of lesion of both the upper and lower 
extremity of the same side, but in the former the paralysis was par- 
tial, in the latter complete. On dissection, it was found that two 
circumscribed abscesses existed in the substance of the right hemi- 
sphere, the larger situated in the corpus striatum, the smaller in the 
optic thalamus. Another case is given of a patient who got para- 
lysis of the side ; the muscular power of the arm being completely 
destroyed, while the leg retained a considerable degree of motion. 
In this case the corpus striatum was but slightly affected, while 
nearly the whole substance of the optic thalamus was destroyed. 
I have also to remark, that Serres performed similar experiments 
on the corpus striatum in dogs, and came to the conclusion, that it 
governs the motions of the lower extremities. The structure, 
extent, and special action of the corpus striatum and optic thala- 
mus, are said to afford some explanation why, in ordinary cases of 
paralysis, the arm is more often affected than the leg, and does not 
recover so soon. The fact of the prolongations of the optic thalami 
being much more complicated and extensive than those of the cor- 
pora striata, is thought to explain their greater liability to disease. 
There are, however, not unfrequent exceptions to this law; and 
it is not uncommon to meet with cases which militate against the 
doctrines laid down by Serres, and other pathologists, particularly 
so far as regards the connection between the corpora striata and the 
government of the lower extremities, so that I would have you look 
upon it as a point by no means fully established. The latest 
observations on this subject are by Andral, who brings forward 
many facts opposed to the opinions of Serres, Foville, &c. &c. 
Out of seventy-five cases of accurately circumscribed disease of the 
brain, the disease being hemorrhagic, or otherwise, he found that, 
in forty, where the paralysis existed in both extremities of one side, 
there were twenty in which nothing was injured but the anterior 
lobe, or the corpus striatum; while in nineteen the lesion existed 
in the posterior lobe, or the optic thalamus. In these seventy-five 
cases, also, were twenty-three in which one arm was paralysed. 
In these, eleven presented the disease in the anterior lobe, or in the 
corpus striatum ; ten in the optic thalamus, or posterior lobe ; and 
two in the middle lobe. Finally, out of these cases were twelve of 
paralysis of one arm; ten of these presented disease in the corpus 213 
ENCEPHALITIS. 
striatum, or anterior lobe; and two only with disease in the optic 
thalamus, or in the posterior lobe. 
These facts prove how uncertain the matter is yet. It would 
appear that when a simultaneous and equal injury of both corpora 
striata and optic thalami exists, it would be natural to expect com- 
plete paralysis of one side, and I believe there are some cases on 
record in support of this opinion. But when you have paralysis 
affecting both sides of the body, you are not to suppose that there 
is necessarily an affection of the corpora striata and optic thalami, 
for such symptoms, in the majority of cases, are found to depend 
upon either an intense congestion of the brain, or a large serous, or 
sanguineous effusion. The same phenomena are produced by the 
pressure exercised by the diseased on the sound hemisphere, in a 
case of local encephalitis, or by disease affecting the upper part of 
the spinal cord. 
With respect to disease of the cerebellum, the only means of 
determining its affections consists in first considering the seat of 
the pain, if any, and, in the next place, the effect on the genital 
system. There are a great number of cases detailed in various 
treatises in proof of the close connection between the cerebellum 
and the genital function. I shall relate a few of these. A man, 
aged thirty-two, got an attack of apoplexy, followed by violent 
erection of the penis, which continued until death; here we have 
a case of apoplexy accompanied by priapism. On dissection, the 
whole of the cerebrum was found healthy; but there was an 
apoplectic effusion in the middle lobe of the cerebellum. 
Another case is given of a man, aged fifty-five, who died of apo- 
plexy in a brothel, and who, after the attack, had violent priapism. 
On dissection, the substance of the cerebellum was found to be 
extensively destroyed, and there was an apoplectic effusion in the 
fourth ventricle. There is a remarkable case on record of a pros- 
titute, in whom the clitoris was extirpated, as it was considered that 
it was the irritation of that organ which brought on a pernicious 
habit, by which her health was greatly impaired; and it was con- 
ceived that, as soon as the supposed source of excitability was got 
rid of, she would give up her vicious propensity, and be restored 
to health. But in this instance it is probable that the effect was 
taken for the cause; for on her death, which took place some time 
after, the cerebellum was found to contain a number of chronic 
abscesses. Serres gives the case of a woman, who died of an 
apoplectic effusion into the cerebellum. During the fit, she had 
hemorrhage from the uterus; and, on examining that organ after 
death, a large clot of blood was found within its cavity, and the 
broad ligaments, ovaries, and, in fact, every part of the generative 
apparatus, were in a state of high vascularity. Yet this female was 
seventy years of age, and her menses had ceased at the usual 
period. There is a most important case bearing on this point on 
record. A gentleman, who was subject to constant and distressing 
nocturnal emissions, consulted his physicians, who, considering 
them to be the result of debility, prescribed various tonic and 214 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
stimulant remedies. He used various preparations of iron, bark, 
camphor, opium, hyosciamus, nitric acid, and many other things of 
a similar kind, but without advantage. Prom the fact of the 
failure of all these remedies, and the circumstance of his having 
complained of an occasional sense of uneasiness in the back of the 
head, his physician was led to think that his symptoms might have 
some connection with an excited condition of the cerebellum; and, 
under this impression, had the back of the head shaved, leeched, 
and covered with a quantity of pounded ice. From this time his 
symptoms began to decline rapidly, and in a fortnight he teas 
quite free from complaint. Now, this case, taken singly, would 
prove very little; but when we view it in connection with the 
number of cases in which disease of the cerebellum has been 
known to be followed by excitement of the genital organs, it 
becomes of considerable importance. I have now seen two cases 
in which this connection was observed. In the case of a young 
man, who was brought into the Meath Hospital some time ago with 
paraplegia, it was observed that the penis was in a state of constant 
erection, and there were continual seminal emissions. On dissec- 
tion, an effusion of blood was found in the cerebellum, and another 
in the hemisphere opposite the paralysed side. There was another 
case of a patient who was attacked with apoplexy and paralysis of 
one side, but with the unparalysed hand he continued to attempt 
the act of masturbation, so that it was necessary to tie down his 
hand. On dissection, there were several effusions in the substance 
of the cerebellum. All these facts strongly go to prove the connec- 
tion which subsists between the cerebellum and the generative 
function; and I think it would not be unsafe to make the diagnosis 
of disease of that organ in cases of cerebral disease, where the 
genital system was much excited.1 
‘A case of this kind was published by the editor some years ago, which 
has been cited as a case of meningitis of the cerebellum, by Di. Abercrombie. 
A boy, aged five, pale and delicate, after having been slightly indisposed for 
four or five days, was seized, on the 9th of August, with violent convulsions. 
On the 10th, there was fever with delirium; a vacant look of the eye, and 
an evident imperfection of vision, which appeared by his attempting to lay 
hold of objects that were presented to him, and missing them; the pupil 
was dilated, and there was slight strabismus. On the 11th, 12th, 13th, and 
14th, the symptoms gradually increased. On the 15th, coma ; constant mo- 
tion of the right arm and leg; the left appearing to be paralysed. In the 
night, he was seized with violent convulsions, which continued till his 
death, which took place on the morning of the 16th. On dissection, the 
brain was found healthy. There was remarkable vascularity on the tuber 
annulare, forming a thick web of vessels. This was connected with the 
arachnoid coat of the right side of the cerebellum, which was thickened, 
with some deposition of coagulable lymph. About four ounces of fluid was 
found at the base of the skull, but not above a tea-spoonful in the ventricles. 
An important point in this case, which Dr. Abercrombie appears to have 
overlooked, was the connection between the state of the cerebellum and 
the genital functions; the latter being much excited, and the penis in an 
almost constant state of erection. See “ Case of Arachnitis Cerebelli, by 
Robley Dunglison, &c. &c.,” in the “ London Medical Repository,” for 
October, 1822; and Abercrombie “On Diseases of the Brain,” 3d edit., 
Lond., 1836. p. 60.—/?. D. ENCEPHALITIS. 
215 
LECTURE XXV. 
Symptoms of encephalitis—Conclusions as to contraction and paralysis—Remarkable 
cases of encephalitis—Abscesses in the brain—Sympathetic affections—Enteritis 
simulating cerebritis—Prognosis in cerebritis—Remote neuralgia a symptom. 
To-day we again take up the subject of encephalitis; and allow 
me here to observe on the extraordinary variety and complication 
of the symptoms of this disease. Unless you study with extreme 
care a great number of separate cases of cerebral disease, you will 
never be able to get clear ideas on the nature of this affection, so 
peculiarly interesting to the pathologist, and the practical physician. 
More circumstances seem to combine in creating a variety in the 
symptoms of cerebral affections than in those of any other viscus 
of the body. We have in the case of cerebral disease all the 
variety of symptoms depending on the peculiarity of the part 
engaged, on the complication of local encephalitis with arachnitis, 
on the results of pressure, the nature and extent of effusions, the 
difficulty created by the phenomena of neurosis, and many other 
circumstances. 
At my two last lectures I drew your attention to some cases of 
local encephalitis, in which the disease was pointed out by certain 
affections of the muscular and generative systems. There are 
several other circumstances connected with this part of the subject, 
which are also deserving of attention, and it is necessary that you 
should be aware that there are other sources of diagnosis in cases 
of local encephalitis besides those already mentioned. There is no 
doubt, that though in many cases the occurrence of contraction, 
spasms, and pain in the extremities, precedes that of paralysis, yet 
we may have paralysis from local cerebritis coming on without 
these 'precursory signs, and as suddenly as in cases of apoplectic 
effusion. This important fact you must never lose sight of. 
Of this I have now seen several instances. I recollect a remark- 
able case of a man who had been bled in the cold stage of an ague, 
with the effect of stopping the intermittent. In a few days symptoms 
of pneumonia set in with great prostration of strength. These 
were followed by signs of disease of the brain, which were that the 
patient became suddenly nearly insensible, and on that day was 
observed to have his hand constantly placed on the right side of the 
head. Next day, without any preceding spasms or contractions 
being observed, he was found paralytic in the left upper and lower 
extremities, with paralysis of the left sterno-mastoid, and loss of 
sight in the left eye. On dissection we found softening of the two 
anterior thirds of the right hemisphere, which were of the consist- 
ence of thick cream. The disease engaged the corpus striatum, 
but the optic thalamus was healthy. 
Another remarkable instance occurred lately in a person labour- 
ing under aneurism of the innominata and hemiplegia. Here the 
paralysis came on suddenly, and its cause was found to be an 216 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
abscess of the brain. I must observe, however, that there were 
some precursory signs in this case, though contraction and spasms 
were not observed. The patient had violent headache, and was 
subject for some time to occasional numbness and pain in the 
affected arm. 
I repeat it, you may have the greatest variety in the succession 
and combinations of the symptoms of this disease, and this observ- 
ation applies to the lesion of muscular motion, sensation, the state 
of the intelligence, and the organic functions. You must study 
numerous cases to get an accurate idea of this disease. I would 
advise you to examine the writings of Lallemand, Bouillaud, Aber- 
crombie, and Serres, on this subject, and then consult the last edi- 
tion of Andral’s Clinique Medicate, where you will find the value of 
the symptoms discussed in a most impartial and philosophical man- 
ner. In this splendid work you will find many cases of cerebritis, in 
which the symptom of spasm and alternate flexions and extensions 
was wanting. Indeed he looks upon it as a symptom which cannot 
yet be called pathognomonic. 
We may, I think, come to the following conclusions on this 
subject:— 
1st. That local encephalitis is often accompanied by various 
forms of muscular contraction in the parts afterwards to be para- 
lysed. 
2d. That in some cases the paralysis is not preceded by muscular 
contraction, though various lesions of sensibility may occur. 
3d. That the paralysis may be gradual, (which is the most 
common case,) or sudden. 
4th. That the contraction may be intermittent, periods more or 
less elapsing when the symptom is absent. 
5th. That in general the contractions occur in the first, the para- 
lysis in the second stage. 
6th. That in a few cases the reverse occurs. 
7th. That in some cases, general or partial convulsions, and in 
others, tetanic symptoms, precede the paralysis. 
You will see in the Gazette Medicale, for October, 1833, the 
particulars of a most interesting case, recorded by Berard, jun., of 
fungous tumours of the dura mater, which was not accompanied 
by any alteration of muscular motion. This was removed, with 
the adhering portion of the dura mater, when the patient was 
attacked, for the first time, with loss of consciousness and convul- 
sions of the trunk and extremities. The operator, justly concluding 
that the sudden removal of the partial resistance of the brain was 
the cause of the symptoms, applied a piece of agaric to the denuded 
surface, and made gentle pressure upon it, when he found that 
immediately the convulsions ceased, and the intelligence was re- 
stored. Thus, gentlemen, does disease often become a second 
nature, and its want is the cause of symptoms. 
As far as we see of the brain, this pathological fact appears cer- 
tain, that injuries of the upper part of that organ are accompanied 
by more marked and distressing symptoms than similar lesions of ENCEPHALITIS. 
217 
the lower part. There seems, indeed, to be a decided difference 
between the sensibility of the superior and inferior parts of the 
brain. The great proportion of those cases in which there was 
extensive latent disease of the brain, have been cases in which 
disease predominated in or towards the inferior surface of that 
organ. In this situation it has been proved by numerous examples 
that you may have extensive disease without those symptoms of 
muscular or mental derangement, which ordinarily characterise 
inflammatory affections of the brain. I recollect the case of a 
patient who was brought into our wards complaining of feverish 
symptoms, with pain of the left temple, extending to the eye of the 
same side. With the exception of this pain, he had no cerebral 
symptoms of any kind ; his intellect was sound, and he was quite 
free from muscular pain, rigidity, spasms, or paralysis. He was 
ordered to take some opening medicine, and to have leeches applied 
over the seat of the pain, but derived no benefit whatever from their 
application. This led me to suspect that something unusual was 
going on, and more particularly when I observed that the leeches 
were repeated without any decided benefit. One morning on going 
into the ward I looked about for him for some time to no purpose ; 
in fact, his countenance was so altered that I could no longer 
recognise him. During the night, the globe of the eye was almost 
suddenly thrust forward by an enormous oedema of the soft parts 
of the orbit, and the pain became excruciating. It was then con- 
ceived that the pain complained of on admission was the result of 
disease of the bones of the orbit, and that abscess had formed behind 
the eyeball. Under this impression, and in accordance with the 
earnest request of the poor sufferer, it was determined to make an 
incision to give exit to the confined pus. A curved bistoury was 
cautiously though deeply introduced over the eyeball, but on with- 
drawing it, only a small quantity of serum escaped. The swelling 
went on increasing, and the eyeball was pushed forward so as to 
be raised above the level of the nose. A curved bistoury was then 
carried extensively round the orbit, but without giving exit to any 
matter. Under these circumstances, I came to the conclusion that 
it was an example of deep-seated abscess of the brain, with symp- 
tomatic cedema of the orbit. This oedema of superficial parts, in 
cases of deep-seated disease, is, you know, a thing of common 
occurrence, and may be observed in many instances of hepatic 
abscess, acute pleuritis, and other inflammations. In fact, there is 
such a remarkable sympathy between deep-seated parts and the 
integuments over them, that you may have this cedema in deep- 
seated inflammations of the organ. The patient now became 
gradually worse, his agony was intolerable, and the protrusion 
continued undiminished, but he had not either delirium or convul- 
sions. He sank into a state of profound coma, in which he 
remained for about twenty-four hours, when death put a period to 
his sufferings. On dissection, there was no pus found in the 
orbit, and its bones were healthy, but in the inferior part of the 218 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
anterior lobe of the brain there was an abscess about the size of a 
large walnut, resting on the cerebral surface of the orbit. I have 
since learned from several of my friends that they have witnessed 
cases of the same description. It is an interesting disease, and one 
which you should be acquainted with. I think the existence of the 
following symptoms should lead you to suspect it. First, pain in 
the head, preceding the appearance of tumour of the orbit, and this 
pain not affecting the orbit itself; for observe, in this case the pain 
was referred to the temple and hot to the orbit. The next thing is 
the pain resisting ordinary treatment, and being followed by a 
sudden cedema of the parts within the orbit, and protrusions of the 
eyeball. These two circumstances, when occurring in conjunction 
should, I think, lead you to suspect acute internal disease. Again, 
in those cases where abscess supervenes on caries of the internal 
table of the bones of the cranium, the affection is much more 
chronic than in this or similar instances of deep-seated abscess of 
the brain. With respect to this remarkable symptom of local 
inflammation of the brain, this external cedema, I shall relate the 
history of another case, as I am anxious to throw as much light as 
possible on this obscure subject. It may appear strange, that when 
a dense bony plate and an extremely strong membrane (besides 
other parts) intervene between the integuments and the seat of 
disease, that local oedema of external parts should take place as a 
consequence of internal inflammation. Strange however as it 
appears, it is true, and the intervention of the skull does not 
prevent it, as will be seen by the following case. 
A boy was admitted into the Meath Hospital, complaining of 
severe pain in the situation of the mastoid process. He was of a 
scrofulous habit, and had for a length of time a discharge of matter 
from both ears, with slight loss of hearing. Some time before his 
admission the discharge had been very copious, but on being- 
exposed to cold it was diminished in quantity, and he immediately 
was attacked with severe pain behind one of his ears. When he 
came into the hospital he was screaming with agony, but had no 
delirium, and the muscular system was unaffected. But what was 
chiefly remarkable in this case was, that, on the second day after 
admission, a distinct tumour formed in the upper portion of the 
neck, about an inch and a half behind the mastoid process. So 
distinct indeed was it, that it was generally believed that the disease 
was periostitis of the base of the skull, which had run on to suppu- 
ration. An incision was made over the tumour, and the knife 
was carried down to the bone, but no matter could be discovered. 
The patient then became gradually worse, the pain was dreadful, 
but there were no convulsions. Shortly before death he had a few 
slight muscular twitches, with delirium, and died in great agony. 
During the whole course of the disease, the discharge from the ear 
had continued and was remarkable for its fetor. On examining 
the brain, we found neither abscess nor arachnitis. On slitting up 
the longitudinal sinus, a remarkable fetid odour was perceived, ENCEPHALITIS. 
219 
which increased as the incision was prolonged in the direction of 
the left lateral sinus. Here there was a quantity of extremely fetid 
matter, of an almost cheesy consistence, and mixed with blood; 
and a communication was discovered between it and the internal 
ear, the bones of which were carious, and its cavity filled with the 
same kind of pus. Here we have a curious example of oedema of 
the external parts depending on deep-seated disease. 
I shall now relate the particulars of a case in which, although 
the symptoms of an affection of the brain were better marked than 
in the foregoing, still they were by no means so decided as one 
would have expected from the appearances revealed by dissection. 
A patient was brought into the Meath Hospital, with symptoms 
which were thought to be those which mark the ordinary form of 
delirium tremens. The man had been a great drunkard, but for 
some time back had given up the use of ardent spirits. He com- 
plained of severe and constant pain of the ear, which he stated 
to be of twelve weeks’ standing, and that it was this which first 
induced him to give up drinking, as he found that it was always 
aggravated by the use of spirits. On admission, he appeared to 
labour under a highly excited state of the nervous system; he had 
general tremours, and was incapable of keeping up a connected 
conversation, though he could answer a few questions accurately. 
Here we observe a remarkable difference between this and the last 
case detailed, in which there was not the slightest evidence of any 
lesion of the intellectual powers. In the present case, the symp- 
toms were pain, tremours, and incapability of supporting a rational 
conversation, but no decided constitutional symptoms. The pain, 
which had never abated since its commencement, became now 
violently exacerbated, he moaned frequently, and kept his hand 
constantly applied to the affected side of the head. To this last 
symptom I beg leave to direct your attention, as it is an exceedingly 
common one in cases of local inflammation of the brain. After a few 
days the mouth was drawn slightly towards the affected side, and it 
was found that the tongue was protruded in the opposite direction. 
Symptoms of fatuity now became more distinct, followed by coma, 
and the patient sank. During the whole course of the disease he 
had no spasms or paralysis of any of the limbs. On dissection, 
there was a circumscribed abscess found in the substance of the 
middle lobe of the brain. The abscess itself was encysted, but the 
substance of the brain round it was soft, particularly at its inferior 
part, where it was found to be connected with a carious state of the 
squamous portion of the temporal bone. There was a considerable 
degree of softening in that part of the brain which lay between the 
abscess and the corpus striatum. Here we have a case in which 
pain of the ear is chiefly complained of; but, in addition to this, it 
was observed that the patient could not sustain a connected con- 
versation, that there was some fatuity, that the mouth was drawn 
to one side, and that coma came on before death. Under such 
circumstances there could be less hesitation in pronouncing the 
disease to be an affection of the brain; and accordingly we find, on 220 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
dissection, unequivocal marks of disease of the middle lobe, in 
addition to the caries of the temporal bone. 
I might detail many cases of a similar kind, without being under 
any apprehension that I should be occupying your time to no pur- 
pose, for the recital of such cases is better calculated to convey 
information on this obscure subject than any lecture. I shall, 
however, content myself with one or two more. A man, addicted 
to the use of ardent spirits, was brought into the surgical wards of 
the Meath Hospital in a state bordering on coma. It was thought 
at first that he was labouring under typhus fever, and, under this 
impression, no particular attention was paid to the cerebral symp- 
toms for the first day or two. At the end of this period, it was 
learned that he had fallen in going up stairs, while in a state of 
intoxication. His head was shaved, but no signs of wound or 
contusion discovered, though his friends persisted still in their 
statement that he had fallen while intoxicated and hurt his head. 
When admitted into my wards he appeared moribund; his pulse 
was imperceptible at the wrist, he had extreme coldness of the 
limbs, and a disposition to the formation of gangrenous spots about 
the ankles. He was in a state of stupor; but when roused 
answered questions tolerably well, and said that he had no pain in 
his head. The remarkable feature however in this case, was a 
great degree of muscular rigidity, affecting all the extremities. The 
fore-arm was flexed, and he had not the power of extending it. 
The penis was in a state of permanent semi-erection, but there were 
no seminal emissions. Here was a case in which, taking all cir- 
cumstances into consideration, the cause of the disease seemed to 
be in the brain. He had been drunk, and was supposed to have 
got a fall while in that state ; he was comatose, from which, how- 
ever, he could be roused ; and he had rigidity of the limbs, with 
erection of the penis. With this view I came to the determination 
of treating it as a case of general inflammation of the substance of 
the brain. I concluded that there was no arachnitis, from the fact 
of his answering correctly when roused, while I felt convinced that 
if there was not actual inflammation of the substance of the brain, 
there was at least very intense and general irritation. The treat- 
ment in this case was successful. After warming the extremities 
by wrapping them in flannel, and the use of artificial heat, the 
head was shaved, a large number of leeches applied, and an ice cap 
ordered to be worn constantly. The leeching was repeated, and 
he used the ice cap for four days. On the second day after this 
plan of treatment had been entered upon, there was some improve- 
ment, but on the following day the accuracy of our diagnosis of 
inflammation of the brain appeared, for the patient had violent 
spasms of the right arm and leg. These however subsided, the 
coma, rigidity, and other symptoms also disappeared, and the 
patient slowly but perfectly recovered. In addition to the means of 
treatment already detailed, the patient’s system was placed under 
the influence of mercury. 
A question might arise as to the exact nature of this case. Was ENCEPHALITIS. 
221 
it a case of actual inflammation of the substance of the brain, or 
was it mere sympathetic irritation produced by some other disease? 
It may be said that it was a case of gastro-enteritis, with a sympa- 
thetic affection of the head. It certainly might be so, but the great 
probability is, that it was not; because such symptoms as were ex- 
hibited in this instance are very rarely the result of gastro-enteritis; 
and if it was a gastro-enteritis, it is not likely that such complete 
success should have followed treatment directed to the head. 
These circumstances make it likely that it was general irritation 
or inflammation of the substance of the brain itself; and, if so, the 
case strongly illustrates the utility of mercury, leeching, and cold 
applications in the reduction of encephalitis. The man was brought 
into the hospital in a dying state, and recovered under the influence 
of physiological treatment. 
While I am on this part of the subject, namely, the possibility of 
the head being sympathetically engaged in some instances to a very 
remarkable degree, I may say that the following conclusions on 
this point seem to be fairly drawn. That when an affection of this 
kind depends upon a gastro-enteritis, the signs of cerebral irritation 
are general rather than local. In children who are labouring 
under apparent symptoms of cerebral affection, it has been long 
known that the irritation of the brain may depend on a variety of 
causes. In adults, too, the symptoms of cerebral irritation may be 
the result of various affections, of gastro-enteritis, worms in the 
intestinal canal, hysteria, hypochondriasis, and many other diseases. 
In most of these cases, however, particularly with respect to chil- 
dren, the symptoms are general, being pain, delirium, coma, and 
convulsions on both sides. But we very seldom witness the 
occurrence of symptoms of local irritation of the brain as produced 
by sympathy with some other disease, though it is a fact that they 
may occur occasionally, and without our being able, after death, to 
discover any existing local encephalitis. A young female was 
admitted into one of the surgical wards of the Meath Hospital for 
some injury of a trivial nature. While in hospital she got feverish 
symptoms, which were treated with purgatives, consisting of calo- 
mel, jalap, and the black bottle, a remedy which deserves the 
name of the coffin bottle, perhaps better than the pectoral mixture 
so liberally dealt out in our dispensaries as a cure for all cases of 
pulmonary disease. She was violently purged, the symptoms of 
fever subsided, and she was discharged. A few days afterwards 
her mother applied to have her readmitted, and she was brought in 
again and placed in one of the medical wards. Her state on admis- 
sion was as follows:—she had fever, pain in the head, violent 
contraction of the fingers, and alternate contractions and flexions of 
the wrist and fore-arm. These muscular spasms were so great 
that the strongest man could scarcely control the motions of the 
left fore-arm. In addition to these symptoms, she had slight thirst, 
some diarrhoea, but no abdominal tenderness. On this occasion a 
double plan of treatment was pursued; the therapeutic means being 
directed to the head, in consequence of the marked symptoms of 222 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
local disease of the brain, and to the belly, from the circumstances 
of abdominal derangement observed in this and in her former 
illness. She died shortly after with violent spasms of the hand 
and fore-arm; and as she had presented all the ordinary symptoms 
of a local inflammation of the opposite side of the brain, we natu- 
rally looked there first for the seat of the disease. After a careful 
examination, however, no perceptible trace of disease could be 
found in the substance of the brain, which appeared all throughout 
remarkably healthy. She had all the symptoms which, according 
to Serres and Foville, would indicate disease of the optic thalamus, 
or the posterior lobe of the opposite side, yet we could not find any 
lesion whatever of its substance after the most careful examination. 
But on opening the abdomen we found evident marks of disease; 
the lower third of the ileum, for the length of six or eight inches, 
was one unbroken sheet of recent ulcerations. This case I look 
upon as a very singular one, showing that we may have well- 
marked symptoms of a local irritation of the brain depending on a 
sympathetic cause. It is fortunate, however, for the study of me- 
dicine, that such cases form the exception and not the rule. I may 
remark here on the latency of the enteritis as to the pain. There 
was no abdominal tenderness, a fact illustrative of the great law 
which so particularly applies to gastro-enteric disease, that when 
the sympathetic affections are prominent, the usual or local symp- 
toms are proportionally latent. 
With respect to the prognosis in cases of local encephalitis, the 
following conclusions seem to be well grounded. As a general 
rule, the prognosis is to be unfavourable, from the nature of the 
organ, its importance to life, and the frequent complicated and 
obscure nature of cerebral affections. In local encephalitis you 
have always two things to apprehend—the acuteness of the disease, 
and its subsequent effects. The patient may die of acute inflam- 
mation, or, if you control this, of the chronic disorganisation which 
frequently supervenes, terminating in apoplexy, paralysis, and other 
consequences. On the other hand, it is consolatory to reflect that 
experience has proved the possibility of curing both general and 
local inflammation of the brain. There are numerous cases on 
record in proof of the success of well-directed treatment. The 
annals of surgical science are filled with cases of extensive injury 
of the brain successfully treated; and it is equally true, that medi- 
cine can exhibit many instances of well-marked idiopathic inflam- 
mation of the brain brought to a favourable termination. In making 
our prognosis on a case of local encephalitis, much will depend 
upon the extent to which the muscular system is affected. Spasm 
of one extremity is more favourable than spasm of both; and an 
affection of the muscles of the face is not so unfavourable as of 
those of the extremities. The next thing to be considered is the 
age of the patient. In the very young, and in persons advanced in 
life, our prognosis is not to be so good as in the case of one removed 
from these extremes, as neither of the former admit of such active 
treatment; but of the two, it is better to have to manage the disease ENCEPHALITIS. 
223 
in a child. It is also singular how well children will often bear 
active treatment. 
There is another point which should not be omitted. There are, 
in some cases of local inflammation of the brain, muscular contrac- 
tions and extensions, alternating with a state of rigidity, while in 
other cases the rigidity is permanent. It is not easy to say which 
of these cases is the worst, but I believe that the most unfavourable 
are those in which we have chiefly violent contractions and ex- 
tensions. Again; with respect to the cessation of the spasms, it 
may be considered either as a favourable or a most unfavourable 
symptom. The circumstance of the cessation of the spasms must 
have been produced by some modification in the state of the cerebral 
affection. If it be accompanied by a return of the power of trans- 
mitting proper motion to the affected limb, it is then a sign of great 
value, as showing that the cerebral irritation is nearly gone. But 
if the spasms subside, in consequence of the supervention of reso- 
lution arid paralysis, then the cessation is a symptom of a most 
unfavourable kind, as showing that actual disorganisation has 
taken place, which seems to be incurable. 
It may be necessary to remind you that if the patient has, com- 
bined with these spasms, alternations of delirium and coma, it 
affords grounds for making a bad prognosis, as such symptoms 
indicate that the inflammation has extended to the periphery of the 
brain, and the arachnoid membrane. The state of the intellect is 
also a matter of importance; the more intact and undisturbed it is, 
the greater is the chance that the affection of the brain is confined 
within a small compass. Here, however, I am anxious to impress 
this upon your minds, that the absence of delirium should not 
mislead you, or induce you to form any favourable conclusions on 
that account alone, in cases of encephalitis, for it is a fact that we 
may have extensive and fatal disease of the substance of the brain 
without delirium. I need not tell you that convulsions, or para- 
lysis of one side, do not indicate so unfavourable a prognosis as 
where both sides are engaged. Lastly, you should bear in mind 
that cases of inflammation of the substance of the brain are very 
subject to relapse. All these circumstances should be taken into 
account, and a favourable prognosis should be always formed with 
a great deal of caution. 
I alluded in a late lecture to the occurrence of pain in some par- 
ticular part of the extremities, as a premonitory sign of this disease. 
A remarkable case, bearing on this point, has come to my knowledge, 
and I think I cannot better employ the remaining part of our time 
than in giving a brief abstract of it. A lady got a pain in the lower 
part of the tendo Achillis, which was considered to be rheumatic, 
and very little notice taken of it. There was no swelling, heat, or 
tenderness on pressure, in the painful part, and the nature of the 
disease was so imperfectly understood that all the efforts of her 
medical attendants were directed to the heel, but without any benefit 
whatever. Matters remained in this state for some time, when she 
was suddenly attacked with convulsions and coma, and died. On 224 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
opening the head some hours after her demise, a large abscess, 
together with an apoplectic effusion, was found to exist in the 
opposite hemisphere of the brain. There are various other exam- 
ples of a similar kind. I have no doubt that many of those 
anomalous pains are frequently connected with incipient disease of 
the brain. I know the case of a gentleman, labouring under a 
painful affection of the face, which had got the name of tic doulour- 
eux, and had been subjected to all the variety of treatment which 
persons labouring under that affection so commonly undergo. But 
it has since been proved that his complaint is by no means analo- 
gous to what has been termed tic douloureux, for it has been most 
successfully treated by shaving the head, and applying leeches and 
an iced cap over the seat of the suspected irritation. At present, 
whenever an attack comes on, he immediately gets a bladder, con- 
taining a quantity of pounded ice, applies it to his head, and in this 
way obtains relief. This shows that the severe pain in his case, 
which many would confound with a local affection of the nerves of 
the face, is decidedly the result of a morbid sensibility of the cerebro- 
spinal centre, 
LECTURE XXVI. 
Encephalitis—Treatment of in the adult—Importance of energetic means—Dangerous 
effects of opening the temporal artery or jugular vein—Copious blood-letting from the 
arm—Difficulty of producing syncope—Employment of cold—Good effects from 
purgatives—Encephalitis caused by piles—Treatment—Beneficial effects of blisters 
—Mercury—Dangerous effects of emetics—Dessault’s treatment—Use of opium— 
Violent counter-irritation of coma—Application of boiling water—Treatment of 
partial encephalitis. 
We have now to enter upon the treatment of inflammation of the 
brain ; and you will find that a knowledge of the general principles 
of the treatment of cerebral inflammation will be quite sufficient to 
guide you, even in the management of cases which present apparent 
exceptions to the ordinary symptoms. The truth is, that the prin- 
ciples which should regulate the treatment of inflammation of the 
brain are nearly the same in all cases. 
I shall commence with the treatment of the acute form in the 
adult. Acute phrenitis in the adult is an exceedingly severe dis- 
ease, characterised in its first period by an high exaltation of the 
functions of the brain, and in its second by a corresponding de- 
pression. In this form of disease we have generally high fever, a 
strong bounding pulse, throbbing of the carotids, intense pain of the 
head, great brilliancy of the eye, with intolerance of light, vivid 
redness of the face, a ferocious countenance, and furious delirium. 
Under such circumstances there is no time to be lost; the brain is 
a delicate organ, and cannot bear much disease, and its powers of ENCEPHALITIS. 
225 
recovering from idiopathic disorganisation seem much less than 
those of the lungs or abdominal viscera. Indeed, we must believe 
that, notwithstanding the assertions of Lallemand, it remains to be 
proved that recovery can take place after the stage of softening has 
set in, in idiopathic encephalitis. The brain differs from the lungs 
or digestive organs in having no excretory duct for the products of 
inflammation, and hence one cause of the greater danger of its idio- 
pathic inflammations than its traumatic, where an opening is formed 
in the skull. In such a case you have to apprehend two patholo- 
gical lesions, the inflammatory softening of the substance of the 
brain, and the inflammation of its serous membranes, with effusion 
into their cavities. The patient, too, may die from congestion, or 
even an apoplectic effusion may occur, illustrative of the proposi- 
tion of Broussais, that all encephalic irritations may produce an 
apoplexy. I have seen this termination, even in the infant under 
a year old ; in such a case I once saw an apoplectic effusion which 
had supervened in the course of an arachno-cerebritis, and which 
amounted to several ounces of blood. Every moment is precious, 
and no consideration should induce you to put off, even for an hour, 
the adoption of the most rigorous measures. In the first place, you 
must bleed; and here let me remark that blood-letting should be 
performed so as to make a decided impression on the symptoms. 
It will often happen, that, from the state of uncontrollable fury 
which the patient is in, it is dangerous and almost impossible to 
bleed him. Here you must endeavour to moderate the delirium, 
and there is no way by which you can accomplish your purpose so 
fully as by cold dashing. Where there is high delirium, I believe 
you will always find it the best plan to precede venesection by 
throwing a few basins of cold water over your patient’s head. 
This will procure an interval of comparative tranquillity, during 
which you can open either a vein or an artery with convenience 
and safety. Of course, if any thing like collapse ensues (which is 
possible) you will not bleed immediately. The object of the cold 
pouring, under these circumstances, is to obtain such a diminution 
of the fury as will allow of your bleeding the patient with safety, 
as to the operation. If you cannot reduce the cerebral excitement 
by this means, it will then be necessary to put on the strait waist- 
coat, pro tempore. There is a difference of opinion among medical 
men with respect to the mode of abstracting blood ; some prefer 
taking it from the arm, some from the jugular vein, and some from 
the temporal artery. Now, I am inclined to think that it is better 
to open a vein in the arm, and that venesection performed in this 
way will be found to answer every purpose. It is said that if you 
take blood from the temporal artery or jugular vein, you deplete 
the brain more directly than you would by opening one of the 
brachial veins. This may be true, though I think it still remains 
to be proved that the drawing of a smaller quantity of blood from 
these vessels will have a more powerful effect on the system than 
from the arm. If you open the temporal artery, there are two 
disagreeable circumstances which you should be prepared to meet. 226 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
In the first place, the patient is in a state of furious delirium, you 
don’t know how long this may last, and it may happen that in one 
of his paroxysms he will tear off the bandage, and, if not watched, 
bleed to death. A case of this kind occurred not long since in the 
person of a gentleman of this city, who had the temporal artery 
opened. He tore off the bandage, and a terrible hemorrhage 
ensued; assistance was procured, and the bandage re-adjusted; he 
tore it off a second time, and died shortly after, his death being 
evidently accelerated if not actually caused by the quantity of blood 
lost. Again, it is possible that an aneurism may be formed as a 
consequence of the operation, which may excite a determination to 
the head, and tend to keep the patient in a state of excitement. 
Thirdly, you must employ a bandage to secure the artery, and to 
this there is a strong objection, in consequence of the pressure 
which it makes on the external vessels of the head. I am there- 
fore strongly opposed to opening the temporal artery in cases 
of acute inflammation of the brain, accompanied by high mental 
or muscular excitement. Now, with respect to the jugular vein, 
you are aware that to command this vessel pressure is also required. 
How this pressure can be made without interfering with respiration 
and compressing the veins of the neck, so as to add to the existing 
congestion of the head, I am at a loss to know. I would advise 
you, therefore, when you bleed in phrenitis, to prefer opening a 
vein in the arm ; by making a free incision you can draw blood in 
such a way as to make an impression on the system, fully equal to 
that produced by either of the foregoing modes ; and without sub- 
jecting your patient to the same degree of inconvenience or risk. 
The quantity of blood to be taken away must be regulated by the 
age, strength, and constitution of the patient, as also by the intensity 
of the disease. Where you have to deal with a young man of 
robust constitution, your first bleeding may amount to thirty 
ounces. You will often find it difficult to produce fainting in this 
disease, for the excited condition of the brain keeps up a constant 
determination to that organ, and prevents syncope. The same 
difficulty is met with in cases of hypertrophy of the left ventricle, 
which causes a great determination to the head. 
Your next step is to have the head shaved. Never omit this. 
The very circumstance of freeing the head from the covering of 
hair, and permitting the free contact of air with the scalp is of 
advantage ; and if you wish to employ cold applications, you can- 
not do so properly without premising this operation. After you 
have done this, you should apply a large number of leeches to the 
scalp, or if you cannot readily procure leeches, employ instead of 
them light scarifications to the temples and nape of the neck, and 
keep on the cupping-glasses until you have obtained a sufficient 
quantity of blood. By acting in this way with promptness and 
decision, you arrest the violent symptoms and gain time. 
In treating a case of this kind it is a very common practice to 
use cold applications. They are for the most part applied in shape 
of a cold lotion to the head, but I need not tell you that this is a 227 
ENCEPHALITIS. 
very imperfect mode of using them, and indeed I have seen but 
very few persons who were acquainted with the proper mode. 
Persons are in the habit of supposing that the mixture of a certain 
quantity of saline ingredients with water should produce a very 
cold lotion, and so it does indeed while the salts are dissolving; 
but as soon as this is accomplished, the mixture rapidly acquires 
the temperature of the surrounding air. The solution is generally 
prepared by the apothecary, (and sent in a bottle, as if they could 
cork up the cold,) but the cold is quickly lost, and, in a few moments 
after the lotion has been applied, you will find it tepid, and passing 
into a state of vapour. Now if you wish to derive any benefit from 
the use of cold applications, you must stand by yourself, and see 
the thing properly done. The object is to have the scalp kept con- 
stantly cold, and this can be done only by the repeated application 
of cold lotions. If you prefer saline lotions, you should have them 
made by the bedside, and applied while in the act of solution, or 
you should put a quantity of ice into your lotion, for while a single 
piece of the ice remains undissolved, the temperature of the lotion 
will be very little above the freezing point. A very good way is to 
have a jar of cold water with a quantity of ice in it, and to apply 
cloths dipped in it every minute, taking care not to immerse the 
hot cloth into the iced water until it has been wrung out in another 
vessel of water. You may also use the ice cap, though this is a 
painful remedy. But the mode of using ice to the head, which I 
prefer in all cases, and particularly in that of the child, is to take a 
piece of smooth ice, about the size of a dollar, and half an inch 
thick; this is to be placed in the hollow of a fine cup sponge, and 
steadily moved over the whole shaved scalp. By this mode you 
prevent the pain which the iced cap produces, and the sponge 
absorbs the water produced by melting, and the application may be 
continued for an indefinite length of time. But one of the best 
modes of applying cold to the head is that recommended by Dr. 
Abercrombie, and, as far as my experience goes, I can safely affirm 
that there is scarcely any remedy of such unequivocal value in 
acute inflammation of the brain or its membranes. Dr. Abercrom- 
bie’s mode is this—the scalp being first shaved, you direct the 
patient’s head to be held over a basin, and then taking a jug of cold 
water, pour its contents over the head from some height in a small 
continuous stream. This measure, simple as it may appear, is one 
of extraordinary efficacy. In fact, so great and instantaneous is 
the depression of the vital power produced by this mode, that it 
must be used with caution. There are numerous cases of persons 
in the highest state of maniacal excitement, reduced in a few mo- 
ments to a low and weak state by this powerful remedy. There are 
also instances of its rapidly depressing effect in the early stages of 
acute hydrocephalus. I have used it more in the phrenitis of adults 
than in the hydrocephalus of children; but in the latter disease I 
know many instances of its value, and believe it to be only second- 
ary to the application of leeches. In acute inflammation this form 
of cold effusion should be employed every hour or half hour, 228 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
according to circumstances, and if you wish to increase its efficacy 
you can do it by placing the patient’s feet in warm water at the 
time of its application. Here, then, gentlemen, is the first set of 
remedies you should employ in a case of acute phrenitis; a full 
bleeding from the arm, premising it, if there be great maniacal 
excitement, by dashing a basin of water over the patient’s head; 
shaving the head, and applying a large number of leeches, or if 
these are not within reach, the use of cupping; and, lastly, the 
constant application of cold lotions, or the use of the cold affusion 
after the manner employed by Dr. Abercrombie. These are the 
great measures which should be boldly and promptly put in prac- 
tice, in order to counteract the first violence of a case of acute 
inflammation of the brain. 
You will next act upon the bowels by purgatives. This is a 
matter of the deepest importance, for there is hardly a disease in 
which the judicious administration of purgatives has been followed 
by more decidedly beneficial effects, than in inflammation of the 
brain, where the digestive tube has been in a healthy condition. 
Purgatives are also found to be of great benefit in the simple 
hydrocephalus of children, and in several cases it has been 
observed that the disease did not yield even after active bleeding, 
until purgation had been employed. Dr. Abercrombie speaks in 
the highest terms of the value of purgatives, even after coma has 
set in. The purgatives which are generally used are those of the 
drastic kind, and they may be given by the mouth or in the form of 
enemata. 
Such are the rules for the treatment of the ordinary form of acute 
encephalitis. I shall now make a few observations with respect to 
the local applications. It may not be necessary to repeat the vene- 
section, particularly if the means which I have recommended be 
put in practice in a regular and proper manner, but it will in most 
cases be requisite to repeat the leeching. Even in the advanced 
stage of the disease, and after coma has made its appearance, 
Dr. Abercrombie lays great stress on the benefits derived fromthe 
application of leeches; and I think I have myself saved some lives 
by the employment of leeches, even after the supervention of coma. 
In all violent cases I would recommend strongly to you the using 
relays of leeches from the first, to keep up a continual detraction of 
blood. In addition to this, the patient must be kept perfectly quiet, 
all loud sounds, and the stimulus of light avoided; the room should 
be kept cool and well-aired, the bed-covering light, the attendants 
few, and the nurse should be a person of cool temper and steady 
disposition. 
These are the principal measures to be employed in the treat- 
ment of acute inflammation of the brain in the adult; there are 
certain cases, however, in which you may add to these measures 
others of a different kind, particularly in cases where the disease 
has occurred as a consequence of the metastasis of inflammation 
from other parts. Suppose you have a case of rheumatism, or of 
some suppressed evacuation in which there is a metastasis to the ENCEPHALITIS. 
229 
brain. Under such circumstances, while you employ the means I 
have mentioned for the purpose of subduing cerebral inflammation, 
you will also put in practice the best measures for restoring the 
original disease. Here, however, you should bear in mind, that 
your attempts to bring back the original disease are always to be 
looked upon as secondary to those for the direct removal of the 
existing irritation of the brain. Some practitioners, in such cases, 
content themselves with endeavouring to restore the original affec- 
tion, but this is playing a dangerous game. An organ of vast 
importance to life is affected, and you cannot calculate how far the 
inflammation may proceed. You should never neglect taking 
proper steps at first to reduce inflammation, while at the same time 
you need not neglect the means calculated to bring back the former 
disease. If the encephalitis be caused by the suppression of bleed- 
ing piles, or a sudden checking of the menstrual flux, leeches to the 
anus or vulva are found useful along with the direct treatment. If 
the disease be produced by the repression of an exanthematous 
eruption, the same principles apply. You should never omit em- 
ploying the means for bringing back the original affection, but you 
should always recollect that they are to be secondary to the mea- 
sures adopted to directly relieve the cerebral excitement. 
With respect to the use of blisters, the same rules apply here as 
in other cases of disease treated of during the course. They are 
never to be used in the early stage of the disease, and while active 
inflammation is present; and, as a general rule, I believe it is better 
to apply them to the nape of the neck, or the inside of the legs, 
than directly to the head. There is only one case in which you 
can apply them with advantage to the head itself, and this is where 
there is coma with a cool skin. Here the stimulus of a blister is 
frequently found to be highly useful. 
As to the use of mercury in cases of acute cerebral inflammation, 
I think we have not as yet a sufficient number of facts on which 
to form any decided opinion. If we look to hydrocephalus, we 
shall find that there are many cases in which the symptoms did 
not yield to the ordinary measures until mercury was employed; 
this, however, we do not find to be so much the case in the acute 
inflammation of the brain in the adult.—I shall return to this sub- 
juct on a future occasion. 
I have little doubt that emetics are very dangerous in this disease, 
from the determination to the head which they produce. 
Any of you, gentlemen, who has vomited, cannot forget the 
violent sense of tension about the head with which the act is 
accompanied; and, if the brain be in a state of acute inflammation, 
you can readily conceive how injurious such an effect must «be. 
The use of emetics in this disease has been adopted in consequence 
of a misconception of the opinions of Dessault. He attributed 
extraordinary efficacy to the use of tartar emetic, in cases of inju- 
ries of the head. But you must be aware that Dessault did not 
give tartar emetic so much with the view of exciting emesis, as of 
producing a degree of nausea calculated to keep down injlanima- 230 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
tory action. Moral, who was a pupil of his for five years, makes a 
statement to this effect, and says that so far from proving beneficial 
when it vomited, the tartar emetic was always attended with 
unfavourable results. When it acted on the skin, or by stool, he 
says the effects were favourable ; but when it vomited, the symp- 
toms of cerebral excitement were always increased. Under these 
circumstances, I think you should be cautious in having recourse to 
the use even of tartar emetic, after the manner of Dessault; for 
even in this way you run the risk of vomiting. On this point we 
have eight very instructive cases given by Lallemand. In the first 
two cases, where emetics were used, the head had been merely 
threatened. The emetics were followed by profuse vomiting, and 
this by symptoms of violent cerebral excitement and rapid death. 
The third case was that of a patient who had apoplexy: the emetic 
was followed by symptoms of inflammation of the brain and death. 
On dissection, there were marks of inflammation discovered round 
the clot. Now it has been observed, in several instances, that 
where the substance of the brain round an apoplectic clot became 
inflamed, that, in addition to the phenomena of apoplexy, symp- 
toms of a spasmodic affection of the muscular system supervened. 
Here we see, that after the use of an emetic these symptoms 
appeared, and their nature was verified by dissection. In the 
remaining five cases, where emetics were employed, the cerebral 
affection was rather increased than diminished; and, in some of 
them, disease of the digestive tube was superadded. Weighing 
these circumstances calmly, I think the use of emetics in aeute 
inflammation of the brain may be considered dangerous. 
With respect to opium I must say, that I am strongly opposed to 
its employment, at least in the early stage of encephalitis. I have 
seen many cases of hydrocephalus in children, in which opium 
seemed to be decidedly injurious ; and I believe that in all cases 
where there is congestion of the brain, its employment will be 
attended by bad effects. But when all the symptoms of active 
inflammation have passed away, and when there remains a peculiar 
nervous condition of the brain, characterised by symptoms of men- 
tal excitement and persistent watchfulness, somewhat resembling 
delirium tremens, here, I believe, that you may have recourse to 
opium with much benefit. In many cases where the antiphlogistic 
treatment had been properly employed at the commencement, there 
frequently remains a neurotic condition of the brain, accompanied 
by great irritation and absence of sleep ; and in such cases I have 
seen much good resulting from the use of opiates. When I speak 
of fever I shall return to this subject. 
In the treatment of this disease, I am anxious that you should 
always bear this principle in mind—that you cannot be too cautious 
in adopting means of coercion. Coercion has always a bad effect: 
it should never be resorted to, except in cases of extreme necessity; 
and you should never suffer the patient’s attendants to employ it. 
without your express permission. It is a common practice in hos- 
pitals, where the attendants always wish to save trouble, to put on ENCEPHALITIS. 
231 
the strait waistcoat as soon as the patient exhibits symptoms of 
delirium. What is generally the result of this treatment ? The 
poor sufferer becomes irritated by confinement, and uses the most 
violent efforts to liberate himself; his struggles increase the excite- 
ment of the brain, and prevent the measures you employ from 
taking effect. I have known many melancholy cases, illustrative 
of the abuse of the strait waistcoat. I shall give you one :—A 
female, of delicate habit, was attacked with fever and some delirium. 
She was supposed to labour under disease of the brain. They put 
a strait waistcoat on her, and tied her down to the bed, where she 
remained for several days in a most deplorable state. A medical 
man, who was called in to see her at this time, found her in the 
situation described, with her head shaved and blistered, and her 
strength sinking. It struck him that there was something peculiar 
in the case, and he asked her several questions with the view of 
testing her sanity; and, finding that she answered rationally, he 
immediately directed that the strait waistcoat should be taken off. 
She then told him that, during the whole course of her illness, she 
had laboured under pain of the right side. He examined her side, 
and found a large tumour in the situation of the liver. There 
was also an eschar on the back. She died shortly afterwards; and, 
on dissection, the liver was found to be in a state of extensive 
suppurative disease ; the brain perfectly healthy. It is unneces- 
sary for me to make any comment on this case. 
While, however, I deprecate coercion as a common mode of 
proceeding, I fully admit that cases will occur that demand it for 
the safety of the patient. The dreadful tendency to suicide is one 
of the characters of this disease, and must never be forgotten in any 
case. All that I wish to impress upon you is, that coercion must be 
used with great caution, and only so long as it is absolutely neces- 
sary. When we come to treat of the nervous systems in fever, I 
shall recur to this subject. 
In all cases of cerebral disease you should never omit enquiring 
into the state of the bladder, for there is often retention of urine. 
This is to be obviated by drawing off the urine with a catheter, 
two or three times a day. 
You will meet with cases of cerebral inflammation in the last 
stage, with profound coma, general paralysis, an imperceptible pulse, 
and tracheal rattle. It is a melancholy thing to be called to a case 
of this description, where the ordinary means furnished by medi- 
cine are so inadequate to the removal, or even the alleviation of' 
symptoms ; and yet it is a fact that, even under these circumstances,, 
cases have been cured by the adoption of an extraordinary measure. 
This consists in the employment of enormous and sudden counter- 
irritation, by pouring boiling water over the lower extremities,, 
while, at the same time, ice is applied to the head. This is certainly 
an extraordinary and barbarous method; but it has succeeded in 
rescuing the patient, as it were, from the jaws of death. One off 
the most singular cases of this kind is recorded by Lallemand— 
that of a man upwards of sixty, who, in consequence of a fall on 232 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the head, was attackd with encephalitis, which was mistaken for 
an essential fever until the tenth day. At this time he was first 
seen by Lallemand, who found him labouring under severe and 
long-continued syncope ; the right extremities flexed ; the hand 
firmly closed; the surface on this side insensible; the eyelids 
closed ; the eyes turned up, squinting, and insensible to light; 
complete loss of hearing and intelligence. The body was covered 
with a cold viscid sweat; the respiration frequent and stertorous, 
and the pulse absent. Lallemand proposed pouring boiling water 
on the ankles, and, at the same time, applying ice to the head, an 
advice which was consented to with great reluctance by the ether 
medical attendants. At the moment the boiling water was applied, 
there was a sudden motion of the whole body: the left arm was 
agitated, the eyes opened, and the pulse could be felt at the wrist. 
In half an hour the boiling water was applied to the thighs with 
still greater effect; colour returned to the face, and the pulse 
became fuller. From this time improvement went on. Deep 
suppurating wounds were produced by the boiling water which 
took more than six weeks to cicatrise. The patient’s recovery 
perfect. 
In Dr. Mackintosh’s work you will find this practice recom- 
mended. It is indeed an extreme remedy, and one which, for 
many reasons, practitioners would have repugnance to use; but 
it is well to be acquainted with such a powerful remedy, and 
to know that it has succeeded under the most desperate circum- 
stances. 
With respect to partial encephalitis, the principles of treatment 
are the same. In this form of disease you will often have ta 
contend with the prejudices of the patient, and sometimes of practi- 
tioners who do not recognise its existence. Its symptoms, you will 
remember, may at first appear slight or insidious, and to the super- 
ficial observer less referable to the head than elsewhere; yet the 
disease is full of danger, slight though it appear. The recent 
researches on this subject have shown, too, that it is commonly a 
comparatively acute disease. Andral gives a table, showing the 
periods in one hundred and five cases: in eighty-nine of them 
death occurred within a month. The liability, too, of secondary 
complication, with general congestion, arachnitis, or apoplexy, must 
be always borne in mind. 
When the symptoms of a local encephalitis are decided, I think 
you should always commence by bleeding from the arm, and then 
apply relays of leeches and cold lotions to the opposite side of the 
head. You will also find the application of tartar emetic ointment, 
so as to bring out an eruption as soon as possible, of great value in 
cases of this kind. Above all things, take care to relieve the symp- 
toms by prompt and decided measures before the stage of paralysis 
comes on, for when this arrives, I believe you can do very little in 
the way of cure. I have seen three cases in which, after the deple- 
tions, the symptoms were relieved by bringing the patients rapidly 
under the use of mercury; and I think local inflammation of the ENCEPHALITIS. 
233 
brain may be treated by mercury as well as localised inflammation 
of other parts. My late lamented friend, Dr. Leahy, communicated 
to me the particulars of two cases in which pain, spasms, and other 
symptoms of a local encephalitis were present, and in which com- 
plete relief was obtained as soon as mercurial action was brought 
on. I recollect an old lady who got pain in the right side of the 
head, with contraction of the finger of the left hand, and alternate 
flexions and contractions of the fore-arm, accompanied by slight 
lesion of the intellectual functions. She was leeched three or four 
times, blistered, and purged, without any decided relief. I then 
determined to try the effect of calomel, and was gratified to find 
that, according as her mouth became affected, the pain and contrac- 
tion of the fingers, as well as the motions of the fore-arm, diminished 
considerably, and as soon as full ptyalism was established all her 
symptoms disappeared. This case is particularly interesting, inas- 
much as it shows that the ordinary treatment by leeching, counter- 
irritation, and purging, failed in giving relief, so that we are justi- 
fied in attributing some value to the use of mercury. In the advanced 
stages of this disease, it seems right to employ a seton in the back 
of the neck; and I would advise all who have been attacked to 
continue the use of this remedy for a great length of time. 
The term ramollissement, or softening of the brain, is one which 
is very extensively used, and I fear often without any precise idea 
of its meaning. In ninety-nine cases out of a hundred this ramol- 
lissement will be found to depend upon local inflammation of the 
brain ; of this I do not entertain the slightest doubt. I think we may 
very safely consider it as analogous to the softening of the lungs, 
liver, or spleen, or from inflammation of their texture. There is a 
peculiar softening of the brain in old persons, which we cannot con- 
nect with actual inflammation, but in all cases in the child, and in 
almost every case in the adult, ramollissement of the brain will be 
found to depend on inflammation. I do not mean to infer from this 
that it is in our power to cure every case of softening of the brain, 
for when it once sets in, the great probability is that the texture of 
the affected part is destroyed ; but we can cure many cases by 
subduing the inflammation from which it derives its origin. Of 
course we cannot expect to accomplish this in the case of old per- 
sons, where the symptoms come on without any inflammatory phe- 
nomena, as in that peculiar softening of the brain which forms the 
subject of Rostan’s work, and occurs in persons beyond the age of 
seventy. This appears to be a species of senile gangrene. That 
form of ramollissement, which occurs in adults and children, is, 
however, very different from this, being, in the vast majority of 
cases, the result of inflammation. You will hardly ever dissect a 
case of partial encephalitis in the adult, or of hydrocephalus in the 
child, without finding more or less of this inflammatory softening. 234 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
LECTURE XXVII. 
Analysis of symptoms of cercbritis—Inconstancy of pain—Arachnitis, pain of—Inter- 
mittent pain—Headache—Phenomena of the eye—State of the pupils—Various 
affections of the functions of vision—Researches of Parent and Martinet—Relief 
by convulsions—Brain considered as a secreting organ—Dangerous effects of opium; 
delirium—Phenomena of organic life—Vomiting in hydrocephalus—Sympathies of 
the digestive and respiratory systems—Treatment of hydrocephalus—Of internal 
remedies—Cancrum oris, treatment of. 
Before we leave the subject of inflammation of the brain, I shall 
draw your attention to a brief analysis of some of the more promi- 
nent symptoms of this disease ; and here I am anxious to impress 
upon you, that the true mode of studying this subject is not by 
reading the descriptions given by this or that systematic writer, 
but by the careful perusal of monographs, in which the details of 
a great number of cases, occurring under different circumstances, 
are accurately reported. You would be mistaken, indeed, if you 
were to conclude that you had acquired a thorough knowledge of 
the symptoms of phrenitis or arachnitis by reading the description 
of Cullen, Thomas, or Mason Good. The only mode of studying 
the subject properly is, to take accurate notes of every case which 
you meet with, and to study with care those monographs in which 
a number of eases, attended by different symptoms, are detailed 
with impartiality. 
I would not occupy your attention further with this subject, but 
that there is much error prevailing with respect to inflammation of 
the brain and its membranes. Persons are in the habit of suppos- 
ing that these symptoms are always constant and well marked, but, 
the truth is, they are subject to very great varieties. The first 
symptom, to which I shall call your attention, is pain. This, you 
will recollect, is a prominent symptom of most visceral inflamma- 
tions, where the disease is situated on, or close to, the surface of the 
organ ; but, when it is deep seated, this symptom becomes more or 
less obscure. Now, in a case of arachnitis, we have a double 
source of pain—one depending upon the affections of the serous 
membrane, the other arising from the circumstance of disease being 
situated on the surface ; and hence it is that, in the great majority 
of cases of arachnitis, pain is a constant and prominent symptom. 
Still, if you were to conclude that pain is always present in arach- 
nitis, you would be wrong—for there are many cases on record in 
which it was either partially observed or completely absent. You 
will be greatly assisted in your pathological studies by attending to 
the different results of inflammation of analogous structures, for we 
find that in some of the inflammatory affections of serous mem- 
branes there is little or no pain. We may, for instance, have pleu- 
ritis, pericarditis, and even peritoneal inflammation latent, so far as 
pain is concerned; nay, many persons have gone so far as to say, 
that it is only where the muscular tissues of the belly are engaged 
that we have pain in peritonitis. I have seen pericarditis run SYMPTOMS OF CEREBRITIS. 
235 
through all its stages without any pain being complained of by the 
patient. Now, if this absence of pain be a matter of no unusual 
occurrence in some inflammatory affections of the pleura, pericar- 
dium, and peritoneum, there is no reason-why it may not occur in 
some cases of arachnitis. Still, it must be acknowledged that pain 
is one of the most remarkable and constant symptoms of arachnitis, 
and that, of all the serous membranes, the arachnoid seems to be 
endowed with the greatest sensibility. 
We might enquire, here, whether the pain of cerebral inflamma- 
tion be significant of any particular lesion of the brain. I believe 
that upon this point the state of our knowledge is very unsatisfac- 
tory. Pain, as a symptom of cerebral inflammation, occurs in very 
different cases. We may have it in connection with disease of the 
superior, lateral, or inferior parts of the brain ; we may have it in 
cases where the result of the disease is a serous, hemorrhagic, or 
purulent effusion. The rale, then, to be borne iti mind is this: 
first, that it is present in the great majority of cases of arachnitis; 
next, that it may accompany many different lesions; thirdly, that 
it may be absent; and lastly, that, with the same lesions, we may 
have pain in one case and absence of it in the other. 
The next subject for enquiry is, does the seat of pain generally 
point out the seat of inflammation? Andral distinctly affirms that 
it does not. In some cases, pain of the frontal region has been 
found to accompany disease of the ventricles, and pain in one side 
of the head, an affection of the arachnoid covering of both hemi- 
spheres. We see the same thing occurring in the case of other 
serous membranes. Thus, in the pleuritic inflammation of phthisis, 
pain is very seldom felt in the situation of the disease, but generally 
lower down ; and I have seen some cases in which pain has been 
complained of only in the sound side. I recollect a case of very 
extensive pneumonia, in which the patient complained only of some 
pain in the region of the kidney and small of the back. 
The pain which accompanies arachnitis generally sets in at an 
early period of the disease, and is characterised by great intensity— 
two circumstances in which it resembles the pain of pleuritis. In 
most cases, it is found that any thing that impedes or oppresses the 
circulation of the brain increases this pain; and hence it is that 
some practitioners are led to think, that, if pain of the head be 
relieved by pressure, it cannot be inflammatory. Now, I wish to 
call your attention to this point, because, in some cases where evi- 
dent marks of arachnitis were found after death, it was observed 
that during life the pain of the head was relieved by pressure. 
The patients have been found with a bandage tied firmly round the 
head, from which they experienced decided relief, and yet a post 
mortem examination gave unequivocal proof of the existence of 
arachnitis. So far, then, as these cases go, it appears that the mere 
fact of pain being relieved by pressure does not prove that it is 
unconnected with an inflammatory cause. The pain, too, of an 
arachnitis may be intermittent, and continue to exhibit this charac- 
ter even for a considerable length of time. I have seen many 236 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
instances of this in children, where the little patient was seized 
with acute pain of the head at a particular time of the day, which, 
after a few hours’ duration, subsided, and then returned again the 
next day at precisely the, same hour, and continued in this way for 
several weeks, until at length his friends were surprised by the 
unexpected supervention of coma, convulsions, or blindness. I 
knew two cases of this kind in which the intermittent character of 
the pain was so prominent as to engross the practitioner’s whole 
attention; so that the real nature of the affection was overlooked, 
and bark prescribed. I have now witnessed three or four of these 
regular quotidian attacks of pain in children, which, after continu- 
ing for days and even weeks, were suddenly followed by perfect 
blindness—in some cases with, and in others without coma. 
You might here ask, whether pain is to be considered as a diag- 
nostic of arachnitis? I cannot say it is. We constantly meet with 
severe pain of the head without arachnitis, and every one knows 
that the headache of fever is by no means an indication of inflam- 
mation of the brain. In many cases of hysteria, the headache and 
determination of blood to the head are violent, and yet unconnected 
with inflammatory action. I know a young lady who is frequently 
attacked with most agonising headache, accompanied by violent 
throbbing of the carotids and great heat of the face and scalp. Yet, 
in this case it is plain that the pain cannot be inflammatory, for she 
has been subject to these attacks once or twice a week for the last 
six years, and yet continues otherwise in a state of good health. 
If her disease were to be measured by the violence of the pain and 
determination of blood to the head, it would be natural to expect 
that death would have long ago put a period to her sufferings. 
This is another proof of the truth of the opinion, that there is no 
single pathognomic symptom of disease. Bear this in mind. I 
might go farther, and say, that, whether we looked to symptoms or 
to signs, the rule was the same. The man who merely looks to a 
single sign or symptom will frequently err; it is only from the 
whole group of signs and symptoms presented by a disease that we 
can arrive at any accurate diagnosis. 
The state of the eye, in cases of arachnitis particularly, has 
attracted much attention. On this subject much valuable informa- 
tion has been obtained by the laborious investigations of Andral, of 
which I shall give an abstract. He states that the phenomena of 
the eye, in cases of cerebral inflammation, may be reduced to three 
classes; its motions, the various conditions of the pupil, and the 
state of vision. With respect to the first of these, it may be ob- 
served that in some cases we find the eyeball in constant motion; 
in others, it is quite fixed ; while in others the balance of muscular 
power is lost, and there is a constant tendency to strabismus of one 
eye or both. Of all these varieties in the state of motion, the last 
appears to be the most valuable, so far as the diagnosis of arachnitis 
is concerned. By many persons this strabismus is looked upon as 
a sign that effusion has taken place, and that the disease has reached 
its incurable stage; a position which I am inclined to doubt, from SYMPTOMS OP CEREBRITIS. 
237 
having seen cases recover in which this symptom was present. 
However, Andral looks upon strabismus as a very valuable sign, 
and thinks that, of all the lesions of motion of the eye, it is the 
most important with respect to the diagnosis of arachnitis of the 
ventricles. With respect to the condition of the pupil, it is stated 
in books that in the early stage you have a contracted, and in the 
advanced a dilated pupil, and that the latter condition signifies that 
etfusion into the brain has taken place. Now, the truth is that 
this statement must be received with great caution, and as admit- 
ting of numerous exceptions; for it has been established that the 
same lesions of the brain are sometimes accompanied by very differ- 
ent conditions of the pupil, and vice versa. Parent and Martinet, 
who have investigated the subject carefully, are the best authorities 
on this point, and I shall give a brief abstract of their experience. 
In cases where both pupils were dilated, they observed that in 
some there was effusion into one of the ventricles, in others, into 
both. In cases where there was no dilatation, they observed that 
in some there was serous or purulent effusion under the arachnoid, 
while in others, in which there was no effusion whatever, the pupil 
was dilated. Lastly, it was found that in some cases, where only 
one pupil was dilated, there was effusion into both sides of the 
brain. You might here ask, whether effusion into the substance, 
or on the surface of one side of the brain, is connected with a 
dilated condition of pupil? In reply to this, it may be stated that 
effusion into the substance—not of one, but of both hemispheres— 
has been known to be accompanied by a contracted state of the 
pupil to the last. You may also have one pupil contracted and the 
other dilated ; nay, you may have an alteration of these conditions 
—the right being dilated to-day, the left to-morrow. The mere 
circumstance, then, of dilatation or contraction of the pupil is no 
sign, when taken by itself, as to the seat or even the existence of 
effusion ; for you may have either condition with or without effu- 
sion, and you may have dilatation of the pupil of one eye with an 
effusion into both sides of the brain. As a general rule, however, 
it seems to be made out, that, in most cases of cerebral inflamma- 
tion terminating in effusion, there is often, towards the advanced 
period of the disease, some dilatation of pupil, and that this con- 
dition generally marks the occurrence of effusion. 
With respect to the affections of the function of vision, there are 
great varieties. Some patients have double vision—others see 
sparks of fire, or muscae volitantes. There are many other phe- 
nomena of the kind, causing a great variety in the symptoms ; and 
this variety is found to depend more on the susceptibility of the 
brain to irritation, rather than on the mere existence of irritation 
of the serous membrane investing it. The same rule applies to 
all cases of serous inflammation, the phenomena of inflammation 
varying according to the susceptibility of the organ which the 
inflamed membrane covers. Thus, for instance, one patient will 
have pericarditis with palpitations of the heart, another without 
them; their occurrence or non-occurrence merely showing that the 238 
STOKES’S THEORY AMD PRACTICE OF MEDICINE. 
heart is more or less susceptible to irritation. So it is with respect 
to the brain, and the symptoms of deranged vision are connected 
with the greater or less susceptibility of the organ, which we know 
varies very considerably in different persons. This remark applies 
to all the forms, and, I believe, all the phenomena of meningitis. 
In acute disease of the brain and its membranes, we often have 
convulsions and paralysis, and in these symptoms also we find great 
variations: in some we have convulsions of one side, in some of 
both, in others we have paralysis, but scarcely any convulsions. 
The same remark also applies to these symptoms, as to some already 
mentioned—namely, that we cannot from them alone form an accu- 
rate estimate of the situation or amount of disease. You may have 
convulsions and paralysis of various kinds with the same kind of 
lesion, and you may have a variety of lesions with the same para- 
lysis and convulsions. The only thing that appears to be pretty 
well established is this—that, generally speaking, in cases where 
the right side of the brain is engaged, you have convulsions and 
paralysis of the left side of the body, and vice versd. 
Before I proceed to speak of delirium, I think it necessary to say 
a few words more with respect to convulsions, as I find Andral has 
not touched on a point to which I beg to call your attention. The 
occurrence of convulsions in a child, labouring under symptoms of 
inflammation of the brain, is always looked upon as formidable; 
and indeed it is natural that convulsions, to persons unacquainted 
with pathology, should seem to point out a great intensity of dis- 
ease. I have, however, been long of opinion that convulsions 
occurring during the existence of hydrocephalus in children, or of 
meningitis in adults, are not so dangerous as persons generally 
think. I will even go so far as to say, that the worst cases I have 
seen, in which a cure was effected, were those in which there were 
the greatest and most violent convulsions; and that, in most of the 
cases which appeared to go on without any benefit from medicine, 
there were scarcely any. I am of opinion that convulsions are 
often of benefit by giving relief to the brain. This statement must 
appear somewhat paradoxical, but I trust I shall be able to prove to 
you that it has some foundation in truth. Broussais has taught 
that there appear to be two great modes of reaction in the economy, 
to obviate the effects of abnormal stimulation applied to important 
viscera—fever and convulsions. The irritations which attack the 
cerebro spinal system may be relieved by convulsions ; those which 
attack the viscera may be relieved by fever and secretion. This 
doctrine, I think, might be expressed otherwise. The irritations of 
organs are often relieved by an increase, with or without alteration, 
of their secretions. But, as we have used the term secretion to 
express something material, we apply the proposition merely to the 
viscera of organic life. Now, it may also be extended to the organs 
of animal life. A violent expenditure of nervous power may relieve 
the brain or spinal cord, and delirium and convulsions prevent or 
modify organic changes, just as secretion from the lung or bowels 
may prevent ulceration. 239 
SYMPTOMS OF CEREBRITIS. 
I have said that the brain might be relieved by convulsions. Let 
us, holding this assertion in view, compare the phenomena and 
results of apoplexy with those of epilepsy. In the first place, it is 
to be remarked that the earlier phenomena of both are the same— 
namely, an active congestion of the vessels of the head. Any one 
who has seen the first stage of both must admit this. But let us 
follow them up through their remaining stages. In the one, we 
have the determination to the head, followed by convulsions more 
or less violent and protracted, which, however, subside after some 
time, and the patient gels well; in the other, there is either death 
from the violent determination of blood and probable effusion, or, 
if the patient recovers, there is very often paralysis, showing that 
injury has been done to the substance of the brain. Now, here 
we perceive that the case of determination without convulsions is 
that in which there is either death or recovery with paralysis; there 
are no such bad consequences to be dreaded where the determina- 
tion to the head is followed by convulsive fits. In apoplexy we 
have congestion followed by death, or recovery with paralysis ; in 
epilepsy we have congestion, convulsions, and relief. It is plain 
that, if we admit the identity of the phenomena in the early periods 
of both, we must then also admit that the only cause of relief we 
can ascertain is convulsions. This idea of the subject will explain 
how it is that a man may continue for years subject to repealed 
attacks of cerebral congestion, and yet continue to enjoy tolerable 
health. It will also explain why it is unnecessary and sometimes 
even dangerous to bleed in epilepsy. It also shows why it is so 
often unaccompanied by paralysis, because the brain is relieved by 
the expenditure of its nervous energy on the muscular system. I 
think we should generally look upon the occurrence of convul- 
sions, in a case of cerebro-spinal irritation, in the light of an attempt 
at a crisis made by nature itself. What is a crisis ? An organ 
labouring under irritation is suddenly relieved by a new process 
taking place, either in itself or in some other part; and when we 
come to examine what these modes of relief are, we find them to 
consist in the occurrence of supersecretion, hemorrhage, exanthe- 
matous eruptions on the surface, or convulsions. There is no 
doubt that, when we look to the results of the sudden supervention 
of a copious secretion in an inflammatory affection of any secreting 
organ, the source of relief is manifest. If we take two cases of 
hepatitis or bronchitis—one attended with copious secretion, the 
other without any secretion at all—it will be easy to conceive how 
much more dangerous the latter is, and how much more difficult 
to manage. Now, if we consider the brain in this point of view, 
we find that it is not a secreting organ, in the ordinary acceptation, 
and that the only mode in which it can relieve itself is by the 
expenditure of its excess of nervous energy on the muscular sys- 
tem, or by the same expenditure of mental energy, as in the case 
of high delirium. I think we might fairly draw an analogy be- 
tween this mode of relief and that which, in other diseases, is the 
result of hemorrhage or secretion. One fact, at all events, appears 240 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
certain, that in two most remarkable cases of different diseases— 
each, however, characterised by the same phenomena in the early 
stage, namely, active determination to the head—we find that the 
case which turns out favourably is that in which convulsions occur 
(namely, epilepsy); while in apoplexy, where these symptoms are 
absent, we have either death or recovery with paralysis. 
If this opinion be well grounded, it would militate strongly 
against the practice of checking the convulsions of meningitis by 
opiates. I feel convinced that this practice is wrong and dangerous; 
its effects may be as injurious as the arresting the reactions by 
astringents in a case of acute inflammation. There are two ways in 
which we can explain its bad effects. In the first place, opiates 
prove detrimental by checking the convulsions, which appear to be 
a mode of relief adopted by nature; and, next, they must do mis- 
chief from their well-known tendency to add to the existing cere- 
bral congestion. I have now seen a good many cases of meningeal 
inflammation in which convulsions took place, and where opiates 
were employed to remove them, and feel compelled to state that the 
opium has certainly relieved the convulsions, but the patients have 
afterwards fallen into a state of profound coma, from which they 
never recovered. I have witnessed this so often, that I should not 
discharge my duty properly, did I not warn you against the em- 
ployment of opium in arachnitis. The same rule most commonly 
holds good in cases of visceral inflammation, where an organ is in 
a state of irritation, and has its secretions suppressed. Here also 
opium, by arresting secretion and increasing congestion, will be 
productive of bad effects. I allude here particularly to the treat- 
ment of pneumonia by opium, as recommended by Dr. Armstrong, 
who lays great stress upon its use in full doses after having pre- 
mised a single bleeding. I have had some experience of this mode 
of treatment, and find that the effect of the opium is not to remove, 
but to convert a manifest into a latent disease. I have seen the 
pain, dyspnoea, and cough subside, but the fever continued, and the 
destructive process of the lung went on as usual. This is the 
result of my experience. 
I shall now make a few observations on the occurrence of deli- 
rium in disease of the brain. In one of my former lectures I alluded 
to the important fact, that, in the majority of cases of meningitis, 
where delirium was present, there was inflammation of the con- 
vexity of the brain. I stated also, that, when inflammation attacked 
the base of the brain, we might have it going through all its stages 
without delirium, and pointed out the importance of this in favour 
of the phrenological doctrines. Andral admits the occurrence of 
delirium in case of inflammation on the convexity of the brain, but 
his reasoning upon this subject appears to me to be inconclusive. 
He divides affections of the convexity of the brain into those which 
are characterised by delirium through their whole course, and those 
in which coma is the most remarkable feature ; and seems to think 
that, where coma is the most remarkable symptom, the results of 
the case are unfavourable to phrenology. But we shall find, on SYMPTOMS OP CEREBRITIS. 
examining these cases, that, in many of them, where coma was the 
predominant feature, there had been delirium in the commence- 
ment. He gives the details of thirty-nine cases accompanied by 
delirium all through, in thirty-six of which there was disease of 
the convexity of the brain, either simple or complicated with arach- 
nitis. As far, then, as his first set of cases go, they are in favour 
of the opinion that inflammation of the convexity of the brain is 
most commonly attended by delirium. It appears, also, that in those 
cases in which coma was the most remarkable symptom there was 
more or less delirium in the commencement; so that, whether we 
take the cases in which there was delirium all through, or those in 
which there was coma, the conclusions appear to be in favour of 
the doctrines of phrenology. 
I shall now proceed to make some remarks on the phenomena of 
organic life in cases of cerebral inflammation. In the first place, 
with respect to the‘tongue, we find that in simple arachnitis it is 
but slightly affected; there may be some trifling degree of foulness, 
or it may be quite clean and moist. You will observe the value of 
this, as connected with the diagnosis of irritation of the brain from 
disease of the digestive system. There are many cases of irritation 
of the digestive system putting on the semblance of hydrocephalus 
to such a degree as even to mislead an experienced practitioner. 
Now, if it be true that in simple arachnitis the tongue remains 
clean, it furnishes us with very material information, as, under such 
circumstances, our attention will be directed to the true seat of dis- 
ease. Andral says, that in some cases of arachnitis he has found 
the tongue red, or dry, or foul, but that at the same time there was 
disease of the digestive system. The majority of his cases, how- 
ever, were simple, and exhibited no marks of an affection of the 
tongue or digestive system. 
There is one more symptom on which I wish to offer a few 
observations, and that is the occurrence of vomiting in the hydro- 
cephalus of children. In all cases where there is obstinate vomit- 
ing, particularly in children, you should have your suspicions 
roused, and look carefully to the state of the head. Vomiting is a 
symptom which occurs in many cases of arachnitis ; in some it is 
slight, in others more constant, while in a third class it is harassing, 
incessant, and produced by swallowing the most unirritating sub- 
stances. The nature of the fluid rejected from the stomach is 
various—being sometimes bilious, sometimes mucous, sometimes 
only consisting of what has been recently drunk. In some of these 
cases you will find the symptoms of incessant vomiting, unaccom- 
panied by pain of the stomach, tenderness of the epigastrium, or 
any other sign of disease of the digestive system. I have even 
seen it co-existing with a good appetite. Many persons have been 
lost by such cases having been mistaken for disease of the digestive 
system, the practitioner being ignorant that vomiting was here only 
symptomatic of disease of the brain. No matter what the situation 
of the meningitis may be, it is now established that you may have 
vomiting as a common symptom. I recollect the case of a delicate STOKES’S THEORY AND PRACTICE OF MEDICINE. 
child, about seven years of age, who laboured for some time under 
catarrhal fever, on the subsidence of which she got an attack of 
vomiting, which came on at different times in the day, but without 
headache, delirium, or intolerance of light. This vomiting con- 
tinued from day to day; and, at the end of a week, the pupils 
became suddenly dilated, and coma set in, under which she died. 
There is one very remarkable circumstance connected with this 
subject, with which I am anxious you should be acquainted. Where 
this incessant vomiting is present, you will have the other symp- 
toms of meningitis more or less latent. This illustrates a law 
before alluded to, that, where the phenomena which are the result 
of sympathy with an affected organ are very prominent, those which 
characterise the disease of the organ itself are more or less latent. 
If we take the reverse of the former case, and consider a case of 
gastric disease, we know that the irritation of the stomach will pro- 
duce violent cerebral symptoms, and that here also the same law is 
exemplified—for we shall have absence of pain, tenderness, and 
vomiting. The great value of this rule is, that a knowledge of it 
will put you on your guard, and that the mere absence of the pecu- 
liar symptoms of an affection of an organ possessing extensive sym- 
pathies, should not lead you to conclude that there was no disease 
of that organ. In some remarkable cases of gastritis, the principal 
symptoms observed were convulsions and delirium; there was no 
vomiting or thirst, very little pain on pressure, and nothing remark- 
able in the condition of the tongue. The same latency of inflam- 
matory disease is frequently seen in cases of delirium tremens. 
With respect to respiration and the state of the pulse in menin- 
gitis, there is very little to be said. You may have meningeal 
inflammation with every variety of pulse—strong, weak, full, rapid, 
slow, or intermittent. Generally speaking, the pulse is, towards 
the close of the disease, feeble and intermitting, but you may have 
the disease running through all its stages without any peculiarity 
in the character of the pulse. Respiration seems to be very little 
affected, and this would appear to favour the opinions of Sir Charles 
Bell. There is no doubt, at least, that the sympathy of the brain 
with the respiratory system is much weaker than with the digestive. 
I shall occupy your time but very briefly oil the treatment of the 
hydrocephalus of children, as it appears to me to be a disease in 
which, of all others, the principles of treatment are most simple. 
The old idea of this affection was, that it was a species of dropsy, 
depending on the relaxed state of the cerebral vessels, and hence 
the term hydrocephalus. Modern pathology has shown that the 
occurrence of serous effusion is a mere accidental circumstance, as 
it is present in one case of arachnitis and absent in another. When 
it does occur, however, it is the result of inflammatory disease, 
and it is to the prevention and cure of this that the practitioner 
must direct his attention. With the symptoms of this disease I 
shall not take up your time, as you will find them sufficiently 
TREATMENT OF HYDROCEPHALUS. SYMPTOMS OF CEREBRITIS. 
243 
detailed in books; but, with respect to treatment, I shall say that 
hydrocephalus is a disease much more under the influence of treat- 
ment than persons generally think. It is said that, when once 
effusion has taken place, the case is hopeless, and nothing can be 
done. This remark appears to me to be unnecessary, for there is 
no symptom from which you can venture to assert that effusion 
has set in. You may, from the inflammatory state of the brain, 
have delirium, coma, deafness, blindness, and paralysis, without 
any effusion of serum; and in many cases life has been saved, even 
after the appearance of all these symptoms. 
This term effusion is one of the bugbears of medicine. Many 
patients are lost from the prevalence of false ideas connected with 
this subject; for, as soon as effusion is supposed to have set in, the 
efforts of the practitioner are given up. Hundreds of patients die 
of bronchitis and pneumonia, in whom life might be saved if the 
symptoms of effusion had been treated for those of inflammation; 
and so it is with respect to the brain. This effusion is not the dis- 
ease—it is not even a constant result of the disease. We have no 
certain means of ascertaining its existence; and we know, that, by 
a persistence in antiphlogistic treatment, life may be often saved, 
even after all the supposed symptoms have occurred. 
Take this with you as a rule in medicine: always to keep your 
eye more upon the causes than the effects of disease. 
The treatment of hydrocephalus in the child should always be 
active, and conducted on the same principles as those of general 
encephalitis in the adult. Shaving the head, bleeding when prac- 
ticable, repeated leeching, cold affusion, calomel, and purgatives— 
these are the great measures upon which we are to rely for success. 
It is satisfactory, too, to reflect, that many cases have been saved by 
the prompt and steady adoption of this simple mode of treatment. 
The use of mercury seems to be that on which you should most 
rely. Some of the most singular recoveries have occurred after 
ptyalism has been produced. Let me remind you, however, that 
the rules connected with this mode of treatment, which I pointed 
out in speaking of hepatitis, apply equally in this case. There is 
a terrible consequence of mercurial action in the lymphatic temper- 
ament, with which you should be acquainted ; I allude to a violent 
and destructive inflammation of the soft parts of the mouth and 
face, which has got the name of the mercurial cancrum oris. An 
oedematous inflammation of the cheeks, lips, and tongue, takes 
place, and, if not checked, rapidly runs on to extensive ulceration. 
I have seen one cheek, half of the nose, the lower eyelid, and the 
opposite angle of the mouth, utterly destroyed, in a case where but 
five grains of calomel were used. This drawing represents the 
disease, after a frightful perforation of the cheek. In this case the 
quantity used was nine grains. I have seen the disease from the 
use of so small a quantity as a grain and a half of calomel! These 
facts show that there is a state of the constitution in which a minute 
OF INTERNAL REMEDIES. 244 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
dose of calomel may have terrible effects. The same, too, may 
arise from the external use of mercury. I recollect the case of a 
young woman in the Meath Hospital, whose head was rubbed with 
one dram only of mercurial ointment, for the purpose of destroying 
vermin. She was attacked, and with difficulty saved. 
The disease may also come on suddenly in a patient who has 
been for some time using mercury in considerable doses ; but this 
is the rarest case. 
You recognise this disease by the sudden supervention of great 
swelling of the lips and cheeks, so as to completely alter the expres- 
sion. The tongue is also swollen. All these parts are hot and 
tender to pressure. The breath is fetid, and the internal surface 
of the mouth excoriated, and often covered here and there with 
patches of lymph. At other times we have a circumscribed osde- 
matous swelling, occupying the centre of the cheek, which runs on 
to ulceration; but most commonly the ulceration of the external 
parts begins at the depending angle of the mouth. 
In a case of this kind, if you are called before ulceration has 
taken place, I believe you can often save your patient, and prevent 
destruction of the face. Treat the disease as a violent inflam- 
mation ; use repeated leeching, poulticing, and the warm bath. 
While you do this, you must keep up your patients strength by 
light nourishment and wine. Apply to the internal ulcerations 
the mel seruginis, the nitrate of silver, or the chloride of soda. I 
have now saved many cases by bold and repeated leeching. I 
remember one case of a man in which ninety leeches were used; 
he recovered perfectly. 
In the treatment of this affection, it is of the utmost consequence 
to attend to the position of the patient. By keeping him as much 
as possible upright, or by preventing him leaning constantly on one 
side, we do much to prevent the occurrence of the ulceration of the 
angle of the mouth. 
As far as I can see, hydrocephalus, when taken in time, is a very 
manageable disease; and there is only one case in which it is diffi- 
cult to treat, and that is where the cerebral affection is accompanied 
by symptoms of gastro-enteric disease. In several cases of hydro- 
cephalus, this complication certainly exists; and you have first 
symptoms of disease of the digestive tube, and then of the head. 
Such cases as these are involved in great difficulty, and in their 
treatment you run the hazard of falling into a twofold mistake. 
The first is your acting on the supposition that the disease of the 
head is only sympathetic, and that it will subside as soon as the 
abdominal symptoms are removed; the other is occupying your 
attention exclusively with the head. Now, there is one rule with 
respect to this, which I think will serve to guide you through many 
difficulties, and this is, never to neglect the head. Though you 
have first an affection of the digestive system, and then of the head, 
it is better (even though the symptoms of the latter still continue) 
to pay attention to the head. You can do this at the same time 
that you are attentive to the condition of the digestive organs. 245 
SYMPTOMS OF CEREBRITIS. 
Another rule is, that the cases of disease in which the purgative 
plan does not answer are generally those in which there is primary 
inflammation of the digestive tube. Dr. Cheyne, in speaking of the 
treatment of hydrocephalus, says, that some cases are benefited by 
purgatives, others not; and that the latter are those in which there 
is disease of the intestinal canal. In such cases you will not irri- 
tate the bowels, or add to the existing inflammation by purgatives. 
Let the bowels be kept open by enemata, and direct your attention 
immediately to the head. Children with largely developed heads, 
and of a strumous diathesis, are very subject to this disease ; and 
I feel convinced that the present rage for the early mental educa- 
tion of children has a strong tendency to produce it in subjects of 
this description. I believe there are many cases of fatal hydro- 
cephalus from which the poor victims would have escaped, but for 
the pernicious efforts of the parents to make them literary prodigies. 
I have observed many cases of this kind among the children of 
persons who, having been originally situated in an humble sphere, 
and deprived of the benefits of education, accumulate wealth ; and 
then, feeling in their new condition the want of education, are 
anxious to communicate it to their offspring; and, with that view, 
have them educated with too much care, and from too early a period. 
The child is constantly kept at his books—his little mind is per- 
petually tasked—a degree of cerebral excitement is kept up—and, 
while he is delighting his gratified parents with the manifestations 
of a precocious intellect, his health is neglected, and the seeds of 
disease are insensibly sown. One of the most ordinary conse- 
quences of this early application of the mental powers is hydro- 
cephalus. These little creatures, too, have a congenital disposition 
to disease of the brain, for they have generally large heads. Such 
cases are examples of the results of an arrest of development. A 
relative condition of head exists similar to that which occurs dur- 
ing foetal life, and this is always accompanied by a remarkable 
susceptibility to inflammation. This peculiar development of head 
also produces a precocious state of intellect, which is increased by 
<the pernicious habit of obliging children to study at too early an 
age. Where you meet with children suffering under these circum- 
stances, you will not discharge your duty properly if you do not 
point out to the parents the mischievous tendency of their conduct. 
In such cases as these it may be justly said that ignorance is bliss. 246 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
LECTURE XXVIII. 
Apoplexy—Cerebritig and meningitis—Definition of apoplexy—Simple or nervous 
apoplexy without disorganisation—Complicated with other diseases—Congestive or 
serous apoplexy—Dr. Abercrombie’s opinions—Apoplexy with extravasation—Sites 
of extravasation—Absorption of clot—Apoplexy in children. 
We were occupied at our last meeting in considering some of 
the most prominent symptoms of meningeal inflammation; and I 
beg of you to recollect, that all these symptoms, with the exception 
of pain, are those which ordinarily characterise inflammation of the 
substance of the brain itself, and are to be explained by referring 
them to some lesion in the functions of that organ. It appears, 
then, that the symptoms of meningitis, with the exception of pain, 
are symptoms of an affection of the brain itself; and this is a point 
which you must always bear in mind, when you agitate the ques- 
tion as to the possibility of making a diagnosis between meningitis 
and encephalitis. We have a set of symptoms characterising 
meningeal inflammation, the majority of which belong to irritation 
of the brain itself; and we find that these may exist with or with- 
out any perceptible alteration in the cerebral substance. Now, in 
cases where you suppose the existence of meningeal inflammation, 
and find these symptoms present, it would be venturing too much 
to assert that there was no complication with organic disease of the 
brain ; and, therefore, we must conclude that, in most cases, it is 
nearly impossible to distinguish between inflammation of the sub- 
stance of the brain and of its membranes. 
In speaking of the more important symptoms of cerebral inflam- 
mation, I alluded particularly to convulsions, and stated, that, as 
far as my observations went, this symptom, formidable as it may 
appear, is not in reality so unfavourable as it is generally thought 
to be. In fact, there are many cases of affections of the brain, 
accompanied by convulsions, in which the danger is by no means 
so great as in others of a different description; and many of the 
worst cases are those in which convulsions are absent, or onl3f 
trifling. I think we may look upon convulsions as being more or 
less a source of relief to the brain, when labouring under the excite- 
ment of irritation or inflammatory disease. You are all aware, that 
one of the great functions of the brain is to regulate and control the 
motions of the muscular system. If a man exercises his limbs 
violently for some time, he becomes tired and exhausted; he can- 
not pursue the same exercise any longer, for, in addition to what- 
ever the muscular system may suffer, there has been a great 
expenditure of nervous energy; and if he should attempt to keep 
up the same exertions, such a degree of muscular and nervous 
debility is superinduced that syncope is the consequence. Now, 
the expenditure of energy produced by the supply of nervous power 
to the muscles, seems to bear a strong analogy to the secretory dis- 
charges from other viscera. In the case of irritation or inflamma- 
tory affections of other organs, you are all aware that there is APOPLEXY. 
247 
nothing which gives such speedy and effectual relief as supersecre- 
tion, or an increased action of the secreting vessels of the affected 
organ. Now, if we look upon the expenditure of nervous energy 
in the same light (and I see no reason why we should not), we can 
easily conceive why it is that convulsions relieve the irritation of an 
over-excited brain. I drew your attention strongly, at my last 
lecture, to the curious and important fact, that if we compare 
apoplexy and epilepsy, with respect to the danger and the chance of 
disorganisation attendant on each, we shall find the danger is infi- 
nitely greater, and the chances of organic change more numerous, 
in the former than in the latter. In epilepsy, where the convulsions 
are violent, we seldom have a fatal termination of the fit, and there 
is rarely lesion of the substance of the brain, until the disease has 
lasted for a great length of time. This is not the case in apoplexy. 
Here, as I have already stated, we have two cases of active deter- 
mination to the head: in one case there are no convulsions, and 
we frequently find the result to be death, or extravasation with 
paralysis and slow convalescence; in the other, we have violent 
convulsions, followed by rapid recovery and no disorganisation. 
From this, it would seem reasonable to conclude, that convulsions 
are a mode of relieving the brain, adopted by nature, and that their 
occurrence in hydrocephalus should not be looked upon as unfa- 
vourable. Now, if this be true, it must strike you, that nothing 
can be more dangerous and improper than to take any steps to 
control an attack of convulsion during the prevalence of hydro- 
cephalic symptoms. The true mode of treating them is to adopt 
measures calculated to relieve irritation of the brain, and not hazard 
the patient’s safety by following the ordinary but mischievous mode 
of attempting to control the salutary efforts of nature. I allude here 
particularly to the practice of administering opiates and antispasmo- 
dics, a practice which I firmly believe to be fraught with danger. 
We have to-day to consider another form of cerebral disease, 
scarcely less important than those with which we have been 
hitherto engaged. In all the former instances, we find the deter- 
mination of blood to the brain followed by that organic change 
which we term inflammation. But we may have accumulations 
of blood in the brain, unaccompanied by inflammation, and this 
brings us to the consideration of apoplectic disease. The term 
apoplexy, as I suppose you all know, is derived from a Greek 
word, signifying a stroke or blow. It is a term which, in the pre- 
sent state of medicine, has been very frequently abused, or at least 
employed in very different senses, and hence the many erroneous 
opinions respecting it. The true meaning of the term expresses an 
alteration of the phenomena of the life of relation, that is, of the 
functions of the cerebro-spinal system. In taking a view of the 
nature of this alteration, we find that the attack generally comes on 
in a sudden manner, and that the functions of the brain are par- 
tially or completely suspended. You are aware that the manifest 
phenomena of the life of relation are those which belong to sensa- 
tion, muscular motion, and the intellect; and that the system of 248 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the life of relation is composed of the brain, spinal cord, and nerves. 
Now suppose, for example, that a man gets an attack of apoplexy, 
we find him paralytic—here is a lesion of the muscular function. 
We find him insensible to external stimulants, he feels no pain— 
here is a lesion of sensation. We may find his sight, hearing, 
taste, smell, and touch, are injured; he lies in a state of insensibility, 
and is unconscious of every thing passing around him—here we 
have an example of interruption in the performance of the intel- 
lectual functions. All these phenomena exhibit the various lesions 
superinduced by an attack of apoplexy, in the functions of those 
organs which subserve to the life of relation. 
I have said that the term apoplexy is frequently abused in 
modem medicine. From the circumstance of most cases being 
accompanied by an effusion of blood on the surface, or into the 
substance of the brain, the term has been also applied to san- 
guineous effusions into other organs, and we hear every day of pul- 
monary and hepatic apoplexy; terms implying the extravasation of 
blood into the substance of the lung or liver. The analogy, how- 
ever, in such cases, will on examination be found to be coarse, and 
the application of the term loose and improper. Apoplexy, as a 
cerebral disease, may occur with or without effusion; in either 
case, the disease, quoad the lesion of function, is the same ; but to 
give the name of apoplexy to hemorrhage into the lungs or liver, is 
improper. The term apoplexy should be used only with reference 
to the brain, and applied to a particular train of lesions in the 
functions of the life of relation, occurring with or without an effu- 
sion of blood, or even congestion. When we have effusions of 
blood into other viscera, we may have them unaccompanied by any 
apparent lesion in the functions of the organ affected (a circum- 
stance rarely met with in the case of the brain); and it would be 
much better to give some other name to those hemorrhages into the 
substance of the liver and lungs, than to designate them by one 
drawn from a loose and imperfect analogy. 
The suspension of the phenomena of the life of relation, complete 
or partial, which constitutes apoplexy, may be connected with any 
of the following pathological conditions. First, great congestion of 
the brain, in which the vascular system of that organ is overloaded, 
but without extravasation of blood or serum; this is termed the 
congestive apoplexy. In the next place, we may have this con- 
gested state of the vessels of the brain with an extravasation of 
blood on its surface. To the latter form, the meningeal apoplexy 
has been applied. Thirdly, with an effusion of blood into the sub- 
stance of the brain, which is the most common case, and, lastly, we 
may have complete apoplexy without morbid appearance, or, if there 
be such, quite insufficient to account for the phenomena. A man 
will fall down suddenly, he will lie in a state of insensibility, with 
stertorous breathing, coma, and paralysis, he will die with all the 
symptoms of the worst form of apoplexy, and yet, on dissection, the 
brain may be found, to all appearance, healthy. This is what has 
been termed, by the older authors, the nervous or convulsive APOPLEXY. 
249 
apoplexy; of the real nature of which we are still as ignorant as 
we are of the real nature of tetanus, hydrophobia, and other nervous 
diseases unaccompanied by perceptible organic change. 
This is the simple apoplexy of Dr. Abercrombie, of which he 
gives several most important cases, and refers to others related by 
the older authors. You will at once admit that it is not more 
extraordinary that apoplexy should exist without perceptible 
organic change, than mania, tetanus, hydrophobia, and other affec- 
tions. Of the fact there is no doubt. Such cases, indeed, are rare; 
which, in one sense, may be looked on as a fortunate circumstance. 
But in the progress of other diseases, this nervous coma, or apoplexy, 
is by no means uncommon. Thus there is no symptom more 
common than coma in typhus; and yet, if you examine the head 
after death, you generally either find no lesion at all, or such as 
will not be sufficient to account for the symptoms. The coma, 
which occurs in cases of painters’ colic, too, appears to be closely 
connected with this nervous apoplexy. You will recollect an inte- 
resting clinical experiment I made in the case of a patient with 
painters’ colic, who had profound coma. In this case, I thought it 
probable that the condition of the brain bore no resemblance to 
sanguineous apoplexy, because the symptoms of painters’ colic are 
seldom or never accompanied by hyperaemia of the nervous or 
other systems. Under this impression, I prescribed a full opiate, 
and this not only did not increase the coma, but, on the contrary, 
produced the very best effect, for the patient was amazingly 
improved the next morning. I do not so much mean to say, that 
opium is useful in nervous coma, as that, in this instance at least, 
the coma was not of the congestive kind. It is not unlikely, too, 
that the coma of jaundice is of the same description, and uncon- 
nected with any decided hyperaemia of the brain. I am aware that 
in jaundice the coma is supposed by some to depend upon a bilious 
condition of the blood circulating in the brain ; but there are so 
many cases of persons who have laboured under jaundice for years 
without having coma, that we must seek for some other explanation. 
Now, so far as we know of the encephalon in persons who have 
died of jaundice, it appears that little or no congestion exists; and 
hence it seems probable that the coma of jaundice is similar to that 
of nervous apoplexy. 
I shall now proceed to the consideration of those forms of 
apoplexy which are connected with changes more or less apparent 
in the circulation of the head, and with which we are, consequently, 
better acquainted. I have told you that simple congestion of the 
brain may be accompanied by symptoms of apoplexy, or that we may 
have the disease presenting, in addition to this, an effusion of blood 
into the substance, or on the surface of the brain. The simplest 
idea you can get of the condition of the brain in the congestive 
form, is to consider what its state is in persons who have been 
hanged. These persons have the vessels of the brain loaded with 
blood from the violent interruption of the venous circulation. 
Now, this increase in the quantity of blood circulating in the brain, 250 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
may arise from two causes, one depending on the interruption of 
the venous circulation, the other produced by an increased action 
of the arterial system. Hence in certain cases of disease of the 
heart, where the blood is sent with great force to the head, there is 
a strong predisposition to apoplectic attacks. The kind of disease 
of the heart, however, which has been found most liable to produce 
this, is not, as you would suppose, Corvisart’s active aneurism, but 
simple hypertrophy of the heart, where the cavity of the left ven- 
tricle continuing the same, its walls are increased in thickness and 
strength, so that, on. the natural quantity of fluid, an increased im- 
pulse is exercised. Such, at least, is the result of Andral’s researches, 
and there is every reason to place confidence in the acccuracy of 
his conclusion. 
About this congestive apoplexy there appears to have been a 
good deal of misapprehension. You have all heard of the serous 
apoplexy. In this form, it has been supposed that the cause of the 
compression of the brain, and all the other symptoms, is an effusion 
of serum, just as an effusion of serum into the cavity of the pleura 
will produce compression of the lung and dyspncea. The idea 
which has been generally entertained is, that the effusion of serum 
is the cause of all the symptoms; and, in consequence, the same 
active treatment has not been adopted as in the other forms of 
apoplexy. This opinion will be best refuted by the investigations 
of Dr. Abercrombie, and I cannot do better than read for you the 
opinions of this eminent writer on the subject, as given in his cele- 
brated and admirable work, which, I have no hesitation in saying, 
constitutes one of the brightest ornaments of British medicine. 
“ This distinction, which has been proposed between sanguineous 
and serous apoplexy, is not supported by observation. The former 
is said to be distinguished by flushing of the countenance and 
strong pulse, and by occurring to persons in the vigour of life ; the 
latter by paleness of the countenance and weakness of the pulse, 
and by affecting the aged and the infirm; and much importance 
has been attached to this distinction, upon the ground that the 
practice which is proper and unnecessary in the one case, would 
be improper or injurious in the other. I submit that this distinc- 
tion is not founded upon observation, for, in point of fact, it will be 
found that many of the cases which terminate by serous effusion, 
exhibit in their early stages all the symptoms which have been 
assigned to the sanguineous apoplexy; while many of the cases, 
which are accompanied by paleness of the countenance and feeble- 
ness of the pulse, will be found to be purely sanguineous ; and one 
modification of the disease in particular will be described, in which 
these symptoms are very strikingly exhibited, while the disease is 
found to be sanguineous apoplexy in its most hopeless form. 
“ Portal has described a series of cases which afford the same 
result; of three, which presented all the symptoms of serous 
apoplexy, one was saved by repeated bleeding, and in the other two, 
which were fatal, there was found extensive extravasation of blood. 
Case XCVI., lately described, forms a remarkable addition to these APOPLEXY. 
251 
observations. If any case could be confidently considered as serous 
apoplexy, this was such. Dropsical effusion had existed in the 
body for months, and, in defiance of every remedy, it had been pro- 
gressively gaining ground. There were symptoms indicating its 
existence, both in the thorax and in the abdomen ; the patient then 
became comatose, with pale countenance, and died; but though 
dropsy was found in other cavities, none could be detected in the 
brain. 
“In other parts of the body serous effusion is very seldom a 
primary disease ; it arises as a result either of inflammatory action, 
or of impeded circulation, and takes place slowly, not accumulating 
at once in such quantity as to induce urgent symptoms. It is, 
therefore, in the highest degree improbable, that it should occur in 
the brain as a primary disease, and accumulate with such rapidity 
as to produce the symptoms of an apoplectic attack. 
“ The quantity of fluid effused, bears no proportion to the degree 
of the apoplectic symptoms. We find it in small quantity, though 
the apoplectic symptoms had been strongly marked and long-con- 
tinued ; we find it in large quantity when the symptoms have been 
slight; and, finally, we find most extensive effusion in the brain 
where there have been no apoplectic symptoms at all. The direct 
inference from these facts is, that, in the cases of apoplexy with 
effusion, the presence of the fluid cannot be considered as the cause 
of the apoplectic symptoms.” 
The same error has been committed with respect to hydrothorax, 
a disease almost never primary, but the result of either pleuritic 
inflammation, obstruction of the heart or lungs, or some analogous 
cause. The cause of the symptoms is not the mere effusion of 
fluid, but some pre-existing disease which has given rise to a serous 
effusion. In Dr. Abercrombie’s work, you will find the remarkable 
fact stated, that there may be a copious effusion of serum in the 
head, without producing apoplectic symptoms. The following 
case, mentioned by Dr. Abercrombie, furnishes a remarkable illus- 
tration :—A patient, who had laboured under hypochondriasis for 
upwards of thirty years, began to decline rapidly in health. He 
was extremely feeble, his bowels costive, his sleep disturbed, and 
his appetite gone. This state continued for some time, and he 
began to sink, but he never complained of headache, giddiness, 
convulsions, or paralysis, and his mental powers remained unim- 
paired until a very short time before his death. Yet, on opening 
the head, there was an exceedingly copious effusion of serum found 
under the arachnoid; and in some places this was so great as to 
give the arachnoid the appearance of small bladders filled with 
water. The ventricles were distended with fluid. Dr. Abercrom- 
bie gives another case, where the quantity amounted to eight 
ounces, and notices a case, mentioned by Dr. Marshall, of a maniac 
who died of mortification of the feet; a few hours before death he 
became perfectly rational, yet effusion was found both on the surface 
of the brain and in the ventricles, amounting to more than a pound. 
All these facts go to prove, that what has been termed serous 252 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
apoplexy is only an apoplectic attack depending on congestion of 
the brain ; that in some cases we may have this congestion accom- 
panied by serous effusion, in others not; that the effusion is second- 
ary, and by no means of constant occurrence ; and that altering 
our practice, and pursuing a less active plan of treatment, in such 
cases, would be improper. The same treatment should be adopted 
in the serous, as in the congestive form of the disease, for where the 
nature of the affection is the same, the same curative means should 
be employed. Why it is that effusion takes place in one case, and 
not in another, we cannot tell; such changes are connected with 
laws of organisation, of which we are at present ignorant. We 
know as little why this should occur as why inflammation of the 
liver in one case is followed by enlargement, in another by the 
secretion of pus, in a third by cancer, or in a fourth by hydatids. 
We now come to the consideration of apoplexy with extravasa- 
tion of blood. This is the form of the disease to which the term 
apoplexy has been restricted by one of the last writers on the sub- 
ject, M. Rochoux. In this affection, the extravasation of blood, 
which constitutes the principal pathological feature of the disease, 
is found to exhibit a remarkable variety as to its seat and extent. 
In some cases, the blood is effused on the surface of the brain ; in 
others, into its substance; and in a few cases into the ventricles. 
De Haen gives some cases of apoplexy produced by rupture of the 
choroid plexus; but, in the great majority of cases, where blood is 
found in the ventricles, the extravasation has taken place in one 
hemisphere, and, tearing through the substance of the brain, has 
made its way into their cavities. Of the three varieties of apoplec- 
tic effusions, the ventricular is the rarest; the next to this is the 
meningeal, or that in which blood is poured out on the surface of 
the brain, and the most common is where it is effused into the sub- 
stance. It has been also found that certain parts of the brain are 
much more liable to sanguineous effusions than others; of the 
reason of this, as of many other phenomena connected with the cir- 
culation of the brain, we are still in ignorance. The following 
table, which you should bear in mind, exhibits a remarkable pre- 
ponderance in the liability to sanguineous effusions of certain parts 
of the brain. It has been taken from the “ Precis d’Anatomie 
Pathologique” of Andral. The following is a summary of the 
results of 386 cases of apoplexy. 
In 202 cases, the effusion took place into the substance of the 
hemisphere of the brain, in that part which is on a level with the 
corpora striata and optic thalami. The portion of the brain next 
most liable to effusions, are the corpora striata ; and here we have 
61 cases. Next to this are the optic thalami, in which we have 35 
cases. In that portion of the hemispheres above the centrum ovale, 
27 cases. Lateral lobes of the cerebellum, a proportion of 16 cases. 
In those portions of the brain anterior to the corpus striatum, 10 
cases. In the mesocephalon, 9. Spinal cord, 8. Posterior lobes 
of the brain, 7. Middle lobe of the cerebellum, 5. Peduncles of 
the brain, 3. Olivary bodies, peduncles of the cerebellum, and APOPLEXY. 
253 
pituitary gland, 1 in each, making 3—total 386. Out of these, we 
find 325 cases occurring in the hemispheres of the brain, corpus 
striatum, and optic thalamus. 
In the number and size of these effusions we find the greatest 
varieties. In some cases, an enormous effusion takes place, and 
many ounces are extravasated into the substance of the brain ; in 
others, the quantity is trifling, being sometimes as small as a pea, 
or even less. It has been observed that in cases where numerous 
extravasations were discovered, they were generally found to be in 
different states, as if they had occurred at intervals, and not simul- 
taneously. This leads us to the knowledge of one of the most 
important facts in pathology, that in many cases of apoplexy, after 
a clot has been formed, nature commences, at an early period, a 
process of cure. The change, which takes place in cases where a 
patient recovers, seems to be the following :—It becomes, at first, 
somewhat gelatinous; it is next observed to be more consistent, and 
it loses its red colour, and takes on a whitish or yellow appearance. 
The clot is gradually removed; and along with the absorption of 
the clot there is a process of isolation going on. A fine membranous 
cyst, furnished with vessels, is formed round the clot. In some 
cases, the clot is replaced by a quantity of serous or gelatinous 
fluid; but in the majority of instances this does not occur, and the 
cyst has been found empty. This is a fact which has been esta- 
blished by numerous observations. 
There is the greatest possible difference as to the period at which 
the absorption of the clot is completed ; but we may safely assert, 
from the number of cases in which, after paralysis, a recovery takes 
place, that this process is of very common occurrence. In several 
cases, where apoplexy, followed by paralysis, has happened several 
times during the lifetime of the patient, a number of those cysts, 
corresponding with the number of attacks, and presenting various 
appearances according to the date of their formation, have been 
found. It appears, then, that the cure of apoplexy depends solely 
on the absorption of the clot; and that, as long as this remains 
unabsorbed, the patient is in danger. In some cases, absorption 
does not take place at all, the clot becomes organised ; and in this 
way it is supposed that some of the tumours found in the brain are 
formed. There are several circumstances which favour the absorp- 
tion of the clot, but nothing so powerfully as a healthy condition of 
the whole cerebral circulation. This leads us to the consideration 
of the importance of paying attention to the head, long after an 
attack of apoplexy. It inculcates the necessity of avoiding every 
thing calculated to add to the existing congestion ; and shows that, 
in the paralytic or after-stage of an apoplectic attack, we should not 
neglect to deplete the head from time to time. The great point is 
to keep the head perfectly free from irritation; for it has been found, 
that, where a cure appeared to be going on, any new irritation 
applied to the brain has had the effect of arresting the absorption of 
the clot, and marring the process of cure. 
I regret I cannot dwell longer on this subject, as I wish to con- 254 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
elude the pathology of apoplexy to-day. There are, however, two 
more observations to be made before I close the subject. The 
source of an apoplectic effusion is very hard to be discovered; it 
appears generally to come from a number of minute vessels, for we 
are seldom or never able to trace it to the rupture of a vessel of any 
size. The age at which persons are most subject to apoplexy, 
appears to be from fifty to seventy. You should, however, be 
aware that apoplexy with sanguineous effusion is by no means 
uncommon, even in persons of a tender age. Billard details an 
instance of this in a child, soon after birth. There are also several 
cases mentioned as occurring in children during the first three or 
four years. Andral gives the case of a boy of nine years of age, 
who died of apoplexy, with a vast effusion of blood. One of the 
most remarkable cases of this kind I ever witnessed, occurred in a 
child who had been just weaned. This child had been labouring 
for some time under symptoms resembling incipient hydrocephalus, 
and then suddenly got an attack of convulsions, followed by coma 
and paralysis of one side. From a careful study of the symptoms, 
I ventured to make the diagnosis of apoplectic effusion, and on 
examining the brain, after death, there were nearly three ounces of 
blood found effused in the base of the brain. 
LECTURE XXIX. 
Apoplectic effusions—Curative process adopted by nature—Connection of temperaments 
with disposition to apoplexy—Researches of Rochoux—Periods of life most subject 
to apoplexy—Principles of diagnosis—Varieties of apoplexy—Connection of symp- 
toms with pathological appearances—Rostan’s division of—Different symptoms of— 
Double effusions—Rupture into ventricles—Hemiplegia—Value of the suddenness of 
paralysis as a diagnostic examined—Symptoms of apoplectic effusions. 
At my last lecture, I spoke of the nature of apoplectic effusions ; 
I stated that they exhibited a considerable variety as to their situa- 
tion, extent, number, and condition in different cases; that it was 
frequently a matter of great difficulty to ascertain their source, and 
that they might occur at any age, but chiefly from that of fifty to 
seventy. I gave a brief sketch of the process adopted by nature in 
effecting a cure, and showed that in many cases, where the effused 
blood is absorbed, there is scarcely any trace of the disease, except 
a slight cicatrix; but that in some instances, where the sanguineous 
effusion has been removed, its place becomes occupied by a quantity 
of serous fluid, and this, with the cyst which contains it, seems to 
explain what the old anatomists termed false ventricles. You will 
find, by looking over some of the earlier writers on anatomy, that 
they have described the brain as containing more than the ordinary 
number of ventricles, and the mistake seems to have arisen from 
their taking for ventricles those serous cysts or cavities which 255 
remained after the absorption of an apoplectic effusion. Of course 
other causes, such as congenital formation, may give rise to the 
appearance. You will see in the museum of the College of Sur- 
geons a fine specimen of abnormal cavities filled with serum in 
different parts of the brain. 
In speaking of the period of life at which apoplectic disease is 
most frequent, I stated, that though it might occur at any time of 
life, still there was a particular period at which there is a greater 
liability than any other. Rochoux has shown that the tendency to 
apoplexy is greatest towards sixty, and diminishes towards seventy 
years of age. The number of cases which occur between sixty 
and seventy are very great, when compared with those between 
seventy and eighty ; and after eighty he considers the liability to 
be still farther diminished. It seems strange, that persons after 
seventy should not be so liable to attacks of apoplexy as before that 
period, but such is the fact. It has been thought that this may be 
explained by the anaemic state of the brain in old persons; it is 
said, that at such an advanced age general emaciation takes place, 
and the quantity of blood is greatly diminished. This explanation, 
however, is doubtful, because it is at present well ascertained, that 
persons of ordinary development, who are nether fat nor thin, and 
also persons of spare and delicate habit, are as much, and even 
more, liable to apoplexy than the fat and plethoric. It has been 
ascertained by careful investigations, that a high degree of plethora 
does not necessarily predispose to the disease, and that it is oftener 
met with in persons not of a plethoric habit than in those who are. 
These considerations throw some doubt on the opinion that an 
exemption from apoplectic attacks is connected with an anaemic 
condition of the system. It generally happens, however, that at 
this advanced period of life, from the general debility of the system, 
and the incapacity for active exertion, a man ceases to employ his 
thoughts about business, and there is little exercise for the intel- 
lectual functions. We now have finished the task; the brain 
reposes from the turmoil of active and incessant thought; there is 
a comparative absence of mental exertion, and this may in some 
degree account for the rarity of apoplexy after the age of seventy. 
With respect to the different temperaments as bearing on this 
point, Rochoux shows that in Paris, at least, there was a nearly 
equal frequency of the disease in individuals of the sanguine, san- 
guineo-bilious, and sanguineo-lymphatic constitutions. The bilious 
temperaments, however, are much less liable. Such is the result 
of the observations in Paris; but it must be recollected, as Rochoux 
observes, that in that city the bilious temperament is the rarest. 
With respect to the sanguine or plethoric, it has been found that 
this temperament does not predispose to apoplexy so much as has 
been generally supposed. The disease has been observed to be most 
common in persons of ordinary development, next to those in per- 
sons of thin, spare habit, and last of all in the •plethoric and fat. 
Rochoux’s researches lead him to conclude that the number of per- 
sons of ordinary development, attacked by apoplexy, is three times 
APOPLEXY. 256 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
that of the plethoric, and that that of the spare habits is little more 
than twice as great as that of the fat and plethoric. If these re- 
searches are correct, they afford great consolation to stout gentle- 
men. 
The conclusion, which has been come to, with respect to tem- 
peraments as bearing on the liability to apoplexy, appears to be 
true, namely, that there is no sign appreciable by the senses which 
will unequivocally point out a predisposition to apoplexy. This is 
of great importance in a practical point of view. You may expect 
the disease in the fair or dark haired, the thin or fat, alike. The 
frequent occurrence of this disease in persons who were never sus- 
pected to have any predisposition to it is another proof in favour of 
this opinion. With respect to the mere medical diagnosis of apo- 
plectic effusion, it would be well if, in making it, you would always 
bear in mind the anatomical characters of the disease. Extrava- 
sation of blood into the substance of the brain generally takes place 
by a tearing or separating of the cerebral tissue. A quantity of 
blood is rapidly effused, the substance of the brain torn, and a cavity 
formed. There can be no doubt that the tissue of the brain is torn, 
for we can see the loose shreds hanging on each side of the cavity, 
and mixed up with the clot. Now, what are the principles which 
should guide us in making our diagnosis ? They are exactly the 
same as those in other diseases connected with a sudden solution 
of continuity in the substance of internal organs. We have, with 
or without any preceding symptoms of a different kind, the sudden 
supervention of new and remarkable phenomena. The pheno- 
mena which are the result of disease proceeding in its ordinary 
course are gradual and progressive; but occurrences of this kind 
are almost always characterised by sudden and well-defined symp- 
toms. Thus, we make the diagnosis of the rupture of an aneurism 
of the aorta from the sudden vomiting or expectoration of blood, 
followed by the death of the patient. Here, you perceive, the 
diagnosis is founded on the sudden supervention of new symptoms. 
In the same way we make the diagnosis of pneumothorax with a 
fistulous opening communicating with the bronchial tubes, and 
calculate, from the sudden occurrence of pain in the side and the 
other signs of pneumothorax, that there has been a solution of 
continuity in the pleura. Again ; if a person labouring under 
hepatic abscess is seized with a fit of coughing, and suddenly 
expectorates a quantity of pus, and that this is found to be accom- 
panied by a subsidence of the tumour in the region of the liver, we 
make the diagnosis of perforation of the diaphragm and pleura, and 
the escape of the contents of the abscess into the substance of the 
lung. Or he may, under the same circumstances, be seized with 
sudden and rapid peritonitis, and here we make the diagnosis of an 
effusion into the peritoneum. It is on precisely the same principles 
that Louis has established the diagnosis of perforation of the small 
intestines in cases of gastro-enteritis. The patient is lying in bed, 
perhaps apparently improving; he is not exposed to any exciting 
cause, and every care may have been taken of him. On a sudden APOPLEXY. 
257 
he exhibits symptoms of intense peritonitis, and rapidly dies. Any 
one conversant with such cases can easily make a correct diagnosis. 
On the same principles we found the diagnosis of apoplectic effu- 
sion. Almost all the instances of disease which I have given occur 
with a sudden violent invasion; and the same thing may be said 
of apoplexy with extravasation. It is true, that there are some 
cases which do not exhibit this character, but the general rule is 
suddenness of attack. 
We may divide apoplectic attacks accompanied by extravasation 
into three great classes; and, if you look to the great majority of 
cases of this disease, you will find that, although they appear to pass 
by insensible degrees into one another, still, when taken and examined 
singly, there will be found a difference between them. This clas- 
sification is that of Rostan, and I have known his principles veri- 
fied in many instances. In the first class of cases, which are the 
worst and generally prove fatal, the extravasation is enormous. A 
person, apparently in perfect health, will fall down in a fit of apo- 
plexy, remain for a short time insensible and paralytic, and then 
die. In such a case as this, the ordinary pathological character is 
an enormous effusion of blood, or excessive congestion. In a case 
of the second class, we have an apoplectic seizure with coma, 
which disappears after some time, and the patient recovers his 
intelligence, but with paralysis of one side. The pathological 
character of this form is, that the effusion is more limited and 
exists only on one side of the brain. Neither is the congestion so 
severe, and the patient recovers from the coma. In the third form, 
we have an attack of apoplexy of a milder description ; there is 
scarcely any coma or loss of intelligence, and the paralysis is slight, 
generally affecting the muscles of one side of the face or of one of 
the extremities. Let us repeat these varieties. In the first, which 
constitutes the apoplexie foudroyante of the French, there is an 
enormous extravasation of blood in both sides of the brain ; or, if 
it be only on one side, the amount of the effusion is frequently such 
as to burst through the walls of the ventricles and get into their 
cavities, and in this way we may have an effusion of one side get- 
ting into the other hemisphere, or exercising such pressure on it as 
may give rise to general symptoms. Such a case as this is, I 
believe, generally fatal; its progress, too, is very rapid, several 
persons under such circumstances having died in the space of an 
hour or less. In the second form, there is coma and loss of intelli- 
gence, and the patient recovers with paralysis of one side. Here 
the extravasation is never so great as in the foregoing case; the 
effused blood is confined to one side, and does not get into the ven- 
tricles. In the third form, the effusion is very much circumscribed, 
the signs of general congestion or extravasation are slight, the 
quantity of blood poured out is not, perhaps, larger than a nut, it is 
followed by partial paralysis, and there is little or no coma or loss 
of intelligence. 
Let us take a brief review of the symptoms which attend each 
of these forms. In a case of the first description, we find a person, 258 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
hitherto in the enjoyment of health, suddenly attacked with symp- 
toms of intense apoplexy. You will recollect that in my last lec- 
ture, I told you that apoplexy consisted in various lesions of the 
phenomena of the life of relation. In the most violent form of 
apoplexy, many authors are of opinion that there is a total paralysis 
in the functions of animal life. The patient falls down and remains 
in a state of complete insensibility, the eye no longer obeys the 
stimulus of light, no sound makes any impression on the ear, or 
odour on the sense of smelling, the sense of taste is destroyed, 
the skin may now be seared with a red hot iron without the 
slightest indication of suffering; in fact, sensation, one of the great 
phenomena of animal life, appears to be annihilated. If we examine 
further, we find that there is a total suspension of the intellectual 
functions, and that the patient is unconscious of any thing passing 
around him. If we go to the muscular system, we find that all 
that part of it which subserves to the purposes of animal life is 
completely paralysed. The neck, trunk and extremities have lost 
their power; and, if you raise the head, trunk or one of the limbs, 
they fall down like dead masses, as soon as the support is with- 
drawn. In some cases there is a certain degree of rigidity in the 
muscular system, in others not. We may observe also, that from 
the paralysis of the buccinators, the cheeks are alternately puffed 
out and sucked in during respiration. As far as my experience 
goes, I believe that this symptom is fatal. Here, then, we see that 
the great phenomena of the life of relation are suspended. The 
functions of organic life, however, still continue to be performed, 
the heart beats, respiration goes on, and the power of secretion 
remains; but, after some time, the functions of organic life are 
also suspended, and the patient dies. In some of these cases, we 
observe evident signs of determination of blood to the head, the 
face is swollen, and the lips livid ; there is considerable turgescence 
of the vessels of the neck, with heat of the head, the skin hot, and 
the pulse full and strong. In other cases, however, we have a 
feeble pulse and a cold collapsed state of the surface. 
Let us now turn for a moment to the pathology of this form of 
the disease. I have already mentioned, that the extravasation 
sometimes occupies both hemispheres of the brain, or that it occurs 
on one side, and, by tearing through the substance of the brain, 
gets into the ventricles, and produces symptoms referable to a lesion 
of both sides. With respect to the simultaneous double effusion, 
the following is a short notice of some cases taken from the 
“ Clinique Medicale” of M. Andral. A man, about thirty-seven 
years of age, fell down near La Charite in a fit of apoplexy. He 
was immediately brought into the hospital, had prompt and careful 
attention paid to him, but without any effect; he lay in a state of 
profound coma, with complete suspension of the phenomena of 
animal life, and died in an hour and a half. On examination there 
was a double effusion of blood found in the brain, but it had not 
got into the ventricles. In another case, marked by simple intensity, 
there was an enormous effusion discovered in the substance of one APOPLEXY. 
259 
hemisphere, which burst into the ventricle, tore through the septum 
lucidum, and passed into the ventricle of the opposite side. In the 
next case, no distinct trace of optic thalamus or corpus striatum 
could be seen, their substance being completely broken up and 
destroyed by the effusion. I have told you that, after a rupture of 
the substance of the brain and the escape of the effused blood into 
the ventricles, persons have not recovered, but it is a fact, and a 
consolatory one indeed, that a person may recover from a simulta- 
neous double effusion. A case in proof of this is given by Andral. 
A female who had been for some time a patient at La Charite, died 
of cancer of the stomach. The history of her case was, that nine 
years before she had an attack of apoplexy, she had fallen down 
in a state of insensibility, and remained comatose for a considerable 
time, that this was followed by paralysis of both sides of the body, 
which continued for two years, after which she gradually recovered 
the use of her limbs. In this case, two serous cysts, such as are 
met with in cases where patients have recovered from apoplectic 
attacks, were found, one in each hemisphere of the brain. In 
another case, the subject of which died of visceral disease, the 
patient had twenty-two years before an attack of apoplexy with 
double paralysis, and recovered with the loss of the use of one side; 
here there were two cysts also found. It appears, then, that though 
extravasation, with rupture of the walls of the ventricles, and es- 
cape of blood into their cavities, always proves fatal, a recovery 
may take place after a simultaneous double effusion. 
Let us now enquire briefly, whether an apoplectic attack, fol- 
lowed by paralysis of both sides of the body, gives sufficient grounds 
to enable us to make the diagnosis of either of these accidents. 
Does it follow, if a person has an attack of apoplexy, succeeded by 
paralysis of both sides, that the effused blood has burst into the 
ventricles, or that a simultaneous double effusion has occurred ? 
Andral inclines to this opinion as far as I can collect. Dr. Aber- 
crombie appears to differ from him, and gives cases in illustration 
of his opinions. The following is one:—A private of the 10th 
Hussars had been complaining for some time of a pain in the head, 
for which he was blistered, and the pain soon went off. On the 
22d of July, 1819, he was seized with giddiness and fell down; on 
being raised, he vomited, and complained of violent headache and 
faintness, but was quite sensible. He was very pale, and his pulse 
slow and languid. He was brought into the hospital, where he 
asked for some cold water, made a few inspirations, and expired. 
Prom the moment of his last seizure he had been paralytic of both 
extremities. Here we have an attack resembling the first form of 
apoplexy, so far as complete loss of power in the upper and lower 
extremities is concerned, but observe, the patient was not comatose, 
and retained his faculties to the last. On examination there was 
nothing found amiss with the brain, but, on removing the cere- 
bellum, a coagulum to the amount of about two ounces was found 
under and surrounding the foramen magnum. Here the paralysis 
appears to have been produced by the pressure of the effused blood 260 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
on the upper part of the spinal cord. This case is an interesting 
one. It appears that the injury done to the functions of the life of 
relation was partial, there was a lesion of the muscular function, 
but there was no coma, and the intellectual faculties were unim- 
paired. As . far then as a single case goes, we may come to the 
conclusion, that we are not to make the diagnoisis of the first form 
of apoplexy, unless, in addition to the double paralysis, there are 
coma and loss of intelligence and sensation. The great points of 
diagnosis are coma, suspension of the phenomena of the mind, and 
paralysis of both sides of the body, both of motion and sensation. 
We now come to consider the symptoms of the second or milder 
form of the disease. A person falls down in a state of insensibility, 
but, when you come to examine him, you find that the coma is not 
so profound, nor is the paralysis and loss of sensation so complete. 
The eyes are to a certain degree susceptible of the impressions of 
light, signs of uneasiness are exhibited when strong pungent odours 
are applied to the nostrils, and indications of suffering are given if 
you pinch or burn the skin. All these circumstances prove, that 
the paralysis of sensation is by no means so complete in this as in 
the former case. You observe here, too, that instead of the cheeks 
being puffed out in the manner before described, there is only a 
partial paralysis of the muscles of the face, and the mouth is drawn 
towards the sound side. The patient, too, instead of dying in a 
comatose state, gradually regains his intelligence, and is only para- 
lysed on one side, or one extremity. All these circumstances point 
out that the injury done to the brain is not so extensive, and the 
occurrence of paralysis on one side shows that the effusion is limited 
to a single hemisphere of the brain. All this, too, is borne out by 
pathological anatomy, which shows us, in the first place, that the 
extent of the effusion is much less, that it exists only on one side of 
the brain, and never bursts into the ventricles. The general con- 
gestion of the head also is much less than in the former case. In 
the third form, the congestion and other symptoms are sometimes 
very slight. A person in health may feel a stunning sensation in 
the head, followed by some thickness of speech and drawing of the 
mouth to one side, or slight paralysis of one arm or hand, but he 
has no coma or loss of intelligence, and the paralysis quickly dis- 
appears. Every thing connected with the attack shows that it is 
very slight, the effusion is extremely limited, and this is confirmed 
by pathological anatomy. 
I have now given you a brief sketch of the three varieties of 
apoplexy; between these you will meet with many intermediate 
cases. 
Let us enquire how far does the circumstance of paralysis point 
out the occurrence of an extravasation of blood into the substance, 
or on the surface of the brain; that is, how far we can say that this 
patient has effusion, because he has become suddenly paralytic. It 
would appear, that the mere suddenness of the attack will not alone 
lead to the formation of a certain and accurate diagnosis. You will 
find in various authors many instances of affections of the head, APOPLEXY. 
261 
not of an apoplectic character, in which there was sudden para- 
lysis. Thus, for instance, there are many cases of tumours and 
encysted abscesses on record in which there was sudden paralysis, 
and where, if you should pronounce the disease to be apoplexy, you 
would be certainly wrong. We had lately, at the Meath Hospital, 
a remarkable instance of this. A patient, who had been for a con- 
siderable time labouring under aneurism of the innominata, in the 
course of the night became suddenly hemiplegic. On examining 
the brain, post-mortem, there was a circumscribed abscess found in 
one of the hemispheres, but no sanguineous effusion. If you look 
to the works of Abercrombie, Rostan, Lallemand, &c., you will find 
many cases detailed in which sudden paralysis occurred from other 
causes than apoplexy. 
But are there no circumstances, which, combined with the sud- 
denness of the attack, would lead us to form the diagnosis of apo- 
plexy ? Now it would appear that, as a diagnostic of apoplectic 
effusion, suddenness of paralysis is only to be relied on where 
there have been no premonitory symptoms of a local disease of the 
brain. In the great majority of cases of cerebral abscess, you will 
find that pains and cramps in some of the limbs, and pain of the 
head in the situation of the abscess, have preceded for some time 
the paralytic attack. But if a person in health, without any of 
these cramps or pains, gets a sudden attack of apoplexy, and be- 
comes hemiplegic, you may make the diagnosis of apoplectic effu- 
sion with tolerable certainty. The fact of the paralysis occurring 
with an apoplectic seizure, renders it highly probable that the case 
is really one of the hsemorrhagic diseases of the brain. On the 
other hand, it is true that we may have apoplectic effusions ushered 
in by symptoms of irritation of the brain ; as in the case of an apo- 
plectic effusion occurring in the centre of a softening of the brain. 
The absence, therefore, of these premonitory symptoms appears to 
be necessary towards forming the diagnosis of simple apoplectic 
effusion. 
LECTURE XXX. 
Apoplexy from ramollissement of the brain—Supervention of apoplexy on encephalitis; 
—Inflammation round the clot—Variety of paralysis consequent on apoplexy—Para- 
lysis croissee—Different forms of paralysis—Origin—Phenomena of face and 
tongue—Paralysis of the tongue—Treatment of apoplexy—Blood-letting—Purgatives 
—Lotions, beneficial effects of—Emetics, dangerous effects of—Use of revulsives and* 
stimulants—Treatment of paralysis—Efficacy of strichnine—Its modus operandi— 
Brucine, its proposed employment. 
I left off at my last lecture in considering how far the mere 
circumstance of suddenness of attack with paralysis could be 
considered as leading to the diagnosis of apoplectic effusion, and 
endeavoured to show that mere suddenness of attack with para- 
lysis was insufficient to form a diagnosis, except where they 262 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
occured in a person who had no previous symptoms of irritation of 
the brain ;—these symptoms being pain of the head, and pains, 
spasms, and rigidity of the limbs. I wish to impress upon you, 
that you may have an attack of apoplexy with effusion ushered in 
by all these symptoms, particularly in cases where the apoplectic 
effusion is consequent on a localised inflammation of the brain. A 
portion of the brain, for instance, becomes inflamed and disorgan- 
ised ; local ramollissement takes place ; and it may happen that 
this, acting as a point of attraction to the fluids, may lead to the 
occurrence of an apoplectic effusion in the originally affected por- 
tion ; and in this way you will have apoplexy preceded by all the 
symptoms which characterise a partial encephalitis. You will 
perceive, then, that the absence of these premonitory symptoms is 
necessary towards forming a certain diagnosis of apoplexy with 
effusion. If these symptoms have preceded the attack, it is pro- 
bably either circumscribed abscess of the brain, or it is local inflam- 
mation followed by effusion. Between these two forms of disease 
we have no means of distinguishing. 
Before I speak of paralysis I wish to make some remarks on a 
condition of the brain which supervenes in certain cases of apo- 
plexy. In cases where absorption of the clot takes place, we cannot 
suppose that any inflammatory condition of the brain exists ; on 
the contrary, we have every reason to believe that a non-inflamma- 
tory condition of the brain is highly favourable to this process, for 
whenever any thing of an opposite character happens, we find that 
it prevents absorption. But sometimes cases occur, in which, at 
an earlier or later period, inflammation is set up round the clot. 
Now, what happens in many of these cases ? Here let me repeat, 
that there are many exceptions to the rules given for forming the 
diagnosis of disease of the brain; the variety in the symptoms of 
cerebral affections being so great, that it is sometimes difficult to 
deduce from them rules of general application. In most cases we 
have apoplexy followed by paralysis with resolution ; but, in cases 
where inflammation takes place round the clot, it has been observed 
that the paralysed limb which had been previously in a state of 
resolution becomes contracted, and then we have paralysis with 
contraction. This contraction generally comes on in a gradual 
manner, but, when the case is severe, it is frequently ushered in by 
violent spasmodic action of the affected limbs. We have, then, the 
following order of phenomena : first, paralysis with resolution, and 
then paralysis with contraction. In circumscribed inflammation of 
the brain, the phenomena are the reverse of these ; we have, first, 
rigidity and contraction of the limbs, and then symptoms of apo- 
plexy followed by paralysis with resolution. 
With respect to the paralysis which is consequent on an attack 
of apoplexy, there is the greatest possible variety. In some cases 
there seems to be paralysis of all, or almost all, of the muscles of 
animal life; in others, it affects only the muscles of one side of the 
body. A rare and extraordinary form of paralysis has been de- 
scribed by the French writers, who have given it the name of 263 
APOPLEXY. 
paralysis croissee. In this form of the disease there is an affection 
of both sides, but not of the symmetrical members; we find the left 
arm and the right leg paralysed, and vice versa. This is an unu- 
sual form, in fact the rarest to be met with in practice. We may 
also have great varieties in the amount of the paralysis; in some 
cases both sides being affected, in others only one, while in others 
there is only a single extremity or one side of the face paralysed. 
We may also have complete paralysis of one side without any 
affection of the face. I remember a remarkable case of this kind, 
of which I shall give you an abstract. A gentleman, of stout 
muscular habit and a strong full pulse, had been suffering for a 
long time under an obstinate gouty affection. From a repetition of 
the gouty attacks he got a chronic swelled state of the lower 
extremities, which continued for some time, he being in other 
respects in the enjoyment of excellent health. The swelling, how- 
ever, preventing him from taking his usual exercise, he applied for 
advice. Laced stockings were advised, the effect of which, was, 
that the oedema subsided, and the motion of the lower extremities 
was restored. It is curious, that, between the period of the re- 
moval of the oedema and the paralytic attack which I am about to 
describe, this gentleman enjoyed excellent health. At the end of 
that time, on attempting to go over a step that led into the yard, 
he found he could not accomplish his purpose, and struck his foot 
against the stone. He immediately became alarmed and sat down, 
and soon after found that he had lost the power of using his arm. 
I saw him in a short time after the accident, and found that there 
was complete paralysis of the arm and leg, but no distortion of the 
face or tongue, or the slightest lesion of intelligence. He continued 
in this state for some time, and then recovered, but it was neces- 
sary to take a large quantity of blood from him. In the first 
bleeding, as the pulse was full and bounding, I took sixty ounces 
of blood from the arm, and I think it was owing to the activity of 
the measures adopted that he recovered so speedily. I mention the 
case merely to show that we may have paralysis of the leg and 
arm, without any affection of the face, or loss of intelligence. In 
some cases we find the paralysis affecting the tongue, face, and 
muscles of the eyelids; in some we have paralysis of the sphincter 
ani, or of the muscles of deglutition, or of the bladder, but these are 
rare, and the most ordinary form is paralysis of the muscles of one 
side, and distortion of the face. There is another circumstance, 
which seems to be so exceedingly frequent as to form a law, per- 
haps the most general of any in medicine, that paralysis occurs on 
the side of the body which is opposite to that on which the effusion 
occurs. If you have an effusion into the right hemisphere, you 
will have paralysis of the left side of the body, and, if the effusion 
be on the left side, the paralysis will be on the right. To this rule, 
however, it has been stated that there have been a few exceptions ; 
how they have occurred it is totally impossible to explain; it is 
sufficient for us to know that such exceptions have been witnessed. 
Cases of this description have been very rarely seen since patholo- STOKES’S THEORY AND PRACTICE OF MEDICINE. 
264 
gical anatomy has been studied with more diligence; it is however 
true, that a few have been detailed by men of great professional 
eminence. We want facts to throw light on this point, and, until 
this is accomplished, we must remain in ignorance of the cause of 
the anomaly. In the vast majority of instances, the paralysis is on 
the opposite side to that on which the effusion takes place, and this 
appears to be explained by the decussation of the fibres of the brain 
at the upper part of the spinal marrow, the fibres of the left side 
passing to the right, and vice versa. It is an interesting fact 
connected with this subject, that the muscles of the face follow the 
same law as the muscles of the extremities, and yet it is a fact, as 
you are well aware, that the nerves which supply the muscles of 
the face come off before the decussation of the fibres of the brain 
takes place. The filth nerve, which supplies the face with muscu- 
lar branches, is given off at a considerable distance from the decus- 
sation of these fibres, and yet we perceive that the muscles to which 
it is distributed obey the same law as those which derive their 
nerves from the spinal cord. Now, if this decussation was the only 
cause of the paralytic symptoms being observed on the side oppo- 
site to that in which the effusion occurs, the muscles of the face 
should be an exception to this law; but we find that they cor- 
respond with other parts of the muscular system in this respect. 
Thus, if a man gets an attack of apoplexy, followed by paralysis of 
the left arm, we find the left side of the face affected, and vice versa. 
We must conclude from this, that the mere decussation of the fibres 
is not the sole cause of this peculiarity, and must look for an expla- 
nation elsewhere, by referring it to the intimate communication 
which exists between both sides of the brain by means of its com- 
missures. Many persons are not familiar with the phenomena of 
the face and tongue in paralysis; they are, however, simple and 
easily explained. Let this diagram represent the head—here we 
have the right hemisphere of the brain, here the left. Now, suppose 
you have an apoplectic effusion in the right hemisphere, the conse- 
quence is that you have paralysis of the left side of the body, 
according to the law already mentioned. What will then happen 
with respect to the face is, that the muscles of the left side being 
paralysed, and their antagonism destroyed, the mouth is drawn by 
the sound muscles of the opposite side from the paralysed side, and 
this is invariably the case. Recollect, then, that the mouth is 
always drawn from the paralysed side, and towards that side where 
the disease exists in the brain. But when you desire the patient to 
put out his tongue, do you find that the tongue follows the direction 
of the mouth ? No ; it goes towards the opposite side. This ap- 
pears somewhat paradoxical at first, but is easily explained. The 
protrusion of the tongue is effected by the action of the genio-hyo- 
glossi muscles, which are, as you all know, a pair of fan-shaped 
muscles, attached to the inside of the chin, the middle line of the 
tongue, and the body of the os hyoides. This diagram will repre- 
sent it. Here is the muscle of the left side, and here is the right. 
When the patient puts out his tongue, this left half being paralysed, APOPLEXY. 
265 
and having lost its antagonism, the tongue obeys the action of this, 
the right half, and the fixed point of attachment of the muscle 
being to the right of the mesial line, the base of the tongue is 
brought forward, and to the right, and its point consequently 
deviates to the left or paralysed side. It has been remarked, also, 
that there is some variety with respect to the paralysis of the 
tongue; some patients can protrude it, others cannot. In some 
cases, too, the patient can put out his tongue well enough, but he 
cannot employ it in the articulation of sounds, and his speech is 
quite indistinct. 
I might occupy your time for several lectures with these subjects; 
and, did my time permit, I could lay before you a vast quantity of 
interesting matter on the subject of paralysis from apoplexy ; but, 
as the number of lectures is limited, all I can hope to accomplish is, 
to point out the great landmarks to you, and leave the rest to your 
own study and experience. With respect to paralysis of the 
extremities, the upper are paralysed more frequently than the lower; 
and, when both extremities are engaged, the upper are generally 
more completely affected than the lower. When a person recovers, 
also, we find that the lower extremities are the first to regain their 
lost power and sensibility. These circumstances have been at- 
tempted to be explained by considering the particular parts of the 
brain in which the effusion has occurred; but, as this has not as 
yet been sufficiently made out, I shall pass it over. I regret, also, 
that I have not time to enter into the subject of the different varie- 
ties of lesion of intelligence in cases of apoplexy. I must however 
observe that the varieties are infinite, and your trouble will be 
amply repaid by reading what has been written on this point 
by Dr. Abercrombie, and Dr. Cooke in his Treatise on Ner- 
vous Diseases. You will find in the latter work an extraordi- 
nary collection of facts with respect to lesions of the intellectual 
functions. 
I shall now endeavour to get through the treatment of apoplexy 
as briefly as the important nature of the subject will admit. I shall 
commence by saying, in the words of Dr. Abercrombie, that the 
remedies for apoplexy are few and simple. The great point is to 
relieve the head from the accumulation of blood, to prevent further 
congestion, and to obviate inflammatory action ; and for these pur- 
poses the only efficient means we possess is bleeding. There is no 
disease in which the efficacy of free and bold depletion by the lancet 
is more remarkable than in apoplexy. I agree completely with Dr. 
Abercrombie in thinking that the symptoms which denote serious 
apoplexy by no means contra-indicate the use of the lancet; for I 
have already shown, that serous apoplexy was nothing but con- 
gestion, that the serous effusion was one of the consequences of this 
congestion, and by no means the cause of the apoplectic symptoms. 
Dr. Abercrombie thinks that, in the commencement of the disease, you 
may bleed where the pulse is feeble as well as where it is strong and 
full, and gives many important cases in which the disease yielded to 
a copious abstraction of blood, though the state of the patient’s pulse 266 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
and general system at the time were such as would deter many from 
bleeding. He gives three cases of persons about seventy years of age, 
on whom this mode of treatment was practised with success, and 
another of a person of spare habit, aged eighty years, whose life was 
saved by a bold and timely use of the lancet. There is also another 
case detailed of a patient who was worn down and dropsical at the 
time of the attack, and received considerable relief from bleeding. 
I do not wish you to conclude from this that you should bleed as 
boldly in the one case as in another ; what I wish to impress is 
this, that in a vast majority of cases it is advisable to have recourse 
to the lancet. With respect to the first bleeding, I think that where 
the pulse is full and strong it should be large, and such as will 
produce some effect on the symptoms. This may be repeated 
afterwards to a smaller amount if necessary; but the subsequent 
bleedings should be rather local than general, except where there 
is any renewal of the cerebral and circulatory excitement, which 
must be always met with activity. I believe the cases in which 
you must make the largest bleedings are those in which there are 
symptoms of an hypertrophied heart. But where this is not present, 
one or two bold bleedings, followed by local depletion of the head, 
will be sufficient. In cases of apoplexy, you may either open a 
vein or the temporal artery, for the objections made to arteriotomy 
in phrenitis do not apply so much to cases of apoplexy. There is 
no violence on the part of the patient, nor is there the same chance 
of the vessel giving way. The head should be shaved and freely 
leeched, and the patient may be cupped on the temples or the back 
of the neck. 
Next in efficacy to general and local bleeding seems to be the 
administration of strong purgatives. There are many cases on 
record in which the coma and other symptoms have resisted bleed- 
ing, both general and local, but have disappeared under the influ- 
ence of active purgation. One of the great objects in the treatment 
of apoplexy should be to get rid of the coma as soon as possible ; 
and for this purpose nothing appears to answer better than the early 
use of brisk purgatives. Dr. Abercrombie recommends croton oil 
as the best purgative that can be employed, and indeed it is an 
excellent one ; but if the patient can swallow, you need not be very 
anxious about the kind of purgative you prescribe ; any active 
purgative followed by a strong enema will do. Where the patient 
cannot swallow, you may mix the dose of croton oil with some 
mucilage, and pass it into the oesophagus by means of a gum elastic 
tube. 
After purgation, the next thing is to apply cold to the head by 
means of cold lotions, or iced water, or by pouring a stream of cold 
water on the head. This is a measure of great efficacy, and one 
which you may employ with safety and advantage. 
In cases of apoplexy, where the coma has resisted free bleeding, 
both general and local, and where purgation and cold applications 
to the head have been employed without any decided effect, it 
seems advisable to apply a blister to the head or nape of the neck. 267 
You will recollect that I told you that blisters were always danger- 
ous in the early periods of all acute visceral inflammations. This, 
however, does not apply so much to cases of hemorrhagic effusion 
like apoplexy, in which blisters may be employed at an earlier 
period than in cases of active inflammation. I would advise 
you, therefore, to use blisters in cases of apoplexy attended by 
persistent coma, having first put into practice the means already 
mentioned. 
APOPLEXY. 
Many persons advise the use of emetics in apoplexy, but the 
facts bearing on this point, to which I have drawn your attention 
when speaking of inflammation of the brain, will also apply here. 
You may take it as a general rule, that where congestion of the 
head exists, vomiting will always increase it, and must be therefore 
exceedingly dangerous. As far as theory goes it is totally against 
this practice, and I believe experience also is opposed to it. In a 
number of cases of disease of the brain, where emetics were em- 
ployed, it has been found that an unfavourable result ensued, and 
there are some cases of apoplexy on record in which the exciting 
cause was a fit of vomiting. 
Suppose that, after having taken away blood, purged actively, 
used cold applications, and blistered the head, the coma still re- 
mains, accompanied by a feeble pulse and cold skin, what are you 
to do ? I believe, under these circumstances and these alone, you 
may venture on the use of internal stimulants. Though this is at 
best but a forlorn hope, still the practice appears rational; we have 
analogy to guide us in the use of stimulants in such cases, and 
there are cases on record of persons who have recovered from this 
state by their judicious employment. The remedies most generally 
prescribed for this purpose are camphor, musk, and carbonate of 
ammonia. In the cases of typhus, we know that these remedies 
have frequently succeeded in removing the coma; but I repeat, 
that you should never have recourse to stimulants until the period 
for depletion has passed by, and all the ordinary means have 
failed. 
I shall now suppose that we have succeeded in removing the 
coma, that consciousness has returned, and that nothing remains 
but paralysis of one side. Our great object is to get rid of the para- 
lysis as soon as possible. Here you will recollect that you have to 
deal with paralysis depending on extravasation, a paralysis which, 
as far as we know, will not disappear under any form of treatment 
until the extravasated blood has been absorbed. The first thing 
then you have to do is to adopt measures to prevent a return of the 
attack. This is to be effected by carefully restricting the patient in 
his diet, by avoiding all causes of cerebral irritation, whether phy- 
sical or moral, and by obviating every thing capable of exciting the 
circulation. But you should not be content with this: you should 
from time to time employ local depletion, which in cases of this 
kind has a double utility. It tends to prevent a repetition of the 
attack, and, by lowering the circulation, keeps the brain in that 
non-inflammatory condition which is most favourable towards pro- 268 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
moting the absorption of the coagulum. In many cases, also, you 
will find it of great advantage to establish a drain in the vicinity of 
the disease, and a great deal of good may be done by putting a 
seton, or an issue, in the neck. You must also pay constant atten- 
tion to the state of the bowels and urinary system in cases of para- 
lysis ; keeping up a steady but mild action of the bowels has an 
excellent effect, and I need not impress upon you the necessity of 
paying strict attention to the bladder. 
The paralysis which supervenes on an attack of apoplexy, is to 
be treated always in the first place by means directed to the head, 
and the brain is to be put in such a state as will favour the removal 
of the clot by the means already recommended; in addition to 
which it will be necessary that the body and extremities should be 
kept in a warm temperature. But there is this very singular cir- 
cumstance connected with some cases of paralysis, that a period 
will arrive when, although the original disease of the brain has 
been removed, and the clot absorbed, the paralysis still continues. 
It is not easy to explain the circumstance; but it has been observed 
in many persons who have been paralytic, that the clot was com- 
pletely absorbed, and no existing trace of disease discoverable, such 
as would account for the continuance of the paralysis. In cases 
like this we must adopt a different mode of practice, and have 
recourse to measures capable of exciting the brain, and we have 
reason to believe that whatever will excite the brain and restore its 
energy (I must use this phrase for the want of a better) will cure 
the paralysis. We find that in some cases where the brain of a 
patient, under such circumstances, has been exposed to any sudden 
stimulus, whether physical or moral, the symptoms of paralysis 
have disappeared, sometimes gradually and slowly, at other times 
rapidly and at once. Now, this disappearance of the symptoms 
shows that the paralysis did not then depend on the presence of a 
clot, for if an unabsorbed coagulum remained in the situation of the 
original extravasation, the paralysis would not disappear. But it 
has been frequently observed, that a patient, labouring under para- 
lysis, may get rid of his symptoms suddenly, or that, at a certain 
period, they begin to decline, and then go away altogether. From 
a consideration of these circumstances we are led to divide the 
treatment of paralysis of this description into two parts, and endea- 
vour first to excite the brain itself, and next the nerves which 
supply the paralysed limbs. For this purpose several remedies, 
supposed to be capable of stimulating the brain, so far as its action 
on the muscular system is concerned, have been recommended, the 
most important of which is the nux vomica, or its active principle, 
strychnine. The researches and experiments of modern medicine 
have already established the efficacy of strychnine in such cases, 
but you will recollect, as I before stated, that this powerful remedy 
can be employed with safety only in cases where the paralysis 
continues after the disappearance of organic disease of the brain. 
Until that period arrives, and all symptoms of congestion and 
excitement are removed, it would be improper to prescribe the use APOPLEXY. 
269 
of strychnine. One of the most recent publications on this subject 
is from the pen of I)r. Bardsley of Manchester, in which you will 
find an exceedingly interesting series of cases treated with strych- 
nine, and many of them with the most decided success. In most 
of these cases you will find that Dr. Bardsley, even where the 
disease has been of some standing, precedes the use of strychnine by 
measures calculated to deplete the head, even though the cases 
were chronic. Hence, whenever you are about to prescribe this 
remedy, you should be satisfied that depletion has been sufficiently 
performed. You may be called to treat a patient for paralysis after 
an apoplectic attack. Here you must consider how far you are to 
premise the use of strychnine by depleting measures, and you must 
also reflect that we here have shadowed out one of the most 
important principles in medicine, that in almost all cases where a 
cure is to be attained by stimulation, it will be effected more rea- 
dily, and with much more certainty, when preceded by local deple- 
tion, no matter how long the disease may have lasted. The efficacy 
of strychnine in paralysis seems to be dependent on the antecedence 
of local or general depletion. 
Strychnine being an exceedingly active remedy, and having a 
most powerful effect in stimulating the brain, it being also one of 
the accumulative class of medicines, it will be proper to commence 
its exhibition with a very small dose, and watch its effects with 
care. The following is the formula which I would recommend 
you to employ. You take a grain of strychnine, and your object 
being to divide it into a number of equal parts, (say sixteen,) to 
ensure an accurate division, you dissolve it in a small quantity of 
alcohol, and, having mixed this solution with a sufficient quantity 
of bread crumb or conserve of roses, you divide it carefully into 
sixteen equal pills. In this way you may be tolerably certain that 
each pill contains one sixteenth of a grain. Begin at first with one 
pill a day, next day you may give two, and so on until you have 
brought it up to half a grain or a grain, watching carefully its 
effects. Now, what are these effects ? They are very analogous 
to the phenomena produced by inflammation of the brain taking 
place in the vicinity of the clot, namely, spasms of the muscular 
system. 
It is also a curious fact, that these spasms are principally observed 
on the paralysed side ; in other words, that the portion of the brain 
which has been affected by disease is more sensible to the stimulus 
of the strychnine, the consequence of which is spasmodic twitches 
in the paralysed limbs. The great nicety of practice in the treat- 
ment of paralysis in this way, is to keep up a certain degree of this 
irritation without letting it proceed to any degree of violence, and 
to omit it whenever the following symptoms become manifest— 
headache, giddiness, weakness and sickness of the stomach, and 
too violent spasmodic twiches of the limbs. 
There is a great difference with respect to susceptibility of the 
effects of this remedy in different individuals; in some the effects 
speedily appear, and you are obliged to intermit its use; others will 270 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
bear large doses for a considerable time, and you may push the 
strychnine until a grain or a grain and a half is taken in the day. 
I have myself given to one patient a grain every day for the space 
of a fortnight without any intermission. In all cases, however, it 
will be necessary to watch the symptoms. There is one effect of 
strychnine which appears to be unfavourable, and whenever it 
occurs you should either omit the medicine or diminish the dose. 
Along with or succeeding the spasms, there is a tonic rigidity of 
the limbs ; when this occurs you should be cautious in the admin- 
istration of strychnine. The length of time which it should be 
continued will of course vary according to circumstances, but you 
should be aware that it requires a considerable period of time to 
produce its effects. In all Dr. Bardsley’s cases, and in all those 
treated at the Meath Hospital, it has been continued for a consider- 
able time, certainly more than a month. It is also necessary for 
you to recollect that strychnine is one of those medicines which are 
termed accumulative, that is to say, remedies the operation of which, 
after remaining latent for some time, suddenly explodes with great 
violence. When this occurs, the strychnine must be immediately 
given up, and steps taken to control its effects. One of the best 
things for this purpose is the carbonate of ammonia with some mild 
anodyne. I have seen very severe spasms from the use of this 
medicine. In one case these spasms were so violent as to roll the 
patient nearly out of bed. 
It has been proposed to employ brucine as a substitute for strych- 
nine. Of this remedy I can say but very little; I have given it but 
very seldom, I believe in only two cases, and in these without any 
sensible effect. It is much weaker than the former remedy, 
one fourth of a grain of strychnine being equal to six grains of 
brucine. Other remedies have been proposed for the same pur- 
pose, among the rest, iodine, which has been recommended by Dr, 
Mansfield. 
The next class of remedies are those which are employed for the 
purpose of exciting the nerves of the paralysed limb. As my time, 
however, has expired, I must postpone the consideration of these 
until our next meeting. 271 
PARALYSIS. 
LECTURE XXXI. 
Local treatment of paralysis—Flesh-brush, shower-bath, &c.—Application of moxa— 
Cases in which it is useful—Professor M’Namara’s plan—Acupuncture with galva- 
nism—Electro-puncturation—Method of applying—Powerful action of a small battery 
—Mr. Hamilton’s observations—Value of galvanism and electricity—Use of, in para- 
lysis of the muscles of the face—Paralysis from disease of the arterial system—Case 
of, by Dr. Graves—Diagnosis of this affection—Pathology of Pott’s gangrene—Du- 
puytren’s mode of treatment. 
Having spoken of the general treatment of paralysis after apo- 
plexy, we come now to the local management of the disease, or that 
portion of its treatment which consists in the application of stimu- 
lants to the nerves and their origins. Local stimulation of paralytic 
limbs may be performed in a variety of ways; all the usual stimu- 
lant embrocations may be employed for this purpose with the best 
effects. I shall not take up your time in detailing the different 
kinds of liniments which are used on such occasions; they are 
universally known, and may be varied ad infinitum. The flesh- 
brush, the shower-bath, either tepid or cold, occasional blisters to 
the spine, or along the course of the nerves, croton oil and terebin- 
thinate frictions—all these are measures that may be employed with 
advantage. The use of the moxa has been also strongly recom- 
mended, and appears to be decidedly beneficial. The efficacy of all 
these remedies, however, seems to depend chiefly on the particular 
stage and nature of the disease, and hence their good effects are 
most apparent in those cases where the paralysis no longer depends 
on organic disease of the brain, but seems to be connected with 
that peculiar state of the nervous system which arises from a long 
interruption of the power of transmitting volition. It is in cases 
like this that the application of the moxa has been found to produce 
the most favourable results. Where the lower extremities are affect- 
ed, it may be applied over the sciatic nerve on the loins, or a little 
below and to the outer side of the popliteal space over the track of 
the peroneal nerve. In case of paralysis of the upper extremity, 
you may apply it to the back of the neck, or in the neighbourhood 
of the brachial plexus. 
A gentleman who does me the honour of attending these lectures, 
has related to me the particulars of a remarkable case, which I 
shall mention en passant. A young female was subject to repeated 
violent attacks of spasms with contraction in one of the upper 
extremities. She had laboured under this affection for a long time, 
and tried various remedies without benefit. At the suggestion of 
this gentleman she tried cupping in the neighbourhood of the 
shoulder and brachial plexus, and found that it produced decided 
relief to the symptoms. In this case it is highly probable that the 
disease was seated in the brachial plexus, and had no connection 
with the brain, for it had continued for a great length of time (more 
than three years, I believe) without any remarkable variation in 
its symptoms. If the spasms of the arm had been produced by 272 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
irritation of the brain, she would in all probability have had para- 
lysis long before this period ; this, however, did not occur, and the 
probability that the disease was seated in the brachial plexus is 
still further confirmed by the fact, that the spasms were relieved by 
local bleedings. Here we have the spasms relieved by antiphlo- 
gistic means, but in a case of atony of the same nerves most 
benefit would be derived from the use of stimulants. The more 
completely the paralysis is of this description, the more sure will 
be the effects of local stimulation. You will sometimes meet with 
cases of paralysis from pressure on the nerves without organic 
disease. Thus there is a case on record of a person who lost the 
use of one of his upper extremities, from having leaned too long over 
a bench at a public meeting. I recollect the case of a man, who 
during a fit of intoxication fell asleep with his arm thrown over 
the back of a chair, and awoke with perfect paralysis of the hand. 
Cases like these are seldom of long duration, and are much im- 
proved by the application of the moxa. I may state, however, that 
permanent paralysis has been induced in this way. The best way 
of using the moxa is, not to make a deep eschar, but to touch the 
parts slightly, and repeat the application frequently. In the case 
of paralysis of the hand, immediate relief followed the use of the 
moxa to the back of the wrist. 
While on this subject I may advise you always to employ the 
moxa in the mode first, 1 believe, devised by my friend and col- 
league, Professor M’Namara. The top of the moxa is to be dipped 
in a strong solution of the oxymuriate of potass, which is to be 
allowed to dry upon it. The moxa being fixed to the part by a 
little gum, a drop of strong sulphuric acid will produce immediate 
ignition. In this way you prevent all the alarm which the patient, 
feels at seeing a lighted candle brought to the bed-side. The same 
rule is to be observed when you employ electricity, the best mode of 
using which is to place the patient on an insulated stool, and draw 
sparks from, or shocks through, the affected limbs. Electricity 
frequently does much good in such cases; but, in order to obtain 
decided benefit from it, you must persevere for some time in its 
employment. It has been lately proposed to employ the stimulus 
of electricity and galvanism in a different way, by transmitting it 
directly to the muscles of the affected limbs by means of needles, 
which are to be inserted into different parts of paralysed extremities, 
and which are intended to act as conductors for transmitting the 
galvanic influence. This has been termed electro or galvanic 
puncturation, and forms an excellent mode of applying the stimulus 
of galvanism. I have made many experiments as to its effects, to 
which I shall briefly direct your attention. 
The first thing to be considered is the manner of its application. 
The following is that which I use at the Meath Hospital:—Having 
procured two fine sewing needles, your first step will be to take 
the temper out of them; for, if you employ them in the tempered 
state, you will run the risk of their breaking in the flesh, and this 
would be very disagreeable. You can easily take the temper out PARALYSIS. 
273 
of them by holding them in a candle until they become red hot, 
and then letting them cool gradually. The next thing is to place 
a head which will remain firm on the needle, and for this purpose 
you pass a small portion of thread through the eye, and then cover 
it with a bit of melted sealing wax. Having thus formed a head 
for the needle, you sharpen its point, and polish it by the emery 
pincushion, and the sharper it is the better. There is nothing 
more simple than to introduce the needles. You make the part of 
the skin tense with your finger and thumb, where you intend to 
introduce them, and, placing the point of the needle perpendicularly 
on it, you press it downwards in a slanting direction, using, at the 
same time, a rotatory motion, and thus easily pass it in ; when you 
have pierced the skin and fascia, there is no difficulty in introducing 
it into the muscular fibres. The distance between the needles must 
be regulated according to circumstances. You then proceed to 
send the galvanic fluid to the part, and, for this purpose, the. best 
mode is to employ a small galvanic battery with a limited number 
of plates. If you have plates of from two to three square inches 
you will find that from fifteen to twenty of these, in a state of 
ordinary action, will be quite sufficient, particularly in the com- 
mencement of the treatment. It is a curious fact, that the intensity 
of the shock is increased to an extraordinary degree by means of 
the needles. A battery which in the usual manner would not com- 
municate any shock, will, when used with the needles, give a 
violent one, and communicate such a stimulus to the nerves as will 
throw the whole limb into violent spasms, and cause a copious 
perspiration to break out over the body. I have seen very great 
effects from a feeble battery in this way, and it would appear that 
this is the result of the direct transmission of the galvanic influence 
to the muscular fibre. In most cases a perspiration is brought on, 
the limb convulsed, and sometimes the whole body is thrown into 
spasms. As an illustration of the power of the battery when used 
in this way, I shall mention the following case:—A patient who 
was under the care of Mr. Hamilton, laboured under amaurosis; 
he was anxious to try the effect of galvanism, and with this view 
inserted one needle in the upper part of the back of the neck, and 
another over the orbit, so as to direct the trajet of the fluid across 
the base of the brain. He intended at first to use a small battery 
of twenty-five plates, but it struck him that even twenty-five might 
be too much. He made the experiment with three pairs of plates, 
and, the shock being given, the patient, to his astonishment, fell 
back as if he had been stunned by a violent blow on the head, and 
remained for nearly a minute in a state of insensibility. In other 
cases, too, where the galvanism was applied in the vicinity of the 
head, I have found that severe headache, giddiness, and even a 
stiffness of the muscles of the face, were produced; all showing its 
powerful action on the nervous centre. 
Some singular circumstances connected with this subject were 
observed in the Meath Hospital. It was found that after a certain 
number of shocks had been communicated to the parts, when you 274 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
came to withdraw the needles there was a very remarkable differ- 
ence in the case of removing them. The needle through which 
the positive galvanic influence had been transmitted, was found to 
be strongly fastened in its situation, while that to which the nega- 
tive pole had been applied, slipped out with the greatest ease. 
This result was constant. In some cases, where half a dozen 
shocks or so have been given, the extraction of the positive needle 
has been only accomplished with considerable pain to the patient. 
It has been suggested by a distinguished scientific friend of 
mine, that this results from the coagulation of albumen at the 
positive pole. Mr. Hamilton, however, who performed most of the 
operations for me, thinks that the true explanation is the paralysing 
effect of the negative pole on the muscular fibre, while the positive 
needle is firmly grasped by the increased contraction. Further 
researches are necessary on this point. Another fact connected 
with this subject is, that when the needles have been inserted into 
a large muscular mass, the positive needle is powerfully retracted, 
and carried, as it were, into the muscles. In one case, where 
the needle was inserted into the lumbar muscles, in a patient 
labouring under sciatica, more than one twelfth of an inch of it 
was drawn in at each shock; so that, after a certain number of 
shocks, it passed up to the head. This is one reason for using 
the sealing-wax head, in order to prevent the complete passing in 
of the needle. 
With respect to our experience of the value of this mode of 
employing electricity or galvanism, I have to remark that, if gal- 
vanism or electricity can be of any use to paralysed limbs, this is 
one of the best modes in which it can be applied. The apparatus is 
simple, can be prepared in a moment, and does not depend on the 
state of the weather, like the ordinary electrical machines. There 
is another advantage, also, it is not so likely to excite alarm in the 
mind of the patient. We have employed it in several rheumatic 
and paralytic cases in the Meath Hospital, but have not as yet 
been able to say that decided benefit has accrued from it to the 
majority of the patients on whom it has been tried. This is more 
particularly true with respect to paralytic patients; in the rheu- 
matic cases we have found it more beneficial. In a remarkable case, 
where the deltoid muscle was paralysed and atrophied from some 
affection of its nerves, Mr. Hamilton tried it for a fortnight without 
any good effects. In a case of senile amaurosis, its effect was to 
produce flashes of light before the eyes, lachrymation, and contrac- 
tion of the pupil, but after a fortnight’s trial there was no improve- 
ment in the sight. We have had, however, distinct and unequivocal 
proofs of its value in one case of paralysis of the muscles of the face, 
which had all the characters of that described by Sir C. Bell, as 
resulting from an affection of the seventh pair of nerves. I have 
not the notes of this case at present, but shall bring them down 
and lay them before you on to-morrow. I may however observe, 
at present, that this patient had been for a long time labouring 
under an affection of one side of the face, and had used a variety PARALYSIS. 
275 
of remedies. Those principally employed were stimulating lini- 
ments and the internal use of strychnine, from which he derived 
some slight benefit; but the application of the galvanic fluid, in 
the way I have mentioned, was followed by decided and rapid 
improvement. Indeed, from the time it was first applied, the 
patient recovered rapidly, so that in a very short time all the 
deformity of face disappeared. Now the value of the application 
is to be estimated in this way. Here we have a case of paralysis 
of a local nature, and not depending upon any disease of the brain; 
in this case the galvano-puncturation was tried, and found to be 
most beneficial. The conclusion, then, as far as a single case goes, 
is, that this mode of treatment is best adapted to the form of para- 
lysis just mentioned, in which we find an affection of some of the 
muscles remaining after the original disease of the brain has 
been removed. The same observation, I need not tell you, applies 
to all other remedies which are employed for the purpose of local 
stimulation. 
Before I leave the subject of paralysis, there are two points to 
which I wish to call your attention. One of these involves the 
consideration of a remarkable form of paralysis in which the dis- 
ease appears, as far as we can see, not to depend on any primary 
lesion of the nervous system. In this form we have a paralysis, 
not the result of any disease of the brain or nerves, but connected 
with an affection of the vessels of the part. This is a very singular 
disease, and I am anxious you should be acquainted with it, for I 
believe it is by no means so rare as many persons think. The 
other point to which I would direct your attention refers to the 
influence of magnetism on the human body ; of this I shall speak 
on a future occasion, confining myself for the present to that 
form of paralysis which is connected with disease of the vascular 
system. 
So as to give you some idea of this affection, I think I cannot do 
better than read for you the notes of a case of it, published 
by Dr. Graves and myself in the fifth volume of the Dublin Hos- 
pital Reports. 
A man, aged 44 years, was attacked in December, 1828, with 
alternate sensations of cold and burning heat in the toes of the 
right foot. These extended to the leg, of which the power became 
diminished. Pains in the foot next occurred, and in a month the 
part became cold and wholly deprived of sensation. 
On the day of his admission the pain suddenly extended to the 
calf of the leg ; and from this time he lost all power of motion in 
the leg. On admission, the temperature of the body, with the 
exception of the affected limb, was natural. The pain had ex- 
tended to the thigh during the night. The temperature of the 
limb was but 58° of Fahrenheit. Slight oedema existed about the 
ankle. There was complete loss of sensation from the middle of 
the thigh to the toes ; the patient could rotate the thigh slightly, 
but there was no other voluntary motion possible. The femoral 
artery appeared like a hard cord, painful on pressure, and without 276 
STOKES’S THEORY AND PRACTICE OE MEDICINE. 
pulsation. By the stethoscope we found that pulsation was also 
wanting in the common iliac on this side, while that of the left 
iliac was plainly perceptible. The patient died on the fourth 
day after admission, the limb having become purple, tender, and 
covered with vesications. 
On dissection, the right common iliac appeared distended and 
livid, and was completely plugged up by a dark clot, extending to 
the external and internal iliacs, and engaging the gluteal and 
obturator arteries. The same occurred in the femoral and pro- 
funda, and extended, as far as they could be traced, to the tibial 
arteries, and to the peroneal. The lining membrane of these 
vessels was soft, villous, and red; the clot in some places being 
separated from it by a layer of puriform matter. No disease in the 
veins. A large portion of the vasti and rectus muscles was white 
and hardened. Here you perceive a train of symptoms, some 
of which might be referred to disease of the brain, if the man 
had any cerebral symptoms, which was not the case, for his intel- 
lect was sound, and he had no evidence of cerebral disease except 
the paralysis. 
His constitutional symptoms were emaciation, prostration of 
strength, and loss of appetite. The temperature of the body was 
natural, but, on examining the limb, we found (and this is a point 
of great importance) that it was as low as 58° of Fahrenheit; in 
fact, it was quite cold. There was also complete loss of sensation 
from the middle of the thigh to the toes, and though he could 
rotate the limb slightly, it was, in all other respects, powerless. 
Here we have paralysis of motion and sensation in one of the 
extremities, with remarkable coldness of the limb. On making 
an examination along the track of the femoral artery, we found 
that it was painful on pressure, without any pulsation, and con- 
veying to the finger the feel of a piece of hard cord. From a 
consideration of those circumstances, we came to the conclusion 
that it was not pervious, and that this would account for the state 
of the limb. In this case, also, we made another remark, and this, 
I believe, is the only instance on record in which such a diagnosis 
was made. Up as high as the groin the pulsation of the femoral 
artery could not be felt, and we were anxious to ascertain how 
far further the disease extended. The state of the femoral artery 
in the left groin was natural. On making an examination with 
the stethoscope, we found that the pulsations of the aorta were 
perceptible down to its bifurcation, but when the stethoscope was 
applied below this on either side, we observed that there was no 
pulsation in the right common iliac artery, but on the left side it 
could be traced distinctly down to the groin. Here then we had 
a train of phenomena, such as ordinarily occur in paralysis affect- 
ing the right lower extremity, and along with this an obstruction 
to the circulation in the thigh and leg. From these circumstances 
we made the diagnosis of obstruction of the right iliac and femoral 
arteries. On dissection, we found that the aorta was healthy to 
within about six inches of its bifurcation; below this point it was PARALYSIS. 
277 
partly filled by a red clot. The left common iliac was healthy, 
but the right was plugged up with a dark red clot, which extended 
into the internal iliac and obturator arteries, filling up also the 
femoral and its branches. The case, in fact, was nothing more or 
less than one of chronic arteritis. 
This remarkable form of disease has been also observed by other 
authors. You will find it well described in Rostan’s work on 
diseases of the brain, where he mentions that this loss of sensation 
and motion in a limb is sometimes produced by obstruction of its 
vessels. In persons advanced in life, the arteries are also frequently 
obstructed by the formation of ossific deposits within them, pro- 
ducing loss of power, coldness, and diminution of sensation, as in 
the foregoing case. A similar effect may occur from the pressure 
of an adjoining tumour on the trunk of a principal artery. 
Paralysis resulting from disease of the arterial system is distin- 
guished from paralysis caused by cerebral disease, by the following 
marks : first, by the colour of the integuments of the affected limb, 
which, in a case of the former description, are generally of a violet 
hue, or of a much deeper tinge than in the latter case, or in a state 
of health. It is very rare to find the two limbs of the same colour, 
as we do in cases of cerebral paralysis. Another mark is, that the 
temperature of the limb is always lower than that of the healthy 
one ; but the distinctive sign of this form of paralysis is the absence 
of pulsation in the arteries in parts where it should be naturally 
observed. If to this description you join the absence of cerebral 
symptoms, you will seldom fail in making a correct diagnosis. I 
have had two cases of this disease under my care ; one of them 
occurred in the upper, the other in the lower extremity, and, from 
observing the characteristic marks already detailed, I had no diffi- 
culty in making the diagnosis. It is to that peculiar form of this 
disease, which is considered by some authors to depend on ossifi- 
cation of the arteries, that the name of “ Pott’s gangrene” has been 
applied. A great deal of light, has been thrown on this disease by 
the researches of modern pathology. It is now pretty well esta- 
blished that we may have this gangrene, not only in old persons 
from ossification of the arteries, but also in the young from arteritis. 
In truth, the pathology of Pott’s gangrene appears to be one of two 
changes—either an arteritis or ossification of the arteries them- 
selves; and of these two causes the first is by far the most frequent. 
You will see at once the importance of this view of the question, 
for if the gangrene occurs in a young person, and is connected 
with inflammation of the arteries, it is a disease more or less under 
the control of medical treatment; but if it be produced by ossifica- 
tion of the arteries, the results of treatment are far less likely to 
be successful. 
We have, then, in a case of paralysis of this description, more or 
less loss of sensation and motion, coldness of the limb, and absence 
of arterial pulsation. With respect to coldness, it may be said that 
it is of little value as a sign, being frequently observed in cases of 
cerebral paralysis. To this it may be replied, that though coldness 278 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
is sometimes present in cases of ordinary paralysis, still it is never 
so remarkable as in this form of the disease, and the temperature of 
the limb is but a few degrees below the standard of health. Dr. 
Abercrombie makes a very interesting conjecture on this subject. 
He says the temperature of paralysed limbs is generally considered 
to be lower than that of the healthy ones, and, indeed, such is the 
case; but the true explanation of this occurrence is, that in this 
condition the limb loses its power of preserving a medium tempera- 
ture, and hence it is, that, according to the temperature to which it 
has been exposed, it becomes hotter or colder than the healthy 
limb. A case is mentioned, of a medical man who laboured under 
paralysis of one of the upper extremities. This gentleman, on one 
occasion, after having applied some warm bran to the paralysed 
limb, was astonished to find, on touching it with the sound hand, 
that he could not bear the heat, though he was at the same time 
unconscious of any increase of temperature in the paralytic ex- 
tremity. 
The symptoms, then, of this form of paralysis are, diminution or 
abolition of sensation and the power of motion, a dark or violet hue 
of the skin, remarkable coldness, and absence of pulsation in the 
arterial trunks which supply the affected limb. These, with a 
tendency to the formation of gangrene, are the characteristic marks 
of the disease, and, by bearing them in mind, you will seldom err 
in making a diagnosis. In the great majority of cases the disease 
is confined to one extremity; but Rostan gives some cases in which 
it was more general. We might also add to the diagnosis, that 
paralysis connected with disease of the brain often comes on sud- 
denly, while in this case its invasion is slow and gradual. It is 
however true, that some cases of paralysis, depending on this cause, 
have come on so suddenly as to render this circumstance of less 
value as a diagnostic. 
With respect to the treatment of this form of paralysis, if the 
patient be young and the disease recognised at an early stage, it is 
possible that you may be able to arrest it by free local depletion and 
other antiphlogistic means. In the case which was under treat- 
ment in the Meath Hospital, the symptoms had lasted for a consi- 
derable time before the disease exhibited any remarkable violence. 
The man was admitted oil the 7th of February, and at this time the 
disease had been five weeks in existence, having begun at the lower 
part of the limb, and extended gradually upwards until it involved 
the whole leg and thigh. Yet it is very probable that this patient 
might have been saved, if proper means had been taken to arrest 
the inflammation of the vessels at an early period. Baron Dupuy- 
tren has published a case, in which it appeared that this disease was 
setting in, but was checked at once by bold antiphlogistic treatment 
directed to the affected limb. PARALYSIS FROM ARTERIAL DISEASE. 
279 
LECTURE XXXII. 
Paralysis from arterial disease—Singular cases of, by Rostan—Diagnosis of paralysis 
from arterial obstruction—Magnetism, use and action of—Effect of magnetism in 
disease—Result of trials in the Meath Hospital—Paraplegia—Mechanical hypere- 
mia—Occurrence without disease of the cord or vertebrae—Cases by Mr. Stanley— 
Effects on urine by division of the spinal cord—Ammoniacal urine—Caries of the 
vertebras—Diagnosis of paralysis with disease of the kidney—Prognosis in para- 
plegia. 
At my last lecture I spoke of that form of paralysis which de- 
pends on arterial obstruction, and mentioned, as one of the principal 
diagnostics, a remarkable coldness of the diseased limb. I quoted 
for you a passage from Dr. Abercrombie’s work, in which he 
suggests that it is probable that the actual condition of paralytic 
limbs, in the usual acceptation, so far as temperature is concerned, 
depends upon their having lost that power which animal bodies 
possess of preserving a medium temperature; so that their tempera- 
ture becomes elevated or lowered, according to that of the surround- 
ing matter. The general rule in cases of this description is, that 
the temperature of a paralysed member is a little lower (say two or 
three degrees) than the rest of the body; but when we find a limb 
reduced to the temperature of 58°, as in the case I mentioned, it is 
quite a different thing, and, under such circumstances, the great 
probability is, that the paralysis is connected with arterial obstruc- 
tion. 
You will see, in Rostan’s works on the Softening of the Brain, 
the reports of two cases of this disease, occurring in patients of 
extremely advanced aged. In one, there was complete paralysis of 
the right arm, which was cold and livid. The fingers were threat- 
ened with gangrene, and no pulsation could be felt in the radial 
artery. By stimulating frictions, a certain degree of warmth and 
motion was restored, and it was even thought that pulsation could 
be perceived. By degrees, the power of the left arm, and of the 
lower extremities, began to fail, with diminution of the force of the 
pulsation. On dissection, extensive disease of the arteries was 
found; the right brachial, at the insertion of the deltoid, was oblite- 
rated by a mass of fibrin, below which the vessel was contracted 
and closed; the left brachial artery was also narrowed, but without 
any clot; and this condition was further met with in the crural 
vessels. The cerebral arteries and the aorta were diseased. In the 
second case, the patient, aged 80, was attacked with violent pains 
in the left leg, which became cold and bluish. There was no 
lesion of intelligence, and the corresponding arm was unaffected. 
In fifteen days, the pains having augmented, a certain degree of 
paralysis supervened, which, however, was never complete. On 
dissection (the disease having lasted a month), the crural artery was 
found extensively obliterated by a fibrinous clot. Here you observe 
that, notwithstanding the great age of both patients, the disease was 
not ossification, but, in all probability, arteritis. 280 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
At our last meeting, I forgot to mention the particulars of a case, 
bearing on this part of the subject, and which goes to prove that 
even complete coldness of the affected limb is not, in itself, sufficient 
to establish the diagnosis of paralysis from arterial obstruction. I 
have had lately under my care, a gentleman who has been for the 
last four or five years labouring under paralysis of the lower 
extremities, unaccompanied by any symptoms indicating disease of 
the brain. His intellect remains not only unimpaired, but in a state 
of high activity ; and, what is equally singular, he has had none 
of the usual symptoms of disease of the vertebras or spinal cord. 
His limbs, however, are quite powerless, and are of an icy coldness; 
and yet you will hardly believe me, when I tell you that I have 
repeatedly felt the femoral, popliteal, and even the anterior tibial 
arteries, pulsating distinctly. This is a singular fact, but I have 
verified it by a number of observations. You will perceive, then, 
that in taking a remarkably diminished temperature as a diagnostic 
of paralysis from arterial obstruction, we must admit that, as a sign, 
it is only valuable when combined with absence of arterial piilsa- 
tion. In this case, the fact of such extreme coldness of the lower 
extremities, at the same time that their circulation continues with 
undimished activity, becomes of great importance, as tending to 
prove that the temperature of the body depends more upon the state 
of innervation than on arterial action. There are, indeed, many 
facts which go to prove that animal heat is more closely connected 
with the nervous system than with the circulating. 
I spoke of the employment of electricity and galvanism in the 
local treatment of paralysis. While on this subject, I shall take an 
opportunity of briefly drawing your attention to the use of mag- 
netism in certain cases of nervous disease. Here let me be under- 
stood, I am not going to lecture on animal magnetism ; it is, at 
present, a theme unsuited for the practical physician ; no one more 
firmly disbelieves, no one more thoroughly despises, than I do, the 
countless absurdities which have emanated from the imaginative 
disciples of animal magnetism. But as in almost every human 
hypothesis there is a fraction of truth, so in the doctrines of animal 
magnetism there is, perhaps, something which may not be entirely 
visionary; and it is possible that there may be some modification of 
the nervous influence, communicable from one person to another : 
this is one of the doctrines of animal magnetism. Another leading 
doctrine is, that organs, which are adapted by nature for the dis- 
charge of some peculiar function, appear in their magnetised state 
to take on a new function. Now, without saying that we are to 
believe in this, or in the extraordinary romances which are given 
in illustration of it, still it is right to admit the possibility of its 
occurrence, to a certain degree ; because we frequently observe, in 
pathology, many instances of organs taking on functions, not 
merely new, but even totally repugnant to our ideas of their struc- 
tural arrangements. We may, then, I think, without going too 
far, admit the possibility of a communication of some modification 
of the nervous influence from one person to another, and that PARALYSIS PROM ARTERIAL DISEASE. 
281 
organs under this influence may take on new functions ; but, in 
the present state of this subject, this is as far as we can go. 
But we have to deal, at present, with a more tangible and im- 
portant subject—namely, the action of magnetism, in its proper 
acceptation, on the human body. You are aware that the term 
animal magnetism, was first applied to the results of certain 
effects on the human system, which were supposed to be brought 
about by the aid of metallic contact; and you are all acquainted 
with the history of the metallic tractors. The term magnetism, 
however, is totally inapplicable to the communication of nervous 
influence from one individual to another; nor have we any grounds 
for connecting such phenomena with magnetism, in its proper 
acceptation. 
That a magnet should act on the human body, is neither extra- 
ordinary nor incredible. You know that electricity, and its modi- 
fication galvanism, have a powerful influence on the system; and 
modern researches have shown that there is a close connection, if 
not an absolute identity, between electricity and magnetism. 
Now, on this subject of magnetism, the researches of some eminent 
men have been, latterly, employed, and the results of their labours 
have been received by some with an undistinguishing credulity, 
and by others with unphilosophical skepticism. One of the prin- 
cipal things which has prevented medical men from entering on 
this subject is, that many persons have confounded the results of 
magnetic action on the human body with the absurdities of animal 
magnetism and metallic tractors. There is, however, I need not 
repeat to you, an essential difference between them. In the Meath 
Hospital I have lately made a number of experiments, with a view 
to ascertain the effects of a powerful magnet on the human body. 
The magnet which I used, was one of considerable power, being, 
in its highest state of action, capable of supporting a weight of 
more than twenty pounds. Now, in almost every instance where 
this instrument was used, we found that, when brought near to 
sensible surfaces, phenomena were produced which were very 
similar, indeed, to those of electricity. These phenomena also 
appeared in so many cases, and with such a remarkable constancy, 
that they could not be accounted for by any supposition of accident. 
We have applied it in cases of rheumatism, sometimes to a healthy 
part of the body, sometimes to the part affected. In one of these 
cases, the application of the magnet was followed by a very rapid 
subsidence of the morbid symptoms, and the patient got well in a 
few days. Here let me remark, that there is no one more opposed 
than I am to the publication of the result of a single case as a proof 
of the success of any particular remedy; and, in putting forward 
this case, I do not wish it to be received as an instance of a decided 
cure of rheumatism by magnetism. The only reason why I quote 
it, is, because in other cases of rheumatism we had distinct 
evidence of the influence of the magnet to a greater or less extent. 
The patient, a stout man, of good constitution and in the prime of 
life, was brought into the hospital for an attack of rheumatism in 282 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the back and left shoulder, which had come on after exposure to wet. 
The first seizure was three days before admission. When brought 
in, he had severe pain in the back and shoulder, increased on 
pressure; he could neither elevate his arm to his head, nor could 
he bend the head towards the shoulder, without great difficulty 
and suffering. The value of this case consists chiefly in this, that 
except using the magnet there was no other remedy employed ; if 
any other medicinal agency had been used, it would have been 
difficult to atribute the merit of the cure to magnetism. I applied, 
in this case, the large magnet to the shoulder, within a short dis- 
tance from the skin. In about half a minute the patient remarked 
that he felt a kind of pricking sensation immediately under the 
magnet; this was succeeded by a feeling of heat in the part, 
which became increased by continuing the application, while at 
the same time the pain was sensibly relieved. The sensation of 
warmth continued in the shoulder for about ten minutes after the 
magnet had been removed, and the patient declared that he received 
great benefit from the application. On the following day, the 
magnet was applied again with precisely the same results; the 
same thing was done on the third day, when the pain was very 
much reduced, and the arm became more movable. On the 
fourth day, the mobility of the limb was increased, and he could 
bend his head in the direction of the shoulder with very little 
inconvenience. On the eighth day, the power of motion was 
restored, the pain gone, and the patient left the hospital quite well. 
I have heard nothing of him since ; but if he had not experienced 
permanent relief, it is very probable he would have returned again, 
for he seemed quite pleased with his treatment. If this was the 
only case in which the magnet had been employed, it would prove 
nothing either for or against its use. It might be said, that the 
cure, in this instance, was the result of keeping the patient in a 
warm bed, and that any good, supposed to be effected by the 
magnet, might be attributed to the influence of imagination. But 
to this it may be answered, that the sensations observed by this 
patient were exactly the same as in others, each having noticed 
the peculiar pricking sensation in the part to which the magnet 
was applied, and the subsequent feeling of warmth. Again, it is 
to be remarked, that although the symptoms in this case were 
severe, the cure was extremely rapid; and when you recollect the 
obstinacy of most affections of this kind, you must allow that a 
week was a very short space of time for its accomplishment. 
The following is another equally interesting case. A woman 
was admitted into the Meath Hospital, labouring under paralysis of 
the right side of three weeks’ standing. The history of her case 
was, that she had fallen into a state of mental despondency, after 
the death of her husband, who was her only support; she then got 
symptoms of derangement of the stomach, and hypochondriasis, 
followed by an attack of paralysis, which deprived her of the power 
of using one side. On examination, we found that, as far as 
motion was concerned, the paralysis was not complete, but that PARALYSIS FROM ARTERIAL DISEASE. 
283 
there was a total loss of sensation in the side affected. I was 
curious to observe what the effect of the magnet would be, and 
accordingly applied it to the spine, moving it upwards and down- 
wards along the cervical and dorsal regions, at about half an inch 
from the surface. After it had been applied for a few seconds, she 
remarked that she felt a sensation “of wind” passing over the left 
shoulder, but not over the right. Observe, it was on the right side 
of the body that the paralysis existed in this case; and you will 
also recollect that it was chiefly a paralysis of sensation. Now, it 
is quite contrary to chances that she should have described it in 
this way, if she had not really felt it in this situation. The action 
of the magnet was naturally felt on the left, which was the sensible 
side, for, on applying it to the opposite or paralysed side, she said 
she no longer felt the sensation of “the wind.” During the opera- 
tion, she saw the instrument; and if disposed to draw upon her 
imagination for a description of her sensations, she might say that 
she felt the aura on the paralysed side ; but this was not the case, 
for she stated that it was no longer perceptible, when the magnet 
was moved from the sound to the paralysed side. In this case, I 
must tell you that magnetism was not the sole remedial agent 
employed, for she had been also leeched and blistered. She was 
admitted on the 12th of August, and on the 17th of the same 
month, the power of motion in the upper extremity was so much 
increased, that she could grasp objects with force, and place her 
hand on the top of her head with facility. On this day, after 
having applied the magnet, she immediately exclaimed that she felt 
the wind for the first time over the right shoulder, and, on examin- 
ation, it was found that sensation, to a certain degree, had returned 
to the right side; and here you will perceive that the first mani- 
festation of the return of sensibility was denoted by her feeling the 
magnetic influence in the paralysed side. 
I shall not take up your time any longer by detailing cases; it 
will be sufficient to state, that it was used in many other instances 
of a similar kind, and in all with the same result. Each patient 
described the same sensation, with very little variety; in some, it 
consisted in a feeling of pricking or tingling; in others, of an aura 
passing over the part. Some stated that they felt a sensation of 
warmth in the part, some time after the magnet had been applied; 
and some, a kind of suction, as if the skin was drawn towards the 
magnet. When it was applied over a very sensible or a blistered 
surface, the patients felt the pricking sensation to amount to pain, 
and the feeling of warmth and suction was proportionally increased. 
I have also to observe, that it was employed on a set of patients, 
the majority of whom were totally ignorant of its nature and 
effects; and yet it is very remarkable that there was an almost 
universal accordance in their descriptions of the sensation produced. 
It has been stated, by some writers on the subject, that the sensa- 
tions differ according to the pole of the magnet employed. This 
statement does not accord with our experience; for in every one of 
our cases the sensation was the same, whether we made use of one 284 
STOICES’s THEORY AND PRACTICE OF MEDICINE. 
pole or the other. As far as our experience goes, it is, I think, fair 
to conclude that a very perceptible influence may be produced on 
the human body by the application of the magnet; it is another 
matter to ascertain how far it may be rendered available as a thera- 
peutic agent. The cases in which I think it might be employed 
with advantage, are cases of nervous and spasmodic affections, and 
muscular rheumatism. That the sensations described by our 
patients had an actual existence, and were not the result of 
imagination, I am firmly convinced. 
Before I leave the subject of paralysis, I wish to draw your 
attention to one more form of the disease, by no means uncommon; 
I allude to that in which both the lower extremities are exclusively 
engaged. This is a disease, or symptom, which may arise from a 
great number of causes, and be observed under a variety of circum- 
stances. Generally speaking, however, it will, in almost every 
instance, be found to depend on some cause which engages the 
spinal marrow, either primarily or secondarily. I believe that this 
paraplegia, as the result of disease of the brain, is never met with 
except in combination with paralysis of the upper extremities. 
General paralysis may be produced by cerebral disease ; and in 
describing the various forms of paralysis which depend on disease 
of the brain, this form has been particularly noticed; but when 
paralysis of the lower extremities alone occurs, it is generally the 
result of some lesion of the spinal marrow, either organic or func- 
tional, below the situation in which the brachial nerves are given 
off. Among the causes by which this paraplegia is produced, the 
following are the principal: inflammations of the membranous 
coverings of the spinal cord, with effusion of lymph or serum; 
spinal apoplexy, ramollissement from inflammation of its sub- 
stance; pressure on the cord, by solid tumours from a variety of 
causes; the bursting of abscesses or aneurismal swellings into the 
vertebral canal, as occurs in some cases of aneurism of the abdo- 
minal aorta. Thus, during the progress of a case of this descrip- 
tion, it has been observed that the patient suddenly became 
paraplegic, and, on examination after death, a quantity of blood, 
which escaped from the aneurismal tumour, has been found com- 
pressing the spinal marrow. Lastly, recent investigations have 
established the fact that we may have paralysis of the lower 
extremities, and yet, on dissection, we cannot detect any traces of 
disease in the bones of the vertebral canal, or in the membranes 
or substmice of the spinal cord. Hence you see how cautious you 
should be in making the diagnosis, so common among surgeons, of 
caries of the vertebrae, in cases of paralysis of the lower extremities. 
The truth is, that in the present state of medicine on this subject, 
we labour under very great difficulties; the diagnosis of these 
affections is exceedingly obscure ; it is a subject still open to inves- 
tigation, and, I need not remark, that it is one of paramount 
importance. 
Paraplegia is one of the most miserable diseases to which the 
human body is liable. It is almost always obstinate and unman age- PARAPLEGIA. 
285 
able, and in the majority of cases incurable. How far the fatality 
of the disease depends upon the want of an accurate diagnosis, and 
a correct plan of treatment, must be determined by future observa- 
tions ; but it is a fact, that a vast proportion of paraplegic patients 
die, and under the most melancholy circumstances. In many 
cases, the formation of gangrenous sores on the back and loins is a 
common occurrence. For this there are two reasons: first, the 
vessels of those parts exposed to pressure from position fall into 
that state which Andral terms mechanical hypercemia, the result 
of which is that they are unable to unload themselves, a stasis of 
blood follows, and this leads to mortification of the part; secondly, 
there is a lesion of innervation. Hence it is, that the great majority 
of patients of this kind die with gangrenous sores on the back and 
loins. They have also most constantly paralysis of the bladder, or 
its sphincter, or both, producing retention of urine, or retention with 
incontinence, or stillicidium urinse. The sphincter ani, too, is 
generally paralysed, and we have a most melancholy and disgust- 
ing source of annoyance. The frequent passing of urine and 
faeces, keeps the unfortunate sufferer in a state at once pitiable and 
loathsome; and when, in addition to his other calamities, the 
gangrenous sores form, the supervention of low diffused erysipela- 
tous inflammation may prove fatal; or he may be carried off with 
symptoms of typhus fever, from the absorption of putrid matter. 
While on the subject of paraplegia, I am anxious to lay before 
you a sketch of some important opinions lately put forward by Mr. 
Stanley, of London. In the last number of the Medico-Chirurgical 
Transactions, this gentleman has written a most interesting paper, 
in which he gives the history of several cases of paraplegia, the 
majority of which were supposed to be examples of caries of the 
vertebra?, but in which, on dissection, no disease could be dis- 
covered, either in the bones of the vertebral canal, or in the mem- 
branes or substance of the spinal cord. You will ask, were there 
no pathological phenomena in these cases? There were; but they 
belonged not to the spine or its contents, but to an organ in its 
immediate vicinity—the kidney. From a candid review of Mr. 
Stanley’s cases, there appears to be reason to believe that disease of 
the kidneys may produce all those symptoms which have been 
attributed to lesions of the spinal marrow, or caries of the vertebras. 
In the four first cases, the symptoms given as of caries of the verte- 
brae were present, and the cases treated as such. On dissection, no 
caries, or disease of the cord, could be discovered in any of them, 
but the kidneys were found to be the seat of extensive disease. 
The fifth case was a remarkable one; the patient had been 
admitted for retention of urine, the consequence of severe gonor- 
rhoea, which had been checked by injections. The bladder and 
sphincter ani became paralytic, and he lost the power of the lower 
extremities to a certain degree. He also complained of severe pain 
at the fifth lumbar vertebra. He distinctly traced the pain from 
the bladder to the left kindey, and then to the right. Paralysis of 
motion, and, nearly, completely of sensation of the lower limbs, 286 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
next supervened, and in about a fortnight he died. On dissection, 
the kidneys were found in a state of inflammatory softening, and 
with numerous minute depositions of pus. The bladder was 
inflamed, but the brain and spinal cord were perfectly healthy. In 
the sixth case, a patient, while in progress of cure of a gonorrhoea 
with phymosis, was suddenly seized with paraplegia. The func- 
tions of the brain were unaffected. He had suffered for a day or 
two from pain in the loins. Sixteen hours alter this attack, he 
suddenly died. 
Prom considering the former cases, Mr. Stanley predicted that 
inflammation would be found in the kidneys. A slight turgescence 
of the vessels of the cord, with a little transparent effusion in the 
theca, were found, but the kidneys were in a state of the most 
intense engorgement. In this case, it was remarkable that, from 
the period of the paraplegia, there was an inordinate secretion of 
urine. The seventh case was that of a patient who, for two years, 
had been labouring under pain of the back, increased by pressure, 
and incontinence of urine. On dissection, there was some vascu- 
larity and effusion of the cord, but both the kidneys were almost 
entirely destroyed by disease. In addition to these, Mr. Stanley 
mentions four more cases, which were seen by a friend of his, Mr. 
Hunt, of Dartmouth, which corroborate his opinions. 
Here, then, we may have well-marked paraplegia, without any 
perceptible organic change in the spinal cord, or its investments, 
but presenting distinct traces of disease of the kidneys. This leads 
us to observe the very close connection which exists between the 
kidneys and spinal cord, a connection which has been long recog- 
nised by medical practitioners, but only in a limited point of view ; 
for though they were of opinion that disease of the kidneys, and a 
discharge of ammoniacal urine, were the results of spinal disease, 
they never seem to have reflected that the reverse of this might 
happen. It seems now, however, to be almost completely esta- 
blished, that disease of the kidneys may produce symptoms which 
are referable to disease of the spine; and Mr. Stanley has the credit 
of having been the first who directed the attention of the profession 
to this circumstance, and his paper must be considered as one of 
the most important, and practically useful, which has appeared for 
a length of time. You should all peruse it carefully. The fact 
that disease of the spine will give rise to affections of the kidney, 
is long known, and has been proved by numerous experiments. 
Thus Olliviet details the experiments of a German physiologist, M. 
Kreimer, who, by dividing the lower part of the spinal cord in 
animals, made the urine almost immediately ammoniacal. You 
will also find, in Dr. Prout’s work, that an ammoniacal state of the 
urine may be rapidly brought on by injuries of the back, from falls 
or bruises on the spine. It is, indeed, singular how quickly those 
profound functional lesions of the kidneys supervene on injuries 
of the spine, sometimes appearing in four or five days, sometimes 
sooner. Medical men have hitherto been in the habit of looking at 
this matter only in one point of view; they know that disease of PARAPLEGIA. 
287 
the spine will produce disease of the kidneys, and here they stop; 
but it has been shown that the reverse of this may happen, and 
that renal disease may produce very remarkable lesions in the 
functions of the spine. Of this very curious occurrence, we have 
many analogies in pathology. Thus, for instance, in several cases 
of cerebral disease, but chiefly in hydrocephalus, we have vomiting; 
here we have functional disease of the stomach depending on an 
affection of the brain. Take the reverse of this—observe the deli- 
rium which attends a case of gastro-enteritis—here you have the 
functions of the brain deranged in a most remarkable manner, and 
this produced by sympathy with an inflamed mucous membrane. 
The truth is, that in the spine and kidney, as well as in various 
other parts of the system, we have two organs which are so closely 
connected by sympathy, that disease of one will bring on serious 
functional lesion of the other. 
Observe, then, the great importance of these enquiries. When 
you meet with a case of paraplegia, you are not at once to conclude 
that it depends on disease of the spine, or caries of the vertebrae. 
You must carefully investigate its history, and ascertain whether 
it may be referred to either of these causes, or whether it may not 
rather depend on disease of the kidneys. That it may depend on 
the latter cause is now established, for the cases are too numerous 
for us to suppose the complication accidental. You will observe 
the importance of making an accurate diagnosis, when you consider 
that this point will most materially influence your treatment. In 
the one case, your treatment will be directed to the bones and car- 
tilages of the spine; in the next, to the spinal cord itself; and, 
lastly, to the kidney, a parenchymatous organ, to which there is a 
great determination of blood. No one will venture to assert that 
the principles of treatment in each of these cases are the same; and 
the chances are, that, if you do not make a correct diagnosis, you 
will practise improperly and without success. I have now seen a 
number of these cases, but there were only two of this description 
in which I was fortunate enough to obtain a post-mortem examina- 
tion. I cannot say that my dissection exhibited remarkable dis- 
ease of the kidneys (they were large and very vascular), but, from 
the many points of resemblance they bore to Mr. Stanley’s cases, I 
was led to conclude, that if they were not examples of actual chro- 
nic disease of the kidney, they were cases of lesion of function in 
the spine, unaccompanied by any organic change to account for the 
symptoms. I shall briefly detail these cases : the first was that of 
an unfortunate man from the country, who was discovered by two 
friends of mine under peculiar circumstances. While on an excur- 
sion, they were requested to visit a poor man who was lying ill at 
a remote farm-house. They heard he had been labouring under a 
dropsical affection for a long time, and had been treated for ascites. 
On arriving at the cottage, they found the man lying in bed, with 
his abdomen very much enlarged; and, on further investigation, 
discovered that he was quite paralytic of the lower extremities. 
On examining the belly more particularly, they found that the 288 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
swelling was produced, not by ascites, but by an enormously dis- 
tended bladder. He had, also, stillicidium urinse, with paralysis 
of the bladder; and this having been mistaken, by the medical 
practitioner who attended him, lor suppression of urine, he had 
prescribed diuretics, and continued this plan of treatment for some 
weeks, totally overlooking the paralysis of the bladder. As little or 
nothing could be done for him in the remote situation in which he 
lived, it was determined to send him up by easy stages to Dublin, 
and procure him admission at one of the public hospitals. On his 
arrival, he was received at the Meath Hospital; and, when I visited 
the wards next day, I found that he was quite paralytic of both 
lower extremities, that the bladder was in the state above described, 
and that his health had suffered considerably, and that bed-sores 
had formed on his back, and were increased by his journey. I 
prescribed cupping and blistering, which were productive of some 
slight relief; but in the space of a few days he began to exhibit 
symptoms of low typhus, as if from the absorption of pus, and sank 
rapidly. On examining his body, we could not detect any traces 
of disease in the bones or cartilages of the spine; neither did the 
cord, or its membranes, present any marks of organic lesion, except 
that towards its lower portion, where it begins to spread out into 
the cauda equina, it was perhaps a little softer than natural. I 
regret very much that I did not note the circumstances of this case 
more fully; but, as far as my recollection of it goes, the general 
features were as I have just mentioned. I had another case, some 
time since, in the Meath Hospital, in which the following circum- 
stances were observed:—The patient, a labouring man, generally 
employed about the quays, was brought into the hospital with 
paraplegia of some standing. The first symptom in his case 
belonged not to the spine, but to the urinary system ; he had had 
an attack of gonorrhoea, for which he had used stimulants and 
balsams; and, in some weeks after, without any injury to the spine, 
he lost the use of his lower extremities. During his stay in the 
hospital, the urine was intensely ammoniacal. On examining his 
body after death, we could not discover any disease of the bones or 
spinal marrow. A layer of substance, resembling fat, or organised 
lymph, was found lying on the theca of the spinal marrow, but it 
was so very small as to be scarcely sufficient to account for the 
symptoms. The kidneys were pale, flabby, and without any vas- 
cularity, but did not present any marked traces of organic lesion. 
Here, then, were two cases which, before the publication of Mr. 
Stanley’s paper, would be considered as examples of organic dis- 
ease of the spinal cord, or its investments ; and yet, on dissection, 
we can find nothing to establish this opinion; and, in the last one, 
the first affection was of the urinary system. 
Is it possible that a f unctional disease of the urinary system may 
produce also a functional disease of the spinal cord 1 
With respect to the diagnosis of caries of the spine, I wish to 
make a few observations. The diagnosis where there is distortion 
of the spine is extremely easy, but this does not hold where the PARAPLEGIA. 
289 
caries is accompanied by distortion. Let us enquire. Are there 
any circumstances which would enable us to arrive at the diagnosis 
of caries without distortion'? One symptom, not observed, as far 
as I can see, in paralysis, connected with disease of the kidney, is, 
that the patient feels exquisite pain on motion. This is an 
exceedingly common symptom in caries of the vertebra, but I am 
not aware that it occurs in cases where the disease is situated in the 
kidney, or the spinal cord itself. There is another remarkable 
circumstance :—When the patient attempts to move, he often feels 
a cracking sensation in the affected portion of the spine ; and this 
has not only been observed by the patient himself, but is also per- 
ceptible to his medical attendants. When this occurs, it may, I 
think, be looked upon as a diagnostic symptom. The exquisite 
pain on motion, the tenderness of the spine on pressure, and the 
crackling sensation, these might be sufficient to make the diagnosis 
of caries of the vertebra, even in cases where there was no distor- 
tion. But if you had a case of paralysis of motion and sensation 
of the lower extremities, and if these symptoms came on without 
any injury of the spine—if there was little or no tenderness on 
pressure—if the patient felt scarcely any pain in turning or 
moving, and if he had at the same time symptoms of disease of the 
kidney or bladder, and ammoniacal urine—under these circum- 
stances the great probability would be, that it was not a case of 
caries of the vertebra, or original disease of the spinal cord, or its 
investments, but a lesion of function of the spine, connected with 
organic or functional derangement of the kidneys. It must be 
acknowledged, however, that the diagnosis of this affection is rather 
obscure. The circumstances which I have just mentioned, might 
enable you to get rid of the opinion that it was caries of the verte- 
brae or organic disease of the spinal cord, and that it was probably 
such a case as Mr. Stanley has described; and if you could arrive 
at this diagnosis at an early period of the case, it would be a matter 
of great importance. By doing this, you would then be aware that 
you had to deal with an inflammatory affection of a highly vascular 
organ ; you would not be led away from the real state of the case, 
or waste time in treatment calculated to stimulate the spine, or 
remove disease of the vertebras. Your plan would be simple, and 
your treatment defined, and all your efforts would be directed 
towards removing the disease of the kidneys. You will easily per- 
ceive that diagnosis is here of vast importance; unfortunately, it is 
still involved in obscurity. 
The prognosis of cases of paraplegia, when once complete para- 
lysis is established, should be always unfavourable. The fact of 
paralysis occurring, is sufficient in itself to prove the existence of 
extensive disease in most cases. There may be, however, some 
cases susceptible of cure, and this particularly occurs in young 
females, in whom a perfect cure has been frequently accomplished 
by the use of stimulant embrocations to the loins. I have seen one 
case of this kind, in which the patient was paraplegic for a year 
and a half, cured by the application of hot oil of turpentine over 290 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the lower part of the spine. Simple as the treatment may appear 
in this case, its success was rapid and complete. Mr. Crampton 
has mentioned to me the particulars of another case, in which the 
patient’s limbs were quite rigid, and could not be moved without 
great difficulty ; in this case, complete relief was obtained by apply- 
ing Pearson’s liniment over the lower part of the spine. This lini- 
ment produced powerful counter-irritation, and an eruption of bullse 
over the body, which were speedily followed by relief. The patient 
is now in the enjoyment of perfect health; and since the period of 
her cure, which is now better than six years ago, has had no return 
of the disease. 
LECTURE XXXIII. 
Sudden paralysis from abscess of the brain—Curious case of paralysis without effusion 
—Previous symptoms of—Demonstration of the cellular tissue of the brain—Com- 
pressibility of the brain—Inaccuracy of the opinions of Drs. Abercrombie and 
Clutterbuck—Pathological states—Arachnitis without delirium—Traumatic apo- 
plexy—Case of paralysis of the portio dura—Peculiar appearance of the affected 
side of the face—Use of the electro-puncturation—Bad effects from—Mechanical 
support of paralysed parts—Neuroses, active and passive—General pathology of— 
Principles of diagnosis—Case of neuralgic liver—Neurosis from moral causes. 
Before I leave the subject of organic affections of the brain, I 
wish to exhibit a few preparations illustrative of some of the prin- 
cipal diseases dwelt on in the preceding lectures. You will recol- 
lect that, in a former lecture, I alluded particularly to the question, 
how far we are able to judge of the existence of apoplectic effusion 
by the sudden occurrence of an attack of paralysis. I endeavoured 
then to impress upon you that we may have sudden paralysis from 
other causes, as well as apoplectic effusion, and stated that there 
were numerous cases of sudden paralysis, with disorganisation of 
the brain, on record, depending, not on apoplectic effusion, but on 
circumscribed abscess of the brain; and that, consequently, the 
diagnosis of apoplectic effusion from suddenness of attack was 
only valuable when it came on unpreceded by symptoms of local 
disease of the brain. I alluded to a remarkable case of aneurism 
of the arteria innominata, in which the patient, soon after the date 
of his admission into the hospital, had become suddenly hemiplegic. 
This was a case in which one would be led to expect an effusion 
of blood into the brain, as the circulation of the head was evidently 
impeded by the pressure of the aneurismal tumour on the great 
veins, and as there was a remarkable distension of the jugular and 
other superficial veins. Of the existence of the aneurism there 
was not the slightest doubt; the tumour could be felt pulsating 
below and above the clavicle on the right side, compressing the 
trachea, so as to cause stridulous breathing, and producing a vari- 
cose state of the veins of the neck by its pressure. We accordingly PARALYSIS. 
291 
made the diagnosis of aneurism of the arch of the aorta, or of the 
arteria innominata. In this case two circumstances—the sudden 
paralysis of one side, and the obstruction to the circulation of the 
neck and head—would, as I have said before, lead to the supposition 
of an apoplectic effusion. On dissection, however, the paralysis 
was found to depend, not on this circumstance, but on the existence 
of a circumscribed abscess in the anterior part of the opposite hemi- 
sphere of the brain. I have the pleasure of exhibiting to you to-day 
this interesting and important preparation. It is too large to send 
round, but you can all inspect it after lecture. Here is the aorta 
from its commencement at the left ventricle—here is the enormous 
aneurism of the arteria innominata compressing the trachea—so 
that it has not only pushed it far to the left side, but has flattened it 
in such a manner as to produce a curious alteration in the appear- 
ance of its musculo-membranous structure. The terminations of 
the rings of the trachea are brought close together, and the muscu- 
lar parts are folded in between them. There is another circum- 
stance here deserving of your notice: the right carotid, you see, is 
obliterated; it is interesting to connect this fact with the absence of 
true apoplectic effusion. The case altogether is a curious one, and 
presents two remarkable circumstances—great mechanical obstruc- 
tion to the venous circulation of the head, and sudden paralysis 
without effusion. It is, however, to be remarked, that in this case, 
though the paralysis was sudden and unexpected, it was preceded 
by some symptoms of local disease of the brain. The patient had 
pain in the head and limbs of one side, accompanied by a sense of 
formication. These symptoms were remarked some days before 
the attack of paralysis, but their importance was not at that time 
thoroughly estimated, in consequence of the greater share of atten- 
tion being directed to the aneurismal disease. 
In this bottle, you have a specimen of that species of ramollisse- 
ment which supervenes on local inflammation of the brain. We 
have every reason, I think, to believe that when this disease occurs 
in the young, or in the adult, it is the result of an active inflam- 
matory process ; and that softening of the brain has in it nothing 
more specific or peculiar than softening of the liver or lungs from 
acute inflammation. Here, you see, is the disease—an irregular 
cavity filled with broken up cerebral matter, somewhat resembling 
cream in appearance and consistence. I may remark here, that it 
is in cases of this description that we are able to demonstrate the 
existence of the cellular membrane of the brain. This cellular 
membrane is extremely fine and delicate—so much so, indeed, that 
some anatomists of high authority have asserted that the brain 
possessed no interstitial cellular tissue. This preparation, how- 
ever, gives a proof of the great light which pathology frequently 
throws on obscure points of anatomy and physiology; for, though 
the interstitial cellular tissue cannot be seen in the sound brain, we 
are able, in the preparation before us, to demonstrate its existence 
with certainty. It is, however, to be observed, that it is only 
in recent cases of ramollissement that this phenomenon can be 292 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
examined with advantage; for. in those of long standing, the cellular 
membrane shares in the general destruction, more or less, and gives 
way. But if you get a case where the softening is recent, and 
then take the softened portion of the brain and expose it to the 
dropping of a filter, you will find that the soft cerebral matter will 
be gradually washed away, leaving behind it a delicate tissue; and 
in this way you can prove the existence of cellular membrane in 
the substance of the brain, like that of other parenchymatous 
organs. 
Here is a specimen of apoplectic effusion : see how extensively 
the substance of the brain has been torn; the cavity formed in this 
way is, you will perceive, filled up with a large clot. Now, there 
is one consideration which strikes us at once, in looking at an effu- 
sion of this kind into the substance of the brain, whatever may be 
its situation or extent—and this is, that the brain must be a very 
compressible organ. Here we see the brain torn, a cavity of large 
size formed, and this completely filled with blood. Now, it is 
obvious that the rest of the brain must give way, in order to give 
room for the formation of this cavity. If, then, it be true that the 
brain is compressible, so far as to admit of the formation of a large 
cavity, it necessarily follows that, contrary to the opinion of Drs. 
Abercrombie and Clutterbuck, the quantity of blood in the brain 
may vary, and be greater at one time than another. These authors 
think that the quantity of blood circulating in the brain never 
varies, but here, you will perceive, we have a remarkable cavity; 
and it is plain that the rest of the brain must have yielded before 
it could be formed; and it follows, as a natural inference, that the 
brain must be compressible, and that, consequently, the quantity 
of blood contained may vary at different times. It may be argued 
against this, that the illustrative proof in this case is derived from 
a pathological condition, and that, under such circumstances, the 
brain has room for the formation of a cavity, by the emptying of 
some of its vessels. Here, it is urged, is a cavity, but the empty- 
ing of the vessels of the brain compensate for it; thus room is 
found, and there is no increase in the quantity of blood circulating 
in the brain. This, however, I look upon as a mere petitio prin- 
cipii; nor have we any reason to think, that, in a case of apo- 
plectic effusion, there is any corresponding emptying of the vessels, 
for dissection almost always shows a surcharged state of all the 
vessels. The result, then, in my opinion, is, that the brain is com- 
pressible, and may admit a larger quantity of blood at one time 
than it does at another. On this subject I advise you to consult 
Dr. Mackintosh’s work on the Practice of Physic, and also the 
review of Dr. Clutterbuck’s Essay on Apoplexy, in the London 
Cyclopaedia of Practical Medicine, as given in the Dublin Medical 
Journal, Yol. II. 
Here is another specimen. You see the brain, with a small clot 
in its substance about the size of a hazelnut. The patient in this 
case did not die suddenly; the clot has nearly lost the appearance 
of blood, and the processes of absorption were going on. I have PARALYSIS. 
293 
got here another preparation illustrative of this effect on one of 
tiiose effusions. I told you, in a former lecture, that in these cases 
one of two things occurred ; either the clot was wholly absorbed, 
and a serous cyst left in its place, or it was not absorbed, and be- 
came to a certain extent organised; and that this might be the 
history of many of the anomalous tumours we meet with in the 
brain. Here is a clot, fully as large as a walnut, in which no 
absorption has taken place, and you perceive it has been converted 
into a mass of a dense solid texture. You can easily conceive 
that the brain, having a clot of such a texture in its substance, 
could not easily recover its functions, and that the paralysis would 
be persistent. Here is another large apoplectic effusion, in which 
a certain degree of change has been produced; the clot, you see, 
has lost a good deal of its colour, and is not so red as in its recent 
state. Here is an excellent specimen of circumscribed abscess of 
the brain in the centre of one of the hemispheres. In this you 
can, to a certain degree, demonstrate the cellular membrane of the 
substance of the brain; but, if the preparation had been manipu- 
lated in the way I have mentioned, I have no doubt that it would 
exhibit it much better—that is, provided the abscess was of 
recent occurrence. If it should happen to be of long standing, the 
cellular membrane generally gives way, and you have nothing but 
a cavity filled with softened matter. This large preparation exhi- 
bits an enormous effusion on the surface of one of the hemispheres 
of the brain; it was the result of an injury of the head, and was 
accompanied by paralysis of the opposite side. It furnishes an 
example of what has been termed traumatic apoplexy. The other 
preparations on the table do not apply so immediately to the illus- 
tration of apoplectic effusions, and I shall pass them over. 
Here is a preparation which I would draw your attention to, as 
it belongs to a very remarkable case. I mentioned before, that, in 
certain cases of arachnitis, where the disease was chiefly situated 
at the base of the brain, it had been observed that there was seldom 
delirium. In this case the patient complained of pain along the 
base of the skull, which occasionally remitted and then returned 
with violence, and it was at first supposed to be neuralgic. He 
continued in this state for some time, having a recurrence of vio- 
lent pain in the ear, temporal and mastoid regions, which lasted for 
several days; when, all of a sudden, without any preceding deli- 
rium, he became comatose, and died shortly afterwards. On dissec- 
tion, the arachnoid covering of the brain was found to be in a state 
of extensive disease over the inferior surface of the anterior lobe, 
and towards the posterior part of the base of the brain. Here we 
had a case of extensive and fatal arachnitis, with total absence of 
delirium. 
When speaking of the employment of galvano-puncturation in 
the local treatment of paralytic affections, I stated that the case in 
which the most decided benefit was observed occurred in paralysis 
of one side of the face, apparently unconnected with actual disease 
of the brain, and of a local nature. This is in accordance with 294 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
what has been observed with respect to the efficacy of all local 
measures employed in the treatment of paralysis ; and, accordingly, 
the more the affection is purely of the nerves of the part, the more 
satisfactory should be the results of galvanism. I shall read for 
you the notes of this case, and I am happy to have it in my power 
to lay before you two excellent drawings of the patient’s appearance 
before and after the use of the galvanic battery, from the pencil of 
my friend, Mr. Berthon. 
“ A bricklayer, named T. Hogan, got an attack of erysipelas of 
one side of the face, accompanied by a feeling of pain and stiffness 
between the angle of the jaw and mastoid process of the right side. 
This was followed by an attack of paralysis of the right side of the 
face, and he presented himself for admission at the Meath Hospital 
in the following state. The features at the right side of the face 
are blank, unmeaning, and motionless, while those of the left side 
retain their natural cast, except that their lines are more strongly 
marked, and the angle of the mouth is drawn upwards and towards 
the left side to a considerable extent. The skin of the right side of 
the forehead is smooth, that of the left furrowed and puckered. 
The lids of the right eye are half closed, and he has not the 
power of moving the upper one. When desired to close his eyelids, 
the eyeball rolls upwards, and the transparent cornea is carried 
behind the curtain of the upper lid. By this movement the patient 
excluded all objects, and was under the impression that he had shut 
his eye. The lower lid hangs down, and is partly everted, expos- 
ing the conjunctiva, and allowing the tears to trickle down the 
cheek. When he breathes, the right cheek is puffed out; it be- 
comes still more distended by an attempt at blowing; and, when 
attempting to drink, a quantity of the fluid escapes at the right 
angle of the mouth. On being requested to draw the right angle 
of the mouth towards the corresponding ear, not the slightest move- 
ment was made, except by the muscles of the opposite side. In 
masticating his food, the morsel gets between the cheek and gum 
of the right side, and he is obliged to put. in his finger to dislodge 
it. Sensation on the paralysed side is unimpaired, and there is no 
deafness, alteration of taste, or loss of vision. With respect to the 
muscular functions of the tongue, they appear to have suffered no 
injury, and he can direct it with facility to either side. Here was 
a fact to show that the paralysis of the face in this instance had no 
connection with cerebral disease. In the majority of cases of para- 
lysis of one side of the face, from disease of the brain, there is 
lesion of motion of the tongue, but here it was in its natural con- 
dition. There is a slight degree of thickness of speech, which can 
be remedied by supporting the paralysed cheek with the palm of 
his hand. He complains of a feeling of stiffness in the jaws, and 
cannot open his mouth more than what would be capable of admit- 
ting a teaspoon. He has had some tenderness over the mastoid 
process. He can press hard substances with his teeth; and the 
temporal, pterygoid, and masseter muscles seem to be as strong on 
the paralysed as they are on the sound side. He can move the PARALYSIS. 
295 
lower jaw so as to incline the symphysis to either side, but more to 
the left than to the right. His general health is good, and his 
bowels regular.” I shall hand round the drawings of this case for 
your inspection. You will observe the peculiar appearance of the 
left side of the face, with the mouth drawn upwards, and the skin 
of the nose and forehead thrown into deep wrinkles. There can 
be no doubt that the exciting cause of the paralysis in this instance 
was connected with the erysipelas of the face. He had no symp- 
toms of any cerebral affection, and the paralysis was limited to 
those muscles which are supplied by the seventh pair of nerves. 
The tongue was quite unimpaired in its motions, and there was no 
lesion of taste, hearing, or smell. It was, in fact, a case of purely 
local paralysis, and bore a decided analogy to those cases which 
have been so accurately described by Sir Charles Bell as depending 
on an affection of the seventh pair of nerves. 
The treatment of this case was in accordance with the views 
already detailed ; the diagnosis was paralysis of the seventh nerve, 
and the treatment founded on this diagnosis proved eminently suc- 
cessful. The first thing done was to apply a few leeches to the 
ramus of the jaw; we then used stimulating applications, and he 
used for some time the liniment, camphorse compos, with extract of 
belladonna. After this he was put on strychnine, which did him 
some good ; but there was so great a susceptibility of its action, 
that we were ultimately obliged to give it up. The last remedy 
employed was electro-puncturation, under the use of which he 
improved rapidly. On the 5th of March the galvanic battery was 
first applied; the needles at that time were inserted—one in front 
of the ear, and the other near the symphysis of the chin; subse- 
quently, they were inserted in various parts of the right side of the 
face, following the different branches of the portio dura. On the 
first application of the galvanic influence, he had spasmodic twitches 
of the paralysed muscles, and soon afterwards he began to complain 
of a burning sensation in the cheek and pain in the head. Here, it 
would appear that headache was the result of the proximity of the 
stimulus to the brain. On the 11th, the symptoms were nearly 
the same, and his general health continued to improve. On the 
15th, the application of the galvanic influence was followed by 
severe headache, which lasted for half an hour. On the 19th, his 
appearance was much improved, and the galvanic battery was not 
used. On the 20th, it was again applied, and in an hour afterwards 
he had rigours and slight headache. On the 21st, after using the 
battery, he had rigours again, followed by headache and a pricking 
sensation in the cheek. On the 24th, he left the hospital in a re- 
markably improved state. Expression had returned to the side of 
the face which had been previously unmeaning and blank; the 
furrows which had deformed the opposite side were removed, the 
thickness of speech diminished, and the paralysis of the buccinator 
had been so far relieved that he was able to manage soft articles of 
food without being under the necessity of removing them from 
between the cheek and gum with his finger. In this case we em- 296 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
ployed an adjuvant which should be mentioned: we supported the 
paralysed parts for some days with strips of adhesive plaster, to 
restore the position of the mouth. This was done on the principle 
recommended by Dr. Pemberton, in the treatment of paralysis of 
the fore-arm and hand from painters’ colic. By applying strips of 
plaster near the angle of the mouth, and drawing them back and 
fixing them behind the ear, we endeavoured to counteract the pre- 
ponderating antagonism of the muscles of the opposite side. For 
the report of this case, I am indebted to Mr. K. Ellison, of Liver- 
pool, who had the charge of the patient in the Meath Hospital, a 
gentleman whose talents are only equaled by his untiring zeal in 
the study of pathological medicine. 
The foregoing case is interesting in two points of view; first, as 
to its peculiar phenomena, and, in the next place, as to the success 
of local treatment. It also shows that we may go too far with 
electro-puncturation, particularly when it is applied to parts which 
are situated close to the brain. You recollect that, in Mr. Hamil- 
ton’s case of amaurosis, three pairs of plates were capable of pro- 
ducing a degree of stunning and insensibility which lasted for 
some time. In this case the rigours and headache showed that the 
galvanic fluid had a powerful effect, and would lead us to be 
cautious in using it too freely, where the parts to which it is to be 
applied are situated in the vicinity of the brain. 
We have now taken a very brief sketch of some of the most 
important organic affections of the brain; but, in the study of dis- 
ease, we constantly meet with a vast number of cases presenting 
the most extraordinary nervous phenomena, and yet we are unable 
to discover, by the closest pathological investigation, any appre- 
ciable lesion of the nerves, spinal cord, or brain. These are the 
class of diseases which have received the name of neuroses. We 
find, in most of these affections, a remarkable alteration in the 
nervous functions without any perceptible or constant organic 
change; we find, too, that this alteration may be connected with 
an exaltation or a depression of the nervous power ; and from this 
circumstance results the division of neurotic affections into active 
and passive—active where the nervous power is elevated, and 
passive where it is depressed. The spasms which accompany an 
attack of flatulent colic, the exquisite pain of tic douloureux, and 
the wild intellectual exaltation of mania, are examples of active 
neuroses. A patient in the second stage of painters’ colic will have 
paralysis of motion and sensation of the fore-arm; there is here an 
obliteration, or at least a diminution, of the nervous function, and 
the disease furnishes us with an example of passive neurosis. 
Of these two classes the active are certainly the most interesting 
in many points of view. We find, under the class of active neu- 
roses, some of the most extraordinary diseases to which the human 
body is subject; all the different varieties of spasmodic affections— 
chorea, epilepsy, tetanus, hydrophobia, tic douloureux, hysteria, and 
a host of others, come under this denomination. It is a melancholy 
reflection then, that, in the present state of medical science, we are NEUROSIS. 
297 
not only ignorant of the ultimate cause of most of these diseases, 
but even of the causes of the variation in their phenomena. 
You will recollect that, in a former lecture, I threw out a con- 
jecture on this point, and stated that there might be changes of an 
organic nature connected with these affections, not appreciable by 
any mode of investigation at present known ; and that it was pos- 
sible that there might be a change in the nervous substance, quite 
independent of any addition or subtraction from the component sum 
of their organic molecules, but in all probability connected with a 
new and different arrangement of these molecules. The analogy 
in this instance is drawn from chemistry, and, I think, may obtain 
here, as well as in the phenomena of Isomerism in inorganic bodies. 
You are aware that many bodies, which seem to present exactly 
the same component elements, are found to be extremely different 
in their properties, and that this difference has been accounted for 
by supposing that it depends, not on any addition or subtraction of 
the component molecules, but on some difference in their mode of 
arrangement. Now, if this happens in the case of inorganic 
bodies, there is no reason why it might not also occur in organic 
substances ; and, if so, we may understand why a state of the brain 
and nerves, which appears to us to be normal and healthy, may still 
be essentially different, and give rise to the most extraordinary 
phenomena. 
I shall not detain you with any further remarks on this subject— 
it is too obscure to be treated of in a course of lectures on the 
practice of medicine; let us turn to the consideration of the actual 
state of our knowledge on the subject of nervous affections. In 
the first place, we know that in the neuroses there is no change 
discoverable which could account for the symptoms; and that, if 
we examine the nervous centres to explain the phenomena of para- 
lysis in one instance, of epilepsy in another, of mania in a third, of 
hydrophobia in a fourth, and so on, the most minute investigations 
will not, in the majority of cases, point out any deviation from the 
healthy condition sufficient to account for the phenomena. We 
find, too, not only that the state of the brain does not present any 
constant difference in the foregoing diseases, but also that there is 
often not the slightest trace of any thing like inflammatory action 
-—a fact borne out by the most extensive experience—and showing 
that treatment which would relieve ordinary cases of inflammation 
of the brain will here prove useless. There is one curious circum- 
stance connected with these neuroses which you should be aware 
of, and this is—where the patient, after suffering from a nervous 
affection for a long time, dies, you may find organic disease on dis- 
section ; but here there appears reason to believe that organic 
changes of the cerebro-spinal centres, taken in the proper accepta- 
tion of the term, are, in reality, the result of some state of these 
centres which existed previous to the attack, and was the cause of 
all the nervous phenomena. We arrive at this conclusion for two 
reasons: first, because such changes are by no means constant.; 298 
STOKEs’s THEORY AND PRACTICE OF MEDICINE. 
and, secondly, because they are only found where disease has been 
a long time in existence. 
Nervous phenomena, independent of organic lesion, have been 
divided into two classes—namely, neuroses of the nerves of animal, 
and neuroses of the nerves of organic, life. With respect to animal 
life, or the life of relation, we may have its neurotic affections of 
an active or passive kind; we may have pains, spasms, and exalta- 
tion of intellect, under the active form; under the passive, we may 
have extinction of muscular motion, sense, and the intellectual 
functions—the life of the individual being still preserved. With 
respect to the system of organic life, it would appear that, if we are 
to speak in general terms, we must admit that there is no passive 
paralysis of the nerves of organic life, they being liable to the active 
neuroses alone—for a passive neurosis of the ganglionic system 
implies death; yet, to a certain degree, as I have formerly stated, 
such a passive neurosis might exist in the visceral nerves. But we 
may have the phenomena of the active neuroses in all parts of the 
body, whether muscular or visceral. It is a singular fact, that in 
some visceral diseases we have signs of high exaltation of the 
nervous functions of the parts, in others not. Why is this the 
case? I think it must chiefly depend on the mode or degree of 
excitability of the brain, which is very different in different persons. 
There is no known organic difference between the gastritis with 
delirium, and the gastritis of a man in his senses; nor is there any 
difference between the hepatitis of a man of bilious, and the hepa- 
titis of a man of nervous, temperament: and we have, in order to 
explain the variety of the symptoms, to refer to some original con- 
formation or mode of excitability of the sentient centre. Whether 
this difference depends on an original organisation, or on excess or 
deficiency of parts, or on phenomena similar to those of Isomerism, 
we know not. As the result of experience, we are forced to admit 
that these phenomena have no necessary connection with the in- 
flammation of the suffering part, or of the brain ; and this proposi- 
tion applies to the great majority of cases which are called nervous. 
Experience has also proved the truth of this from the results of 
treatment—for it has proved that the most successful treatment is 
that which is by no means calculated to remove inflammation (in 
its ordinary acceptation), either from the brain or from the suffering 
parts. The progress and duration of these cases, also, tend to prove 
the same thing; for, if we were to measure the degree of inflam- 
mation by the amount of pain suffered, it would be of an intense 
character and rapid fatality; and yet we find that, notwithstanding 
the violence of the symptoms, these diseases may go on for a number 
of years. 
It is quite plain, then, that the pathological condition of a neu- 
rosis is not inflammation. Now, one of the most common mistakes 
in the practice of medicine is the taking these neuroses for cases of 
local inflammation; and this, I need not tell you, is frequently 
productive of most distressing consequences. There is one point 
connected with those violent nervous attacks which leads to a per- 299 
sistence in this error; and this is, that local antiphlogistic treatment 
gives temporary relief, although, in the majority of instances, this 
is of very brief duration, and the pain and other symptoms return, 
leaving the patient worse than he was before. From the fact of 
temporary alleviation following depleting means, however, the idea 
of inflammation gets into the practitioner’s mind, and the patient 
himself is favourably disposed to that plan of treatment from which 
he has obtained a momentary relief. The consequence is, that a 
system of general and local depletion is continued, until a period 
arrives when the nervous excitability gets to an alarming height. 
Now, is there any circumstance, or class of circumstances, which 
would lead to the diagnosis of these affections ? I feel certain that 
in many instances this must be a matter of some difficulty. By a 
careful study of the symptoms, however, you will, in most cases, 
be able to arrive at the truth. The first thing to which I would 
direct your attention, in studying the diagnosis of such cases, is, 
the extreme violence of the pain. Now, this intensity of suffering 
seldom occurs in cases of inflammation; and it is a curious fact, 
that the most painful diseases are the non-inflammatory. The 
agonies of a patient labouring under neuralgia of the liver, or of 
the left side, or under tic douloureux, are dreadful; the pain is far 
more intense than in any case of inflammation : and yet, notwith- 
standing all this excess and persistence of suffering, we do not see 
that the duration of life is necessarily curtailed. In the next place, 
you will observe that these attacks frequently recur, and that, 
though long continued and violent, they do not affect the patient’s 
life, which would not be the case if they were connected with in- 
flammatory action. If you add to all these circumstances a know- 
ledge of the constitution, temperament, and habits of the patient, 
you will have still clearer notions. But there are other circum- 
stances besides these to guide you. In the majority of cases, you 
will find that all the local and general signs of inflammation, with 
the exception of pain, are absent. A female, labouring under neu- 
ralgia of the liver, will have frightful pains in the right hypochon- 
drium, and yet, if you examine her, you find that she has little or 
no hepatic derangement, no tumour in the region of the liver, no 
derangement of the digestive system, and (though the disease has 
lasted for years) no dropsy, and in many cases no appearance of 
jaundice. She has no fever, thirst, or loss of appetite ; her tongue 
is clean, her complexion clear, her stools natural, and her pulse 
soft. All these circumstances tend to show that, however violent 
the pain may be, it has no connection with inflammation. You 
will be assisted further in your diagnosis, by finding that the access 
and cessation of these attacks are equally sudden and unexpected 
—two characters which do not belong to organic disease. The 
quick supervention and sudden cessation of these diseases should 
lead you to suspect that they were not inflammatory. It may hap- 
pen, in cases of inflammation, that pain may come on suddenly, 
and as rapidly cease; but, though it may come and go in a brief 
space of time, still you will find that lesion of function or structure 
NEUROSIS. 300 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
remains. Thus, in a case of pleuro-pneumonia, the pain of the 
side may cease suddenly under treatment; but the stethoscope 
informs you that the layers of the pleura do not as yet glide freely 
on each other, and that there is some obstruction still to the free 
passage of air into the air vesicles. There is also another point. 
When we come to enquire into the exciting causes of these neu- 
roses, we observe that they are most generally found to depend 
upon various circumstances connected with improper nutrition and 
with moral influences. Of these two classes of causes, the latter, 
though perhaps not the most numerous, are by far the most remark- 
able. A violent neurosis may be brought on in a single instant by 
moral causes. A nervous female, in apparent good health, may, 
from a sudden fright or fit of passion, get an instantaneous attack 
of neuralgia of the liver, and be thrown into a state of intolerable 
agony. Lastly, you will be greatly assisted in these cases by a 
knowledge of their history and previous treatment. What you 
will generally find is, that the patient has gone through a long and 
harassing course of general and local antiphlogistic treatment. The 
failure of this treatment will be of great value in guiding you to a 
correct diagnosis; and you will be further confirmed in this view 
of the case, by finding that the treatment which has the power of 
relieving or curing consists in improving the state of the whole 
system by the use of tonic, and, in many cases, of stimulant reme- 
dies. These observations will apply to almost all cases of purely 
nervous affections. 
LECTURE XXXIY. 
Principles of treatment of neuralgic affections—Connection with organic disease— 
Neuralgia of the liver—Treatment—Hemicrania—Treatment—Use of iron, quinine, 
and opium—Endermic method of using opium—Tic douloureux—Opinions of Sir C. 
Bell—Remarkable case related by—Inflammation of frontal sinuses—Violent symp- 
toms—Mr. Crampton’s treatment—Affections of the fifth and seventh nerves in 
cases of cerebral disease—Neuralgia of the side—Researches of Lombard and Brande 
on the effect of nitrate of silver—Injury to the skin. 
To-day I purpose to speak of some of the general principles con- 
nected with the treatment of neuralgic affections ; and here I beg 
leave to remind you, that we mean by neuralgic affections an exalt- 
ation of the nervous sensibility independent, quoad, its production, 
of any organic disease which we can detect in the nerves, brain, or 
spinal cord. There is no proposition better proved than this, that 
the phenomena of nervous affections are not the same as those of 
inflammatory diseases; every thing tends to prove it, whether we 
look to the history and symptoms of the case, the results of treat- 
ment, or the appearances seen on dissection. 
As the nervous system is diffused all over the body, and as there 
is no part of the system which does not, under certain circum- NEURALGIC AFFECTIONS. 
301 
stances, exhibit indications of sensibility, it follows that we may 
have neuralgic pains in any of the component tissues. Still, it is 
remarkable, that neuralgic affections are much more frequent in 
some parts than in others; and we find that, of all parts of the 
nervous system, the superficial nerves are those which are most 
commonly affected. With respect to the nervous affections of the 
viscera, we know very little as to their exact seat, but it has been 
generally observed that the pain is situated in the situations of the 
plexuses of the great sympathetic. 
In entering upon the principles which should regulate the treat- 
ment of neuralgic diseases, 1 have to remark that they are but 
slightly modified by their situation ; in fact, it may be stated gener- 
ally, that the same principles of treatment apply, no matter where 
the disease may be situated. But are we to consider this subject 
as totally apart and having no connection with the occurrence of 
inflammatory or organic disease ? If we did so, we should get but 
a limited and erroneous view of the matter. I have told you before, 
that, in long-continued cases of functional disease, organic altera- 
tions were very apt to take place. The reverse of this proposition 
also is true, that organic affections may precede an attack of nervous 
symptoms ; in other words, you may have cases presenting, at first, 
phenomena amenable to antiphlogistic treatment, and yet a period 
will arrive when new symptoms occur, and this mode of treatment 
will be no longer applicable. This is of importance in the prac- 
tice of medicine, for if, in such a case, you persevere in the use of 
depleting measures, you will affect nothing towards the removal 
of distressing symptoms, and may do your patient’s constitution 
much injury. A common example of this is, where a person 
receives some local injury, as, for instance, a blow on the cheek. 
This is followed by all the symptoms of inflammation, as pain, 
swelling, heat, redness, &c. Well, then, you have a case of local 
inflammation to deal with, and you must treat it as such. But a 
period may arrive when, the heat, swelling and other symptoms of 
an inflammatory affection subsiding, the pain alone continues. 
Here the pain may be purely nervous ; and if you were to go on 
leeching, purging, and depleting your patient, you would not only 
lose your time, but, in all probability, do mischief. Here, as in 
many other cases, we have local inflammation followed by an active 
neurosis. You remember, when speaking of hepatitis, I remarked 
that many persons were subject to pains in the region of the liver, 
independent of any known organic disease. I also drew your at- 
tention to the fact, that after the symptoms of hepatitis are removed, 
the pain sometimes continues, having no longer any connection with 
organic disease, and taking on the character of a neurosis. You 
will see of what importance this is when you reflect on the mis- 
chief done to such patients by persevering in bleeding, blistering, 
and the use of mercury, when the disease is amenable, not to this, 
but to a plan of treatment calculated to remove the neuralgia of the 
liver. It is the same thing with respect to the mammae, injuries of 
which are frequently followed by severe neuralgic affections. In 302 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
the case of the heart, it sometimes happens that, after an attack of 
pericarditis, the patient will be subject to pain in that region, which 
may continue for years. Dr. Bright gives a very remarkable case 
of neuralgia which supervened on the disappearance of a cutaneous 
affection. All these facts tend to show, that the mere pre-existence 
of local inflammation in any individual case does not prove that 
the pain is not neuralgic, and hence it is plain that in such a case 
it might be improper to persevere in the treatment used for local 
inflammation. This persisting in the taking of a neuralgic pain for 
the continuance of inflammatory or organic disease is a common 
error, and often productive of the most frightful consequences. 
Without a earful consideration of such cases, you will fall con- 
stantly into error. Never forget that although neuralgia may be 
the first and sole affection, yet, that it is often combined with 
organic disease, which it may precede, accompany, or follow. 
One of the most common forms of neuralgia which you will meet 
with in private practice, is what has been termed hemicrania, the 
chief symptom of which is violent pain in one side of the head 
and face. The symptoms are exceedingly violent; there is a high 
degree of exaltation in the sensibility of the surface of the face ; the 
eye is exquisitely sensible to light, and the ear to sound. The 
patient is very much prostrated, and his spirits depressed, and the 
slightest cause is sufficient to bring on an attack of pain. In some 
cases the pain is constant, in some remittent, in other intermittent. 
The sensibility is deranged only at one side of the head and face, 
and the pain seldom extends beyond the median line. As far as 
we know of this affection, it seems to depend on some morbid state, 
either of the sentient extremities of the fifth nerve, or of that portion 
of the brain which receives its impressions. 
In cases of hemicrania we may have symptoms existing else- 
where, and this leads us to the consideration of the exciting causes. 
These will be often found to depend on deranged digestion. Here 
the irritation is reflected through the sympathetic system to the 
brain and sentient branches of the fifth pair, for there exists be- 
tween these two nerves a very close and remarkable sympathy. 
Thus we frequently observe, that tic douloureux, as well as hemi- 
crania, are the result of some injury or irritation of those parts to 
which the ganglionic nerves are distributed. In treating a case of 
hemicrania, then, you must enquire whether there be any visceral 
irritation present, and remove it as soon as possible. You must 
also carefully inspect the teeth and gums, for a carious tooth or a 
diseased gum will prove the exciting cause of an attack. I have 
seen many cases of hemicrania where the patient was subjected to 
a variety of treatment without success, and where complete relief 
was obtained by the simple process of extracting a carious tooth. It 
is a very curious fact, that in those instances the pain was referred, 
not to the diseased tooth, but to the whole surface of the face. 
Cases of this kind are given in which the pain lasted for many 
years, resisting every form of treatment, and were afterwards cured 
by the extraction of a decayed tooth. There is one circumstance NEURALGIC AFFECTIONS. 
303 
in these cases which is very apt to mislead, and this is, that the 
pain is often not referred to the tooth ; and relief, to a certain 
extent, is obtained by the use of narcotics and carbonate of iron. 
This, however, should not lead you to think that the disease has 
no connection with the state of the tooth and gum ; and this fact is 
illustrative of a most important principle, viz., that temporary relief 
by a purely anti-neuralgic treatment does not prove that no 
organic origin exists. How often has hysteria depended on local 
disease, and the practitioner been misled by the temporary relief 
afforded by antispasmodics. I have seen the most melancholy 
examples of this, and have more than once been misled myself. 
With respect to the remedies most generally employed in the 
treatment of hemicrania, they are chiefly preparations of arsenic, 
iron, sulphate of quinine, and opium. Of these, the recently pre- 
cipitated carbonate of iron appears to be the best; indeed its success 
is frequently heroic. In proof of this you will find several very 
interesting cases detailed by Mr. Hutchinson in his excellent work. 
The best way of giving it is to combine it with an aromatic and a 
laxative ; a small quantity of the pulv. cinnamomi comp, a few 
grains of rhubarb, and fifteen grains or a scruple of the carbonate 
of iron, will form a powder which may be given two or three times 
a day with advantage. It has been asserted, that the carbonate of 
iron is suited for fixed, and not for intermittent, cases of neuralgia ; 
I have found the contrary to be the fact. I had lately a lady under 
my care, who, in attempting to remove some furniture, received an 
injury by striking her cheek against a chest. She was treated for 
six weeks with purgatives, local bleeding, and mercury; the swell- 
ing, heat, and redness of the part went off, but the pain remained, 
being regularly intermittent, and occasionally very severe. This 
lady was perfectly cured by atonic regimen, and the carbonate of 
iron, in scruple doses, three times a day. The sulphate of quinine 
has been proposed as being peculiarly adapted for intermittent 
cases; it will sometimes succeed, but I have known several cases 
where it completely failed. I grant that the character of intermis- 
sion would naturally induce a practitioner to have recourse to it, 
but I have known so many instances of its failure, in purely inter- 
mittent neuralgia, that I give a decided preference to the carbonate 
of iron ; I recollect the case of a gentleman who for six weeks had 
daily attacks of terrible hemicrania. When the attack came on he 
was obliged to remain perfectly motionless, the tears streaming from 
the eye of the affected side, the ear was exquisitely sensible to the 
slightest sounds, and he remained in a state of intolerable suffering 
for some hours. For the space of six weeks he took quinine in 
enormous doses without any improvement, and was ultimately 
obliged to give it up as useless. I have seen the same result in a 
great many cases, and as far as my experience goes, I would not 
place much reliance on quinine, even where the attack was of a 
purely intermittent character. I have seen some cases, indeed, 
where it has done good, and you may try it; but if, after three or 
four full doses, you find there is no improvement, you may be 304 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
almost sure that it will prove useless. When it succeeds, one of 
the first effects produced by it is to put back the paroxysm for an 
hour or two, just as occurs when it is successfully given in a case 
of ague. But I feel certain, that if it is likely to succeed its bene- 
ficial effects will be seen in the course of a few days, and to persist 
for weeks in using it is not only unnecessary but improper. In the 
very remarkable case to which I have just alluded, the gentleman, 
after having tried quinine without the slightest improvement for 
six weeks, was suddenly and completely relieved by a full dose of 
opium. At night, on retiring to rest, he took a strong opiate, awoke 
in the morning refreshed and free from pain, and has continued 
from that time to the present (a period of ten years) without any 
symptoms of hemicrania. Dr. Mackintosh says that the sedative 
solution of opium, or the acetate of morphia, are the best remedies 
for this disease he is acquainted with, and that he has seen many 
cases where they succeeded, after every thing else had failed. You 
may also employ in such cases the external use of narcotics with 
great advantage, of which one of the best is the extract of bella- 
donna. If you prescribe a liniment composed of a drachm of the 
extract of belladonna, with an ounce of the compound camphor 
liniment, you will have a powerful remedy, and one which, when 
applied to the surface of the affected parts, will often produce great 
relief. I have sometimes used the acetate of morphia in the ender- 
mio mode, by putting on a small blister, and leaving it on until 
vesication was produced, when the raised cuticle was cut away 
with a pair of fine scissors, and the surface dressed with an oint- 
ment composed of a drachm of lard, and from a grain to a grain and 
a half of the acetate of morphia. I remember two cases of inter- 
mittent hemicrania which yielded to this treatment. You will 
also frequently derive benefit from the internal use of stramonium 
and belladonna. There are many other remedies used for this 
purpose, but I shall not detain you any longer on this part of the 
subject; it will be sufficient to remark that the carbonate of iron, 
sulphate of quinine, and opium, externally and internally, are the 
remedies on which the most reliance is to be placed. 
We have now to consider one of the most painful affections to 
which man is subject. This affection has been generally consi- 
dered under two points of view, either as functional or organic. 
The functional, as far as we can judge of it, appears to be a pure 
neurosis; in the organic it is supposed that the disease is connected 
with an organic affection of some part of the brain; of these the 
first kind is that most commonly met with in practice. 
Tic douloureux is one of the most melancholy and harassing 
affections to which the human frame is liable; in some instances 
the poor sufferer, after having lived for years in a state of exqui- 
site misery, is at last worn out by the intensity and persistence of 
his agonies. Such was the fate of the late celebrated but unfor- 
tunate Dr. Pemberton. A great deal of light has been thrown on 
the nature of this affection by the researches of Sir Charles Bell. 
He seems to have succeeded in establishing several points connected NEURALGIC AFFECTIONS. 
305 
with the nature and seat of this affection, one of the most important 
of which is, that the seat of this disease is in the sentient branches 
of the fifth pair of nerves, and not, as it has been supposed, in the 
portio dura. He has shown pretty clearly that the portio dura is 
the nerve which regulates the muscular motions of the face, pro- 
ducing all those modifications of features which we call expression, 
and also peculiar motions or changes connected with certain states 
of respiration ; in a word, that it is the expressive and respiratory 
nerve of the face. It is, according to him, never the seat of tic 
douloureux, and the practice of dividing it for this complaint is as 
unscientific as unsuccessful. The division of the portio dura in 
such cases, not only fails to give relief, but also entails disgrace on 
the practitioner, and disfigurement and misery on the patient. Its 
effect is paralysis of the muscles of one side of the face, and great 
distortion, without the slightest relief. Yet it is a melancholy fact 
that such operations have been performed. Sir C. Bell’s researches, 
however, have put an end to this malpractice, for he has shown that 
the fifth nerve is that which supplies the face with sensation, and 
that it is in its branches the disease is situated. We are then, I 
think, to look upon this disease as a neurosis situated in the expan- 
sions of the facial branches of the fifth pair of nerves. Sir C. Bell 
relates a very remarkable case, in which the patient had suffered 
from a series of dreadful attacks, the pain coming on in violent 
paroxysms. From the accounts given by this patient, and from 
personal observation, he says that one could trace with anatomical 
precision the course and direction of the branches of the fifth nerve, 
for, on the recurrence of an attack of pain, he applied his fingers to 
his face, and made pressure on the foramina, where the different 
branches of the fifth nerve issue. Having done this, he would 
press the nerves with all his force, and remain in a fixed posture 
while the paroxysm continued. 
Sir Charles Bell’s idea with respect to the cause of this disease, 
is, that it generally depends on some visceral irritation reflected 
through the sentient branches of the fifth pair of nerves. 
I have told you that this disease is one of the most melancholy 
affections to which man is subject, it is also one of the most obsti- 
nate. A vast number of remedies have been employed or proposed 
for its treatment, and this affords an illustration of the fact, that the 
more incurable a disease is, the more extensive is the list of its 
remedies. A few only are deserving of attention, and these I have 
already mentioned when speaking of hemicrania, namely, the pre- 
parations of arsenic, iron and quinine, and opium. Where these 
fail after a full trial, Dr. Bright looks upon the case as hopeless. 
Narcotics in every form and of every description have been em- 
ployed, both externally and internally, but to all these the same 
remark applies ; many of these remedies will give temporary relief, 
and the physician will flatter himself on the prospect of a favourable 
termination, but in a short time he is annoyed at finding that the 
disease has returned and left the patient as bad as ever. Many a 
time have I seen a poor sufferer excited by hope on receiving tern- 306 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
porary alleviation from the use of arsenic or iron, and sinking into 
despair when he found that his torturing malady returned, and that 
the remedies which on the first trial gave relief on the second proved 
useless. The general principles which should guide you in your 
treatment are, first, to investigate carefully whether any visceral 
irritation exists, and remove it as far as possible, taking care at the 
same time to improve the general state of the patient’s health; and 
the next thing is to allay the sensibility of the nerves of the 
part, and avoid all exciting causes. In certain cases this disease 
appears to be connected with an affection of the brain, and this 
seems to be an explanation of the fact before mentioned, that in 
some cases, where all specific treatment had completely failed, relief 
had been obtained by shaving the head and applying ice to the 
scalp during the paroxysms. I have already mentioned to you a 
case in which this mode of treatment proved eminently successful. 
This is a curious fact, and one which, being of practical importance, 
you should hold in memory. 
We have a form of disease consisting of violent paroxysms of 
pain, apparently nervous, and in which no doubt the branches of 
the fifth pair of nerves are engaged ; it is generally found to depend 
on a local cause, being connected with some disease of the bones of 
the face or skull, and bears a close analogy to tic douloureux. I 
have now witnessed several instances of this disease; in some cases 
it is produced by a carious tooth, in others by disease of the maxil- 
lary bones, and I have observed it to occur in one case of abscess 
of the antrum. The same thing has been observed by Dr. Bright, 
who gives a case in which the extraction of one of the bicuspids 
was followed by a gush of matter from the antrum and complete 
relief of the violent pain. I have also seen cases in which this 
affection appeared to be the result of disease of the lining mem- 
brane of the frontal sinus, of this also Dr. Bright gives an example. 
The case I witnessed was that of a lady who got a dreadful attack, 
resembling hemicrania, in consequence of being exposed to cold 
shortly after leaving a warm climate. She suffered the most violent 
agonies for some time, until one day she had a discharge of puru- 
lent matter from the nostrils, which was almost immediately followed 
by relief. This has recurred at intervals since that period, the 
pain ceasing when the discharge comes on, and returning when 
the discharge goes away. The pain is most intense, and situated 
in the direction of the frontal sinus, and running down along the 
side of the face; it is constant, and without any intermissions, 
returns upon the occurrence of any cause which checks the dis- 
charge, and is sometimes so excessive as to render her quite frantic. 
Whenever an attack comes on she applies a number of leeches over 
the frontal sinus, then warm fomentations, and this has the effect 
of bringing on the discharge and giving relief. In a conversation 
which I had with Mr. Crampton on this case, he stated to me that 
he had met with two similar ones, and that he had succeeded in 
accomplishing a perfect cure by inserting a large caustic issue over 
the top of the head. I accordingly advised my patient to have the NEURALGIC AFFECTIONS. 
307 
same thing done. She has since that time left the country; but 
previous to her departure I certainly observed an improvement in 
her symptoms, and the principle of treatment appears to be perfectly 
rational. 
This leads us to consider some affections of the sentient and 
motor branches of the fifth pair of nerves, in which the disease is 
connected with an affection of the brain. A very interesting and 
important case bearing on this point is given by Sir Charles Bell, 
which I shall briefly relate. The patient, a lady, had remarked, 
that for twelve months before the case began to assume a serious 
character, she felt an unusual sensation in the tip of the tongue, 
towards the left side, as if it had been burned. This sensation 
gradually extended over the whole of the left half of the tongue, the 
left half of the palate, gums, and face, accompanied by an almost 
total loss of proper sensation in the parts affected. The sensation 
of heat and uneasiness was increased by the least motion of the 
face, the application of her hand, and other trifling causes. This 
case was communicated to Sir C. Bell by Dr. Whiting, under whose 
care it was. She had paralysis of the buccinator of the affected 
side, and the morsels of food had to be removed on that side with 
the finger, so that she was obliged to perform mastication with the 
opposite jaw alone. The motions of the face, however, were 
properly performed, showing that the functions of the superficial 
branches of the portio dura were unimpaired, and the temporal 
and masseter muscles continued in their natural state. Her general 
health also was pretty good, and she complained of nothing but the 
affection of the side of the face, tongue, and palate, and the impossi- 
bility of masticating her food with comfort on the left side, in conse- 
quence of the state of the buccinator. Some time afterwards, while 
engaged in eating, she found that a new train of symptoms were in 
progress ; her face became distorted by the retraction of the mouth 
to one side, the masseter and temporal muscles of the left side ceased 
to act, the tongue became protruded, with its tip directed to the left 
side, hearing ceased on the same side, she had some difficulty in 
performing the motions of the eye, and the eyeball began to waste 
and diminish. About a month before her death she became quite 
stupid, and spoke very indistinctly. She died after the disease had 
continued for two years. 
Here was a case, presenting in the first instance symptoms of a 
nervous affection of the left side of the face, tongue, and palate, 
unaccompanied at that time by any paralysis of the muscles of the 
face. About a year afterwards, however, she began to exhibit 
symptoms of paralysis of that side affecting those muscles which 
are supplied by the branches of the portio dura and fifth nerve. 
Expression was now lost, the temporal and masseter muscles ceased 
to act, the mouth was drawn to one side, and the tongue protruded. 
In addition to this the sense of hearing on one side was lost, and 
the globe of the eye began to waste. On dissection, it was found 
that a tumour, appearing to be a morbid growth from the left crus 
cerebri, about the size of a pigeon’s egg, and containing some fluid, 308 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
was situated over the left temporal bone. This production was 
partly cellular and partly membranous. But the most interesting 
part of the case was the examination of the state of the nerves. 
The first and second nerves were undisturbed, and so was the 
fourth. The third was slightly displaced ; but it was on the fifth 
that the principal impression seemed to have been made, for it was 
flattened, thin, and wasted, as if from the direct pressure of the 
tumour. The sixth nerve was uninjured. The seventh was 
involved and lost in the tumour, from within a quarter of an inch 
of its origin as far as the meatus auditorius internus. Here is 
a drawing of the case ; here is the fifth nerve flattened and wasted, 
and here is the seventh involved in the tumour. 
Mr. Stanley gives a case very similar to the foregoing, of which 
I shall give you an abstract. The patient had hemiplegia of the 
left side, without loss of sensation in the affected arm or leg, but in 
the left side of the face there was a complete loss of sensation and 
motion. The loss of sensation and motion in this case would 
argue that there was an injury of the seventh nerve as well as the 
fifth. The mucous membrane of the left nostril was red, and there 
was opacity and disorganisation of the cornea of the left eye, with 
total loss of hearing on the same side. The patient died some 
time after the paralytic symptoms were established. On dissection, 
a tumour was found lying close to the tuber annulare, and com- 
pressing the fifth and seventh nerves. 
Here was a case in which there was hemiplegia of one side, and 
complete loss of motion and sensation in the corresponding halt of 
the face, with an erysipelatous redness of the nostril, inflammation 
of the conjunctiva, and disorganisation of the cornea. It is a 
curious fact, that in cases where the sentient branches of the fifth 
nerve, which are distributed to the face, become affected, the eye 
is frequently disorganised. The cause of this appears to be that the 
eye, under such circumstances, loses the sensibility of its external 
surface, which is supplied by the branches of the fifth pair, and is 
intended to obviate and guard against all causes of irritation, and is 
consequently left in a state in which it can no longer protect itself 
from external injuries. In a case of this description which came 
under the notice of Mr. Crampton, the finger could be rubbed over 
the eyeball without giving the patient any pain, and there was 
chronic inflammation of the conjunctiva. 
The principles which should guide us in the treatment of neu- 
ralgic affections of other parts of the body are the same as those 
which have been laid down in speaking of the neuralgic affections 
of the face. You will often meet with affections of this nature in 
females: they are situated generally in the right or left side, and 
are frequently, I regret to say, mistaken for cases of local inflam- 
mation. I have already dwelt on the disastrous consequences of 
mistaking a neuralgia of the liver for hepatitis, and showed the 
mischievous consequences of treating it with purgatives, leeching, 
blistering, and mercury. There is an analogous affection of the 
left side, which has frequently been mistaken for disease of the NEURALGIC AFFECTIONS. 
309 
heart, and treated accordingly. It is most commonly observed in 
females of a nervous habit. To this affection the same principles 
will apply as to hepatic neuralgia; by regulating the patient’s gene- 
ral health, prescribing a mild nutritious diet, giving up all anti- 
phlogistic measures, and the judicious employment of tonics and 
narcotics, you will be able to effect a cure. 
It has been lately proposed to use the nitrate of silver in the 
treatment of cases of this description, from its success in epilepsy. 
A very interesting memoir on this subject has been recently trans- 
mitted to me from Paris by Dr. Lombard, in which he dwells on 
the utility of the nitrate of silver in several nervous affections. 
Some persons, but in particular the disciples of the physiological 
school, think that nitrate of silver relieves cerebro-spinal irritation 
by creating a new irritation elsewhere ; that its efficacy consists in 
its causing a revulsion of the gastro-intestinal mucous membrane ; 
and that thus we cure an epilepsy by substituting a gastritis. In 
proof of this they bring forward cases where a chronic gastritis was 
found to supervene on the removal of an epilepsy by this remedy. 
This, however, is by no means a fair or logical deduction. The 
epilepsy might have been preceded and produced by the chronic 
gastritis, though the symptoms of the latter were not recognised, 
owing to the existence of other symptoms of a more prominent and 
striking character. The gastritis might have had a priority of 
existence, and might have been the cause of the epilepsy; the 
epilepsy might be cured, and the patient die afterwards with symp- 
toms of chronic gastritis. This shows you how cautious you should 
be in receiving, on medical subjects, the post hoc ergo propter hoc 
argument. This mode of explanation of the cure of one irritation 
by the substitution of another, sprung from the denial of all speci- 
ficism, in disease and its remedies, by the school of Broussais, one 
of the greatest errors of the “ physiological doctrine.” The use of 
mercury in syphilis, of bark in ague, and many other instances 
have been quoted against it. If in these diseases there be nothing 
but local irritation, why does not ordinary antiphlogistic treatment 
always suffice for their removal? Why is it that mercury is the 
best revulsive in syphilis ? The specific character appears under 
this view, as well as under any other. The term specific may be 
objectionable as not being precise, but we use it for want of a better, 
and it rather expresses what the disease is not than what it is. 
There is another and a more rational objection to the employ- 
ment of nitrate of silver ; namely, that it has produced a blackening 
or discoloration of the skin. This, in my opinion, is an objection 
which will always weigh against the use of the remedy, for there 
are few who would like to encounter the risk and consequent blame 
of such an event. It has not been proved that nitrate of silver has 
cured epilepsy by superinducing gastritis, but it has been proved 
that it may blacken the skin. Dr. Lombard admits that this may 
and does occur, but he thinks the frequency of its occurrence much 
overrated, and states that in the majority of his cases it did not 
happen at all. He mentions a very interesting fact connected with 310 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
this subject. It has been supposed that exposure of the skin to the 
influence of sunlight during the use of the nitrate of silver is the 
cause of the blackening. Now Dr. Lombard says that this cannot 
be the case, for one half of his patients were peasants who worked 
in the open air, and never took the slightest precaution against 
exposure to the sun’s rays ; and yet, among them all, there was no 
instance of discoloration. He is of opinion, therefore, that the 
influence of the sun’s rays should not be taken into account in a 
case of blackening of the skin ; and this appears to be confirmed by 
the fact, that in all cases where the nitrate of silver produced dis- 
coloration, the patients were inhabitants of towns, and consequently 
less liable to exposure. This blackening of the skin, though a rare 
circumstance, will, as long as we are ignorant of the causes which 
produce it, and the means of controlling them, be a great obstacle 
to the internal use of nitrate of silver. I have used this remedy in 
cases of epilepsy and other diseases, and cannot say much for it; in 
the hands of some of my friends, however, it has been much more 
successful. Dr. Lombard thinks very highly of its value. In some 
cases in which he prescribed it a perfect cure followed, in others 
more or less relief. He gives some cases of facial neuralgia, in 
which it appears to have produced a cure. He has also prescribed 
it with success in epilepsy and chorea. 
There is one fact, which appears to show that the cause of the 
blackening: of the skin is connected with something else besides the 
influence of the solar rays, which I had almost forgotten. In a late 
number of the Quarterly Journal of the Medical Sciences, Mr. 
Brande gives an account of some experiments he made on the 
bodies of persons who were tinged by the nitrate of silver. He found 
on examination that the deep-seated parts were tinged as well as 
the superficial, and was able to detect the oxide of silver in the 
bones, and even in the substance of the viscera, as well as in the 
skin. If this be the case, we cannot attribute the discoloration to 
the solar rays, though it generally happens that the face appears to 
be darker than other parts of the body in persons who have 
undergone this change of colour. The fact, however, that in Dr. 
Lombard’s cases the peasants escaped while the citizens became 
tinged, and Mr. Brande’s discovery that the deep-seated parts are 
equally liable to discoloration, furnish a weighty objection to the 
opinion that the blackening of the cuticle is produced by the decom- 
posing power of the sun’s rays. SCROFULA. 
311 
LECTURE XXXV. 
Scrofula; former opinions on—White and red capillaries—Division of the system into 
red and white tissues—Vascularity of the white tissues—Dr. Graves’s views of the 
lymphatics—Analogies of lymphatics and veins—Meckel, Cruikshank, and Magen- 
die’s opinions on—Relations of the circulating and nervous systems—Vitality of 
serous membranes—Reproductive power of white parts—White blood and white 
tissues more prevalent in women than men—White tissue more liable to cancer, &c. 
—Analogy of the white parts with cold-blooded animals—Increased sensibility of 
white tissues—True nature of the scrofulous diathesis—Reference to arrest of 
development—Explanation of its phenomena. 
In the varied catalogue of morbid atfections to which man is 
liable, there is scarcely one of such paramount importance, such 
engrossing interest, as scrofula—whether we look to the obscurity 
of its origin, its insidious progress, the number and variety of the 
organs which it attacks, or its remarkable intractability and exten- 
sive fatality. It is, indeed, a subject of deep concern to every one 
who is engaged in the pursuit of medical knowledge; and I do 
therefore entreat your undivided attention while I endeavour to 
give you some clear ideas as to the meaning of what has been 
termed the scrofulous diathesis, and scrofula itself. 
It is now generally admitted, that a great proportion of our im- 
proved knowledge on the subject of scrofula, as well as many other 
diseases, has been the result of those splendid anatomical and patho- 
logical investigations which have distinguished modern times. The 
older authors knew little of pathological or comparative anatomy ; 
and hence it was that scrofula, on which pathology has shed such 
a broad and searching light, was to them an intangible essence— 
something which they knew to exist, but could neither portray nor 
define. If we look to what their opinions were on this subject— 
opinions which, I regret to state, are not yet sufficiently exploded 
—we shall find that they are based on the then prevailing doctrines 
of exclusive humoralism ; and that, instead of attempting to reduce 
the phenomena of scrofula to a fixed and tangible formula, they 
sought to explain it by referring to certain peccant and noxious 
humours in the system. But, in order to arrive at accurate notions 
on this subject, we must begin with the first formation of the human 
body; we must trace scrofula back to its primal source, and care- 
fully explore its anatomical constitution. 
If we examine the capillary circulation in its physiological state, 
we shall find two kinds of circulating fluids: one distinguished by 
its red colour, and called blood; the other transparent and whitish, 
or colourless, and termed lymph. In fact, we have two kinds of 
capillaries—one containing fibrin and colouring matter blended 
with an albuminous fluid, the other circulating only a colourless 
fluid containing little or no fibrin, and almost identical with serum. 
This is a fact which is now generally admitted. It has been sup- 
posed that the red and white capillaries differ only in point of size; 
and this is rendered probable by the fact, that, in cases of inflam- 
mation, vessels which previously contained only a colourless fluid 312 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
become dilated, and are rendered capable of transmitting red blood. 
This goes very far in support of the doctrine, that the red and 
white capillaries differ only in respect to size. Let us take a few 
out of many examples of this kind. The circulation of the serous 
membranes in their healthy state is entirely white, but in an inflam- 
matory condition we can, with the greatest facility, trace numerous 
red vessels ramifying through their substance, as you may observe 
in inflammations of the arachnoid, pleura, peritoneum, and other 
white tissues. You may see the same also in the case of a mucous 
membrane—as in that of the conjunctiva where it passes over the 
transparent cornea. This condition subsides with the disappear- 
ance of the inflammatory action. 
These investigations, however, as to the cause of the difference 
between the red and white capillaries, are not of great moment in a 
pathological point of view ; it will be sufficient for our purposes 
merely to admit this difference, and bear chiefly in mind the rela- 
tive compositions of the fluids which circulate through them. One 
of these, as has been already stated, is called blood, and contains a 
quantity of fibrin and colouring matter; the other is termed lymph, 
and is chiefly composed of water and albumen: the former is cha- 
racterised by the presence of fibrin, a highly animalised product as 
containing a large proportion of azote ; the latter consists of mate- 
rials of an inferior degree of animalisation, and in which we can 
scarcely detect the existence of azote. Recollecting this remarkable 
difference in the nature of the circulating fluids, we find, when we 
come to examine the solids of the body, that some organs are sup- 
plied with red blood, while others receive only white blood, and 
hence the grand physiological division of the body into red and 
white tissues: the red containing fibrin and colouring matter, and 
endowed with great vitality ; the white containing chiefly albumen, 
and possessing vital power in a comparatively weak and imperfect 
degree. To give you an example of this, let us take the muscular 
fibre, (which may be looked upon as the most highly vitalised of 
animal products,) and we shall find that its tissue is red, it is sup- 
plied by red vessels, and exhibits an acute sensibility to external as 
well as internal stimuli. On the other hand, we observe that the 
white tissues—such as cartilage, tendon, and serous membrane— 
have a white and albuminous fluid circulating through them; that 
they are of an inferior organisation, and of a lower degree of vital- 
ity ; and that, in a state of health, they are almost insensible to 
ordinary stimuli. 
In order to prove the close connection which exists between the 
white tissues and a white circulation, it is necessary that we should 
admit that these tissues are vascular ; and on this point, it must be 
confessed, there is some difference of opinion among physiologists. 
Some say that the serous membranes and other white tissues are 
not supplied with vessels and nerves like other parts of the body, 
but that they are to be considered as a mere exudation. This is 
the opinion of Rudolphi. This notion, however, does not appear 
to be founded on truth; it has been disproved by the investigations SCROFULA. 
313 
of many eminent physiologists, but by none more than by Dr. 
Graves in his excellent lecture on the lymphatic system. Let us 
enquire, briefly, whether it be true that these tissues are supplied 
with vessels containing white blood. That such is the case appears 
from the fact of the sudden development of red vessels in those 
tissues when in a state of inflammation. Now, it cannot be sup- 
posed that an irritation which has lasted only for a few minutes 
could be capable of forming new vessels. That vessels already 
formed might become dilated in a very short space of time, we can 
easily conceive; but that they should start into existence in the 
space of a few minutes, is totally incomprehensible. The sudden 
appearance of these vessels does not by any means prove that they 
are new creations; it rather tends to show that they must have 
existed previously to the attack of inflammation which rendered 
them visible, and that they escaped observation before that occur- 
rence, from their extreme minuteness and from the colourless 
nature of the fluid they contained. The next thing to be adduced 
in support of this view of the question is this: that parts uncon- 
nected with any red tissue shall themselves become red under the 
influence of the inflammatory process. Thus, in a case of pleuritis, 
for instance, we observe that the lymph which has been effused 
becomes gradually organised, and ultimately converted into the 
serous membrane, forming those bands of adhesion with which you 
are all familiar. At certain periods of this process, vessels carrying 
red blood may be distinctly seen shooting through the lymph, which, 
you must bear in mind, is surrounded on all sides by the original 
serous membrane. These vessels are sometimes of great size; I 
have seen them, in a case of peritonitis, as thick as a crow-quill. 
As the organisation advances to completion, we find that these 
vessels disappear, and a colourless serous membrane is formed. 
Now, here we have a newly organised tissue, presenting the same 
characters as serous membrane, and having no connection what- 
ever with any red tissue; and yet it is not less curious than true, 
that, if this new tissue be attacked with inflammation, it will become 
distinctly red, and will have red vessels developed in the substance 
which may be examined and traced with the naked eye. The red 
vascularity of the synovial membrane, when inflamed, may be also 
quoted in proof of the same fact; for this, you will recollect, is a 
white tissue, super-imposed on other white tissues, the cartilage 
and capsular ligament. In addition to this, we have an argument 
drawn from the great similarity which exists between the serum of 
the blood and lymph. Dr. Graves believes that the lymphatics, 
which are supposed to act merely in carrying back the debris of 
the system, really enjoy a higher function ; that they are to be re- 
garded as the veins of the white tissues, or, in other words, that 
they are to the white arteries of the white tissues what the veins 
are to the red arteries of the red tissues. He brings forward many 
striking analogies between the veins and lymphatics. Both have 
valves, the effect of which is to direct the contained fluids towards 
the centre of the circulation; in both the fluid flows with an 314 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
equable current toward the heart, and in both its course is directed 
toward the organ where it is destined to undergo the process of 
aeration. Dr. Graves quotes Cruikshank and others to show that 
lymphatics, coming from a white organ or tissue, become capable, 
in the inflamed state of that organ, of carrying red blood ; and this 
is a strong argument in proof of his opinions. We find, too, that 
the white blood, like the red, is separable into a watery portion and 
a crassamentum. If any thing else were necessary to show the 
close connection between the veins and lymphatics, it is furnished 
by the fact of their numerous anastomoses—a fact which has been 
placed beyond all dispute by Meckel, in his magnificent work on 
the lymphatics, which he has dedicated to his illustrious country- 
man, Soemmering. Lastly, it has been shown, by Magendie, that 
the veins and lymphatics discharge a similar function—both being 
engaged in carrying on the process of absorption. Both, then, 
have a similarity of structure; in both the contained fluids flow in 
an equable current toward the heart, and are destined to be sub- 
mitted to the same process of aeration; both contain a fluid sepa- 
rable into a clot and a watery portion ; under the influence of the 
inflammatory process, the one carries red blood as well as the 
other; they are intimately connected with each other by innume- 
rable anastomoses, and both are alike engaged in discharging the 
functions of absorption. 
It may be admitted then, I think, that the white tissues are vas- 
cular, and that the lymphatics are the veins of the white tissues. 
Now, pursuing this investigation further, if we examine the differ- 
ent organs and parts of the human body, we find that most of 
them are composed of a combination of red and white tissues, but 
that some consist of white tissue alone. Thus, if we look to the 
constitution of muscular substance, we find that it is composed of 
muscular fibre which is a red, and cellular membrane which is a 
white, tissue. In the parenchymatous organs we find the same 
combination of red and white tissues present. But, on the other 
hand, we observe that serous and synovial membranes, ligaments, 
tendons, aponeuroses, and cartilages, have no mixture of red tissue 
in them, and are composed of white tissue alone. The fact is, 
that both enter into the composition of most of our organs, but in 
some the white tissue prevails exclusively. The same conforma- 
tion is observed in all the vertebrated animals, but particularly in 
the mammalia and birds. Now, admitting this, it appears that the 
proportion of red solids is in the ratio of the red fluids, and that 
of white solids in the ratio of the white fluids. This proposition 
we can establish by a number of indisputable facts. In the higher 
classes of the mammalia, the red solids and fluids are found in great 
abundance in the viscera, as well as in the muscular parts. In 
birds the quantity of red blood is great, and consequently we find 
the muscular substance red and firm, the circulation active, and 
the temperature high. In the amphibious animals the flesh is paler, 
the quantity of red blood diminishes, and, as the red tissues disap- 
pear, the white increase in proportion. Descending in the scale SCROFULA. 
315 
we come to fishes: here we find that the quantity of red blood is 
very small, and that the white tissues predominate. When we 
arrive at the invertebrated animals, or those who have no spinal 
system, we observe a disappearance of the red fluids and red tis- 
sues. I shall here beg leave to read for you an extract from Dr. 
Graves’s lecture. “The view already taken of the intimate con- 
nection, in all the different classes of animals, between the develop- 
ment of the white parts and that of the lymphatic system, is easily 
explained on the supposition of the lymphatics being the veins of 
the white parts. In invertebrated animals, which have no red 
blood, it would be more rational to call the vessels conveying the 
white blood back to the heart lymphatics than veins; for it is more 
consistent with analogy to suppose, that, in the lower animals, the 
retained portion of the circulating system corresponds with the 
former, as in the superior animals the lymphatics are connected 
with parts which, in their degree of vitality, most resemble the 
structures of the lower animals. 
“ In the higher classes of animals there are not only two circu- 
lating systems—one of red blood, and the other of white blood— 
but also a twofold system of nerves, the cerebral and the ganglionic ; 
the latter of which, in invertebrated animals, seems to perform all 
the nervous functions necessary to their state of existence, while 
these animals are remarkable for possessing only a simple vascular 
system. 
“ We find, therefore, a correspondence between the vascular sys- 
tem of red blood and the nervous system of the brain and spinal 
marrow. They are most perfect in animals most abounding in 
highly aerated red blood, and decrease according to the descending 
scale proportioned to the decrease of red blood, until at last we 
arrive at the invertebrated animals possessing no red blood, and no 
brain or spinal marrow.”—Op. Cit. p. 24. 
These facts seem to establish the law, that the proportions of red 
and white solids are in the ratio of their respective fluids. But let 
us consider this question in a different point of view. The human 
foetus, in the earlier periods of its existence, presents the appear- 
ance of a white mass without any red tissue or red vessels—in fact 
it resembles one of the lower or white-blooded animals; but, as the 
process of development goes on, the red fluid begins to appear, and 
the red tissues increase ; as it progresses towards perfection, these 
changes become more manifest, until at length, having arrived at 
the summit of the zoological scale, the predominance of the red 
tissues is established, and even the new-born infant exhibits the 
distinguishing characteristics of that being which holds the first 
rank in the order of vertebrated animals. 
We have seen that, in proportion as the animal rises in the scale 
of being, the proportion of the red to the white tissues is increased ; 
and that the lowest animals, who possess only a white circulation, 
enjoy a degree of vitality not far removed from that of the vege- 
table kingdom. Red blood, then, is the pabulum vita—the charac- 
teristic of superior organisation and vitality—the rich stream by 316 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
which the nobler parts of our system are nourished. Applying 
this to the different states of our bodies in health and disease, we 
find that the predominance of red blood and red tissues is a proof 
of health and vigour, while that of white blood and white tissues 
shows the feeble and unhealthy individual. Before we pursue this 
further in its application to the investigation of disease, let us refer 
for a moment to some illustrations. In the Albinos, the white tis- 
sues are more abundant and the quantity of red blood smaller; the 
muscular fibres are lax, and the constitution delicate. Again— 
compare woman with man. In the former the white tissues are 
more prevalent than in the latter, the skin is fairer, the vessels car- 
rying red blood smaller, and the muscular system less developed. 
Women have more white blood and white tissues, and consequently 
their strength is less, and their constitution more delicate. Again, 
if we examine the hybernating animals, who pass long periods of 
time without taking food, we find that, at the termination of their 
hybernating season, their strength is remarkably reduced, and their 
tissues much paler than under different circumstances. The same 
diminution in the quantity of red blood and red tissues, and cor- 
responding increase in the relative quantity of white tissues, occur 
in the case of persons advanced in life. From some cruel experi- 
ments made in France, it appears that, by starving animals, their 
tissues became blanched in a remarkable degree, and they came to 
represent animals of an inferior grade, so far as the preponderance 
of white tissue was concerned. These considerations are highly 
interesting and important, and remind us of Lord Bacon’s aphorism, 
that white is the colour of defect. 
We may, then, conclude that the white tissues are less highly 
animalised than the red, and of a lower degree of vitality; and, 
arguing d priori, we would say that they are less able to resist 
death, and that in them disease would be slower and more obstinate 
than in the red tissues. Such, too, is the fact, for we find that the 
white tissues are most liable to morbid affections of an intractable 
character, frequently terminating in the total destruction of the dis- 
eased parts. Cancer, tubercle, ulceration in the cartilages, liga- 
ments, or cellular substance—all these belong to the affections of 
white tissues. All these terrible inflictions are to be met with in 
those tissues which rank low in the scale of vitality; they occur in 
persons of weak habit and diminished vital energy, and in whom 
the white tissues predominate over the red; and they are less under 
the influence of those curative means which are ordinarily employed 
in the treatment of diseases of the red tissues. Thus we find that 
many of the means, which are employed with such good effects in 
dispersing inflammations of red parts, seem to possess very little 
power in removing the diseases of white parts. In making these 
observations I have spoken only in reference to chronic disease; 
but let us turn to the acute diseases. Here we arrive at a very 
curious fact. If we take, for instance, the serous membranes, we 
shall find that, although strictly belonging to the class of white 
tissues, they are, nevertheless, very liable to acute and violent SCROFULA. 
317 
diseases. It appears strange that parts, possessing only an inferior 
degree of vitality, should be subject to such frequent and violent 
attacks of inflammation. Such, however, is the fact. It is very 
difficult to explain this apparent anomaly; I shall, however, throw 
out a few considerations which strike me on this point, having 
premised that you are to look upon them, not as proved, but lying 
open to future investigation. 
If we examine the pathology of serous membranes, we shall find 
that they are liable to inflammation in proportion to the quantity 
of red vessels in the organs they cover; or, in other words, the 
more they are connected with organs enjoying a high degree of 
vitality, the more they are subject to inflammation. If we take 
the serous membranes lining the three great cavities of the body, 
we shall find that this position is, to a certain degree, borne out by 
the facts. One of the most common cases of inflammation is that 
of pleurisy; we seldom open a body without meeting with evi- 
dences of its existence at some period or other of the life of the 
individual. Now, we know that the lung is the most vascular 
organ in the body, and that through it alone the whole of the cir- 
culating blood is transmitted. Next in order to the pleura, we have 
the peritoneum—peritonitis being a much more common affection 
than arachnitis, for the intestines receive a greater quantity of red 
blood than the brain. Among the viscera of the three great cavi- 
ties, the brain is the whitest, and receives the least blood, and we 
accordingly find that its investing serous membrane is least liable 
to attacks of acute inflammation. We have also a number of 
curious facts with respect to the nature of the connection which 
exists between any inflamed parenchymatous organ, and the serous 
membrane by which it is covered. Thus, in a case of hepatitis, 
we find that that portion of serous membrane which invests the 
liver exhibits traces of inflammation, while the rest of the perito- 
neum remains in its normal and healthy condition. You will see 
the layer of the peritoneum covering the liver in a state of inflam- 
mation, and will frequently find adhesions between it and the 
corresponding portion of the parietal layer, but no other sign of 
extension of inflammation. This fact is strongly in favour of the 
connection between the inflammations of serous membranes and 
of the organs they cover. There is another form of partial peri- 
tonitis which is exceedingly common—namely, the inflammation 
of that portion of it which embraces the uterus, and which is so 
frequently met with in puerperal fever. Now, here we have two 
considerations to bear in mind. During utero-gestation, there is a 
remarkable development of the uterus; and, about the period of 
delivery, it is a vast red organ, having a powerful determination of 
blood to its substance, as well for its own support as that of the 
infant. We accordingly find that after delivery peritonitis fre- 
quently sets in—its occurrence being favoured, in the first place, by 
the connection between the peritoneum and a large vascular red 
organ, and, in the next place, because the determination has not yet 
ceased, and the blood which went to the uterus (but cannot do so 318 
STOKEs’s THEORY AND PRACTICE OF MEDICINE. 
any longer to the same extent) seems to be directed to the perito- 
neum. Another consideration bearing on this point is, that, when 
lymph has been effused in the case of inflammation of serous mem- 
branes, the process of organisation and cure goes on the more 
rapidly, the nearer the inflamed membrane is to a red and vascular 
organ. If we take a case of pleuritis with effusion of lymph and 
serum, when is it that we find the process of organisation set up in 
the effused lymph? It is when the fluid has been removed by 
absorption, and the two serous layers of the pleura are no longer 
prevented from coming in contact; for, as long as that portion 
investing the lung is separated from the costal pleura, either no 
organisation at all takes place, or, if it does, it is of a slow and 
imperfect character. But as soon as the effused serum is removed, 
and the costal pleura come into close apposition with a red and 
highly vascular organ, the lymph immediately undergoes a process 
of rapid organisation. The high degree of vascularity of the lung 
should be reckoned as one among the causes of the great frequency 
of pleural, as compared with peritoneal, adhesions. 
A question may be asked here, connected with the idea that 
serous membranes possess only a low degree of vitality. If the 
vitality of serous membranes be of an inferior kind, why is it that 
their inflammations are so acutely painful ? This, I must confess, 
is a question not easy to be answered. There is no doubt, how- 
ever, that during the existence of inflammatory affections the vitality 
of these parts is considerably increased. They are elevated in the 
scale for the time. Their vessels carry red blood, their sensibility 
becomes exquisite, and they enjoy a reproductive power, as is shown 
in the case of the formation of new synovial membranes, capsular 
ligaments, and serous membranes ; thus, as Dr. Graves has beauti- 
fully remarked, showing an analogy of organisation and function 
between the white tissues of the higher, and the whole constitution 
of the lower animals, in whom the power of reproducing parts is 
so remarkable. This circumstance seems to be strongly in favour 
of Broussais’ doctrine, that inflammation is nothing more than a 
plus degree of local vitality. Some persons think that the pain in 
serous inflammation depends upon the density and unyielding 
nature of the affected membranes, for you are all aware that one 
of the effects of inflammation is at first to distend the inflamed 
organ. This may be true. Again, it is said that we are also to 
take into account the extensive and constant motions of the serous 
membranes. As long as respiration goes on in the chest, or diges- 
tion in the belly; while the ribs are elevated and depressed, and 
while the diaphragm descends, or while the peristaltic action of the 
intestines goes on; there will be motion in the serous membranes 
which invest their respective viscera. We know, also, that the 
brain enjoys a certain degree of motion. We must, then, in ac- 
counting for the pain of serous inflammation, take into considera- 
tion the dense structure and little distensibility of the parts, as well 
as their constant and uniform motion. There is one fact, however, 
which, as far as it goes, is of importance, and should not be forgot- SCROFULA. 
319 
ten when we consider the motions of serous surfaces in reference 
to pain. Of all the serous membranes, the pericardium is that 
whose motions are most constant and violent. Yet I have now 
seen many cases of its inflammation, where quantities of lymph 
were effused, as detected by the stethoscope and by dissection, yet 
in which no pain whatever existed. 
It appears to me that we can add something to these views in 
the way of explanation. When lecturing on hepatitis, I drew your 
attention to the fact, that if we compare the inflammations of the 
different solid viscera with respect to pain, we find that there is 
always less pain when the inflammation affects the central parts 
of an organ than when it is superficial. In deep-seated pneumonia 
there is scarcely any pain, in pleuro-pneumonia the pain is often 
acute. In arachnitis the pain is violent, in deep-seated disease of 
the brain there is frequently no pain at all. Inflammation of the 
central parts of the liver is generally a painless affection ; but, 
when it approaches the surface, it is always accompanied by more 
or less suffering. Now, if we consider the serous membrane of the 
abdomen, for instance, to be an organ of low vitality and inferior 
sensibility, we must seek for some other explanation of the pain 
which attends superficial inflammations of viscera. The following 
idea may be of some assistance towards an explanation. Let us 
take, for example, a case of inflammation occurring in one of the 
glandular viscera. You are aware that Muller has reduced the 
structure of all glands to one formula, that is to say,—a gland, in 
its simple state, consists of a cavity, shut at one end and open at 
the other, and the difference between the various glands does not 
depend on any departure from this rule, but on a difference in the 
mode of aggregation and arrangement of these little structures. 
You will have a notion of the structure of glands by comparing 
them to a bunch of grapes, the grapes representing the glandular 
part, and the stalks their excretory ducts. Now you are aware 
that in most glandular organs the secreting portion is placed 
towards the circumference, and the ducts accumulate towards the 
centre ; and, as the glandular portion always possesses a higher 
degree of vitality than the ducts, we can understand why the 
superficial parts of a glandular organ may be endowed with a 
higher sensibility than the deep-seated or central, and, consequently, 
that inflammation affecting the superficial parts of glandular vis- 
cera will be attended with more pain than when seated towards 
the centre, and affecting the excretory portion of the organ. 
We are now, gentlemen, prepared to enter on the consideration 
of scrofula, on which much error still prevails, notwithstanding all 
that has been said and written on the subject. One great cause of 
the confused notions respecting scrofula arises from the circum- 
stance, that some persons have understood the term as expressing 
mere local disease, as, for instance, of the glands of the neck, and 
having no reference to any peculiar constitutional diathesis ; while 
others use it with reference to a peculiar condition of the system, 
which is called the scrofulous diathesis; and a third class apply 320 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
the term scrofulous to a number of very opposite diseases, which 
have no character in common but chronicity and incurability. 
By considering the subject physiologically, we escape those errors 
and acquire more accurate ideas as to its real nature; and, as far 
as I can see, we cannot help adopting the opinion of Broussais,— 
that scrofula implies nothing specific ; but, simply, that there is an 
undue preponderance of the white over the red tissues, and that, in 
such persons, there is of course a greater liability to diseases of the 
lymphatic system. Where there is an undue preponderance of 
the white over the red tissues, there we have the scrofulous consti- 
tution, and the liability to its accompanying diseases. Observe, 
there is nothing specific in this; an individual, originally free from 
scrofula, may afterwards be subject to it, and it may, under certain 
circumstances, occur in all constitutions. 
The characteristics of what has been termed the strumous habit 
are known since the time of Galen. The skin is white, the com- 
plexion delicate and transparent, the hair fair in general, but some- 
times dark; the features delicate, the upper lip thick, the alae of the 
nose large, the head fully developed, the chest rather narrow, the 
joints large, a great tendency to sanguineous congestions, internal 
and external, which are very little under the influence of antiphlo- 
gistic means ; the intellectual faculties early developed and of a 
higher order, great refinement, and delicacy of taste. In such per- 
sons there is generally a considerable preponderance of the white 
tissues, and they are much disposed to scrofulous disease, which is 
nothing more than a chronic irritation of the white parts and of the 
organs immediately connected with them. 
We may look on the scrofulous diathesis as a condition of the 
human body which is to a certain degree imperfect, and which is to 
be attributed to arrest of development. There is a period of foetal 
life, in which the whole mass of the body consists of white tissues. 
According as the individual progresses towards maturity, the red 
tissues become more abundant; and when he arrives at maturity of 
maturation the proportion between the tissues becomes completely 
altered, the red being now more abundant than the white. But if 
this process should happen to be arrested, either shortly after birth 
or during life, we have then an individual of a lowerdegreeof vitality, 
and approximating.to the class of white-blooded animals. That we 
may reduce the scrofulous diathesis to arrest of development seems 
to be borne out by other considerations. We find in persons of a 
strumous diathesis proofs of arrest of development in various parts, 
so that whether we consider the question as to the development of 
the whole or of particular parts of the body, the same conclusion 
obtains. Scrofulous children have large heads, and it has been 
long known that they are exceedingly subject to hydrocephalus. 
The great size of the head in this instance is reducible to the prin- 
ciple of arrest of development; and here we have some explanation 
of the fact of the activity of the intellectual powers in scrofulous 
persons. Again, scrofulous children have large bellies; and here 
we have another proof of the arrest of development. In the foetus 321 
SCROFULA. 
the belly is larger in proportion than it is in the adult; and if the 
individual grows up with this predominance, it is a proof of arrest 
of development. The liver in the foetus is, as you all know, 
very large. Now it is a fact that many persons of a scrofulous 
habit grow up with this foetal condition of the liver ; and, accord- 
ingly, we find this organ enlarged, not as the result of disease, but 
because an equal and proportionate increase of other parts has not 
gone on : and here we have another fact confirming the principle 
of arrest of development. Scrofulous children are observed to have 
small limbs and contracted chests. Here, too, we again meet with 
the fcetal condition. In the foetus the chest is small and contracted, 
and the extremities are puny and ill-developed. How beautifully 
this tallies with the state of the lung at that period of life, when 
there is very little employment for the thorax, and when the active 
functions of the lung have not as yet been called into operation. 
This, too, informs us, why it is that such children are so liable to 
affections of the lungs. We find that scrofulous persons are of a 
feeble frame, find have weak and flabby muscles; and, in accord- 
ance with this, we find on examination that the muscular system 
to a certain degree represents the condition of foetal life, that the 
blood is albuminous, and its proportion of fibrin small. We observe 
that scrofulous children are subject to rickets, and that the propor- 
tion of phosphate of lime in their bones is small. Now this is pre- 
cisely the condition of the bones in the foetus. Thus, whether we 
look to the whole or to particular parts of the body, we find that 
scrofula is reducible to arrest of development, and that there is not 
in it any virus, any thing particular or specific, as has been erro- 
neously imagined. To these considerations it might be added, 
that nothing is more common than to see those monstrosities, dis- 
tinctly referable to local arrest of development, occurring in the 
scrofulous subject; and the statistics of monstrosity show that in 
this respect the female sex predominates over the male. 
There has been much disputation as to the question whether 
scrofula be hereditary or not. You can easily solve this question, 
by reflecting on what you have already heard. No doubt it is often 
so ; one or both parents may be scrofulous, and it is as natural that 
a child born of such parents should inherit their scrofulous constitu- 
tion as that it should resemble them in features. But, on the other 
hand, we sometimes find that scrofulous parents beget healthy 
children. This appears to be an anomaly, but it may be explained 
by the circumstances of the child having a good healthy nurse, 
living in pure air, and having comfortable warm clothing, all cir- 
cumstances calculated to develope the red tissues, and of course 
strengthen the system. Thus a scrofulous taint may be completely 
worn out in a few generations. It sometimes, on the other hand, 
happens that healthy parents may have children of a strumous habit. 
This, however, is the rarest case, but can be explained by reference 
to causes which would disturb the balance of development, and a 
person of an originally sound constitution may, under certain cir- 
cumstances, become scrofulous. Children may be badly fed and 322 
STOKEs’s THEORY AND PRACTICE OF MEDICINE. 
have insufficient clothing; they may be kept confined, and deprived 
of free air, light, and exercise; they may have an ?arly irritation 
of the digestive system, from bad and unwholesome food, and 
in this way may acquire the scrofulous character without any 
hereditary disposition. Thus we come to the fact, which has been 
so frequently noticed, that scrofula will often pass over a genera- 
tion, and that the grandfather and grandson may labour under it, 
while the son escapes its infliction. 
It may be objected to this view of the question, that we frequently 
observe persons of dark hair and robust constitutions falling victims 
to scrofula. This is certainly true, but it is not on that account 
an argument calculated to militate against the doctrines which 
have been propounded on the subject. There are many causes 
capable of producing this increase in the white tissues, this pecu- 
liar state of the constitution, which we call the scrofulous diathesis. 
Excessive mental or bodily exertion, all the depressing passions, 
injuries of innervation of various kinds, deprivation of light, air, 
and exercise, early and continued gastro-intestinal irritation, per- 
sistent and exhausting diseases,—all these have a tendency to 
impair the functions of nutrition, and to destroy the balance be- 
tween the different tissues of the body. If we look to those animals 
in which tubercles are found, we see that they are often those 
which have been brought from a hot to a cold climate, and kept in 
a state of confinement for a long time, and hence it is that we so 
often find fatal tubercular disease in animals which are kept for the 
purposes of exhibition. The same liability to tubercle is observed 
in several of our domestic animals kept in unhealthy situations, 
and deprived of air, light, and exercise. The truth is, that a com- 
bination of such causes will generate scrofula in constitutions which 
were originally sound and good; but it will occur at an earlier 
period, and with much more certainty when these causes are 
brought to act on persons in whom there is an original or con- 
genital predominance of the white tissues. This fact is so well 
known as to require no further illustration; it is now generally 
admitted, and you will have many opportunities of verifying it in 
practice. 
Allow me in concluding this subject, to direct your attention to 
the following considerations. If we were to connect the pheno- 
mena of scrofula with a predominance of the white tissues, it would 
follow that woman would be more liable to the disease than man. 
Louis, in stating the relative liability of the sexes to consumption, 
makes the proportion of males to females as 70 to 92. Cancer, 
which is also a disease of the white tissues, is, you all know, much 
more frequent in women than men. 
Scrofula, then, to use the term as expressing local disease, seems 
to have in it nothing of a specific character, or reducible to the 
supposition of a virus existing in the system; it seems to be a slow 
irritation of the lymphatic system, occurring in persons who have 
a predominance of white fluids and white tissues. It would appear, 
also, that this predominance of white tissues may be either con- 323 
FEVER 
genital, or it may be acquired, and that, in this case, it is superin- 
duced by various causes, all having a direct tendency to diminish 
the proportion of red tissues, and lower the vitality of the system. 
This, which appears to me to be the true meaning of what has been 
termed the scrofulous diathesis, you will find to be borne out by a 
multitude of facts, and you will have numerous opportunities in 
practice of proving the value and importance of this view of the 
question. In this way we get rid of that mode of treatment which 
was based on the supposed specific nature of scrofula, and of which 
the object was the removal of an imaginary virus, and we are guided 
to the knowledge of a more philosophical and more successful line 
of practice. We arrive thus at the few and simple, but grand and 
efficient principles, in the treatment of scrofula; we see that scrofula 
is in its nature closely connected with the predominance of white 
and the diminution of red tissues, and we accordingly find that our 
curative means must embrace every thing calculated to invigorate 
the system, and add to the existing sum of vitality. 
LECTURE XXXVI. 
Fever—General considerations on—Erroneous modes of investigation—Importance of 
the labours of French pathologists—Complication of fever with local disease—Pri- 
mary and secondary fevers—Relation of, to local changes—Tendency to spontaneous 
termination—Principles of treatment—Errors of Brown and Bronssais—Researches 
of MM. Gaspard and Magendie—Their pathological conclusions—Importance of the 
knowledge of secondary lesions—Effect in preventing crisis—Treatment—Humo- 
ralism and solidism. 
It may be safely asserted, that, in the whole range of medical 
science, there is no subject on which so much has been written and 
so little known as fever. You will find, in the writings attributed 
to Hippocrates, a series of observations on the rise, progress and 
termination of febrile affections, which it must be acknowledged are 
characterised by singular beauty and truth; and I think I may 
venture to say, that such is their extreme accuracy, such the com- 
prehensiveness, acumen, and power of the master mind that, made 
them, that scarcely a single one has been overturned by the 
researches of modern times. From the period of Hippocrates almost 
down to the present day, the contributions to this department of 
medicine, though numerous and varied, were of very inconsiderable 
importance; they effected little towards the improvement of our 
knowledge of fever, and many of them were calculated rather to 
puzzle and mislead, than to throw light upon what was difficult 
and obscure. In place of studying the phenomena and effects of 
fever, instead of applying themselves to what was tangible and 
useful, the minds of medical men were occupied in tedious but 
profitless attempts to discover the proximate cause of fever, and it 324 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
was to this subject that the labours of some of the greatest men in 
medicine were exclusively directed for a series of years. The con- 
sequence of this was, that our knowledge made no real progress, 
and as little was known about fever in the time of Cullen and 
Brown as in that of Hippocrates. We had innumerable discussions 
as to its cause and nature, we had a vast quantity of learned 
writing and ingenious speculation, but they produced nothing avail- 
able for practicable purposes, nothing tangible or real. The inves- 
tigators failed, because they reversed the Baconian method of 
arriving at the truth ; they first built up a theory, and then thought 
to make the phenomena of nature square with it; they forgot that, 
to be truly philosophical, we must first collect, compare, and 
arrange facts ; and, when we have done this, we may deduce from 
them a theory, cautiously, and with a strict regard to truth. They 
did not pursue this course, and the consequence is that they added 
nothing to the sum of our available knowledge. Their disciples 
knew nothing more than was known to Hippocrates ; in fact, they 
knew less, for their notions on the subject of fever had reached 
them through an erroneous and distorted medium. The followers 
of Cullen viewed it through the theories of Cullen, the Brownists 
through those of Brown ; both alike forgot nature, and both were 
consequently inferior to Hippocrates in true knowledge. They 
attempted to discover the proximate cause of fever, and they failed, 
as men generally do, when they attempt to investigate first causes. 
We know very little, indeed nothing, of the nature of first causes; 
they are, and will in all probability remain for ever, beyond the 
range of human intellect. It may be argued, that Cullen and Brown 
did not seek to ascertain the first cause, but only the proximate 
cause of fever; but this is only a play upon words, both are shroud- 
ed in the same obscurity, and in both the same difficulty attends 
our investigations. Even suppose we say with Cullen, that fever 
is a spasm of the extreme vessels; or with Brown, that it is asthenia 
of the whole system, what do we learn by this, or of what use is 
our knowledge ? Have we more defined and accurate notions of 
fever ?—Certainly not. They failed, as all men do who occupy 
themselves in the fruitless labour of searching after first causes. 
There is but one First Cause, and even of Him we know nothing 
accurate, but what He has vouchsafed to reveal. 
Modern pathologists have pursued a course very different from 
this, and the consequence has been that they have arrived at the 
most splendid results. Instead of attempting to investigate proxi- 
mate causes, they have studied the phenomena and effects of fever, 
they have examined dead bodies, they have accurately appreciated 
the series of pathological changes they present, and endeavoured to 
connect those changes with the symptoms. In this great work the 
French pathologists took a prominent part; indeed, I think it may 
be asserted, without fear of contradiction, that, a vast proportion of 
our improved knowledge on the subject of fever is due to the 
French. It has been, I regret to say, too much the fashion to 
decry the labours of the French pathologists ; but I believe this has FEVER 
325 
been chiefly done by persons who would gladly possess the know- 
ledge they affect to despise. The French pathologists have pur- 
sued with respect to fever the same method they have so success- 
fully employed in the investigation of other diseases ; and though 
their researches have not thrown any important light on its proxi- 
mate cause, they have taught us a vast deal as to its phenomena 
and complications, they have established a great number of valuable 
facts, and unfolded a series of beautiful truths ; and, I need not say, 
that it is in the appreciation of these facts that a proper knowledge 
of fever consists. 
In the first place, they have strongly drawn the attention of the 
medical world to this great truth, which should be engraven on your 
minds—that mere fever, without local disease, is of very rare 
occurrence. Here was a new and extraordinary light thrown upon 
the misty doctrines of the older pathologists. With them fever was 
a nonentity, something they endeavoured to describe but could not, 
something apart from, and totally unconnected with, organic change. 
The result of this mode of viewing the question was a variety of 
crude hypotheses and fanciful speculations. Bear this always in 
mind—mere fever, unaccompanied by local disease, is very rarely 
met with. Recollect, too, that it has been established beyond the 
possibility of doubt, that fever, complicated with local disease, is 
the rule, and its non-complication the exception. We have fur- 
ther learned from modern pathology, that every system and every 
organ in the body may be, and f requently is, diseased during the 
course of fever, and that, in the vast majority of cases, death is 
the result of one or many local inflammations. We further learn, 
that the character and symptoms of fever are infinitely varied, and 
that the cause of this variation mainly depends on the seat, the 
number, and the nature of the local affections. It is to these that 
we are to attribute the principal modifications in the character and 
phenomena of fever, and it is by these that its course and termina- 
tion are mainly influenced. 
Dr. Fordyce, in his work on fever, attempts to give a definition 
of the disease, and as I feel convinced that it is, if not a definition, 
at least one of the best descriptions of fever, I shall give it as nearly 
as possible in his own words. The style of this description is 
quaint but expressive. “ Fever,” says he, “ 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 skin, fibres, muscles, and membranes; it affects the body, 
and it affects the mind; it is, therefore, a disease of the whole sys- 
tem in the fullest sense of the term. It does not, however,” says 
he, “ affect the various parts of the system uniformly and equally, 
but, on the contrary, sometimes one part is more affected than 
another.” This last observation is totally at variance with the idea 
that fever is a mere morbid condition of the whole system without 
reference to local lesions, for he expressly states that it does not 
affect the whole system uniformly and equally. This excellent view 
of fever seems to be borne out completely by modem pathology, and 326 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
particularly the last part, where he says, that in cases of fever one 
part is more affected than another. We have, for instance, cerebral 
fevers, nervous, bilious, gastric, and catarrhal fevers, by which, it is 
to be observed, we do not mean to imply that there is nothing more 
than simple disease of the brain, or nerves, or liver, or bowels, or 
respiratory system, but that in each of these fevers, disease predo- 
minates in some particular part. So that when we speak of these 
fevers, we speak of such a disease as Fordyce has described, in 
which one part of the body is affected more than the rest. In 
many of the schools you will still meet with Cullen’s division into 
synocha, synochus, and typhus, a division by which we gain no- 
thing at all, these terms being but mere words and no more. Will 
any one define what is meant by synocha, or synochus ? Will any 
one say what is typhus ? Will any one say that a particular class 
and character of symptoms and morbid changes apply to any of 
these affections ? It would be quite impossible. What we gene- 
rally find is, that in the different cases of what have been termed 
synocha, synochus, and typhus, though they may present the symp- 
toms belonging to each separately, yet in these same cases, at some 
period or other, the symptoms pass into one another so as to 
confound the original distinction. We have synocha to-day, syno- 
chus to-morrow, and then typhus ; or we may have typhoid symp- 
toms at first, and inflammatory ones afterwards, and so on. We 
find, too, that similar causes will produce in different individuals 
essentially different forms of fever, and hence it is that we cannot 
found any distinction of fevers on their exciting causes. Nothing 
is more common than to see in two patients the same lesion pro- 
ducing, in one the synocha, in the other the typhus of Cullen. 
Thus, whether we look to the progress, symptoms, or exciting 
causes of fever, we find that this division has no foundation in 
nature, and is purely scholastic. Synocha, synochus, and typhus, 
are but mere names without meaning, terms which belong to the 
dogmatism of theory, and not to the expression of truth, and yet it 
is dreadful to think of the numerous lives which have been sacri- 
ficed at the shrine of this dogmatism. 
Fevers may be divided into two classes. We have, in the first 
place, fevers which we may call primary or essential, in which we 
find (as far as human investigation can go) affection of the whole 
system, of the fluids as well as of the solids. This genera] state of 
the whole system seems in such fevers to have the initiative, consti- 
tuting the first step in the process of disease ; but it is also true, 
that, in almost every instance of essential fever, local disease springs 
up at some period or other of its course. We have, then, in these 
fevers this primary state of the system, the cause and nature of 
which are unknown, and we have this followed by various se- 
condary lesions, affecting different parts of the body, and presenting 
characters by which we can arrive at a knowledge of their nature, 
more or less. 
In the second class of fevers, we place all those in which the 
first affection is local, and the fever secondary. Observe the dis- FEVER 
327 
tinction between this and the former class. In the first kind, or 
primary, the local disease is consequent on the fever, in the se- 
condary, fever is the result of local disease. Let us take an example 
of each. A person in health is exposed to the contagion of typhus; 
he becomes languid and weak, has troubled sleep, bad digestion, 
and low spirits; after some time, what is called fever sets in, and 
during the course of this, various local diseases may supervene. In 
the other case, a person, also in health, from exposure to cold, or 
from some local injury, gets an attack of inflammation of the lungs, 
or some other local lesion, and, as a consequence of that lesion, has 
symptomatic fever. 
Now the relation which the fever bears to the local symptoms in 
each of these cases is different. In the first case, the fever is pri- 
mary, and the local affections secondary ; and it may happen that, 
although the local diseases may be modified or removed, the fever 
will still continue ; but in the second, the fever always vanishes on 
the removal of the local disease. We have to enter on the consider- 
ation of the first of these to-day, and to examine that morbid state 
of the whole system in which local disease supervenes at some 
period of the fever; in other words, where the lesions of particular 
parts or organs are symptomatic of the fever. 
I have already mentioned, that one of the great truths at which 
modern pathologists have arrived is, that local disease commonly 
occurs during the course of fevers. It has also been established 
that, in the great majority of cases, the cause of death is one or 
more local inflammations. The experience of every candid pa- 
thologist is in favour of this doctrine. Patients seem to die of fever, 
but the fact is that some die by the brain, some by the lungs, others 
by the digestive system, that is to say, during the course of fever 
they get disease of various organs, some of the brain, some of the 
lung, and a vast number of the digestive system, often sufficient to 
destroy life if there was no fever at all. It is an undeniable fact, 
that, in the great majority of cases, there is local disease of some 
part or other of the body, and that a vast proportion of fever patients 
are carried off by local inflammation. How plain then is the 
deduction from these facts, that the man who neglects the viscera 
in fever is practising with his eyes shut. 
So much for the first great fact of the complication of fever with 
local disease, and its important bearing on practical medicine. But 
there is another general consideration with respect to these primary 
fevers, they have a tendency to terminate spontaneously \ of the 
cause of this spontaneous termination we are still in ignorance. 
One of the most simple and familiar examples of this is the paroxysm 
of an intermittent. A patient, who is at present apparently in 
good health, will in the space of an hour or less be attacked with 
severe rigours, followed by all the symptoms of fever, a flushed 
countenance, hot skin, quick pulse, and high coloured urine, and 
in some time afterwards a copious perspiration breaks out, which is 
attended with complete relief to the symptoms, and the patient 
gets well again. From this time until the period of the next attack STOKES’S THEORY AND PRACTICE OF MEDICINE. 
he continues to all appearance in health. Now, if we consider each 
of these paroxysms as an attack of fever, we see in them an evident 
disposition to terminate spontaneously. The same thing occurs in 
the case of the exanthemata. Scarlatina, measles, and small-pox, 
have a regular course, which generally terminates at stated periods; 
they also exhibit a succession of stages characterised by corre- 
sponding symptoms. We observe the same disposition to terminate 
spontaneously in most continued fevers, and it has been further 
remarked, that this spontaneous termination generally occurs on 
particular days. We have then two great leading facts in the 
history of all primary fevers, first, that they are most commonly 
complicated with local disease, and, in the next place, that they 
have a great tendency to terminate spontaneously and on particular 
days. 
Now, gentlemen, you will please to observe, that a knowledge of 
these two very important facts furnishes us with two great indica- 
tions—one, to discover and remove, or modify the local inflamma- 
tions ; the other, to support the patient’s strength, so that he may 
not become exhausted during the progress of the disease, and thus 
lose his chance of this spontaneous favourable termination. These 
two indications, though apparently incompatible, are not so in 
reality. You will of course understand that the extent to which 
we pursue one or other of these indications, must necessarily vary 
according to circumstances. The rapidity, violence, and particular 
seat of the local inflammation, the duration of the attack, the age, 
sex, and constitution of the individual, all these are circumstances 
which must be taken into account in-adopting any plan of treat- 
ment, whether calculated to remove local disease, or support the 
patient’s strength. 
The similarity between the different individual cases of fever, is 
too faintly shadowed out to amount to any thing like identity; in fact, 
there are no two cases of fever perfectly alike. You might as well 
expect to find two human being exactly alike as to find two cases 
of fever perfectly similar. The causes of this remarkable variation 
are reducible to the extent, variety, seat, and complication of local 
disease, and to the peculiarities of the patient’s constitution. These 
two classes of circumstances produce infinite varieties in the ap- 
pearance and character of fevers. 
The followers of Brown saw nothing in fever but debility, and 
their practice was to support the strength, and give stimulants from 
the commencement, ignorant of the fact, that neglected local inflam- 
mation will produce and keep up debility. The followers of M. 
Broussais, on the other hand, think that fever is sympathetic, that 
it depends on local inflammation, and that it must be subdued by 
depletion. Truth lies between. We must do both, we must com- 
bat the local inflammations by antiphlogistic means, and we must 
support the patient’s strength by a well regulated regimen. These 
two indications are by no means incompatible, but their application 
must vary according to circumstances. If it be true, then, that 
local disease is very common in fever, and a frequent cause of FEVER 
329 
death, it is plain that to practise without a knowledge of the state 
of the viscera, would be acting like the physician mentioned by 
D’Alembert. He compares him to a blind man armed with a 
club, who comes to interfere between nature and disease. If he 
strikes the disease, he kills the disease : if he strikes nature, he kills 
nature. 
A discussion has arisen in modern times, as to whether we 
should look upon all fevers as sympathetic. This is one of the 
leading doctrines of the school of M. Broussais. He declares that 
all fevers are sympathetic, that there is no such thing as an essential 
fever, or, in other words, that there never exists that peculiar mor- 
bid state of the whole system to which we apply the term fever; 
that in all cases fever is the result of local lesions, and that on the 
removal of these lesions its cure will depend. To this conclusion 
the school of M. Broussais was compelled to come in consequence 
of their exclusive solidism. They endeavour to reduce all the phe- 
nomena of life, whether in a state of health or disease, to the mutual 
action and influence of the viscera and solid parts on each other. 
They are solidists, in the strict sense of the word, and can have no 
conception of fever as existing independently of some primary 
local lesion. But it seems that the leading points of this doctrine 
have not been able to stand the test of an impartial examination, 
and may at present be looked upon as disproved. You will see 
at once the importance of this, when you consider that if it be true 
that all fevers are sympathetic, the practice must necessarily consist 
in the discovery and removal of local lesions, and no more. But I 
said that these doctrines are now disproved, and the following 
arguments may be laid before you in proof of this statement. 
In the first place, let us enquire whether any cause acting on the 
whole economy is capable of producing local disease. Mark, the 
object of our enquiry is to ascertain whether any cause operating 
on the whole economy is capable of producing local disease. Now, 
I believe it is quite certain that such is the fact, and that we may 
have, first, a morbid condition of the whole system, and, consequent 
on this, various local lesions. Several continental pathologists, but 
in particular MM. Gaspard and Magendie, have shown, by repeated 
experiments, that we can produce all the phenomena of typhus in 
the lower animals, by introducing putrid substances into the system. 
These gentlemen injected putrid substances into the veins of ani- 
mals, and applied them to the surfaces of wounds, and, in every 
case where these experiments were performed, they observed that 
the animals became ill, had languor, loss of appetite, thirst, prostra- 
tion—in fact, all the symptoms of bad typhus; and, in case of 
death, that they exhibited, on dissection, local lesions correspond- 
ing with those we meet with in the human subject in fever. 
Now, observe, these animals were, previous to the experiment, in a 
state of perfect health; they are, then, subjected to the operation of 
a cause which is found to produce a morbid state of the whole sys- 
tem ; they die, and on dissection inflammation and ulceration of the 
mucous membrane of the digestive tube, and other lesions, are dis- 330 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
covered in almost every instance. It would be quite absurd to say 
here, that the ulceration of the bowels was the cause of the morbid 
symptoms, for the animals were previously healthy. We can come 
to no conclusion, then, but that the introduction of putrid matter 
produced that morbid state of the whole system which is termed 
fever, and that the local inflammation was the result of this state. 
It is the same thing with respect to the exanthemata. A child is 
exposed to the contagion of small-pox ; for some time nothing par- 
ticular is observed ; he then gets ill and feverish, and this is fol- 
lowed by an eruption of variolous pustules. Here we have a local 
disease consequent upon a circumstance affecting the whole system, 
and in this, as in the former examples, the local lesion is se- 
condary. We might as well argue that the pustules were the cause 
of the symptoms in one case, as to say that the ulceration of the in- 
testines was the cause of the other. Every one, I think, will admit 
that the pustular eruption in a case of small-pox is secondary, and 
not the cause of the symptoms ; and the same argument will apply 
to the secondary affections of typhus. If it be true, as appears by 
M. Magendie’s cases, that fever follows the introduction of putrid 
substances into the body, and that this morbid state of the system 
produces inflammation of the intestinal mucous membrane ; if, too, 
we admit that in small-pox the pustules are secondary, and conse- 
quent on a morbid state of the whole system originating in con- 
tagion, the same argument will hold good in all cases of local 
inflammation, (whether of the liver, lungs, brain, or any other 
organ,) which may arise during the progress of fever. These facts 
are adduced in support of the first part of the argument—that local 
lesions may be and are consequent on that morbid state of the whole 
system to which the name of fever is applied. 
The next thing to be observed with reference to this question is, 
that if it be true that typhus is merely symptomatic of local disease, 
it would then follow that there should be as constant a relation 
between the symptoms during life and the morbid changes seen 
on dissection, as there is between the fever of pneumonia and the 
changes presented by the lung. But this is not at all the case, for 
we find that there is no constancy, no uniformity, either in the seat 
or extent of the local disease. Two patients will exhibit symptoms 
of typhus not differing in any material point, and yet, on dissection, 
you will find little or no traces of disease in the intestinal canal of 
one ; in the other, you will find in the same parts a vast amount of 
disease. Two others will also present symptoms very similar; in 
the one you will find the lung healthy and normal, in the other, 
you will find it extensively disorganised. Would it not be absurd 
to assert here, that the fever was symptomatic of the local lesion, 
seeing that there is no constant relation between the symptoms and 
the morbid changes, either as to situation or extent ? Again ; it is 
a fact, that you may have several patients presenting different symp- 
toms, and yet, when you come to examine their bodies, you find 
the same morbid changes in all. One may exhibit all the pheno- 
mena of typhus ; in another, this condition is but slightly marked j 331 
in a third, it is absent; and yet, on dissection, you find a similarity 
of local lesion. Lastly, it may be argued that if typhus were symp- 
tomatic of any particular local lesion, we should be able to cure it by 
removing that local lesion. This, however, is not always the case ; 
that it sometimes does occur I am willing to admit, and this is there- 
fore to be considered as the weakest of my arguments. But, on the 
other hand, if it be admitted that the local lesions are accidental and 
secondary, we can easily understand why their removal should not 
necessarily cause the removal of the fever. Such are the arguments 
on which I ground my objections to the doctrine—that all fevers are 
merely symptomatic of local disease; and in these views I think I 
am borne out by the opinions of the soundest modern pathologists. 
But though we admit that local inflammations are secondary, 
and bear the same relation to typhus as the eruption of small-pox 
to the morbid state that precedes it, still they are not the less 
important; and it is by a careful study of them that we arrive at a 
key to correct and successful treatment. They are of great import- 
ance from being exceedingly common in fever; in fact, so common 
that their occurrence is the rule, their absence the exception. 
They are also, in the majority of cases, the cause of death, and this 
they bring about in two different ways. First, directly, as in a case 
of simple inflammation. A patient in fever, who gets an attack of 
violent enteritis, may die of it as well as if he got an attack of pri- 
mary enteritis ; or he may die of pneumonia coming on during the 
course of his fever as well as the man who dies of pneumonia from 
cold. Thus we see that the secondary inflammations may produce 
death directly. They may also produce it indirectly, by preventing 
the efforts of nature towards a favourable termination. You recol- 
lect I told you, that in fevers there is a strong tendency to termi- 
nate spontaneously and on particular days. Now we find that this 
disposition is greatly impeded by the presence of local inflammation, 
so that local inflammation may operate to the destruction of life in 
two ways ; either directly, by its intensity and extent, or indirectly, 
by preventing a critical termination. 
This leads us to look still deeper into the matter. We find that 
these local or secondary affections may also produce a train of 
sympathetic phenomena of a very remarkable character. There 
is no reason why enteritis coming on during the course of a fever 
may not react on the economy as well as the enteritis from cold, 
which we know generally produces symptomatic fever. In the 
case of two patients, one, for instance, meets with some lesion of 
the intestinal mucous membrane, and, as a consequence, gets en- 
teritis and sympathetic fever ; another gets enteritis during the 
course of a typhus ; in the one case, the local lesion plainly reacts 
on the system, in the other this is less apparent, but there is no 
reason to suppose that it does not produce some effect on the system 
in one case as well as in the another. The law appears to be this, that 
in almost all cases of fever there is a combination of the essential 
and the sympathetic fevers, the essential the result of the first cause, 
and the sympathetic the result of the local lesions which arise 
FEVER 332 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
during its course. Indeed, nothing seems to be better established 
than that local disease reacts on the system and prevents a critical 
termination. You will get a very good idea of this by considering 
the paroxysms of an intermittent. What are the periods in which 
an intermittent is most liable to terminate favourably ? The earlier 
ones. What are the periods in which a favourable termination is 
least likely to happen ? The later ones. Now what are the periods 
in which there is little or no accompanying organic lesion? The 
first or earlier. What are those in which there is more or less of 
organic change? The later, in which we generally find, on 
making a careful examination, that disease of some organ, or organs, 
has taken place, and is presenting an obstacle to a favourable termi- 
nation. It is the same thing with respect to fever. 
In the treatment of fever, it is a most important rule to investi- 
gate the condition of the viscera, and remove, if possible, any exist- 
ing local inflammation. By this we accomplish a double purpose ; 
we prevent the direct danger of death from the violence of local 
disease, and we obviate the inconveniences arising from sympa- 
thetic irritation. We give nature fair play, we reduce the case to 
a state of the greatest simplicity, we prevent the liability to new 
local affections, and we thus effect a great deal towards a favour- 
able termination. It is an interesting and singular fact, and one 
dwelt on by the school of Broussais, that in many cases of fever 
the removal of the local inflammations is speedily followed by a 
subsidence of the fever. It is chiefly from this fact that they argue 
in favour of the opinion, that all fevers are symptomatic of local 
disease. This argument, however, as I have already proved, is 
more specious than solid. The true reason is, that by removing 
local disease we remove the barrier which opposes the salutary ope- 
rations of nature. Every attempt at a favourable termination is 
impeded by the co-existence of local disease, and the more intense 
and extensive this is the greater is the obstruction. You are not 
by any means to conclude that a fever is symptomatic, because it 
disappears on the removal of local disease; the true explanation 
is, that by subduing the local inflammation you have removed 
a focus of irritation, and given scope to the preservative powers of 
nature. 
These I believe most firmly to be the true principles which 
should guide us in considering the subject of fever. They have 
been obtained by careful and accurate deduction, and are based on 
a numerous series of well conducted experiments. Weigh the 
matter calmly, and I think you will be disposed to agree with me, 
that fever in its origin implies no tangible condition of the system, 
and that we know it only as consisting of a group of phenomena, 
varying as to their cause, seat, effect, and duration. The humor- 
alists erred by fixing its seat in the fluids, the solidists by limiting 
its locality to the solids. We recognise no distinction between the 
fluids and solids, so far as fever is concerned; they all form parts 
of the great whole; one cannot act without the other, but their 
mutual reaction is extensive and various. From these considera- 333 
INTERMITTENT FEVER. 
tions we deduce the important rule, that there is no mode of treat- 
ment universslly applicable, and the man who treats fever with 
wine and stimulants only, or he who contents himself with purga- 
tives and diaphoretics, or he who limits his practice to leeches and 
the lancet, that man knows nothing of fever. Though his hair be 
gray and his authority high, he is but a child in knowledge, and 
his reputation an error. On a level with the child so far as a 
correct appreciation of the great truths of medicine is concerned, 
he is very different in other respects; his powers of doing mischief 
are greater, he is far more dangerous. Oh ! that men would stoop 
to learn, or at least cease to destroy ! 
LECTURE XXXVII. 
Intermittent fever—Definition and character of—Phenomena of the paroxysm—Cold 
stage—Internal congestions—Pathology of—Hot stage—Ague not a simple fever— 
Affections of various viscera—Theory of Broussais—Effects of bark, quinine, &c.— 
Modus operandi of. 
To-day we commence the consideration of intermittent fever. 
One of the most prominent characters of this atfection is expressed 
by its name; we have all the phenomena of fever making their 
appearance at certain periods, and then disappearing, leaving an 
interval in which the constitution seems to be in the normal state, 
and continues so until the supervention of a second attack. It has 
been also termed a primitive or essential fever, in which there is 
no original local disease, and where the fever, in the beginning, is 
not symptomatic of any local lesion. We may define intermittent 
fever as a primitive, or essential fever, composed of many paroxysms 
which recur at certain periods, and in the intervals between which 
we have a state of apyrexia, or freedom from fever. This defini- 
tion, though applying to the great majority of cases, is still to a 
certain degree imperfect, for we meet with examples of this disease 
in which the periods of attack are by no means regular or certain, 
and the state of apyrexia between the paroxysms not well marked. 
Thus, in two cases of intermittent, we observe that in one the 
patient appears, during the interval, to be completely free from 
fever, while in the other we find that the febrile symptoms continue 
to a certain extent after the subsidence of the paroxysm. As a 
general definition, however, the foregoing is tolerably good, and 
will be quite sufficient for practical purposes. 
Another remark to be made on this subject is, that an intermit- 
tent is not necessarily an essential fever. We may have it from 
lesions of various kinds. You are all familiar with that form 
which attends bad cases of stricture and retention of urine, and 334 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
which has been called urinary fever. Here we have fever of an 
intermittent character, not essential, but depending upon a local 
lesion. We have many other instances of a similar kind, and I 
could easily multiply examples. 
I shall not take up your time by entering into a description of 
the various divisions of intermittent fever; it is a species of know- 
ledge unconnected with any point of great practical importance, 
nor does an acquaintance with the nature of the disease, so far as 
frequency of paroxysm is concerned, shed any useful light on its 
treatment. The same principles of treatment are applicable to 
quotidian, tertian, quartan, and every other variety of intermittent. 
Besides, we know nothing whatever of the nature of an intermit- 
tent. We are here as much in the dark as we are in the case of 
continued fever. We are still in complete ignorance as to the 
cause of the periodicity which is so remarkable a feature of this as 
well as of other diseases. It is enough for us, in the present state 
of medical science, to know that such things exist, and, leaving the 
researches after the cause of the disease and its periodicity to future 
investigations, let us study the effects of the disease, and direct our 
attention to things within our reach. 
Let us, as far as we can, examine what takes place during the 
paroxysm of an intermittent. I think it my duty, as a lecturer on 
practical medicine, to direct your attention to this point rather than 
to the history of intermittents ; this is, I grant, not devoid of inte- 
rest, but it is a subject on which you will find ample information 
in the various systematic treatises on medicine. My intention is to 
endeavour to point out the true principles of treatment; I shall, 
therefore, enter no farther into the history of intermittents than 
what is connected with diagnosis. This will certainly diminish 
the interest of a lecture on intermittent fever, but this cannot be 
helped; it would, in a limited course of lectures like this, be quite 
out of my power to lay before you the mass of curious and instruct- 
ive matter connected with the history of intermittents. The 
paroxysm of an intermittent fever has been divided into three 
stages—the cold, the hot, and the sweating; but it simplifies the 
matter very much, to consider it as divisible into two stages, the 
sweating being the result of the hot stage. With respect to the 
cold stage, I shall endeavour to establish three great propositions. 
In the first place, it appears (and this is highly important) that, in 
the majority of cases (I do not say in all, for there is no general 
rule in medicine), there is, during the cold stage, a perceptible 
lesion of one or more internal organs, and that there is congestion 
of many, if not of all, the viscera of the three great cavities. To 
use a modern phrase, we have, during the cold stage of an ague, a 
state of hyperaemia of the internal and anaemia of the external 
parts, or, in other words, the balance of the circulation is lost, the 
blood forsakes the surface and accumulates in deep-seated organs. 
The next proposition is, that this hyperaemia, from frequency of 
repetition, or excessive violence, may be accompanied by, or pro- 
ductive of, an inflammatory condition of these organs. Lastly, that INTERMITTENT FEVER. 
335 
organs thus altered may in themselves become sources of irritation, 
react on the system, and powerfully tend to keep up disease. You 
see, then, that, in considering the phenomena of intermittent fever, 
we must follow the same road as in continued fever, and regulate 
our enquiries more in relation to the effects than the cause of the 
disease. 
The first of these propositions—that during the cold stage of an 
ague there is a congested state of almost all the viscera—is proved 
in every way that a pathological proposition can be proved. It is 
confirmed by an examination of the symptoms, by the results of 
treatment, and by the appearances seen on dissection. In this 
country, we very seldom have an opportunity of examining the 
bodies of patients who have died in the cold stage, for the intermit- 
tents of this country are trifling in comparison with those which 
are observed in warm climates. But the fact is fully borne out by 
an examination of those who have died in this country under such 
circumstances, as well as by the more numerous examples occur- 
ring in countries in warmer latitudes. Let us take the different 
parts of the system during the cold stage, and see how far the 
symptoms point out an accumulation of blood. First, let us 
review the nervous system. There is a feeling of tension and ful- 
ness about the head, the patient complains more or less of head- 
ache, the sensibility is diminished, and there is frequently stupor 
and coma, and in violent cases there may be convulsions. All 
these circumstances are indicative of congestion of the brain ; and 
accordingly we find, where we have an opportunity of making an 
examination, that the venous system of the brain is in a state of 
engorgement. In some cases, the carotids and their branches have 
been observed full of dark-coloured blood, the congestion of the 
lungs having interfered with the process of aeration. In the inter- 
mittents of warm climates still more remarkable effects have been 
witnessed—enormous congestion of the vessels of the brain, and 
frequently effusions of blood into its substance ; so that the symp- 
toms during life, and the appearances seen after death, tend to con- 
firm the fact of congestion, so far as the brain is concerned. If we 
turn to the pulmonary system, we find that nothing is of more 
common occurrence, during the cold stage of an ague, than lividity 
of face, anxiety, cough, and hurried breathing; and when we come 
to examine the chest, we find more or less dulness of sound on 
percussion, and the other physical signs of congestion of the lung. 
This is further confirmed by dissection; the lung is congested, and 
of a dark red colour; it will often sink in water, and presents a 
condition closely bordering on hepatisation. If you examine the 
heart, you will find that its action is oppressed, the pulse is small 
and irregular, and the right ventricle, with the vessels attached to 
it, are found engorged. Proceeding to the abdominal cavity, we 
find the same indications of congestion. There is a sense of pain 
and fulness in different parts of it; the patient has vomiting, often 
diarrhoea, and a copious discharge of urine; all this shows a 
violent determination of blood. You have often heard of the tume- 336 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
faction of the spleen which accompanies the cold stage of an inter- 
mittent. Now, so rapidly does this occur, and so extensive is the 
engorgement, in many instances, that shortly after an attack we 
can readily feel and trace it distinctly. On dissection, we meet 
with abundant proofs of congestion ; we find the liver highly 
engorged, the intestinal mucous membrane very vascular, the 
mesenteric and portal veins filled with blood, the kidneys con- 
gested, and the spleen enlarged. Cases of rupture of the spleen, 
from excessive congestion during the cold stage of ague, and of 
hepatic apoplexy from the same cause, are described by Badly. 
These facts are sufficient to prove the truth of the first proposition 
—that, during the cold stage of an intermittent, most of the internal 
organs are in a state of congestion. We are led to suspect this 
from the symptoms, and our conjectures are confirmed by dissec- 
tion. Indeed, the most superficial observer must be struck with 
the remarkable retreat of blood from the superficial parts of the 
body. The skin is pale and shriveled, the bulk of the limbs 
diminished, the countenance collapsed, the whole surface cold, and 
superficial vascular tumours are observed to lose their vascularity 
and become reduced in size. All these circumstances lead us to 
the supposition of internal congestion, and this is corroborated by 
the results of dissection, which show the various internal organs 
in a state of hypersemia, and shows the retreat of the blood from the 
surface, and its accumulation in deep-seated parts. 
The next proposition is equally important—that the frequent 
repetition, or excessive amount of these internal congestions, may, 
and does, give rise to an inflammatory condition of the affected 
organs; in other words, that the hyperaemic condition of certain 
viscera, during the cold stage of ague, and their subsequent organic 
lesions, stand in the relation of cause and effect. We find that the 
effect produced by the cold stage on the viscera is twofold ; we 
may either have congestion independent of any organic change, or 
we may have inflammation. In some cases, particularly in those 
which occur in warm countries, the congestion is followed by 
violent inflammation; in others, as in the cases of this country, we 
have chronic inflammation produced. But whether we meet with 
one or the other, whether the inflammation be acute or chronic, we 
find that, as soon as the viscera become affected in this way, a state 
of constitution is brought on in which the power of the usual 
remedies is diminished, and their use frequently prejudicial. New 
local inflammations are set up in various organs, and these, which 
were in the beginning only the effect of the disease, become, by 
reacting on the system, the cause of its continuance. In warm 
climates, where the congestion is excessive, there is nothing more 
common than to see fatal pneumonia, or violent gastritis, or rupture 
of the spleen, or cerebritis, supervening on a bad attack of ague. 
Strictly speaking, the production of inflammation in organs seems 
to belong more to the hot than the cold fit, and this we can easily 
understand. In the cold stage, the viscera are in a state of intense 
congestion ; violent reaction then comes on with the hot fits ; and 337 
INTERMITTENT FEVER. 
when we have in any organ a stasis of blood, and violent action of 
its vessels, occurring during the existence of this stasis, it is not 
surprising that inflammation should be the result. 
In the hot fit, all the phenomena, which we have been just now 
examining, are reversed. Every thing indicates that the energy of 
the circulation is about being restored, and that there is a powerful 
determination to the surface. The pulse gradually rises in strength, 
the rigours gradually disappear; the skin, which was cold and 
shriveled, becomes hot and tense; the face, which was blanched 
and collapsed, assumes a full and flushed appearance; the cough 
and hurried respiration are relieved; the vomiting, diarrhoea, and 
discharge of urine, cease; and the stupor is removed. The vessels 
on the surface of the body become more and more distinct: and in 
those who have large superficial veins, those vessels (though there 
was no appearance of them during the cold fit) stand out in bold 
relief like so many thick cords. I have alluded before to the 
greater severity of the cold fit of the intermittents of warm coun- 
tries ; the hot fit exhibits a corresponding degree of intensity. The 
cold fit is generally accompanied by violent vomiting and purging, 
spasms and convulsions ; the hot stage is attended with fits resem- 
bling apoplexy, and is frequently succeeded by intense pneumonia, 
cerebritis, and other forms of visceral inflammation. Such occur- 
rences are rarely seen in the fevers of this country. 
The great principle to be borne in mind with respect to intermit- 
tent fever is, that during the cold stage the viscera are in a state 
of congestion, and consequently fitted for the reception of disease. 
When the hot fit comes on, this state of congestion generally dis- 
appears ; but if it should continue, we shall have a chance of 
inflammatory action being set up in one or more viscera, and in 
this way we may have a number of points of irritation in the 
system, complicating the original affection, and tending to retard 
the operations of nature and art towards a favourable termination. 
You can easily understand, that if the lung, which has been in a 
highly congested state during the cold stage, does not, during the 
succeeding hot stage, throw off the load of blood completely, it 
will be less able to accomplish this at the next attack, and so on, 
until at length the process of inflammatory alteration is firmly 
established. The same observation applies to the other viscera. 
In some cases, just as in continued fever, we have the brain chiefly 
engaged, in others the lung, in others the digestive system; and, 
in the intense agues of tropical climates, we often have the three 
great cavities simultaneously attacked. You will observe here, 
that the production of visceral disease depends on two circum- 
stances—first, on the intensity of the congestion, and, secondly, on 
a frequent repetition of the attack where the symptoms are less 
violent. In this country, the latter seems to be the principal cause. 
From these considerations, we come to the important law that, 
after some time, we are not warranted in looking upon ague as a 
simple fever, but as a fever of a compound nature, involving affec- 
tions of many important viscera, to which we must attend carefully, 338 
STOKES’s THEORY AND PRACTICE OF MEDICINE. 
if we seek to practise with safety and success. It is singular, that 
the majority of medical men appear to look upon the effects of 
an intermittent as being very circumscribed. You have all heard 
of enlargement of the spleen. Now, I have known some practi- 
tioners who appeared to think that this was the whole pathology of 
intermittent fever ; in fact, that there was a very close connection 
between enlargement of the spleen and ague. This, I need not 
tell you, is a very imperfect view of the question; the spleen 
suffers like other viscera, but there is no separate relation between 
its enlargement and the production of intermittent fever. The 
reason why attention has been chiefly directed to it is, because its 
lesions are generally more manifest than those of other viscera. It 
is composed of a loose, spongy, erectile tissue; it receives in its 
natural condition a great quantity of blood ; it becomes rapidly and 
extensively enlarged during the cold fit; and hence it becomes a 
very prominent and remarkable sign of the disease. But I believe 
that in all cases where the spleen is found to be enlarged you will 
also be able to detect disease of the liver or lung. All the viscera 
are more or less liable to suffer under similar circumstances ; there 
is, in a word, no single acute or chronic disease which may not be 
the result of intermittent fever. In this country, it generally gives 
rise to chronic disease; in warm climates, acute visceral inflam- 
mation is more commonly the result. Here we arrive at another 
very important consideration, namely, that it may happen that the 
phenomena of an intermittent shall cease, and yet the chronic dis- 
ease produced by the violence or persistence of the original malady 
will continue. This is exceedingly common. We frequently meet 
with chronic disease of the heart, lungs, or brain, with dysentery, 
diarrhoea, peritonitis, affections of the kidney, and chronic inflam- 
mations of the liver and the spleen, brought on by intermittent 
fever, in this country. These local affections are the result of 
violent congestion, and the continued irritation which accompanies 
the early paroxysms of the disease; and though the symptoms of 
ague may subside, the morbid irritation, which has been set up in 
the constitution, may proceed to such an extent that death may be 
the result of a complication of visceral affections thus produced; 
and this I believe to be the history of many chronic cases of ague. 
Chronic affections of the lung, liver, brain, and digestive system, 
are, then, the chief things to be dreaded or guarded against in a 
case of intermittent fever; for after all that has been said about the 
enlargement of the spleen, it seems to me to be the least important 
of the visceral lesions which follow ague. It appears in almost 
every instance (at least as far as we can see of it in this country) to 
exercise but very little influence over the economy. In warm 
climates, indeed, it is sometimes so much enlarged as to produce 
serious inconvenience by its pressure and bulk. Thus, in South 
America, it has been observed, that in bad cases of ague the spleen 
has become so enormously increased in size as to fill nearly the 
whole abdominal cavity, producing great derangement of the diges- 
tive organs, and actually hernia. Dropsy, jaundice, chronic hepa- INTERMITTENT FEVER. 
339 
titis, diarrhoea of an intractable character, various nervous affections, 
amentia, an atrophied state of the system, phthisis, hectic, typhus, 
all these constitute part of the morbid affections which follow in 
the train of ague as it appears in this country, and all will be found 
connected with various chronic visceral lesions which have been 
the immediate results of the original disease. 
When called to treat a case of ague which has been going on for 
some time, you will generally meet with one of two things; you 
may find that the viscera have, or that they have not, suffered 
much from the effects of congestion. Now, when organic changes 
of viscera take place, we have the remarkable circumstance of their 
active tendency to keep up the original malady. Here you will 
frequently see practitioners prescribing bark, and if you watch its 
operation, you will sometimes find that it does more harm than 
good. But if, on the other hand, attention be directed to the local 
lesion, neglecting the intermittent for some time, you will find that 
the removal of the local disease brings back the intermittent, more 
or less, to its original state of simplicity, and renders it amenable 
to the specific. Observe the importance of this. The same rule 
holds in intermittent as in continued fever; you must practise 
with an eye to the state of the viscera, and recollecting that the 
disease, which results from one as well as the other, may be, in its 
turn, cause and effect. Here I shall take an opportunity of making 
a few observations with respect to a theory of intermittent fever 
which has been put forward by such high authority that we cannot 
pass it over. I allude to the theory of M. Broussais, in which he 
endeavours to show that intermittent and continued fevers are 
reducible to the same form, namely, an irritation of the digestive 
system. To this view of the question a great many facts are 
opposed, all tending to prove that disease of the digestive system 
(which is so common in intermittent as well as continued fever) is 
to be looked upon more as an effect than as a cause. It is absurd 
to say that intermittent fever is merely an intermittent gastro- 
enteritis, when dissection shows that we have not only disease of 
the digestive tube, but also of the heart, lungs, and brain. The 
fact of coexisting visceral inflammations was passed over by M. 
Broussais, and certainly it must be acknowledged that this is a 
very simple mode of getting rid of a strong objection. His doc- 
trine was, that fevers, intermittent as well as continued, are only 
examples of the effects of irritation of the digestive system, the con- 
tinued fever being significant of severe and extensive disease, the 
intermittent of an affection of a milder character. He also main- 
tains that the rigours are produced by, and proportionate to, the 
internal irritation. Now, admitting, for argument’s sake, the two 
first propositions, what do we find to be the fact ? That in con- 
tinued fever, where the irritation is greatest, the rigours are compa- 
ratively trifling, while in the intermittent, where the irritation is 
less violent in degree, the rigours are remarkably intense. Here we 
see intense rigours with slight disease, and trifling rigours with 340 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
intense disease, two facts strongly militating against the proposition 
of M. Broussais. 
Another argument may be urged against these doctrines: I allude 
to the effect of bark. This is a point which very much puzzled the 
physiological school, and they have accordingly exerted all their 
ingenuity to explain it away. At first, I believe, they were strongly 
inclined to deny altogether the specific powers of this remedy; they 
were subsequently, however, compelled to subscribe to the fact of 
its efficacy, which was too notorious to be denied, and they had 
then to explain how bark could cure a gastro-enteritis. Hard as it 
was to explain how bark could be instrumental in removing gastro- 
intestinal inflammation, it was a matter of unavoidable necessity to 
attempt something like an explanation, in order to maintain the 
integrity of the physiological doctrine. They therefore set about 
the task, and endeavoured to show that bark cures the ague, or its 
cause, gastro-enteritis, by substituting one irritation for another. 
The whole gist of their arguments is founded on this point:— 
quinine, they say, is a stimulant; ague is the irritation produced 
by gastro-enteritis. Now, it is a fact that stimulants will frequently 
remove existing irritations ; thus, we frequently observe, that blen- 
norrhagia, chronic ophthalmia, and diarrhoea, are cured by stimu- 
lants. This argument, however, is more specious than solid. 
There are certainly cases of irritations of mucous surfaces which 
may be removed by stimulants, but these are cases of chronic, and 
not of acute disease. No one would dream of employing stimu- 
lants in a case of acute febrile diarrhoea, few would think of apply- 
ing irritants to an acutely inflamed and painful conjunctiva; it is 
only when the character of the inflammation alters, and the affec- 
tion acquires more or less chronicity, that these remedies prove at 
once serviceable and safe. Now this is not the case in ague. If it 
depends upon an acute gastro-enteritis, we are, according to this line 
of argument, to conclude, in the teeth of their other doctrines, that 
the best mode of curing an acute attack of gastro-enteritis is to stimu- 
late the inflamed mucous surface. Here, you see, we arrive at the 
argument ad absurdum. Another observation on this subject:— 
In a case of intermittent fever, supposing it to depend on gastro- 
intestinal irritation, it is a matter of indifference whether you give 
the bark during the paroxysms, or during the intermissions. Now, 
it is a matter of experience, that, bark will be far more effectual 
when given during the intervals of apyrexia. Again, if bark cured 
by producing a new irritation, we ought to see the symptoms of 
that irritation succeeding the administration of the remedy. 
Thus, whether we look to the symptoms, the appearances seen 
on dissection, or the results of treatment, and the efficacy of bark, 
we must conclude that the morbid state of the digestive system 
stands in the relation of effect, and not of cause. As far as we can 
judge of ague, it appears to be some profound alteration of innerva- 
tion, some affection of the whole system, the nature of which we 
cannot understand, but the effects of which we perceive in the INTERMITTENT FEVER. 
341 
various derangements of internal organs, by which it is attended. 
Intermittent fever is not intermittent gastro-enteritis, because dissec- 
tion reveals various other important lesions, and because it is 
cured by bark, which has nothing in it calculated to remove acute 
inflammation. We know that if a patient labouring under ague 
has acute inflammation of the stomach, bark, so far from curing, 
will do him a great deal of harm. Bark cannot cure by exciting 
irritation, because, if it did, it would increase the supposed gastro- 
enteritis, and we should have more violent symptoms during the 
intermissions, the time when it is always given, than during the 
paroxysms. Lastly, there is no analogy between the effect of stimu- 
lants on acute and chronic inflammations. What the modus ope- 
randi of bark is, we cannot explain. Many things, connected with 
the phenomena of life in health and disease, are, and probably will 
for ever remain, concealed from human ken. We daily witness 
the effects of stimulants, but we cannot explain their mode of 
action. This, however, is no opprobrium to medicine. This is 
the right way of viewing the subject; part of it is capable of admit- 
ting an explanation, the rest constitutes a portion of the inscrutable 
arcana of nature. It fortunately happens, however, that, for all 
practical purposes, the knowledge of these occult portions of medi- 
cal science is as yet comparatively unimportant. 
LECTURE XXXVIII. 
Intermittent fever—Symptoms—Occasional irregularity of the paroxysms—Convulsive 
motions of the foetus in a pregnant woman during ague—Exciting causes of ague— 
Treatment—Complication with other diseases—Importance of careful investigation 
—Visceral lesion, how far contra-indicating the use of bark—Bark almost a specific 
in ague—Large doses of quinine in ague—Rapidity of its operations in some cases 
—Fowler’s solution of arsenic—Prussian blue—Its advantages. 
Let ns proceed with the subject of intermittent fever. I gave 
you, at our last meeting, an analysis of the phenomena which 
accompany the paroxysms of this disease, and endeavoured to 
show that intermittent fever was not reducible to any form of fever 
symptomatic of local inflammation, but that it was, as far as we 
could see, an original affection of the system, connected in all pro- 
bability with some profound lesion of innervation. I shall now 
proceed to a brief review of some of the more prominent symptoms. 
The first approach of a paroxysm of ague is, generally speaking, 
pointed out by a degree of languor and debility more or less marked. 
The patient, without any apparent cause, becomes weak and rest- 
less, throws himself on a bed or couch, feels chilly, and has a 
sensation as if a stream of cold water was running down his back ; 
his features are considerably shrunk, and his skin pale and corru- 
gated. In some cases the surface of the body is cold, and I believe 342 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
in most cases the patient has a strong sensation of cold, evert 
though the skin may continue warm during the rigour. By degrees 
the chilly sensation which is first felt along the back extends to all 
parts of the body ; the patient begins to shiver ; has horripilatio and 
chattering of teeth; and as the symptoms increase, the rigours are 
so violent as to shake the bed on which he lies. The sensation of 
cold now becomes intense ; he calls for warm drinks, and begs of 
his attendants to heap more bedclothes on him. He is anxious, 
restless, and uncomfortable, and if questioned answers briefly and 
with reluctance. His pulse is small, weak, and irregular; the 
action of the heart oppressed, and respiration more or less laboured. 
The general sensibility is impaired ; in some cases there is delirium, 
in others a state of stupor amounting to apoplexy. Headache is 
most commonly present, and there is often pain in the loins and 
sides. The situation of the patient is indeed truly pitiable ; he lies 
beneath a heap of bedclothes, with his teeth chattering, his whole 
frame agitated by the shiverings, an icy sensation running through 
his whole frame, and which neither warm drinks nor accumulated 
covering can relieve. Add to this the headache, the delirium, the 
stupor, the nausea, and diarrhoea, and you have the picture of suf- 
fering complete. This extraordinary condition may last for some 
time. It is generally terminated by a copious attack of bilious 
vomiting, when the rigours begin to decline, and are succeeded by 
alternate flushings of heat. The rigours now cease ; the flushings 
become more frequent and protracted ; the patient begins to feel the 
return of heat; the skin becomes gradually hot, and this increases 
until the heat gets far above the natural standard, being in some 
cases as high as 110°. In a few cases, particularly in warm cli- 
mates, the temperature during the hot fit has been known to exceed 
this. Accordingly, as vascularity returns to the surface, the fea- 
tures lose their contracted appearance and the skin its paleness; the 
face becomes full and flushed, the limbs regain their ordinary 
dimensions, and the skin becomes smooth and almost tense. The 
nausea and vomiting abate, the patient is hot and thirsty, and has 
scanty high-coloured urine. The pains in the loins and back still 
continue, the headache is generally increased in intensity, and the 
tendency to delirium greater. The pulse is strong, quick, and 
bounding, and all the symptoms of high inflammatory fever are 
present. After some time, a tingling sensation is felt all over the 
body, accompanied by a degree of moisture, which soon increases 
to a copious and universal perspiration. With this all the un- 
pleasant symptoms subside; the patient seems to luxuriate in his 
relief; thirst, headache, fever, vanish altogether; he declares that 
he is quite well, gets up, and continues in the enjoyment of appa- 
rent good health until the next attack. 
The length of time which the whole paroxysm may last will 
vary from one to twenty-four hours. I have seen the three stages 
pass through their course and subside in the space of an hour ; on 
the other hand, I have known them last for a day—this, however, 
is very rare. INTERMITTENT FEVER. 
343 
I told you in my last lecture, that in this country we seldom 
observe those violent symptoms which characterise the agues of 
warm climates. In the bad cases of those countries a train of 
symptoms occur marked by extraordinary intensity; the patient 
has violent convulsions and tonic spasms, a wild staring eye, high 
delirium, excessive vomiting and purging, terrific rigours during the 
cold fit, and when the hot stage comes on, he frequently has fits 
resembling epilepsy or apoplexy, and inflammation of the brain, 
or lungs, or digestive system. Sometimes two or all the great 
splanchnic cavities are simultaneously affected. 
It is generally believed, that in the different types of intermittent 
fever the paroxysms come on at particular periods:—thus we hear 
of the paroxysm of quotidian occurring in the morning, of tertian 
at mid-day, and of quartan in the afternoon. In Dr. Good’s Study 
of Medicine, a work remarkable for its learning, you will find all 
these circumstances detailed with an elaborate minuteness, and you 
will see that the author has considered them of importance sufficient, 
to make a generic difference between the various forms of intermit- 
tent. Many of his observations, however, on this subject, betray a 
want of accurate observation. The truth is, that in every form of 
intermittent we may have the access of fever at any hour in the 
day. In the Meath Hospital we have found that the rule before 
laid down does not hold good ; for we observed that the paroxysms 
of both quotidian and tertian occurred at all hours of the day and 
night. Andral, in his Clinique Medicale, gives twenty-five cases of 
ague, of which eleven that were cases of quotidian came on between 
four and eleven in the afternoon. Out of seven cases of quartan, 
one came on in the morning, the rest in the afternoon. These facts 
show that the rule is by no means so general as has been imagined, 
and that it is not of sufficient importance to ground upon it any 
generic difference. There are also many varieties in the complica- 
tions of intermittent described besides those which are witnessed in 
this country, but these I am inclined to think as being of very little 
value, for as yet we have no therapeutic indication founded on the 
divisions of intermittent fevers quoad their type. However, as some 
of you may be hereafter placed in such circumstances as to find 
this species of knowledge a matter of importance, I shall make a 
few observations on the point. 
During an epidemic of intermittent fever, you will meet with 
some cases in which there will be an extraordinary regularity in 
the access, duration, and intermission of the paroxysms, while in 
other cases you will find them irregular as to the time of invasion, 
the phenomena of the different stages, and the period of subsidence, 
as well as the interval of apyrexia. This is what is called irregu- 
lar ague, and seems to be the same as that which Frank lias 
described under the title of febres intermittentes larvatce. These 
are cases in which, to use an expression common in this country, 
the ague has gone astray. In some instances we meet with a very 
peculiar type of intermittent, the double quotidian, or that form in 
which we have two attacks in the course of a day similar in theiif 344 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
phenomena and character. This is a very rare form of the disease; 
I have never observed it but on one occasion in the Meath Hospital. 
There is also another kind which has been called double tertian. 
In this variety, you have a paroxysm every day, but the coinci- 
dence between the nature of the paroxysms and the period of inva- 
sion is to be observed only every second day, just as if there were 
two tertians, each attacking on alternate days. You have a pa- 
roxysm every day, one to-day at twelve o’clock, which is of a mild 
character, another to-morrow at the same hour which will be 
severe ; on the third day the paroxysm of the same character as on 
the first, and in this way you have, as it were, two fevers having 
their access on alternate days. There are some other varieties of 
intermittent fever, but they are so exceedingly rare that I will not 
take up your time in describing them. 
The duration of an intermittent fever is subject to considerable 
variety, but, in general, they are tedious if not interfered with, and 
apt to assume a more or less obstinate character. Agues which 
occur in spring and summer subside much sooner, cceteris paribus, 
than those which occur in autumn. Of all forms of the disease, 
quartan appears to be the most obstinate; there are many cases of 
it on record which have lasted for years, indeed, it seems to be well 
established, that it may continue for a great length of time. In 
one very remarkable case it lasted for forty years, and during that 
time the patient had his paroxysms every third day. Schenck 
gives the details of a case in which the patient had quartan from 
his birth, where, in fact, the disease seemed to be congenital. There 
is another remarkable one bearing on the same point. A female, 
labouring under an attack of tertian ague during her pregnancy, 
observed that on the alternate days, when she was well, the 
foetus appeared to be affected in a very singular manner. Violent 
convulsive motions of a certain character occurred at fixed periods, 
lasted for a certain length of time, and then regularly subsided. It 
would appear, that in this instance the foetus was afflicted with the 
same disease as the mother, nor is there any thing improbable in 
the supposition. We have well established cases of the existence 
of ague from birth, and there is no reason why the nervous system 
of a child should not be modified in this way, as well as that of the 
mother. We know, too, that the fcetus in utero is liable to many 
diseases, even of a chronic character, and it has been proved that 
they may have chronic inflammation of the mucous membrane of 
the digestive tube, abscess, tubercles, small-pox, and many other 
affections. 
I shall say but little with respect to the exciting causes of ague. 
A common opinion, and one which is taken up by too many medi- 
cal men, is, that ague is generally produced by unwholesome ema- 
nations from marshes, or what has been termed malaria, or marsh 
miasma. It cannot be denied, that in many cases we observe a 
coincidence between the existence of marsh miasmata and endemic 
ague; but it is to be investigated how far we are to believe in the 
existence of any separate and distinct miasm. There are numerous 345 
facts to show that other causes, the nature of which is much 
more easily understood, are capable of producing all the varieties 
of intermittent fever. Cold and moisture are fully capable of pro- 
ducing ague, independently of any miasm whatever. In Sir G. 
Baker’s and Sir Gilbert Blane’s writings you will see that in several 
instances no ague was found to exist in the marshy districts, while 
in hot and dry situations it was endemic. My friend Dr. Dundas, 
who resided for some time at Bahia, mentioned to me some very 
remarkable facts connected with this circumstance. The town of 
Bahia is built in a low marshy valley, which is separated from the 
sea-shore by a range of high hills. The streets are narrow and 
filthy, and, being exposed to the direct influence of a burning sun, 
it has every thing in it calculated to produce unhealthy emanations. 
Yet it is a curious fact, that in the town ague is almost unknown, 
while, on the neighbouring highlands which separate the valley 
from the Atlantic, and where the soil is dry, and the air pure, it is 
endemic. When Dr. Dundas went to reside there, these hills were 
pointed out to him by the natives, and he was told that there was 
the ague country. This appeared so strange to him, that he did 
not believe it until some time afterwards, when he had an oppor- 
tunity of correcting his error. A merchant who lived in the town 
with his family, all in good health, was attracted by the beauty of 
the hills, and wished to purchase a country house which had every 
advantage of situation to recommend it. Before he removed his 
family thither, however, he was anxious to have Dr. Dundas’s opi- 
nion as to the salubrity of the place. On arriving there Dr. Dundas 
found it in every thing calculated apparently to promote health, a 
fine, dry, luxuriant soil, a situation commanding a range of beautiful 
scenery, an airy house, and a plentiful supply of excellent water. 
Under these circumstances, he thought he might safely recommend 
the place, and the gentleman removed thither accordingly. In the 
course of ten days the following occurrences took place. The mas- 
ter and one of the servants were attacked with violent intermittent 
fever ; and an old female, of a low weakly habit, got symptoms of 
typhus ; two other servants were attacked with dysentery, and an 
European gentleman who had joined the family a few days after their 
arrival got intense pneumonia. In fact, almost every individual of 
the party was laid up with some disease or other. Of this variety 
of disease, occurring in cases where the exposure has been the 
same, we have many analogous examples. You will find in the 
writing of Dr. James Johnson, how an apparently similar case will 
produce different diseases in different individuals. It may be 
observed, however, that although these diseases differ in their seat, 
they do not differ in their nature, being all referable to the same 
pathological condition, namely—irritation of organs. 
I shall now proceed to consider the treatment of intermittent 
fever. Suppose you are called to treat a case of ague, and have 
ascertained its history, type, and period of access, &c., what are 
you to do ? Here, gentlemen, let me entreat of you to lay this down 
for yourselves as a rule never to be departed from, that before you 
INTERMITTENT FEVER. 346 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
prescribe the slightest medicine you first make an accurate and 
perfect survey of the state of the viscera. I do not mean to say 
that you may not be able in a great many cases to arrive at a 
proper and successful mode of treatment without taking this trouble; 
but, if you succeed in many, you will be certainly disappointed in 
some, if you neglect the state of the viscera; whereas, by adopting 
this rule you will always be on the safe side. Depend upon it, that 
if medical men were to do this more generally than they do at 
present, it would render their practice more certain, and tend to 
raise the character of medicine. The great error of medical prac- 
tice is the absurd habit of prescribing for names and not diseases- 
Well, then, the first thing you do is to ascertain precisely the 
nature of the disease, and see whether it be an original and essential 
intermittent, or one of a secondary nature and depending upon 
local lesion. You are aware that we have many cases of continued 
fever, which are the results of local lesion, and we may in like 
manner have the symptomatic in intermittent as well as in con- 
tinued fever. Now the whole nicety of treatment turns on this. 
If the case be one of the essential kind we know the remedy which 
will answer, if not in all, at least in the majority of cases. If it be 
symptomatic, your treatment must be directed to the removal of the 
local lesions. It would be wrong to begin the treatment of a case 
of urinary intermittent by giving bark ; it would be equally absurd 
to pursue the same course in any other intermittent depending on 
local irritation. It would be only exasperating the disease, at the 
same time that its cause is allowed to continue. If the patient has 
come from a situation where ague frequently prevails, there is a 
chance that it is a case of essential, and not of symptomatic, disease. 
If ague be raging as an epidemic at the time, it is very probable 
that any one particular case is of the same description. But you 
are not for these reasons to conclude that it is a case of essential 
intermittent; if you did so, without investigating its precise nature, 
your practice would be empirical, and probably unsuccessful. I 
recollect on one ocasion, after the subsidence of an epidemic fever, 
we had a vast number of cases of ague in this city. Previously to 
this period the few cases we had were generally imported, the 
patients being in almost every instance poor Irish labourers, who 
had been engaged during the autumnal season in agricultural 
labour through the fenny districts of England. These poor fellows 
frequently exhibited symptoms of ague on their arrival in Dublin, 
and of such the majority of our patients consisted; but, after the 
epidemic of 1826, we had a vast number of cases in and about 
Dublin. At this time we frequently had from a dozen to twenty 
ague patients in the Meath Hospital together. 
During the early part of tin's period, a patient came in with all 
the symptoms of well-marked tertian. He had a regular cold, hot, 
and sweating stage about noon on every second day, and a distinct 
interval of apyrexia. In this case I made no examination, but, 
taking it as one of a simple essential character, I put the patient at 
once on the use of quinine. On the day of the next access, I was INTERMITTENT FEVER. 
347 
surprised to find that the paroxysm was much more severe than 
the one which preceded it. On the next day I observed that the 
type had changed, and that it was now a double tertian. This led 
me to suspect that something was going wrong. On turning down 
the bedclothes to make an examination, I was struck with the enor- 
mous size of one of his legs, and found that he was labouring under 
phlebitis, with oedema. I immediately ordered his bark to be dis- 
continued, applied leeches along the limb, and had him put on a 
strict antiphlogistic treatment. In the course of a few days the 
swelling of the limb was removed, and the intermittent disappeared. 
I mention this case to put you on your guard. In entering on the 
treatment of a case of intermittent, you must investigate several 
circumstances ; first, the character of the paroxysms, and whether 
they are of a mild or severe description, and how long they last; 
next, the duration of the whole disease; thirdly, and this is a point 
of importance, whether the intermissions be complete or not; and, 
lastly, the nature and extent of the complications. By a careful 
investigation of these circumstances, you will be able to arrive at 
the precise character of the disease, and can judge of the probability 
of the existence or non-existence of internal lesion. In my lecture 
of Saturday, you will recollect I stated that the liability to internal 
disease was in proportion to the duration of the ague, and the vio- 
lence of its paroxysms. If the disease be recent, and the paroxysms 
not violent, there is nothing, perhaps, to contra-indicate the use of 
bark. By carefully examining the intermissions, you will arrive at 
some very important conclusions. You will find them either perfect 
or imperfect. Now, if they are imperfect, if there is not a state of 
complete apyrexia between the paroxysms, it points out one of two 
things, either that the disease was from its commencement more of 
a remittent than of an intermittent character, and consequently less 
under the influence of bark, or that the febrile condition is kept up 
by some local internal disease. If you find on examination that in 
the early period there was complete apyrexia, but that this is no 
longer the case at the time you see the patient, the great probability 
is, that it is some organic visceral affection which keeps up the 
fever during the intermissions. You now proceed to examine the 
state of the viscera, and first the nervous system. Observe whether 
there is any headache, lesion of intellect, or stupor ; whether there 
is any affection of the muscular system, any derangement of sensi- 
bility, any throbbing of the vessels of the head and neck, or any 
signs of inflammation of the brain. Go then to the chest, and 
carefully investigate its actual condition. Here you will derive 
great advantages from the use of the stethoscope and percussion. 
In all cases of any considerable duration, never omit making this 
examination, for in ague, as in continued fever, visceral affections 
are remarkable for their latency. A patient may have the lung in 
a very dangerous state, and yet during the periods of apyrexia will 
not present any remarkable symptom. 1 have seen cases where 
the lung was actually solidified from repeated congestion, and yet 
the cough was but trifliny, and the distress of breathing slight 348 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
during the intermissions ; but when you applied the stethoscope to 
the posterior and lateral portions of one or both sides of the chest, 
they were found to be completely impervious. You then proceed 
to examine the belly. See whether it is flat, or prominent and 
swelled ; whether it is tender on pressure, and where the tender- 
ness is greatest; inspect your patient’s tongue, and ask him has he 
thirst, nausea, or diarrhoea; observe whether the solid viscera of the 
abdomen are enlarged or not, and carefully note the condition of 
the liver and spleen. It is necessary to make this examination in 
every suspicious case, and you can do it easily and rapidly. In the 
majority of cases which have lasted for any considerable time, you 
will hardly fail to detect some internal lesion. 
Here we arrive at a very important question. Does the existence 
of any amount of visceral lesion necessarily contra-indicate the use 
of bark? The answer to this question is—the mere existence of 
visceral lesion does not contra-indicate the use of bark, if the lesion 
be slight and recent, and does not keep up febrile irritation after 
the cessation of the paroxysms. If the lesion has not arrived at 
that state in which it becomes reciprocally cause and effect, it does 
not present any obstacle to the employment of bark. A slight 
degree of bronchitis may be present, but you should not on that 
account suspend the use of the specific ; a trifling enlargement of 
the spleen may exist, but this should not alter your practice. In 
these cases the lesions arc trifling, and do not react on the system, 
and in all such cases bark may be given with a reasonable prospect 
of success. 
I shall commence the treatment of ague by at once recommending 
to you its great specific. If there is any thing in medicine which 
deserves the name of a specific, it is bark in ague. I do not mean 
to say that this is to be received in the full sense of the term, for 
there is no such thing as a complete specific. There are many 
cases of symptomatic ague made worse by bark, and the same thing 
is to be said of cases of essential ague, where the local lesions stand 
in the light of cause and effect. The more the case is free from 
visceral disease, the more simple and essential in its character it is, 
the more certain will be the action of quinine. Many persons com- 
mence the treatment of a case of ague by unloading the bowels. 
To this practice there is no objection, and it has many advantages. 
It is not however absolutely necessary, and may sometimes be 
dispensed with; but if you do it gently, avoiding strong irritating 
purgatives, it is an excellent mode of preliminary treatment. You 
may give the bark in large doses at considerable intervals, or you 
may give it in small and frequently repeated doses. There is some 
difference of opinion as to the comparative value of these two 
modes. Our experience with respect to this point is, that you will 
cure an intermittent more certainly, easily, and with less loss of 
quinine, by giving it in large doses at considerable intervals. Thus, 
if you treat a case by giving ten grains of sulphate of quinine in a 
single dose once a day, you will cure your patient sooner than if 
you gave the same quantity in a day in divided doses. INTERMITTENT FEVER. 
349 
You will find it stated in books, that the interval between the 
paroxysms is the best time for giving bark. Of this there can be no 
doubt; not because the powers of bark are greater at one time than 
another, or that they are impaired during the paroxysms, but it is 
difficult to give a patient in that state any kind of medicine, for the 
stomach is generally irritable, and will not bear it. But it is a fact 
that you can give it at any period, and it is remarkable how rapidly 
its febrifuge properties will sometimes act. There is no doubt that 
its effect may be, to a certain extent, produced in the course of an 
hour. I have seen cases with bad paroxysms to-day, and on the 
next day have observed that a dose of quinine, given during the 
paroxysm, has produced a sensible effect. 
It is a matter of little consequence what way the quinine may be 
administered. You may give it in pills, in solution, or in the form 
of enema. The latter seems to be the most convenient mode of 
giving it to children who will not swallow the pills or the solution. 
If you take four ounces of water, four grains of sulphate of quinine, 
a few drops of dilute sulphuric acid, and a few drops of laudanum 
or liquor muriatis morphias, you have an excellent febrifuge injec- 
tion, and you can vary the proportions of quinine and opium 
according to the age and condition of the patient. In employing 
this injection, you should recollect that it is given to be retained; 
the bulk should therefore be small, and it should be of a medium 
temperature, neither hot nor cold. If you find on the following 
day that the paroxysm, instead of coming on at twelve, is delayed 
until two o’clock, it is a sign that the bark is acting favourably; if, 
on the next accession, the paroxysm is still further protracted, you 
may be sure the patient will soon get well. In some cases the 
disease has been cut short by giving a single large dose; but as far 
as I can judge, it appears to me that the best way is to remove it 
gradually. It is a curious fact, that when the ague has been 
arrested at once, new local diseases have supervened. In all cases, 
therefore, where the symptoms have rapidly and suddenly disap- 
peared, you should be on the look-out for new symptoms. 
Of all remedies for ague, quinine appears to be the best. I have 
made a number of comparative trials of sulphate of quinine, Fow- 
ler’s solution, and the per-ferro-cyanuret of iron. All these remedies 
were found to have a good effect; among them, however, quinine 
holds the first rank, next in value is Fowler’s solution, and then 
Prussian blue. I may remark here, that the introduction of Prus- 
sian blue is a great improvement in medicine. It may be given 
with safety, it is a remedy of no ordinary power, and from its 
cheapness is particularly adapted for dispensaries and institutions 
where the funds are limited. We have given it in doses of from a 
scruple to half a dram three times a day, and though it is inferior 
to bark, still it is a remedy from which much advantage is derived. 
At our next meeting I shall speak of the endermic mode of using 
quinine, and lay before you some curious researches on this subject 
made in France ; and these, with a few additional observations, 
will conclude the treatment of intermittent fever. 350 
STOKERS THEORY AND PRACTICE OF MEDICINE, 
LECTURE XXXIX. 
Use of quinine—Disease not a simple increase or decrease of vitality—Bark a specific 
in ague—To be given in the period of apyrexia—Large doses at considerable inter- 
vals—Arsenic followed by dyspepsia—Mercury, its effects in ague—Treatment dur- 
ing the paroxysms—Dover’s powder, heat, laudanum, carbonate of ammonia— 
Pressure on large arteries to arrest the cold stage—Used in a case of hydropho- 
bia with temporary relief— mode of using quinine 
—Bleeding in the cold stage—Generally with safety and advantage—Supervention 
of other diseases. 
At our last meeting I spoke of the use of quinine in intermittent 
fever. With respect to its modus operandi I may observe, that 
we know as little of it as we do of that of other remedial agents. 
The truth is, that this part of medical knowledge is still involved 
in great obscurity, and that we know almost nothing of the mode 
of action of various medicines. But that different remedies have 
different actions, and that there are such things as specifics, seems 
to be established, and this fact of the existence of remedies, which 
may be termed specific, is a strong argument against the formula 
which has been proposed for all diseases by the school of Broussais, 
viz. that they are reducible to a plus or minus degree of local 
vitality. If this were the case, the peculiar applicability of the 
properties of bark and mercury, for the cure of certain affections, 
could not exist. The fact of particular remedies possessing a power- 
ful influence over certain diseases shows, that there is something 
in those diseases more than a mere increase or decrease of vitality, 
and that in such instances there is some modification in the pheno- 
mena of vitality, which only admits of being modified, or removed, 
by the action of certain remedies. One of the most remarkable 
instances of the adaptation of peculiar remedies to peculiar diseases, 
is the use of bark in pure ague, and I believe I may safely say, that, 
in pure simple intermittent, bark may be justly called a specific. 
In speaking of the use of bark in intermittents, I showed that it 
might be given either during the paroxysms or the intermissions, 
but that it was much better to give it during the period of apyrexia, 
on account of the greater facility of exhibition, and because there 
was less chance of its being rejected by the stomach. Having 
alluded before to the different modes of using bark, I shall not take 
up your time with this part of the subject, Happily for medicine, 
quinine has completely superseded the use of bark ; but where you 
cannot get quinine, you may employ the bark itself, either in the 
form of powder, electuary, decoction, or tincture, 
With respect to the question whether it is better to prescribe 
large doses of quinine at considerable intervals, or to give it in small 
and repeated doses, I have stated, that as far as our experience in 
the Meath Hospital went, it was decidedly in favour of the practice 
of giving a large quantity at once. The best way appears to be, 
to order the patient to take ten grains of quinine at a single dose, 
about two or three hours before the paroxysm eomes on. In Italy, INTERMITTETTFEVER. 
351 
where ague of a severe character is frequently met with, the quan- 
tity given at a time is much larger, fifteen and twenty grains being 
often taken at a single dose by an adult. In some cases as much 
as one hundred and eight grains have been taken before a cure has 
been accomplished. You can easily understand why such large 
quantities are prescribed, when you recollect that in Italy and other 
warm countries, where pernicious ague prevails, it is of the utmost 
importance to introduce the remedy as soon as possible into the 
system, for if you are not able to cut short the disease soon after 
the first or second paroxysm, the patient may fall a victim to its 
violence. Professor Speranza, in his excellent medical reports, 
defends this practice, and observes, that it is absurd to maintain 
that the doses of medicines should be the same in all countries; 
and when we consider the different intensities of particular diseases 
in different countries, we must allow that there should be some 
variation in the dose. 
I spoke of arsenic as one of those remedies which exert a consi- 
derable influence over intermittent fever. This medicine, which 
was imported from the East, was first strongly recommended to 
the profession by Dr. Fowler, who has given a formula for employ- 
ing it, and there is no doubt that it possesses febrifuge properties. 
It is stated, that, in consequence of the establishment of a smelting 
house for copper, in a particular district of Corn wall, ague, which 
frequently appeared in that situation, has entirely ceased. You can 
understand this by recollecting, that in the smelting of copper ore, 
arsenic fumes are often copiously extricated. 
Sir Gilbert Blane states, that in the ague which prevailed among 
our troops at Walcheren arsenic was used with good effects in cases 
where bark would not be borne. In these cases it was generally 
prescribed in combination with opium and aromatics. Under cer- 
tain circumstances, also, it may be employed with greater advantage 
than bark ; but as a remedy it is decidedly inferior to bark, and there 
is one objection which applies to it, but not to bark, namely, that 
in several cases where arsenic had been employed in the cure of 
this and other diseases, the patients, after their recovery, fell into a 
state of bad health, became weak, emaciated, and presented remark- 
able derangement of the digestive organs. Some of these persons 
sunk in the course of a few years, others continued to drag on a 
miserable existence. In several instances, where large quantities 
of arsenic had been taken for the cure of skin diseases, I have 
observed that the patients never recovered from its effects, and there 
can be no doubt that it is a substance highly inimical to the system, 
and that its long continued use is productive of mischievous results. 
We should, therefore, decline its employment whenever we can 
dispense with it, and though we may not be able to procure Peru- 
vian bark, or sulphate of quinine, we should recollect that there are 
many other astringent barks possessed of febrifuge properties, and 
which may be employed with safety and advantage. 
It has been proposed to cure intermittent fever with mercury, and 
this requires a few observations. In cases where mercury has been 352 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
used instead of bark, it has been observed that the disease has been 
checked for some time, but that as soon as salivation disappeared 
the disease returned. It produces a suspension of the paroxysm, 
but does not eradicate the complaint. It is related, that in two 
ships-of-war, whose stock of bark happened to be exhausted at a 
time when ague prevailed extensively among the crews, the medi- 
cal officers had recourse to mercury, and it was found that as soon 
as salivation was established, the paroxysms of ague disappeared. 
But three-fourths of the patients thus treated relapsed when the 
salivation disappeared, and this happened even in cases where 
mercury had been used three or four times for the same affection. 
Mercury is certainly of great utility in removing some of the 
diseases consequent on intermittent, but it does not appear to pos- 
sess any specific power over the disease. The fact of the subsid- 
ence of the paroxysms of an ague on the establishment of mercurial 
action has many analogies, for we all know that there is a vast 
number of diseases which will subside as soon as the mercurial 
action is set up in the system. 
I shall now draw your attention to some other circumstances 
connected with the treatment of intermittent fever, and first with 
respect to the management of the paroxysms. In the cold stage, 
there is scarcely any thing necessary but to keep the patient well 
covered, and give him mild warm drinks. In very bad cases, the 
use of the warm foot-bath, the application of warm bricks, or stupes, 
to the feet, and small quantities of warm wine, or carbonate of 
ammonia, will be required ; but I would advise you to be sparing 
in the use of internal stimulants, unless the cold fits are extremely 
severe. We may venture to say (and this applies to cholera as well 
as to the cold stage of ague) that the extent and danger of re-action 
and its accompanying diseases in the hot stage is often proportioned 
to the quantity of stimulants used during the cold stage. There is 
one remedy, however, to which this remark does not apply, namely, 
opium—this may be given with advantage at the commencement 
of the paroxysm. A dose of laudanum will diminish the duration 
and violence of the cold fit, without increasing the hot, and if com- 
bined with some preparation of ipecacuanha, its effect will be still 
better. What we generally give in the Meath Hospital is, from ten 
grains to a scruple of Dover’s powder. Dr. Fordyce mentions a 
case of quartan ague which was cured in a few days, after having 
resisted the use of bark for two years. Two hours before the 
paroxysm came on, he gave the patient a full opiate draught com- 
bined with a small quantity of carbonate of ammonia. The effect 
of this was to increase the quantity of perspiration during the 
sweating stage, and produce a change in the character of the 
paroxysms. The disease then came under the influence of bark, 
and the patient was rapidly and permanently cured. This case is 
of great importance, as it shows that in some instances where the 
disease resists the use of bark, it may be rendered amenable to it 
by first making an impression on the system with opium, and then 
trying the specific. INTERMITTENT FEVER. 
353 
A curious circumstance in the treatment of the cold stage of ague 
is the effect of pressure on the extremities. If you apply strong 
pressure to the extremities, particularly in the vicinity of their 
nerves, it is a fact that the rigours, even though they may be 
remarkably violent, will often cease. This I have seen very often. 
I remember when I was a pupil at the old Meath Hospital, a little 
boy who was labouring under intermittent, used to send for me as 
soon as the rigours came on, and beg of me to “ hold him,” as he 
said, while the shivering lasted. My practice in this case was to 
compress the anterior and internal parts of the thigh and opposite 
arm with all my force, and I have observed that in almost every 
case where pressure was employed, the hot fit came on much earlier 
than usual. The same thing was observed by Dr. Kelly in 1794. 
He advises the use of the tourniquet for this purpose, and states 
that, in some cases, the hot fit came on in three minutes after its 
application. It is difficult to explain how the tourniquet acts in 
arresting the cold fit; at present, I believe, we must confess our 
ignorance as to its mode of operation. It, however, goes to prove 
that ague is a nervous disease, for if it were an intermittent gastro- 
enteritis, as the physiological school teach, how could it be possible 
to remove it by pressure on the extremities ? Besides, we have 
analogous instances of the same effects being produced by pressure 
in other diseases of the nervous kind. We have them, for example, 
in hysteria and epilepsy. In a very remarkable case of hydro- 
phobia, which was, some years since, under the care of my father, 
pressure on the extremities was attended with very singular results. 
The patient, a female child, was brought into the Meath Hospital, 
with symptoms of well-marked hydrophobia, which had come on 
some time after she had been bitten in the foot by a rabid dog. 
The tourniquet was, by my father’s direction, applied over the 
middle of the thigh of the bitten extremity, and he found that as 
soon as it was sufficiently tightened, the spasms ceased, and the 
hydrophobic symptoms disappeared, for the patient could drink 
freely, and without inconvenience. During the course of the night 
the paroxysms came on again ; on making an examination, it was 
found that the tourniquet had become loosen, d, and had slipped 
downwards ; on being again tightened the paroxysms ceased. After 
thirty-six hours the tourniquet was removed, and the paroxysms 
again returned with all their original violence. During the course 
of a clinical visit, the patient was asked if she had taken any drink; 
she replied she had not, and dared not make the attempt unless 
the tourniquet was applied. This was immediately done, and she 
drank freely. In this case my father proposed amputation, but 
nothing was done, and the little patient died, with all the terrific 
symptoms of the disease. It is a curious fact, however, that, in this 
case, the paroxysms were arrested, and the progress of the disease 
clearly suspended, by the use of the tourniquet. 
There is a form of intermittent, common in warm climates, and 
not unfrequent in this country, to which the name of gastric-inter- 
mittent has been applied by Frank, and which is generally met 354 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
with in the autumnal season. This disease is known by the 
presence of symptoms of gastro-enteric irritation combined with the 
phenomena of ague. The symptoms of gastro-enteric disease may 
be recognised, not only during the paroxysms, but also during the 
intermissions. The patient complains of thirst, nausea, and loss of 
appetite ; there is a desire for cold drinks, the tongue is loaded, and 
the epigastrium tender on pressure. The skin is slightly yellow, 
the eyes have a semi-jaundiced appearance, and the urine is turbid 
and high coloured. In the treatment of this affection, Frank re- 
commends us to commence with an emetic. I cannot speak from 
experience of the utility of this practice; he, however, recommends 
it very strongly. The plan which I would advise you to pursue 
is the following: you must here hold in view, that there is a com- 
bination of intermittent fever with local disease of the gastrointes- 
tinal mucous surface, and that the latter demands your attention as 
much as the former. In some cases the gastric-irritation is so con- 
siderable, that if you were to proceed at once to the use of bark, 
you would in all probability do mischief. After having directed 
such measures as will abate the violence of the paroxysms, I gene- 
rally begin with the application of leeches to the belly, and the 
employment of all the ordinary means to relieve gastrointestinal 
irritation. By this mode of treatment, you will find that the gastric 
character of the disease will disappear in a great degree, and then 
you can have recourse to bark with safety. In a few cases I have 
observed, that even without the use of bark, all the symptoms of 
ague have been removed by treatment directed to the gastrointes- 
tinal disease. If they do not, you can easily give quinine; and 
where the irritation has been subdued, it will act both safely and 
expeditiously. Allow me to repeat the circumstances under which 
you recognise the necessity of leeching and other measures to re- 
move the affection of the digestive tube. These circumstances are 
drawn chiefly from the state of the patient during the intermissions, 
for in this kind of ague we seldom have complete apyrexia. Thirst, 
nausea, foul tongue, epigastric tenderness and fulness, a semi-jaun- 
diced state of the skin and eyes, and turbid high coloured urine: 
these are the symptoms which mark the co-existence of gastric 
disease with ague ; and, under these circumstances, I would advise 
you never to omit leeching, the use of purgative injections, mild 
mucilaginous drinks, and every other means calculated to remove 
gastro-enteric irritation. When you have accomplished this, you 
may then employ quinine with safety. 
There is one point connected with the treatment of this form of 
intermittent which you should be acquainted with. It occasionally 
happens, that the symptoms of gastro-enteritis will disappear, but 
the tongue still continues foul. It is a common opinion in this 
country, that the tongue is a correct index of the state of the 
bowels; and the inference in such cases would be (according to 
this opinion) that in these circumstances it would be improper to 
prescribe bark. If nothing remains, however, but foulness of tongue, 
it should not prevent you from giving bark, for the state of the INTERMITTENT FEVER. 
355 
tongue here is connected with the morbid condition of the whole 
system, and not with disease of the digestive tube. 
I shall now proceed to make some observations on the endermic 
mode of using quinine. A number of curious and interesting re- 
searches have been made on this subject not long since in France, 
and it is necessary that you should be acquainted with them. In 
some cases bark or its preparations cannot be taken internally; the 
stomach will frequently reject the remedy; and in cases of inflam- 
mation of the digestive tube its employment would be dangerous. 
It has been stated, however, by those who have used it in the 
endermic mode, that even in cases of ague complicated with gastro- 
enteritis, they have been able to accomplish a great deal of good, 
and that quinine may be always employed in this way with safety. 
The first author who wrote on this subject was M. Martin, who 
published a memoir on the endermic mode of using quinine, in the 
Archives Generates. In this memoir he states, that the application 
of quinine to a blistered surface, even where the quantity employed 
was very small, never fails in arresting the symptoms of ague. 
You are to observe, however, that quinine cannot be employed in 
this way in its simple state; if this were done, it would excite a 
high degree of irritation, and the proper effect of the remedy would 
not be obtained. One of the most severe and troublesome forms of 
ulceration I have witnessed for a long time, occurred in a case 
where quinine in its simple state had been applied to a blistered 
surface. Over the whole extent of skin to which it had been ap- 
plied, numerous ulcerations took place, which resisted for the space 
of six weeks every attempt to heal them. But it is a singular fact, 
that when quinine, reduced to a fine powder, is incorporated with 
a certain quantity of cerate, no such effect is produced. The ad- 
vantages of this mode of using quinine are, first, that it can be 
safely employed in cases where its internal use is dangerous, as in 
the case of gastric intermittent; secondly, it is stated that a smaller 
quantity will be required than if taken internally; thirdly, that it 
will act more rapidly; and lastly, that it can be employed with 
advantage in cases where the patients are averse to taking medi- 
cines internally. These are the grounds on which M. Martin 
claims a superiority for the endermic mode of using quinine. He 
further remarks, that it cannot be supposed to act as a counter-irri- 
tant when used in this manner, for any local irritation produced by 
it would exert an unfavourable influence over its effects, and render 
them less certain. All this may be easily understood by recollect- 
ing what the phenomena of absorption are, and how they are pro- 
moted or obstructed. Where the application of quinine has caused 
a considerable degree of irritation, a quantity of gelatinous fluid 
will always be thrown out, and this must obviously prevent the 
entrance of the remedy into the absorbent vessels. In proof of this 
M. Martin gives some cases. A robust man, aged thirty-five, had 
been labouring under an attack of quartan ague, for which he had 
taken bark internally four times shortly before he came to consult 
M. Martin. When seen during the hot fit of the next paroxysm, 356 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
his skin was intensely hot; he had cough, mucous expectoration, 
and rapid laborious breathing; considerable excitement of circula- 
lation, and a red dry tongue. Sixteen ounces of blood were taken 
from his arm on account of the pulmonary symptoms. In three 
days after, the paroxysm returned as usual, and on the next morn- 
ing a blister was applied, and the raw surface dressed with six 
grains of sulpnate of quinine mixed with a quantity of cerate. 
From this period he had no return of the ague, and his general 
health improved. In this case no irritation attended the applica- 
tion of quinine. He gives another remarkable case. A woman, 
aged twenty-three, who had oppression of breathing, pain in the 
chest, and cough, was attacked with quartan ague in the month of 
September, but recovered under treatment. The ague again re- 
turned in the following December, accompanied by hard quick 
pulse, difficulty of breathing, and cough. In this case also vene- 
section was performed. The patient had then four grains of qui- 
nine applied to a blistered surface, and the paroxysms never returned. 
The blistered surface in this instance was somewhat red, but the 
irritation disappeared rapidly. In both these cases you will observe, 
that bleeding was performed before quinine was employed, and, so 
far as they go, they cannot be looked upon as unexceptionable 
examples of the cure of intermittent fever by the endermic mode, 
as from the researches of Dr. Mackintosh, we learn that many 
cases of the disease will recover after bleeding in the cold stage 
alone. 
M. Lembert, another writer on the same subject, states, that in 
ten minutes after the application of quinine to a blistered surface 
on one of the extremities, a sensation of gentle warmth diffused 
itself along the limb towards the trunk, and so on over the whole 
body. The hot fit, says he, also comes on much sooner than usual, 
and the violence of the whole paroxysm is diminished. The sen- 
sation of warmth is coincident, according to his account, with a 
diminution of the symptoms and an increase of muscular power, 
and he thinks that the reduction of heat during the paroxysms is 
a necessary consequence of this mode of using bark. There is 
another case given, which exemplifies some of his statements. A 
stout young man, who had got ague during the expedition to Spain, 
presented himself with the usual symptoms of the disease, accom- 
panied by foul tongue and a semi-jaundiced colour of the skin. 
For the space of ten days, he took from eight to ten grains of sul- 
phate of quinine daily, but without any improvement. The quinine 
was then applied to a blistered surface. His paroxysm came on 
after the application about the usual time, but its duration was half 
an hour shorter than before. The next attack was also shorter, 
and the fifth was prevented altogether by applying ten grains of 
quinine at once. He was then considered to be cured, but about 
fifteen days afterwards, in consequence of an error in diet, he got 
another attack. The endermic mode was again tried, but without 
success ; the internal use of quinine was then resorted to, and was 
followed by a perfect cure. 357 
INTERMITTENT FEVER. 
These facts do not show that the external mode of using quinine 
has any great advantage over the internal. Where it would be 
improper to prescribe it internally, it is certainly a valuable mode, 
but it remains to be proved whether employing it in this way be 
preferable to giving it by the mouth or in the form of enema. 
I shall now make a few observations on the last subject connected 
with the treatment of intermittent fever, and this is the proposition 
of bleeding in the cold stage, put forward so ably by my distin- 
guished friend, Dr. Mackintosh, of Edinburgh. In the writings of 
almost all the older authors it was laid down, as an undoubted fact, 
that the cold stage of ague was essentially a stage of debility ; they 
saw that the cold stage of intermittent fever was attended with con- 
siderable prostration of the powers of life; they regarded it as one 
of pure debility, and they completely overlooked its effects on the 
viscera. From an accurate observation of the phenomena of the 
cold fit, from perceiving that the signs of a retreat of blood from 
the surface to internal parts were evident, from ascertaining by dis- 
section that the viscera were overloaded with blood, and from recol- 
lecting that in chronic cases of ague visceral disease was of constant 
occurrence, and often the cause of death—from all these circum- 
stances, Dr. Mackintosh was led to conclude that the old idea 
respecting the cold fit was a mistaken one, and that much good 
might be done by bleeding in the cold stage, so as to relieve the 
congestion of internal organs. This idea he entertained for some 
time without venturing to put it in practice, so strong were the 
existing prejudices against any kind of depletion in what was 
looked upon as a distinct example of debility; he ultimately, how- 
ever, determined to make trial of it, and, with the self-devotion 
which characterises true science, first put it in practice on himself. 
On being attacked with intermittent fever, he boldly rejected the 
venerated dogmas of the schools, and had himself blooded in the 
cold fit. The operation was performed; and, so far from any of the 
dreaded results occurring, it was followed by great relief. Since 
that time, the remedy has been extensively tried, and he has given 
an interesting and detailed account of it in his admirable work on 
the practice of physic. 
An incorrect view of Dr. Mackintosh’s opinions on the treatment 
of intermittent fever has been taken by some persons. It has been 
said that he neglects and disregards bark, and that he considers 
bleeding in the cold stage as the only remedy required for the cure 
of ague. This is not true. All that he proposes to establish is, 
that there is congestion of the viscera during the cold stage, and 
that although the phenomena of debility are present, blood may be 
taken away safely and with the greatest possible relief in many 
instances. Of course all those persons who are attached to the 
practice of studying and prescribing for names rather than actual 
diseases, are still opposed to Dr. Mackintosh’s treatment, for nothing 
shocks them so much as that which has a tendency to overturn 
and expose their favourite dogmas. For this reason they looked 
upon the new opinions as heterodox, and the practice as a danger- 358 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
oils innovation. Notwithstanding all this, no sensible practitioner 
can entertain a doubt that Dr. Mackintosh has conferred a most 
valuable boon on medicine, first, by demonstrating the real nature 
of the cold stage of ague, and, in the next place, by showing that 
bleeding may be performed in it with safety and advantage. 
It is a question, however, which remains to be discussed, whe- 
ther we can have recourse with safety and success to this mode of 
practice as the ordinary treatment of intermittent in this country. 
My own impression is, that, in this country, the practice is unne- 
cessary in the great majority of cases, and that you can remove all 
the simple cases of ague with certainty and safety, by means of the 
specific alone. I told you in a former lecture, that I had endea- 
voured to render my experience on this subject as extensive as pos- 
sible, and that during the epidemic ague of 1827, I had made trial 
of Dr. Mackintosh’s practice on not less than one hundred patients. 
Now the general conclusions which I was induced to draw from 
an accurate examination and comparison of these cases, were, that 
in the vast majority, bleeding in the cold stage of an intermittent 
may be performed with safety; that there is very little or no danger 
of the patient dying of debility, as was formerly apprehended ; and 
that, in many cases, this treatment was found to diminish the vio- 
lence and ameliorate the character of the paroxysms, and, in some, 
had the effect of completely arresting the disease. Dr. Mackintosh 
has witnessed several cases in which bleeding in the cold stage has 
cut short the disease at once, and of this I am fully convinced, but 
I believe it to be a rare occurrence. I have certainly seen it in a 
few cases. In one instance, where the ague had resisted the ordi- 
nary treatment for a considerable time, the patient was cured at 
once by bleeding freely in the cold fit. As far as my recollection 
goes, the number of cases in which this singularly favourable ter- 
mination occurred, did not exceed three or four. 
But, you will ask me, did I observe any bad effects to result from 
this practice ? I have seen some cases in which the cold and others 
in which the hot fit were increased in violence after bleeding in 
the cold stage. I have seen several cases in which the paroxysms 
were brought more closely together, and the period of their occur- 
rence anticipated. Now this is a very unfavourable occurrence, 
for the nearer an intermittent approaches to remittent fever, the 
more unmanageable it is, and the less is it under the influence of 
bark. This observation has been further confirmed by my friend 
Mr. Gill, who went into the fenny parts of Lincolnshire, during the 
prevalence of an epidemic ague, to put the practice to the test. In 
a communication which he made to me on this subject, he states 
that he felt quite certain that he had it in his power to convert 
many cases of intermittent into continued fever by bleeding in the 
cold stage. 
We observed also in the Meath Hospital some other effects, 
which, however, do not particularly apply to bleeding in the cold 
stage, as they have been observed to follow the employment of other 
measures,—I allude to the supervention of new diseases. 1 have TYPHUS FEVER. 
359 
seen cases of intense pneumonia, of inflammation of the brain, and 
of gastritis, occurring immediately after the disease had been cut 
short by bleeding. This, however, is no argument against the 
practice of Dr. Mackintosh, for the same thing might happen 
where the paroxysms had been arrested by bark. I have hazarded 
a conjecture in one of my clinical lectures, that if bleeding in the 
cold stage were useful, it would be chiefly in the intense agues of 
warm climates. Where life is threatened by the violence of the 
congestion, or by the excess of inflammatory action in warm coun- 
tries, in such circumstances I think bleeding may be looked upon 
as a valuable remedy in intermittent fever. Since that period, Dr. 
Mackintosh has received a number of communications from the 
East Indies, and from these it appears that the practice has been 
attended with great success. 
I may remark, in conclusion, that the foregoing observations 
apply to almost all the cases which came under our care in the 
Meath Hospital, for in almost every instance we were obliged to 
have recourse to bark after the use of the lancet, and we could not 
say that the patients required less quinine than those who had not 
been blooded. However, in all cases of intense congestion, but 
particularly in the pernicious ague of warm climates, I think this 
practice of great utility, and I am almost inclined to think that it 
may be employed with advantage in cases where bark, after a suffi- 
cient trial, does not exert any influence over the disease. Under 
all circumstances, the medical profession is deeply indebted to Dr. 
Mackintosh, for being the first to demonstrate the real nature of 
the cold stage of ague, and that the visceral congestion may be 
relieved by bleeding; and it is to be remarked, that my chief trials 
of the treatment were made on the cases of an epidemic fever, a 
circumstance which of course diminishes the value of my results, 
as arguments against the treatment of sporadic or ordinary cases. 
LECTURE XL. 
Continued fever—Varieties of fever infinite—Typhus1 fever—Symptoms of typhus— 
Petechi®, sign of typhoid character—State of the tongue various—Progress of the 
disease—Typhus produced by injection of putrid substances into the veins—Hemor- 
rhage from the intestines, &c.—Opinions on fever—Prognosis—Phenomena arising 
from each system—Jaundice an unfavourable sign. 
Before I enter on the consideration of exanthematous diseases, it 
will be necessary to examine the subject of ordinary continued 
fever. My reason for this is, that the phenomena of continued 
fever bear a closer relation to those of intermittent than they do to 
those of the exanthematous ; and as I have introduced the subject 
of fever by lectures which apply more obviously to the pathology 
of continued than to that of exanthematous fevers, I think it better 
to conclude this part before we proceed to the rest. 360 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
I do not know of any subject so difficult to lecture on as fever. 
It is, in the first place, next to impossible to give any description of 
it which will apply to all, or even to the majority of cases. The 
varieties of fever are infinite. It varies according to situation and 
climate, to the peculiar character of the epidemic, the constitution 
and habits of the individual, and the numberless complications of 
local disease. One of the best modes of examining fever is to take 
a brief but general sketch of the usual symptoms of what is called 
typhus, and, proceeding thence analytically, to review fevers of a 
nervous type, or those in which the symptoms are chiefly referable 
to disease of the brain and spinal cord, together with their respective 
nervous connections ; next, to examine those fevers in which there 
is a predominance of diseased action in the respiratory system; 
and, lastly, to ascertain the character of those in which the digestive 
tube seems to be principally engaged. 
You will recollect a principle which I have more than once im- 
pressed upon your attention, that we are to look on these fevers as 
general affections of the system, complicated, in the vast majority 
of instances, with local disease; and that I stated that there was 
the greatest possible variety in the number, seat and extent of these 
local affections. In some cases, they make their appearance almost 
at the commencement of the fever; in others, they supervene at a 
more advanced period. In some instances, they are confined to a 
single system, or even a single organ ; in others, the morbid action 
extends to all the splanchnic cavities. 
The symptoms of typhus may be divided into two classes—the 
precursory or latent, and the actual or manifest. The precursory 
are, more or less prostration of strength, a feeling of malaise without 
decided illness, an unusual paleness, a sensation of coldness and 
perhaps some shivering, a sense of weight about the head, indiffer- 
ence to objects of business or pleasure, troubled sleep and frightful 
dreams, some nausea, foulness of tongue, and loss of appetite. 
These symptoms may continue from a few hours to three or four 
days. In other cases, you will see the phenomena of typhus setting 
in at once, and with an awful rapidity. This occurs chiefly in 
cases where a severe epidemic is prevalent, or where the miasm of 
fever exerts its influence over bodies of men closely cooped up 
together, as we see exemplified in camp and jail fever. 
Typhus fever frequently sets in with a state of the system closely 
resembling inflammation. The skin is hot and dry, the pulse full 
and bounding; and this often leads the practitioner to think that 
he has to deal with ordinary inflammatory fever, and he bleeds 
with the expectation of cutting it short; but it too commonly hap- 
pens that we are very seldom indeed able to effect this desirable 
purpose by blood-letting. You may succeed in modifying the symp- 
toms, but you cannot arrest the disease. It is, in fact, a question, 
how far general bleeding is admissible in the great proportion of 
cases of typhus. I shall examine this point more particularly when 
we come to the treatment of fever. If you take blood from the 
system generally in this apparently inflammatory condition, you TYPHUS FEVER. 
361 
may find, in some instances, that the clot will be of a red colour, 
and crusted at top with a slight coat of buff; in other cases* you 
will perceive that the quantity of serum is trifling, the clot of a dark 
red colour, easily broken up, and without any buff. 
Whether bleeding has been performed or not, the pulse begins to 
alter about the third or fourth day, and this simulated appearance 
of inflammation goes away; then comes a train of nervous symp- 
toms—anxiety, restlessness, delirium, tinnitus aurium, with an 
augmentation of the febrile symptoms towards evening. In the 
morninof the patient feels better; and this is almost always the case, 
for we seldom meet with a case of typhus without morning remis- 
sions. In some cases the symptoms are aggravated on alternate 
days, so as to bear some resemblance to double tertian. Sometimes 
the exhalant vessels of the skin are in a state of great activity, and 
the patients sweat profusely almost from the commencement of the 
disease. These cases we have found in the Meath Hospital to be 
extremely tedious. In the greater number of cases the skin remains 
dry, and this often continues through the whole disease up to its 
termination. With respect to the appearance of petechise, they 
may occur at an early period, or not until towards the close of the 
fever. The appearance of petechise has one particular value, as 
being a symptom most commonly connected with fevers of an essen- 
tial type, and rarely with those of a simple inflammatory character, 
or where the fever is symptomatic of local disease. Thus, We Very 
seldom meet with petechise in the fevers which accompany cere- 
britis, or pneumonia, or gastro-enteritis. On the other hand, where 
the inflammation of these organs is secondary, and supervening on 
typhus, petechise are exceedingly common. 
As the disease advances, we observe other symptoms. The 
patient has more or less stupor, sighs frequently, answers briefly 
and impatiently when questioned; his eyes are red, glazed, and 
filled with the lachrymal secretion; his nostrils obstructed with 
adhesive mucus, which he repeatedly attempts to remove; he is 
sometimes quite deaf, without any apparent affection of the ear; 
his lips are dry and chapped, and his teeth and gums crusted with 
a dark sordes. If you ask him to put out his tongue, he moves it 
slightly forwards, being unable to thrust it out fully, from its dry 
state and the injury of its muscular functions. Its upper surface 
is generally of a dark brown colour, or even black; its mucous 
covering chapped and inclined to bleed, and feeling quite dry and 
relaxed; 'but there is an infinite variety in the state of the tongue 
in typhus fever. Not unfrequently it is moist; and I have seen 
cases in which it was nearly natural throughout the whole course 
of the disease. In many cases it is red, dry, tremulous, and pointed; 
and in such cases we have generally observed symptoms of gastro- 
intestinal irritation. But it is a well-established fact, that we may- 
have fever with gastro-intestinal disease, and yet without any cha- 
racteristic appearance of the tongue. In typhus, the tongue is not 
a correct index of the state of the intestinal canal; and if you were 
to take it as the grounds of your diagnosis, you Would often fall 362 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
into error. You should, therefore, as I have before taught you, 
study the appearance of the tongue in fever more as indicative of 
the general condition of the patient than of the state of the gastro- 
intestinal membrane. You may have extensive disease with a 
natural tongue, and you may have a morbid state of the tongue 
without any appreciable intestinal lesion. You will often see in 
the advanced stage of fever a red, dry, and chapped tongue become 
pale, moist, and smooth, under the use of wine, carbonate of ammo- 
nia, and other stimulants; and yet, in such cases, if you were to 
judge by the tongue alone, you would say that there was inflamma- 
tion of the intestines, and that the employment of stimulants was 
dangerous ; and, indeed, if it was ordinary inflammation, we know 
that it would be exacerbated by stimulants. 
In some cases of typhus there is thirst, and a desire sometimes 
for hot, sometimes for cold, drinks; in other instances, the patient 
drinks very little, and never complains of thirst. At one time wine 
is relished, at another time it is not. The skin varies as to its con- 
dition, being sometimes bedewed with profuse clammy perspirations 
of a well-known odour; but in the greater number of cases it is 
dry and harsh. Sometimes there is diarrhoea, tympanitis, and ten- 
derness of the belly; occasionally it is soft and flaccid, and pres- 
sure is borne without inconvenience. The state of the urine, which 
engrossed so much attention in former times, cannot be looked upon 
as a diagnostic in typhus. In bad cases, it is, as well as the stools, 
passed involuntarily. This at first occurs during the patient’s sleep, 
but as the disease advances it is passed unconsciously. It is not 
uncommon, on the other hand, to meet with retention of urine. 
As the symptoms advance, the patient lies entirely on his back, 
quite indifferent to every thing, with his lower extremities sepa- 
rated, and the trunk constantly sliding down in the bed from 
debility. The eye is dull, without meaning, and of an ecchymosed 
appearance. During his brief and unrefreshing slumbers, the eye- 
lids are only half closed, and the eyeball is turned upwards. The 
delirium, feebleness of pulse, and prostration of strength, increase. 
A quantity of liquid fasces is discharged involuntarily, the belly is 
tympanitic, and hiccup comes on, which generally proves a very 
distressing symptom. At this period, also, we frequently have 
hemorrhagic discharges from various parts of the body—the nose, 
stomach, bowels, and urinary organs. If the patient holds out for 
any considerable length of time, bed-sores begin to form on the 
back and loins, which are frequently surrounded by an erysipe- 
latous border, and have a great tendency to run into mortification. 
The patient gradually gets weaker, his extremities become cold, 
his pulse thready, irregular, and indistinct; the hiccup increases, 
and there is sometimes regurgitation. He now begins to sink 
rapidly, his eye is glazed, his jaw fixed, his face Hippocratic, his 
stupor increases, and he dies with tracheal rattle. 
The foregoing is a tolerably correct account of the symptoms of 
ordinary typhus, but of course it cannot be looked upon as com- 
plete, for the symptoms of this disease are remarkable for their TYPHUS FEVER. 
363 
great variety. With respect to the prognosis, it is also found to 
vary. Some patients will have almost all the symptoms above- 
mentioned, and yet may recover ; but, generally speaking, the 
prognosis under such circumstances is unfavourable. The worst 
symptoms are those which point out lesions of the nervous system, 
and a morbid condition of the fluids. All the phenomena of nerv- 
ous derangement, delirium, coma, subsultus tendinum, and spasms, 
are to be looked upon as unfavourable ; and the same may be said 
of bad petechise, hemorrhages from the intestines and urinary 
organs. In cases presenting these symptoms, the prognosis is 
always of the worst kind. The most malignant form of typhus 
is that which arises among bodies of men closely crowded together 
—as we see in the camp, jail, and hospital fevers. Here the disease 
appears to be the result of an excessive and highly-concentrated 
dose of the poison of typhus. Where a number of persons are 
confined together in close apartments, you can easily conceive that 
the poison of the disease will act with tenfold severity, and it is in 
such cases that we often observe the phenomena of local inflamma- 
tion to be most extensive and violent. I have before alluded to the 
experiments of MM. Gaspar and Magendie, and mentioned the fact 
of fever, of a distinctly typhoid character, being produced by the 
injection of putrid substances into the veins of animals. Now, in 
those cases, it was observed that the greater and the more concen- 
trated was the dose of putrid poison, the more closely did the conse- 
quent fever resemble bad typhus, and the more violent and extensive 
were the local inflammations. Now, if these local inflammations 
are in proportion to the quantity and concentration of the dose of 
poison, you can easily conceive why local disease should assume 
such threatening appearances in the jail and camp fevers. This 
excess in quantity and concentration in the virulence of the typhus 
poison, I look upon as the true cause of the malignant nature of 
these fevers. And if we take the reverse of these cases—if we look 
to the remarkable effects which result from separating the sick 
from those who are in health—we have an additional light thrown 
on this subject. In cases of camp fever, it has been repeatedly 
observed, that, when the camp was broken up, and the sick sepa- 
rated into different parties, the fever totally disappeared, although 
the patients happened to be exposed to bad weather and the jolting 
of carriages. 
Before we proceed to analyse the symptoms of typhus as they 
appear in the nervous, vascular, respiratory, and digestive systems, 
it will be necessary to make a few observations on petechiae. On 
this subject there are two opinions: one is, that they are analogous 
to the exanthematous eruptions, and, as it were, an attempt of 
nature to relieve the internal disease by external revulsion. An- 
other opinion is, that they proceed from a weakened state of the 
cutaneous capillaries, accompanied by a dissolved'condition of the 
blood, and that they are in fact a kind of passive ecchymosis. I 
am inclined to think that we may adopt both opinions. There can 
be no doubt that petechiae are sometimes of an exanthematous cha- 364 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
racter. We see them at an early period of the disease, when there 
is but little debility, and where there are no other signs of a morbid 
condition of the fluids ; and we know, too, that they are sometimes 
productive of relief, and that they form elevations, and desquamate 
like the exanthematous eruptions during the progress of the disease. 
All this proves that petechias are sometimes to be looked upon as 
bearing a close analogy to the exanthemata; on the other hand, 
we may And them without any of these characters, and presenting 
a livid or black colour. Quiarin divides such into three classes— 
the red, the livid, and the black. The black are of the worst cha- 
racter, the livid are less dangerous, and the red are the most favour- 
able, though he does not say that they are entirely devoid of danger. 
It is the red petechioe, however, that are to be considered as having 
a resemblance to exanthematous eruptions. It sometimes happens 
that they are of very considerable size, simulating the appearance 
of purpura hemorrhagica. In the advanced stage of fever, large 
petechias of a livid or black colour are dangerous, and point out a 
morbid alteration in the fluids. On the other hand, the earlier they 
appear, and the redder and smaller they are, the better; but when 
they occur at an advanced period of the disease, are of a dark 
colour, and accompanied by hemorrhages from the bowels or urin- 
ary organs, they may be looked on as indicating an unfavourable 
prognosis. Huxham looks upon them as sometimes critical; I sup- 
pose he alludes to the first or exanthematous description. Pringle 
is of a different opinion. Our experience in the Meath Hospital 
does not enable us to make any other remark on this subject, than 
that we have seen them followed by some relief, but no exact or 
distinct crisis. The worst form in which they can appear is that 
of vibices, or large dark spots like purpura hemorrhagica; and in 
this form, as Huxham observes, they afford grounds for making a 
most unfavourable prognosis. 
It is hardly necessary for me to state that persons differ exceed- 
ingly in their power of bearing up against an attack of fever. It 
is a fact, almost universally known, that one man may be favour- 
ably circumstanced for resisting the disease, while another may be 
a bad and unfavourable subject. Any thing that has a tendency to 
weaken and depress—as excessive apprehension, exhausting labour 
of body or mind, the debility brought on by mercury, bad food and 
foul air, grief, care, and other depressing moral causes—all these 
are circumstances which, generally speaking, render fever exceed- 
ingly dangerous. Inhabitants of towns are worse oft’ in this respect 
than those who live in the country: this is a fact which has been 
well established. 
Let us now enumerate briefly the symptoms of typhus, arranging 
them in separate groups, according as they appear in the nervous, 
respiratory, or digestive systems. First, with respect to the nerves. 
We observe in typhus a remarkable prostration of strength, and it 
has this peculiarity in it, that it cannot be referred to a local cause. 
This is what has been termed direct prostration, in contradistinction 
to that which occurs as a consequence of various local inflamma- 365 
TYPHUS FEVER'. 
tions. It would not be correct to look upon it in the same light as 
you would the prostration which attends simple primary inflamma- 
tion of the digestive system, or peritonitis; for we know that bleed- 
ing will remove this, and restore the patient’s strength. But the 
prostration of typhus cannot be removed in this way, for it exists 
generally without any perceptible local cause to account for it. We 
have, in the next place, agitation, anxiety, and loss of sleep—a 
remarkable and very unfavourable symptom ; so unfavourable is it 
that, when present, though all the other symptoms may be trifling 
and free from danger, the chances are often against the patient; 
whereas, if he sleeps well, the case will very seldom go on badly, 
even though there may be other circumstances in it of a very 
threatening character. We next meet with the different varieties 
of delirium, furious excitement of the brain, or low and quiet mut- 
tering ; then the symptoms connected with the muscular system— 
as floccitatio, subsultus tendinum, pains and spasms in various 
parts of the body, tremours, and paralysis of the sphincters. Now, 
with respect to the circulation, I told you that, in the commence- 
ment of the disease, we frequently observe an excitement of the 
heart and arterial system simulating the phenomena of active in- 
flammation. In the advanced stage this disappears, and we have a 
weak and jerking action of the heart, with a feeble irregular pulse, 
which can be compressed by a slight touch of the finger. In some 
cases, where the pulse is naturally irregular, the effect of fever is to 
render it regular: this is a curious circumstance, and you should 
not neglect enquiring into it. Another remarkable symptom is, 
that you may have a very obvious disproportion between the action 
of the heart and the pulse ; this is most commonly a sign of disease 
of some internal organ. With respect to the state of the blood 
itself, I do not intend to make any particular observations. We 
know almost nothing on this very interesting subject. All we can 
say is, that the blood is altered in its condition; but what the nature 
of that alteration is, we know not. Notwithstanding all that has 
been written on the subject, there has been as yet no valuable indi- 
cation, no practical improvement, founded on the state of the blood 
in fever. There can be no doubt, however, that the condition of 
the blood (if known) would furnish a most important link in the 
chain of phenomena, and would be productive of a more certain 
and successful treatment. Still it is only a link, and the treatment 
of fever will still continue to partake of a more or less empirical 
character, as long as we remain ignorant of those profound lesions 
of innervation, with which it appears to be so intimately connected. 
When we turn to the respiratory system, we find typhus present- 
ing here also a very numerous and important group of symptoms. 
In some cases we have hurried breathing, with cough, and signs of 
organic lesion of the lung; in other instances the breathing is 
accelerated, but we are not able to detect any appreciable lesion. 
Here we have a purely nervous dyspnoea; in the former case we 
have it co-existing with disease of the lung, which can be detected 
by the stethoscope. Hurried respiration is an unfavourable symptom 366 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
in fever. It points out either an organic affection of the lung, 
or a sympathetic excitement. Hurried respiration, without pulmo- 
nary disease, is an anomalous symptom, and all such are to be 
looked on with suspicion. We have sometimes the symptoms of a 
general affection of the respiratory system—cough, dyspnoea, livid- 
ity of countenance, and bloody expectoration. There is nothing 
more common in typhus than catarrh, or congestion of the lungs, 
or pneumonia. A jrreat many fever patients die of extensive but 
latent and neglected bronchitis. The patients may go on for days 
and weeks without presenting any thing capable of arresting the 
attention, or exciting the suspicions, of the mere symptomatologist; 
they will die with tracheal rattle, and, on dissection, the whole 
bronchial mucous membrane will be found in a state of intense 
inflammation. 
When we come to the digestive system, we find numerous mor- 
bid alterations. The lips are dry and chapped; the gums red, dry, 
and covered with an adhesive mucus; the teeth crusted with a 
peculiar sordes; the tongue in some cases natural, in others appear- 
ing as if it had been dried and then glazed over; in some covered 
with a dirty white mucus towards the centre, and clean towards 
the edges and tip ; sometimes its mucous papillae are enlarged, red, 
and prominent; while, in other cases, it is of a dark brown or black 
colour, its upper surface chapped and inclined to bleed, and its mus- 
cular functions impaired, so that the patient is unable to put it out 
when desired. Then we have thirst, nausea, vomiting, and hiccup. 
In some cases the desire is for cold drinks, in others for hot, and 
occasionally there is no thirst; and the patient drinks only when 
he is requested, and then swallows merely what is sufficient to 
moisten the mouth and fauces. In some cases the fluid ejected 
from the stomach is of a bilious character; in others it is dark, or 
like coffee-grounds. The evacuations from the bowels present a 
very remarkable variety. They may be thin and liquid, or solid 
and figured; they may be clay-coloured, brown, or black; and they 
may be passed at considerable intervals of time, or they may be fre- 
quent and harassing. Generally speaking, they are liquid, of an 
unhealthy colour and consistence, and have a peculiar and very 
offensive odour. Obstinate constipation may be met with, but this 
is very rare, and in the great majority of typhus fevers there is 
rather a tendency to diarrhoea. You will have eructations, borbo- 
rygmi, and tympanitis. You may also have jaundice, and this is 
generally to be considered as a bad symptom in fever. 
In order to get an accurate idea of these symptoms, you must 
proceed analytically—you must pass in review the cerebral, respi- 
ratory, circulating, and digestive systems—and see how far the 
symptoms can be connected with actual disease of the three great 
cavities. TYPHUS FEVER. 
367 
LECTURE XLI. 
Nervous symptoms in typhus—Uncertainty of development—Opinions of Dr. Clutter- 
buck—Unfrequency of lesions of the brain in typhus—Occurrence of all nervous 
symptoms, independent of any appreciable symptoms of the brain—Nature and 
treatment of headache in fever—Delirium, researches of Louis on—Its treatment in 
early and advanced stages of fever—Pathological state of the brain in delirium—Use 
of wine and opium—Dr. Greaves’s remarks on—Nature of adynamia—Principles of 
treatment of the local inflammations in fever—Errors of the school of Broussais on 
this point—Use of stimulants at certain stages. 
At my last lecture I enumerated the symptoms of typhus, which 
are referable to lesions of the nervous system. The principle of 
these are the occurrence of headache, the different varieties of deli- 
rium, coma, spasms, subsultus tendinum, and various lesions of 
sensibility. Now, you are all, I believe, aware that the followers 
of Clutterbuck place the seat of fever in the brain, or, in other 
words, they look upon fever as being symptomatic of inflammation 
of the brain. 
This doctrine has acquired a considerable degree of interest, 
from the circumstance of being supported and put forward by such 
high authority, and is therefore entitled to our notice. It must, 
however, be admitted, that it does not rest on a very secure basis, 
for it has been contradicted by the results of the recent investiga- 
tions with respect to the pathology of fever. These investigations 
prove, that lesions of the brain are, in their nature, analogous to 
those of other parts, and can no more explain the phenomena of 
typhus than similar affections of the lungs, or digestive system. It 
has been shown, in the first place, that lesions of the brain (which 
are supposed by Clutterbuck to be the cause of fever) are by no 
means constant in their appearance ; that there is the most remark- 
able variety in their seat and extent; and that the appearances, on 
dissection, do not correspond with the symptoms observed during 
life. If we were to consider fever as symptomatic of disease of the 
brain, we should always expect to meet with lesions of the cerebral 
substance under such circumstances, just as we find proportional 
lesions of the lung in the fever of pneumonia, or of the digestive 
system in that of gastro-enteritis. Even in cases where these 
lesions of the brain are found to exist, we do not find that they are 
in proportion to the symptoms, for we may have severe delirium 
and headache in typhus with slight cerebral lesion, and, on the 
other hand, we may have extensive organic disease of the brain 
with a fever, in which the nervous symptoms are but little marked. 
Here, then, we have a character absent which should necessarily 
exist, if typhus was symptomatic of disease of the brain. Thirdly, 
the symptoms, referable to mere irritation of the nervous system, 
independent of typhus, have not the initiative, for we frequently 
observe the symptoms of typhus to precede those which belong to 
irritation of the brain. A patient in typhus will go on for days 
without exhibiting any symptoms of cerebral irritation, and then, 
perhaps, towards the termination of his illness, will get symptoms 368 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
of disease of the brain, Blit they are not the first link in the chain 
of morbid phenomena. Again, in cases presenting a similarity, 
nay, almost an identity, of symptoms, you will meet with the 
greatest possible variety in the nature, seat and extent of the 
organic alterations. It has been farther shown that, with the 
same amount of nervous symptoms, with symptoms perfectly alike 
in their nature, intensity, and duration, we shall find one class of 
patients presenting remarkable lesions, and another class with none 
at all. Lastly, we meet with the same state of the brain in cases 
where no typhoid symptoms existed, as in those where all the 
characters of typhus were distinct and prominent. 
Now, if we admit the foregoing facts, and I think they cannot be 
denied, we must reject the theory of Dr. Glutterbuck. The lesions 
of the brain are by no means constant in typhus; the symptoms 
observed during life do not correspond with the phenomena of 
dissection ; we may have extensive organic changes with modified 
symptoms of typhus, and severe typhus with slight organic change; 
and we may have, in patients presenting similar symptoms, great 
organic changes or none at all. The conclusion which has been 
come to by the most eminent pathologists of the present day on this 
subject is, that, in fevers of an essential type, there is no single 
nervous symptom which may not, and does not, occur independ- 
ently of any appreciable lesion of the brain, nerves, and spinal 
cord; that the state of the nervous centres, after death, cannot 
explain the symptoms during life, and that the nervous symp- 
toms, in particular, cannot be referred, in many instances, to any 
known organic alteration of the brain. 
This is a conclusion which may appear humiliating, and you 
may think that it depreciates medicine by representing it as 
obscure, perplexed, and deficient. This, however, is not the proper 
way of considering the matter ; you are only to enquire whether 
it be just and well founded or not, and then to steer as well as you 
can. We cannot say any thing certain with respect to the nature 
of these and various other symptoms unconnected with any appre- 
ciable lesion of the nervous system; we merely observe them as 
facts, and find that they square with experience. Experience has 
shown, long since, that these symptoms frequently subside under 
treatment which could not be employed if they depended on inflam- 
mation. How could we explain the disappearance of delirium, 
under the use of opium and wine, or the removal of spasms and 
subsultus tendinum by stimulants, if they depended on active 
inflammation of the brain or its membranes ? This is another fact 
which tallies exactly with these already mentioned, and showing 
that the nervous symptoms of typhus are frequently unconnected 
with inflammation of the brain. 
One general observation may be made with respect to the nervous 
symptoms of fever, that the greater their number and intensity are, 
the more unfavourable is the prognosis to be. I may here mention, 
that the worst description of nervous symptoms are persistent sleep- 
lessness, constant headache, violent delirium, subsultus tendinum, TYPHUS FEVER. 
369 
and coma. All these point out profound lesions of innervation, 
and are met with in the worst cases of typhus. They do not point 
out the existence of extensive organic derangement of the brain, or 
that you should treat the case by means adapted to deplete the head, 
but that the fever is of a severe character, and that the shock which 
the system has received is likely to endanger life. Headache is one 
of the most constant symptoms of fever, It is sometimes partial, 
sometimes general; it may be more severe at one time than at 
another, or in one part of the head than the rest, and it may be 
dull, acute, or pulsative. It may or may not be accompanied by 
other symptoms, such as heat of the head, throbbing of the arteries, 
and the different varieties of delirium. In cases of fever where 
there is sympathetic headache, without any other sign of cerebral 
irritation, we are not at all warranted in looking on the case as one 
of disease of the brain. With other symptoms it may, and, conse- 
quently, under these circumstances should, command our attention, 
but alone it is to be looked upon as one of the general symptoms, or 
as symptomatic of some of those secondary affections which occur 
in the course of fever. When it is symptomatic, it is most gene- 
rally connected with irritation of the digestive tube. There is 
nothing more common than headache in gastric fever, and you 
will constantly see this headache disappear after the application of 
leeches to the epigastrium. This I have witnessed, not in one, but 
in many instances. 
Now, with respect to the treatment of the headache of fever, I 
may observe, that it must be more or less modified by circumstances. 
In mild and simple cases, where the pain of the head is not very 
severe, you may be content with cold applications, which you will 
commonly find to answer very well, particularly where the head- 
ache is accompanied by heat of the scalp, and throbbing of the 
arteries. You will also find the warm foot-bath of service, and 
you may, if necessary, increase its efficacy by the addition of 
mustard. Where the headache resists this treatment, you must 
have recourse to leeching the temples and behind the ears, shaving 
the head, and applying cold or iced lotions. Now it might be 
urged here, that if the best mode of relieving headache is found to 
consist in the application of leeches and cold lotions to the scalp, 
are we not justified in concluding that the symptoms, in these 
instances, are to be looked upon as depending on inflammation ? 
I have stated to you, when lecturing on diseases of the brain, that 
headache was not to be considered as connected in all, or even 
many cases, with arachnitis; and besides, it does not follow that 
the symptoms must depend on inflammation, simply because they 
have been relieved by antiphlogistic treatment. What does the 
occurrence of pain in the head prove? Nothing more than this, 
that there is an excited condition, a deranged sensibility of the part 
affected. This derangement of sensibility may be accompanied or 
not by organic disease; but whether it is or not, experience has 
shown that it may be relieved by the use of local antiphlogistic 
means. I think you may lay this down as a rule, with respect to 370 
STOKES’S THEORY AND PRACTICE OP MEDICINE. 
the pain of the head in fever, that where you meet with headache 
or delirium, and find them connected with other symptoms, indi- 
cating- a decided affection of the digestive system, you should seek 
for the cause of the headache in the sympathies which attend irrita- 
tion of the gastro-intestinal surface, and direct your plan of treat- 
ment accordingly. If a patient, labouring under gastric symptoms, 
as red tongue, epigastric tenderness, swelled belly, and diarrhoea, 
complains of pain in the head, you may be pretty sure that the 
headache proceeds from sympathy, and that it will be most effectu- 
ally relieved by leeching, and other means calculated to relieve 
gastric irritation. There are two reasons for this : of all the second- 
ary irritations of fever those of the digestive system are the most 
common ; and they are, in the majority of cases, productive of more 
or less functional derangement of the brain, with which the gastro- 
intestinal mucous membrane is linked in the closest sympathy. I 
have seen cases of fever where the patient complained of bad head- 
ache, and where the symptoms were combated unsuccessfully from 
day to day by the application of leeches to the head, and yet I have 
seen complete relief obtained by putting a few leeches to the 
epigastrium. If, therefore, you find, in cases like this, pain on 
pressure, tympanitis, diarrhoea, thirst, and other signs of irritation 
of the digestive tube, you will direct your attention to the belly, 
and see whether the headache may not be removed by means 
adapted to subdue gastric irritation. What I wish to impress on 
you is this, that secondary gastric disease will produce headache, 
and that this may be removed by applying leeches to the belly. 
We now come to speak of a very important symptom in fever— 
delirium. I believe I may here assort that the same pathological 
observations apply to this symptom as to headache, and that, taken 
alone, it cannot by any means be looked on as a decided indication 
of actual organic or inflammatory disease of the brain. Before I 
enter.on the subject of delirium, 1 wish to make a few remarks on 
the occurrence of hysterical symptoms in fever. In some persons, 
you will find that, at the commencement of fever, fits, like those of 
hysteria, will come on, and this may happen even in the case of 
robust men. One of the worst cases of fever I ever saw, was 
ushered in by these symptoms. The patient had violent fits of 
laughing, crying, and other symptoms of an hysteric character, and 
these were succeeded by profound typhus. Indeed, the complica- 
tion of hysteria may be looked upon as favourable in all cases 
except fever; but the occurrence of hysterical symptoms, at an 
early period of fever, affords grounds for making a bad prognosis. 
In fever, we meet with two kinds of delirium—the violent, and 
the low muttering delirium. The high and violent delirium is a 
disagreeable symptom, from the unmanageable state of the patient, 
and the difficulty of doing any thing for him. It is most commonly 
observed in the commencement of the disease, whereas the low 
muttering kind is generally observed towards the termination. 
This is the most usual way, Iput sometimes the reverse takes place; 
and when this occurs, it is to be looked on as dangerous, on this TYPHUS FEVER. 
371 
principle, that any departure from the ordinary course of things is 
unfavourable, and gives cause for a bad prognosis in fever. Thus 
the occurrence of low muttering delirium in the commencement, or 
of the violent kind towards the termination, of the disease, is always 
alarming. Low delirium is most frequently observed towards the 
close of fever, and we find it always accompanied by other symp- 
toms, indicating a low and prostrated condition of the system, as 
subsultus tendinum, picking of the bed-clothes, involuntary stools 
and urine, hiccup, and cold extremities. 
Let us consider how far we are to consider this symptom as con- 
nected with actual disease of the brain. Louis, who has devoted a 
considerable share of his attention to this point, has examined care- 
fully the state of the brain in twelve fever patients who had little or 
no delirium, and in twelve others, who died with violent delirium, 
and the following are the results of his experience. In the first 
table he places those who had no delirium ; and here we find, that 
in four cases there was some redness of the cortical substance of 
the brain; in one, inflammation of the optic thalamus; in one, 
slight softening of the brain; and in the remaining six, the cerebral 
substance was quite healthy and normal. Now, in the cases where 
violent delirium was present, the following circumstances were 
observed. In five cases the morbid appearances were slight, there 
being some redness and vascularity of the cortical substance, but 
no more ; in one, there was slight ramollissement; in one, livid 
injection of the brain and its membranes; in the remaining five, 
the substance of the brain was of a natural colour and consistence, 
and appeared to be quite healthy. Now, in these two tables you 
will observe that the difference in the morbid appearances is 
extremely slight, and that the presence or absence of delirium 
seems to have very little connection with the perceptible state of 
the brain. In those cases where there was no delirium, we find 
four patients presenting redness and vascularity of the cortical sub- 
stance ; in those which were attended with violent delirium, we 
find five patients similarly circumstanced. In the cases without 
delirium, there was one with inflammation of the optic thalamus, 
and another with ramollissement; in those where violent delirium 
prevailed, there was one with ramollissement, and another with 
dark venous congestion of the brain and its membranes. In the 
first table, where delirium was absent, we find six cases in which 
the brain was, to all appearance, healthy and normal; in the second 
table we find five cases similarly circumstanced. Recollect, too, 
that these observations were made by one of the most accurate 
pathologists in the world; a man who had no theory to support, 
who merely records what he has seen, and whose statements are 
therefore entitled to the most complete credence. With respect to 
induration of the brain, M. Louis remarks that he has met with it 
in two instances of fever; in one, the patient was delirious ; in the 
other, the mental powers were unaffected. In the Clinique Medi- 
cale of M. Andral, we find that he has observed induration of the 
brain to be connected with stupor and coma. Thus we see that in 372 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
one case this state of the brain is found in connection with delirium, 
in another with stupor, and in a third with no appreciable lesion of 
the intellectual faculties. The conclusion, then, which we must 
come to is, that inflammation of the brain does not necessarily 
imply delirium, nor does delirium imply any certain disease of the 
brain. 
In the foregoing tables, we have a healthy state of the brain with 
delirium, and a morbid state without it. Observe the practical 
deduction to be drawn from this. You might suppose that you 
could draw no conclusion from this, which would not have a ten- 
dency to embarrass your practice, and depreciate the value of medi- 
cal science. This, however, is not the fact. The conclusion is an 
obvious and a just one, that, in the treatment of a case of delirium, 
we are not to expect that we shall be always able to remove this 
symptom by treatment calculated to relieve inflammation, because 
it may occur with or without disease of the brain. Whenever you 
meet with a case of delirium, you should carefully investigate its 
nature and origin, as far as you possibly can, and if it be probable 
that lesion of the brain is going on, you should direct your treat- 
ment to the head; but if it be merely sympathetic, you must look 
for its source elsewhere, and regulate your treatment accordingly. 
You cannot always relieve delirium by antiphlogistic means, 
directed to the head. This is an undoubted fact, and squares with 
what has been stated with respect to headache, for we find that 
delirium is frequently removed by measures which would be quite 
inadmissible if it depended on actual inflammation of the brain. 
In all cases of febrile delirium, where it is accompanied by pain of 
the head, heat of the scalp, throbbing of the arteries, and other 
signs of determination of blood to the brain, you should not neglect 
the employment of local depleting means. For this purpose, you 
may use with great advantage the cold affusion, as recommended 
and practised by Dr. Abercrombie. I have seen patients who were 
for nights without sleep, and in whom the delirium was so uncon- 
trollable that the strait waistcoat was necessary, and I have observed 
that those persons slept soundly and tranquilly after the cold affu- 
sion. In cases of high delirium with strong reaction, the use of 
blisters has been recommended. This practice appears to me to be 
questionable and hazardous, and I feel convinced that they very 
often do mischief. A much better practice is that of applying sina- 
pisms to the feet. The strait waistcoat is a measure very frequently 
adopted in the treatment of delirium, but it is one which you should 
be cautious in employing. It is too generally resorted to from 
apprehension on the part of the attendants, and is continued 
through mismanagement. In Dr. Cheyne’s valuable report on the 
epidemic fever of Ireland, he remarks, that some patients have 
perished from exhaustion in struggling with their attendants, or in 
endeavouring to free themselves from the restraint of a strait waist- 
coat. If a patient gets out of bed and walks about the room, there 
is not the slightest risk of his receiving any injury, provided he be 
properly covered. When he endeavours to get out of bed, the TYPHUS FEVER. 
373 
nurse should calm him if possible, and, if he perseveres, use her 
authority over him, but never resort to violence. She should even 
permit him to put on his clothes, sit on the side of the bed, or walk 
about the room, and wait until the violence of the delirium abates. 
This generally occurs in a short time, and the poor patient becomes 
quite amenable. Such are Dr. Cheyne’s views. I believe, firmly, 
that the strait waistcoat is too often abused. Coercion should be 
used only in extreme cases, and where there is danger of life; and 
it should be dispensed with on the first opportunity. 
In the advanced stage of fever, even where delirium is present, I 
believe we may often give wine with advantage. I have seen the 
tongue, which was dry and black, or red, become pale and natural 
under the use of wine, opium, and other stimulants. This tallies 
exactly with what I mentioned as to the tongue being rather an 
index of the state of the whole system, than of any particular 
condition of the intestinal canal. With respect to the use of wine, 
Dr. Graves remarks, that it is a common opinion that wine should 
not be allowed while the patient’s eyes are red and suffused. He 
is of a different opinion, and thinks it may be often given with 
safety and advantage even in this state. “It should be borne in 
mind,” says Dr. Graves (and this is important), “that want of sleep 
will make the eyes red and suffused ; and this being very common 
in fever, it cannot be brought forward as an argument against the 
use of wine. Neither does hot skin contra-indicate the use of wine, 
particularly when there is at the same time a tendency to coldness 
of the extremities.” Now, to come to the subject of delirium, so far 
as this is connected with giving wine and stimulants, or withhold- 
ing them, Dr. Graves thinks that when the delirium is violent, 
wine should not be given. I would modify this assertion, and say, 
that it should not be given in the delirium which comes out at an 
early period of fever; but in the advanced stage I have seen it do 
good. The patient may be irritable, restless, and delirious, and 
yet in a state which demands the use of wine and opium. You 
will find patients in the advanced stage of fever talking incohe- 
rently, and incapable of giving direct answers to your questions.. 
This state of mind is frequently accompanied by an anxiety about 
their illness, and want of sleep. Now, to procure sleep, and remove 
the delirium, you will have recourse to the use of wine and nar- 
cotics. “ Headache,” says Dr. Graves, “is, at any period of fever, 
a bad circumstance; for it does not allow the patient any sleep. 
Now, we must, in the first place, endeavour to remove this symp- 
tom by depleting the head, and by purgatives. These measures- 
frequently succeed, but sometimes they tail, and we cannot pursue 
this line of treatment any farther. (This is the case to which I 
have already alluded.) In this case,” says he, “we must prescribe 
an opiate to procure sleep, and from this sleep the patient often' 
awakes much improved. Before you employ the opiate, you may 
apply a blister to the head.” Much benefit may be derived “from the* 
use of the common starch injection with tincture of opium. Thirty 
or forty drops of laudanum, in two or three ounces of the mucilage 374 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
of starch, is a very good way of employing opium to procure sleep in 
fever. The general rule with respect to the use of opium is this: 
Where you have nervous symptoms remaining after treatment 
calculated to remove inflammation, or where they have occurred 
unaccompanied by any signs of inflammation of the brain—in 
these cases I feel no doubt that opium may be employed with safety 
and success; in fact, that it is the best means you can adopt. 
Observe, all that I now state is founded on facts, and independent 
of any theory. You will observe, too, that it squares with the 
pathology of fever given in a former lecture—namely, that we are 
to look upon it as a general affection of the whole system; and that 
the presence of any one single symptom does not necessarily imply 
the existence of local inflammatory disease. There is one practical 
remark with respect to local inflammation which I have already 
made, but I shall here beg leave to repeat, as it is connected with 
the point in question. When we compare the three great cavities 
with respect to the comparative frequency of inflammatory disease 
observed in them, we find that the account stands as follows:— 
local inflammatory disease is most frequent in the belly, next in the 
chest, and lastly in the head. We much more frequently meet 
with organic affections of the digestive system in fever, than of the 
pulmonary, and of the pulmonary than of the nervous. 
In the advanced stage of fever, we have often to combat with a 
very distressing symptom—namely, coma. The patient lies in a 
state of lethargic stupor, and cannot be roused, or if he exhibits any 
signs of consciousness, it is only for a moment, and then he relapses 
again into the same stupid state. This is a bad symptom, but not 
a fatal one, if it be properly managed. What seems to answer best 
is, keeping the head cool, and using counter-irritation. These two 
measures may appear inconsistent with each other, but they are not 
really so. Some of the worst cases of febrile coma, which I have 
seen recover, were those in which blisters were applied to the back 
of the head, or vertex, or nape of the neck, the rest of the head 
being kept cool. In addition to these measures, you may employ 
counter-irritation to the extremities with advantage. You will see, 
in the works of Lallemand and Mackintosh, some very remarkable 
cases of coma, where the patient was, as it were, snatched from the 
jaws of death by pouring boiling water on the extremities, at the 
same time that the head was kept cool. In the advanced stage of 
fever, where the skin and extremities are cool, the existence of 
coma does not contra-indicate the use of wine. You may also 
employ musk in doses of ten or fifteen grains every third hour, 
either alone, or in combination with camphor, or carbonate of 
ammonia. These, with blistering the head and keeping up coun- 
ter-irritation in the lower extremities, are the principal curative 
means used in the treatment of coma. I shall conclude this lecture 
with some observations on adynamic fever. Whenever you meet 
with this remarkable prostration of strength, it will be necessary 
for you to enquire carefully into its nature. You must here hear 
in mind two propositions which should never be forgotten—first, 375 
TYPHUS FEVER. 
that the adynamia may be secondary, and produced by visceral 
lesions, for the removal of which antiphlogistics may be necessary ; 
and, secondly, that it may exist as a consequence of the morbid 
state of the whole system, and independent of any decided local 
inflammation. The first of these is called false, the second true, 
adynamia. One of the most important questions in fever is con- 
nected with this point, and I beg your particular attention to it. It 
was long taught, and is to a certain extent still believed, that fever 
is a disease of debility ; and hence all the phenomena indicative of 
this debility were treated by stimulants; and it is melancholy to 
reflect that, even at the present day, hundreds of persons are sacri- 
ficed at the shrine of this dogmatism. Now, when you recollect 
that fever most commonly presents a group of local inflammatory 
affections, and that the excess, or extent, or seat of a local inflam- 
mation will produce debility, you will very readily perceive that 
there are two causes for the adynamia of fever—one the reaction of 
local disease on the constitution, the other depending on a peculiar 
morbid state of the whole system; and it is in striking a balance 
between these two causes that the judgment of the physician con- 
sists, and it is on the accuracy of his judgment that his success 
will decidedly hinge. In all cases where the prostration is uncon- 
nected with inflammation, or, even if inflammation should exist, 
where antiphlogistics can be no longer employed, you must have 
recourse to the cautious but decided use of stimulants. In some 
cases, particularly where the prostration is not excessive, you may, 
at the same time that you are prescribing stimulants, employ local 
antiphlogistics and counter-irritants with great advantage. When 
I say this, I do not wish you to believe that in treating the inflam- 
matory affections which arise during the course of fever, you are to 
proceed with the same boldness as in original simple inflammation. 
I have before marked the distinction between them. In the second- 
ary local inflammations of fever, where profound lesion of innerva- 
tion and a morbid state of the fluids exist, you should always 
modify the activity of your antiphlogistic measures; but, on the 
other hand, where the local inflammations are simple, and the con- 
stitution strong, your measures must be prompt and energetic. 
There is one great rule which is applicable to most fevers:—In 
the early stages, antiphlogistics are required; in the advanced, 
stimulants and tonics. This rule applies not only to fevers, but 
also to most cases of local diseases. In the early stage of fever, you 
may always employ the antiphlogistic treatment so far as regimen, 
local depletion, and the prohibition of all stimulants are concerned; 
in the latter periods, where the patient’s strength is reduced from 
depletion, extent, or duration of disease, and want of nutriment, 
your object must be to support the strength, and even to give stimu- 
lants. This is the great point which has been overlooked by the 
school of Broussais. They looked upon fever as depending on 
local inflammation, and concluded that stimulants were inadmissi- 
ble at any stage of the disease ; and their practice was accordingly 
to continue the use of antiphlogistics throughout the whole case. 376 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
By thus neglecting to support the system, they permitted exhausted 
nature to sink, ignorant of the fact, that while you are taking 
measures to remove local inflammation, you may at the same time 
give nutriment to support strength, and that at certain periods of 
all inflammatory affections, stimulants become antiphlogistics. 
The same thing occurs in local inflammation of a simple and 
original character, as in fever. In healthy inflammation we cannot 
pursue the antiphlogistic plan all through; after a certain period it 
loses its effects on the local disease, and it will run the patient down 
if persevered in ; a cure is to be obtained only by the use of stimu- 
lants and tonics. So it is with respect to fever, in the advanced stage 
of which stimulants become antiphlogistics. The great rule, then* 
with respect to the treatment of adynamia is this :—First ascertain 
if there is any existing local inflammation, and if it be of sufficient 
extent and intensity to produce prostration, adopt means to modify 
or remove it, as far as your patient’s strength will admit; in the 
next place, if you find no local inflammation to account for it, or if 
it occurs at an advanced stage, when the powers of life are sinking, 
give wine and stimulants to support nature in the struggle which 
she is making with disease. In the treatment of the secondary 
local inflammations which arise during the course of the fever, we 
should always endeavour to moderate the symptoms as far as we can* 
and gain time. If we can succeed in prolonging life, we give our 
patient every chance for recovery, and allow the powers of nature 
time and opportunity to act. Hence it is that one of the most 
important objects of the physician, in the treatment of the advanced 
stage of fever, is to prevent his patient from becoming too much 
debilitated. Even though local inflammations should be present, 
yet, if the patient be sinking, and the fever of considerable duration, 
he knows that his only resource lies in judicious stimulation, which 
I fully believe not only acts beneficially on the general fever, but 
also on the local disease, whatever it may be. In all probability, 
the original affections have changed their character, and the irri- 
tated capillaries have passed from a sthenic to an asthenic state; 
in other words, to a state where antiphlogosis will be, to them, 
insufficient, and, to the disease, dangerous, but where stimulation is 
their cure, and also what nature demands. The great point is to 
know the exact time when we should change our practice. This 
period occurs in all fevers, but the time of its supervention is infi- 
nitely various; and it is in the knowledge of this, as well as in 
striking a proper balance between the dangers to be apprehended 
from local inflammation on the one hand, and constitutional debility 
on the other, that the great nicety of treatment consists. It would 
be impossible to teach this in a lecture; the only way in which it 
can be learned is by exact and long-continued clinical observation. FEVER 
377 
LECTURE XLII. 
Opium in fever—Dr. Latham’s opinion on—Symptoms for the exhibition of opium— 
Affection of the sensorium in fever—Adynamia, consequence of fever—Direct ady- 
namia—Indirect adynamia—Treatment of—Stimulants in fever—Dr. Grant’s notions 
of fever—Symptoms of typhus—Catarrh of fever—Opinions of Andral, Louis, and 
Laennec—Bronchitis with fever—Increase of r&les on decrease of disease—Affection 
of the gastro-intestinal mucous surface—Symptoms of pneumonia and bronchitis— 
Pneumonia of fever—Symptomatic affections of the respiratory system in fever— 
Sympathy between the left lung and stomach—Phthisis, consequent of fever. 
I drew your attention, at our last meeting, to the employment of 
opium in the treatment of some of the nervous symptoms of fever. 
Before I leave this subject, I wish to lay before you a brief abstract 
of Dr. Latham’s opinions on this point. I believe I may say, that 
one of the first persons who proposed and administered opium in 
fever was the celebrated Sydenham. His opinion of it was, that, 
after purgation, it is generally productive of good effects. At the 
present day, there is considerable difference of opinion with respect 
to giving opium in fever, but there can be no doubt that it may be 
given with propriety in many cases, and that it has a powerful 
effect in combating some of the worst symptoms of typhus. Dr. 
Latham observes—“ In some cases of fever the disorder of the sen- 
sorium keeps pace with that of other parts, and thus the disease 
proceeds until it is somewhat advanced, when the harmony between 
its symptoms is disturbed; those of the brain outrun the rest; new 
indications of treatment arise, and if the patient can be saved at all 
it must be by opium. Thus the heart and arteries may be full of 
activity, and every symptom in proportion to it. Remedies are 
accordingly addressed to the vascular system, and succeed for every 
purpose they are intended to fulfil, except one. By venesection, or 
topical bleeding, the general symptoms are relieved, and each organ 
loses its peculiar distress, but still the delirium continues. With 
an improved state of the circulation and of other organs, this con- 
dition of the sensorium remains, and to this subsultus tendinum is 
liable to be added, and the unrestrained passage of the different 
evacuations.” 
“ In such a case as this,” says Dr. Latham, “ I have seen a single 
dose of opium, dexterously administered, change the whole com- 
plexion of the disorder in a single night, and place the patient at 
once in a state of safety. Again, I have seen the sensorial affec- 
tions incident to fever, which require opium for their cure, manifest 
themselves in another form. There has been high vascular action 
from the first, and large depletion has been required to subdue it, 
and guard particular organs, and especially the brain, from injury. 
Under such treatment all has gone on successfully, and the patient 
has reached the point of convalescence, when suddenly (the tongue, 
pulse, and all other circumstances continuing favourable) some 
strangeness of manner has arisen, and then the wildest delirium, 
and then the unrestrained passage of the evacuations. I have 
known a transition from such a state of convalescence to such a 378 
stokes’s theory and practice of medicine. 
state of peril take place in a few hours; and I have known the 
patient again brought back to a state of convalescence in twbnty- 
four hours, by a moderate dose of opium.” 
Three circumstances call for the employment of opium in fever: 
first, where there is persistent watchfulness; secondly, where an 
actual inflammatory condition of the brain existed, and has been 
subdued by proper antiphlogistic treatment, but delirium and other 
nervous symptoms still remain ; and, lastly, where an excited state 
of innervation of the brain exists, without heat of scalp or remark- 
able throbbing of the arteries of the head. 
There is another remark of Dr. Latham, which appears to me 
to be so important that I shall offer no apology for laying it before 
you in full. After observing that the affections of the brain in 
fever are capable of much illustration, from a knowledge of the 
habits and state of health of individuals before they become the 
subject of fever, he goes on to say—“And here I would make one 
general remark, that, by knowing what a man is, and how he lives 
habitually, the physician often arrives at a much better judgment, 
and a better treatment of his diseases. It is trying a man’s diseases 
by his health, and a most valuable test it is. 
“ In healthy and vigorous bodies, there is a certain balance and 
regularity of function which, even when disease befalls them, is 
seldom lost; but their morbid action is still harmonious and propor- 
tional. In them, diseases are often severe, but they are generally 
simple; they often require the most active remedies, but they are 
generally easy of cure. On the other hand, the weak and valetu- 
dinary—who. at the best, are full of jars and incongruities—are 
obnoxious to the strangest forms of disease, hard to understand, and 
hard to treat. Now, fever, when it happens to a perfectly vigorous 
and healthy man, is never characterised by any such peculiar affec- 
tions of the sensorium as have been mentioned. These are inci- 
dent, according to my observations, to those only whose habits and 
mode of living have been calculated to do an abiding injury to the 
nervous system, and who have been long actually suffering from 
such an injury. Every class of society has furnished me with 
instances of this form of fever, and every instance has confirmed 
the truth of the remark. 
“ Among the higher and educated classes, there is in this age and 
country a wonderful striving for all the objects of wealth, and 
honour, and power. We need only think upon the strife of poli- 
tics, the hazards of mercantile gambling, and the wear and tear of 
hard professional toil, to see how many there must be who, from 
the common business of life, have derived, both to their minds and 
bodies, new feelings and impulses, and new susceptibilities of dis- 
ease. These susceptibilities chiefly belong to the brain and nervous 
system, and they are apt to come forth in frightful activity when 
such men become the subjects of fever. The trouble of the brain 
gets the mastery (as it were) of the disorder of every other part. 
“ The poor and mean among mankind have the mind over- 
wrought, and the nervous system exhausted, by real calamities, FEVER. 
379 
just as the high and educated by their more refined ; and thus they 
often claim an unenviable approximation to them in the character 
of their diseases. 
“ To these moral causes,” says Dr. Latham, “ I will add one 
physical cause which is of most extensive influence—the habitual 
indulgence in spirituous liquors. Individuals who have done a 
permanent harm to the nervous system by the abuse of spirits, do 
never, when they become the subjects of fever, suffer delirium of 
the ordinary kind, in which the brain is excited nearly in the same 
proportion as the blood-vessels, and which, by remedies addressed 
to the blood-vessels, is uniformly controlled; but they suffer a deli- 
rium in which the brain is actuated disproportionately to, and (per- 
haps) independently of, the blood-vessels; and, if curable, to be 
cured by opium. This I venture to state almost absolutely and 
without exception.” 
I can only state here, that the foregoing eloquent and philoso- 
phical observations are in perfect accordance with what I have 
observed of fever in Dublin. In all cases where the patient has 
been exposed to the depressing effects which high intellectual or 
moral excitement, or the abuse of spirituous liquors, produces on 
the nervous system, you will have, during the course of fever, more 
or less disorder of the sensorium. Here, but particularly if the 
delirium exists independent of any affection of the blood-vessels, 
opium is our sheet-anchor. With respect to the quantity to be 
administered, there are some cases in which it will be necessary to 
feel your way, and indeed I believe that in all cases this is the best 
and safest practice. In place of giving a large dose, as in delirium 
tremens, you commence with a moderate quantity, and if you find 
thp.t this agrees with the patient you can increase it; at all events, 
by pursuing this plan you will be certain of doing no harm. It 
frequently happens, too, that small doses act very well in this affec- 
tion ; you should, therefore, begin with a moderate dose, watch its 
effects on the patient, and then repeat it in increased or diminished 
quantity, according to circumstances. 
Towards the conclusion of my last lecture, I drew your attention 
generally to the subject of adynamia in fever, and endeavoured to 
show that in most fevers you have to contend with indirect as well 
as direct adynamia. Direct adynamia is that prostration of the 
system which results from the original disease ; indirect adynamia 
is that which is produced by the reaction of the secondary local 
affections. I showed you that in many fevers we had, in addition 
to the debility consequent on an affection of the whole system, an- 
other source of adynamia depending on the local diseases which 
arise during the progress of fever, and that consequently the treat- 
ment of adynamia must vary according to the circumstances under 
which it occurs. I said that the indirect adynamia must be com- 
bated by local antiphlogistic means directed to the inflamed organs, 
but that, in the employment of these means, we should not be so 
vigorous as in cases of idiopathic inflammation, and that the gene- 
ral state of the patient should be always kept in view. You will 380 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
readily assent to this proposition, when you consider that, in idio- 
pathic disease, you have inflammation occurring in a constitution 
previously healthy; but in the case of local disease supervening 
on fever, in a constitution previously debilitated by general morbid 
derangement. It occurs, in fact, in that state of body in which 
there is a profound affection of the solids and fluids, of circulation, 
of digestion, and of the nervous system. You can, therefore, easily 
understand why the antiphlogistic plan must be employed with 
more caution, and followed up with less vigour, in the treatment 
of those secondary affections which arise during the progress of 
fever. 
I mentioned, too, that in most cases of advanced fever, and some- 
times even at an early period of the disease, the employment of 
stimulants may be necessary, even where the fever is accompanied 
by local disease. A period occurs in all fevers (generally at the 
advanced stage) when general stimulation will be demanded, even 
though you may at the same time be able to detect local irritation. 
In such cases as these we might say that direct adynamia was pre- 
dominant, and that, as danger was to be chiefly apprehended from 
this cause, we must meet it with stimulants. You will recollect I 
mentioned, at my last lecture, that a state of the general system and 
of the local disease occurred at an advanced period, to which anti- 
phlogistics were no longer applicable, and in which, by giving 
stimulants, we assisted the efforts of nature, and gained time for 
the treatment of the local affection ; in a word, that the formula of 
treatment for most cases of fever was the same as in cases of idio- 
pathic inflammation. In the early period we employ antiphlogistic 
means, both general and local; in the advanced stage we use stimu- 
lants and tonics. In all cases of simple inflammatory disease, a 
time arrives when you must change your hand, and have recourse 
to an opposite line of practice; and the same thins: occurs with 
respect to fever, whether we view it as an original affection of the 
whole system, or as symptomatic of some local irritation. I showed 
you, too, that you might in many instances combine local antiphlo- 
gistics with a general tonic treatment—the latter to be regulated so 
as to support the patient’s strength without increasing the local dis- 
ease. It will often happen, that, in the advanced stage of fever, 
you will meet with enteritis, or pneumonia, or some other local 
inflammation; here, while you are engaged in reducing the local 
inflammatory affection, you may also support the patient’s strength 
with light nutritious diet, and even a little wine. In Dr. Grant’s 
work on fever there is an important remark bearing on this point, 
which I shall beg leave to quote. “ I know,” says he, “ two phy- 
sicians, both in considerable practice, and both honest men, who 
have constantly treated fever badly from different causes. The one 
never gave cordials, wine, or nutritious food, during the whole dis- 
ease ; the other, after the fourth day, never gave any thing else. 
A combination of both these modes, employing each according to 
the circumstances of the case, would be very excellent practice. 
Their error, however, was not entirely the same, nor did the same FEVER 
381 
effects result from these opposite modes of treatment. The patients 
treated by the physician who persevered in the antiphlogistic sys- 
tem seldom died, but their recovery was tedious and protracted; 
those who were treated by stimulants throughout the entire disease 
seldom recovered.” Observe how well this agrees with the doc- 
trines I have laid down for the management of fever. The first 
practitioner generally cured his patients, but their convalescence 
was slow and difficult, because he used antiphlogistics too boldly 
and too long. He was ignorant of the fact, that, after a certain 
period and at a particular stage of the disease, antiphlogistics lose 
their efficacy; and his patients may therefore be said to have reco- 
vered by the unaided powers of nature. He was ignorant also of 
the fact, that, at a certain period of fever, certain conditions of 
innervation exist, in which what are called stimulants have a pow- 
erful effect in removing the disease, even though characterised by 
symptoms which have been termed inflammatory; while he who 
used nothing but stimulants, being ignorant of the number and 
consequence of the local inflammations, lost his patients by a too 
early and indiscriminate stimulation. 
I shall now proceed with the analysis of the symptoms of typhus, 
and the proper mode of treating them. Having discussed those 
which belong to the nervous, let us now take up the consideration 
of those which characterise affections of the respiratory, system. 
Before, however, we leave the subject of nervous symptoms, I may 
mention that some researches have been lately made on the state of 
the spinal cord and ganglionic system in fever ; but there has been 
no result from these investigations calculated to throw any new 
light on the nature and treatment of the disease. Indeed, it is a 
remarkable fact, that in many instances of fever, remarkable for 
the extent and persistence of nervous symptoms, we cannot detect 
any lesion of the brain or spinal cord. In certain cases it has been 
stated that the sympathetic nerves were found diseased; but this 
occurs so seldom, and with so little constancy or correspondence of 
the existing symptoms with the derangement of the nerves, that it 
is impossible to establish any connection between lesions of the 
ganglionic system and typhus. 
I believe I may say that a considerable number of cases of 
typhus are either unaccompanied by thoracic symptoms, or, if they 
do exist, they are in general slight and easily manageable. In some 
instances, however, the pulmonary system is severely attacked; 
and, in many cases of this description, death is caused by asphyxia 
from exorbitant secretion, brought on by extensive bronchitis occur- 
ring during the course of fever. There is one general observation, 
which applies not merely to the derangement of the respiratory 
system, but also to the morbid changes which may take place in 
any viscus of the body during the progress of typhus ; and this is, 
that the functional derangement observed in each particular organ 
during life is seldom in proportion to the changes discovered after 
death. With symptoms of an apparently trifling character, and by 
no means calculated to alarm, you may, in the case of the lung, 382 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
find after death marks of universal bronchitis, of enormous con- 
gestion, or extensive pneumonia. The same character of insidious 
latency applies to all the inflammatory affections which come on 
during the progress of fever. If we seek for an explanation of this 
fact, we shall perhaps find it in considering that, during the exist- 
ence of fever, the nervous system appears to be labouring under 
some profound injury; and we know that where innervation is 
injured sensibility is impaired, and hence the symptoms expressive 
of suffering or disorganisation are more or less latent. Hippocrates 
observes, in one of his aphorisms, that in cases of severe disease, 
where no pain is complained of, there is disease of the brain ; thus 
accounting for the absence of suffering by referring it to some lesion 
of the sensorium. 
In speaking of the catarrh of fever, I beg of you to bear in mind 
that this, like all the other inflammatory affections supervening on 
fever, is to be looked upon as a secondary inflammation. When I 
use the term catarrhal or gastro-catarrhal fever, I do not mean to 
express fever symptomatic of catarrh, or of catarrh combined with 
gastritis, but that the catarrh, whether simple or combined with 
gastro-enteric disease, is one of the results of fever. There can be 
no doubt that, in the majority of instances, this is the case. All 
the arguments which I have adduced, to prove that affections of the 
brain were not the cause of fever, apply also to disease of the lungs; 
and we shall find the same thing to hold good when we come to 
the digestive system. The experience of Andral, Louis, Laennec, 
and various British authors who have written on fever, perfectly 
coincides on this point. You will see, in Laennec’s work on aus- 
cultation, that he has devoted a good deal of his attention to those 
secondary affections of the lungs which occur during the progress 
of fever. 
Now, in many cases, this bronchitic derangement may exist dur- 
ing the whole course of the disease without any degree of violence, 
and the patient will recover without having any attention paid to 
it; in fact, many will go through fever with lesion of the bronchial 
mucous membrane so slight as to have no claim to notice. The 
occurrence of an affection of so trifling a character as this is not 
sufficient grounds for altering or modifying your prognosis; still it 
should always put you on your guard, for it may, in the course 
of six or seven days, become greatly exacerbated, assume a \rery 
intense character, and even carry off the patient. Whenever, then, 
you discover any increase in the bronchitic symptoms, direct your 
attention immediately to the state of the lung, and be on your guard 
lest the disease should get ahead of you. What we generally ob- 
serve in these cases is, that the patient has some cough, but this is 
neither hard nor troublesome ; you can hear now and then a few 
sonorous r&les over the chest, but it sounds quite clear on percus- 
sion. Such a case as this, as long as it remains unchanged, is of 
very little consequence. In some instances, however, the affection 
of the bronchial membrane becomes a most formidable symptom: 
the patient has lividity of face, cough, hurried breathing and expec- FEVER 
383 
toration, and all his symptoms point out the existence of a very 
extensive disease of the lungs. In other cases, the symptoms of 
bronchitis may be almost entirely absent; and yet, if you make an 
examination with the stethoscope, you will detect the existence of 
a latent but general and intense bronchitis. Here, persons unac- 
quainted with the stethoscope, and depending on symptoms only, 
may be led into great and fatal errors. Nay, even persons ac- 
quainted with the use of this instrument may, by neglecting to 
make a proper examination, fall into great mistakes. Thus, if you 
apply the stethoscope to the patient’s chest while he is lying on his 
back and breathing in the ordinary way, all you can ascertain is 
that there is feebleness of respiration, with here and there a sono- 
rous rale. If you were to content yourself with such an examina- 
tion, and decide as to the state of the bronchial mucous membrane 
from the siogis afforded by ordinary respiration, you would be 
wrong; for, though the rales may be few and scattered during 
ordinary breathing, you will find that when you raise the patient 
up, and make him take a full inspiration, so as to cause the air to 
enter the minute bronchial tubes and air vesicles, the rales become 
intense and are audible over a large portion of the lung. You will 
find, also, that the disease generally affects the rpiddle, inferior, and 
posterior parts of the lung, and that it produces here symptoms 
approximating to those of pneumonia. Another curious circum- 
stance connected with cases of this description is, that, according 
as the patient gets better, the rales become louder and more distinct; 
and here we have the apparent anomaly of an increase of the mor- 
bid sound pointing out a decrease of the disease. This is explained 
by recollecting that, at the height of the bronchial affection, the 
minute bronchial tubes and air vesicles are chiefly engaged; and, 
as from the engorgement of the lining membrane, the quantity of 
mucus which fills them, and the feeble state of respiration, the air 
either does not enter into them, or, if it does, only imperfectly, the 
consequence is that the characteristic rale, or morbid sound, is 
scarcely heard. But when the disease is on the decline, and the 
minute tubes become free, the bronchial affection being then chiefly 
confined to the larger tubes, we can hear the sonorous rale distinctly 
during ordinary breathing. Many cases of this kind terminate 
fatally. The patient continues in a low adynamic state, with hur- 
ried breathing and lividity of face, for two or three days; then 
comes a rattle in the throat, and in the course of ten or twelve 
hours he dies. On dissection, the marks of general bronchitis are 
evident, and the bronchial tubes are found filled with a sanguino- 
lent. mucus. In some of these cases, super-secretion from the bron- 
chial mucous membrane sets in with extraordinary rapidity, and 
carries the patient off at once. 
This form of disease is ordinarily co-existent with derangement 
of the gastro-intestinal mucous surface, and this forms one of the 
most common and fatal varieties of fever in this country. In some 
cases the disease predominates in the respiratory, in others in the 
digestive, system; and in some instances you will see a very 384 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
curious alternation of this predominance of morbid action between 
the thoracic and abdominal cavities. To-day the breathing is hur- 
ried, the cough troublesome, the stethoscopic signs well marked; 
in two or three days after, the cough disappears and the breathing 
is relieved, but the belly is more swollen and tender, and the tongue 
has become redder and more parched. Then the abdominal symp- 
toms will improve, and the indications of pulmonary irritation 
become again more manifest; and thus, even during the course of 
the same fever, we may have several alternations of this kind. 
This complication of disease of the thoracic and abdominal cavi- 
ties is extremely common in fever; in fact, it may be almost laid 
down as a general rule, that, in the affections of the respiratory 
system in fever, there is a complication with disease of the digestive 
tube. Now, you should always bear this in mind, and, when you 
prescribe medicines to relieve the pulmonary affection, you should 
take care that they shall not produce irritation of the digestive 
system. 
In most cases of severe, bronchial inflammation, you will observe 
more or less lividity of countenance. This is not seen in cases of 
simple pneumonia occurring in fever. Bronchitis has a much 
more powerful effect in producing this phenomenon than pneumo- 
nia, and hence it is that slight bronchitis will cause more lividity 
of countenance than extensive pneumonia. This fact seems to be 
in accordance with the opinion, that the portion of the lung in 
which the process of aeration is carried on is the bronchial mucous 
membrane, and not the air vesicles. In inflammation of the air- 
cells of the lung we have little or no lividity, but we never see a 
case of extensive bronchitis without it. I may mention here, also, 
that I have seen several cases of bronchitis with very remarkable 
lividity, in which the temperature of the body was above the natu- 
ral standard, thus giving a direct proof that animal temperature 
depends on something else besides the aeration of the blood. 
We come now to speak of the pneumonia of fever. This affec- 
tion may occur under two forms; that is to say, its symptoms may 
be manifest and prominent, or they may be latent and inappreciable, 
except through the medium of auscultation. Of these forms the 
latter is the most common. You may in typhus have all the symp- 
toms present which characterise idiopathic pneumonia—you may 
have hurried breathing, cough, pain in the chest, bloody expectora- 
tion, &c.—hut I believe that, in the majority of cases, the pneumo- 
nia of fever is more or less latent. It often happens, that, at an 
advanced period of fever, without any increase of dyspnoea or 
cough, the patient gets worse; and this change, you may be sure, 
is indicative of some great visceral lesion. The pulse gets smaller 
and more feeble, and, on making an examination, we generally find 
the cause to be an extensive but latent pneumonia. Without mani- 
festing its existence by any of the usual symptoms, the disease 
comes on insidiously and rapidly; and, on examining the chest 
with the stethoscope, we hear the crepitating rale over a large por- 
tion of the lung, and the chest sounds dull on percussion to a very FEVER 
385 
considerable extent. Observe, here, the importance of a thorough 
knowledge of auscultation. I think I may safely venture to assert 
that a person, ignorant of percussion and the stethoscope, is totally 
incompetent to undertake the treatment of any case of fever. I 
know it has been asserted, by some authors, that these affections of 
the respiratory system are more of a congestive than an inflamma- 
tory nature. To this opinion I cannot subscribe. We find in such 
cases, on dissection, all the pathological appearances of active in- 
flammation, redness, thickening, and ulceration of the mucous 
membrane, sanguinolent secretion, congestion, hepatisation, puru- 
lent infiltration, and even abscess of the lung. 
It is a very remarkable circumstance, that the pleura seems, of 
all the pulmonary tissues, to be the least liable to morbid alterations 
in fever. From the details of a great number of modern dissec- 
tions, it appears that, in many cases of fever where extensive 
bronchitis and pneumonia were found to exist, the pleura has in 
almost every instance escaped. If this be true, it would seem to 
point out some difference between ordinary idiopathic pneumonia 
and the pneumonia of fever. In the former, we have generally 
more or less pleuritic inflammation; in the latter, it is rarely met 
with. There is, in most cases of bad fever, an effusion of bloody 
serum into the cavity of the pleura, and the same thing has been 
observed in the case of animals who have been poisoned by the 
introduction of putrid substances into the veins. This leads us to 
the knowledge of a fact connected with the history of typhus, that 
the tissues which are most liable to secondary inflammation are the 
mucous membranes and parenchymatous organs. On the other 
hand, the serous membranes seem to enjoy a comparative exemption 
from active disease. We meet with arachnitis now and then, but 
very seldom with pleuritis, pericarditis, and still more rarely with 
peritonitis. Though you may have extensive pneumonia in the 
chest, or enteritis in the belly, you will have no trace of the exist- 
ence of inflammation of the peritoneum or pleura; and there can 
be no doubt that serous membranes are least liable to inflammation 
in fever. We might attempt to explain this, by considering that 
serous membranes possess but very little sensibility, and conse- 
quently are less susceptible of irritation. In the healthy state they 
seem to be insensible, and we cannot trace nerves in their substance 
or on their surfaces. This insensibility appears to be one cause of 
their exemption; another is, that they are supplied with white blood, 
a portion of the circulation which seems to be least altered in fever 
—that which is most affected being the fibrine and colouring 
matter. 
Let us now discuss the symptomatic affections of the respiratory 
system in fever. You may have dyspnoea, hurried breathing, and 
cough, and yet, on examination, you cannot find any distinct signs 
of bronchitis or pneumonia. You will often meet with symptoms 
of pulmonary derangement in fever, and yet, when you come to 
apply the stethoscope, you find either no sign of disease, or, if there 
be any, quite insufficient to account for the symptoms. Under these 386 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
circumstances, the affection of the chest must be looked upon as 
sympathetic, and the disease which is its most common cause is 
gastro-enteric inflammation. Here, again, we have another remark- 
able instance of the value of the stethoscope. Symptoms indicating 
marked pulmonary derangement exist; and. if we had not this 
means of regulating our judgment, we should most probably con- 
clude that there was actual disease of the lungs, and would proceed 
to treat a sympathetic for a real affection. But, by the aids which 
physical diagnosis affords, we arrive at a knowledge of the real 
seat of the disease, and are enabled to direct our curative measures 
with certainty and effect. But, when I say this, I beg of you to 
understand that I do not mean that you should be satisfied with a 
slight or single examination of the case. It may happen that these 
symptoms (wholly dependent on sympathetic irritation) may go on 
in this way for several days, and then a change may take place, 
and organic disease of the lung supervene. It is a common, but, 
generally speaking, a true observation, that sympathetic irritation 
of any organ (when long continued) has a tendency to terminate in 
actual disease. The circumstances which favour this change are, 
first, the excessive violence of the functional derangement, and, in 
the next place, its long continuance. You must be, therefore, on 
your guard, and examine the chest from day to day; and, if any 
signs of inflammation appear, meet them with promptitude, and 
you will generally succeed in averting dangerous consequences. 
There is another circumstance worthy of remark. If you have 
sympathetic irritation of any organ without fever, the chances are 
that it may go on for along time without producing any bad effects; 
but, if it be accompanied by fever, there is a greater probability of 
its being converted into organic disease. This should make you 
cautious in cases of sympathetic affections of the lung in fever. As 
far as my observation goes, I would say, that, when disease of the 
gastro-intestinal surface is followed by an affection of the lung, the 
morbid action generally takes place in the left lung and in its lower 
lobe. There seems to be a greater sympathy between the left lung 
and the stomach, than the right, and you should therefore direct 
your attention particularly to the left side of the chest. It is a 
curious fact, that inflammation of the lower part of the left lung is 
very frequently connected with pericarditis and gastritis. There 
seems to exist a very remarkable sympathy between organs on the 
same side of the body. This is a curious fact, and demands some 
other explanation besides that which was given by Mr. Hunter, 
who attributed it to contiguity of position. 
The last subject to which I shall allude is, that a liability to 
chronic disease of the lung very frequently occurs in those cases of 
pulmonary derangement durinof fever, and this is apt to come on 
after the symptoms of the original attack have subsided. In seve- 
ral instances of this kind, you will observe that the bronchial symp- 
toms which are present in fever, and which do not excite any 
degree of alarm, will very often, on the subsidence of the fever, 
assume a more threatening character, and pass into phthisis. There 387 
FEVER 
is something in the course of fever which has a strong tendency to 
develope tubercles in persons who are in any way liable to them. 
We have had numerous examples of this fact among the fever 
patients treated in the Meath Hospital. Such of you as are anxious 
for more detailed information on this point, I would beg leave to 
refer to some researches of mine on this subject, published in the 
Transactions of the College of Physicians. In the epidemic of 
1826, it was a common thing to see our patients, after recovering 
from fever, attacked and carried off by phthisis. This form of 
phthisis ran through all the usual stages, from the recent formation 
of tubercles up to the formation of cavities, and was generally very 
rapid in its progress. In one case the patient died of consumption 
in seven days after the subsidence of the fever. 
If, then, you find towards the close of fever that the patient has 
dulness under one or both clavicles, with feebleness of respiration, 
and the other signs of phthisis, you should be on the look-out for 
tubercles. If you find the dulness increase every day, you may 
be pretty sure of the occurrence of tubercular development. On 
the other hand, you should remember, that, of all the cases in which 
bronchitis is most likely to simulate phthisis, it is when it comes on 
after fever. A patient, getting an attack of bronchitis after fever, 
will, in that weak and debilitated condition, exhibit in a short time 
all the symptoms of phthisis. He will have bad cough, laborious 
breathing, great emaciation, and well-marked hectic; yet, in many 
instances, I have seen such patients recover under a judicious 
treatment. 
To-morrow we shall again take up the consideration of the pul- 
monary system; and this, with some observations on the secondary 
lesions of the gastro-intestinal surface, will conclude what I have 
to offer on the subject of fever. 
LECTURE XLIII. 
Peripneumonie des agonizans of Laennec—Congestion of the lungs from position— 
Avenbrugger’s opinions on—Precaution of Boyer—Importance of position in typhus 
—Treatment of catarrh and pneumonia in typhus—Principles of treatment— 
Management of excessive secretion—Employment of emetics—Use of sulphate of 
quinine and opium in injections—Typhoid pneumonia—Gastric symptoms in fever— 
Broussais’ physiological theory—Brown’s sthenia and asthenia—Remarks of the 
physiological school—Different treatments of fever. 
Before we proceed to the consideration of the abdominal symp- 
toms of fever, there are a few more pulmonary affections on which 
I wish to make a few observations. There is one lesion of the 
lung, not unfrequent in this disease, which consists in a congested 
state of the posterior and inferior parts of the lung, and is chiefly 
observed in persons who labour under great debility, and who have 388 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
lain a long time on their backs. It is of importance to be acquainted 
with this, because there can be little doubt that though in all cases 
it is merely the effect of the fever, it may be, in many instances, the 
cause of death. You can easily conceive that it might be the cause 
of death, when you recollect that extensive congestion of the lung 
will produce asphyxia, by obstructing the pulmonary circulation. 
This affection has got from Laennec the name of jjeripneumonie 
des agonizans; but I feel satisfied, that, in giving it this appella- 
tion, he has taken only a limited view of the matter, for it may 
come on long before the fatal termination of the disease; in fact, it 
may occur in all cases where the patient has lain for a long time 
on his back, and where the fluids have undergone any amount of 
morbid change. Indeed, there seems to be some analogy between 
this affection and the discolorations of the skin of the back and 
nates, which result, in such cases, from a long continuance of the 
supine position, and which may be observed in many other affec- 
tions as well as typhus. If you raise a patient in bad typhus, after 
having been in this posture for a considerable time, and examine 
the postero-inferior part of the chest, you will often find a degree 
of dulness on percussion, and perhaps some crepitus ; but if the 
patient continues in the erect posture for a little time, these pheno- 
mena gradually disappear, and the lung resumes its ordinary per- 
meability, except in cases where the congested state has been of 
several days’ standing. Avenbrugger was aware of the occurrence 
of this affection of the lung. In his remarks on the use of percus- 
sion in the exanthematous diseases, he alludes to the occurrence of 
congestion in the posterior part of the lung, before the eruption 
makes its appearance. The celebrated Boyer has also alluded to 
this matter in his works. In giving directions with respect to the 
posture of the patient in case of fracture, he alludes to the proba- 
bility of congestion of the lung from this cause, and dwells on the 
dangers likely to arise from long lying on the back. It would 
appear, from some modern researches of M. Piorry, that some 
persons are much more liable to this condition than others, particu- 
larly those who labour under old age, weakness, or disease of the 
heart. 
Now, suppose you have a case of typhus, in which the position 
on the back has been long maintained, and particularly if the 
patient be advanced in life, in a state of great debility, or labouring 
under organic disease of the heart, you should be on the look-out 
for this congested state of the lungs. In some of these cases it has 
been found that local bleeding, counter-irritation, and changing the 
position as much as can be done, have succeeded in removing this 
condition; but in the vast majority of cases it has occurred in 
persons reduced to a very weak and exhausted state, and at a 
period when the fatal termination was fast approaching. We can 
therefore say little or nothing about its treatment. One thing 
appears certain, that although we cannot remove this affection 
when once established in the last periods of life, we may do a 
great deal towards preventing its occurrence; and for this purpose FEVER 
389 
nothing is of so much importance as attention to position. We 
know that it is the postero-inferior part of the lung which is sub- 
ject to this mechanical hyperaemia and consequent solidification. 
Now, in the early stage of this affection, and in milder cases, we 
observe that this incipient congestion disappears when the patient 
is placed in the erect position, and from this we derive the follow- 
ing indication, that in all cases of typhus, where there is great 
prostration of strength, and where there is reason to suspect a 
deterioration of the fluids, it is advisable to change the position of 
the patient frequently. You should be careful in making him lie 
on his side, changing his position occasionally from one side to the 
other, and in not permitting him to lie on his back. Four circum- 
stances tend to produce this hypostatic pneumonia: first, lesion of 
innervation ; secondly, the change of the fluids; thirdly, position; 
and, lastly, the want of proper action in the lung ; for when the 
patient is lying on his back, the posterior part of that organ 
expands but little on respiration. If you then place him upright, 
or lay him on his face or side, you get rid, more or less, of the bad 
effects of position, and enable him to counteract the inaction of the 
lung, the full expansion of which seems to be a powerful means of 
relieving this apparently mechanical congestion. In many cases, 
too, I have found that the use of the cupping-glasses over the 
affected position, followed in some cases with a blister, had the best 
effect in removing the affection. In the case of this hypostatic 
pneumonia in fever, it will generally he right, to support the 
patient’s strength, to give a little wine, and the decoct, polygalae, 
with carbonate of ammonia. 
Let us now proceed to the treatment of catarrh and pneumonia 
in typhus. I have already stated that in most of these cases there 
is a complication with disease in the digestive system. Suppose, 
then, you meet with a case of typhus, in which you find the 
mucous membrane of the lungs extensively inflamed, is it advisa- 
ble here to perform general bleeding? Some time ago I was 
strongly opposed to the use of general bleeding in any case of this 
secondary typhoid bronchitis, because we found that in many cases 
it did little good, and in some, by reducing the powers of life, 
seemed to do great injury. Since then, however, I have been less 
opposed to this practice, having witnessed its good effects in cases 
where the disease occurred in persons of robust constitution, at an 
early period of fever, and accompanied by hot skin, quick pulse, 
considerable reactive powers, and great dyspnoea, produced not by 
the supervention of enormous secretion into the bronchial tubes, 
but by their inflammatory condition, which could be ascertained 
by the stethoscope. Dyspnoea depending on inflammation may 
be relieved by bleeding; dyspnoea depending on excess of secretion 
is not. Here the loss of blood will increase the danger of asphyxia, 
for as the general strength is diminished, the powers of expectora- 
tion cease, and tracheal rattle comes on. Here we have a beautiful 
practical illustration of the utility and value of the stethoscope. 
If, then, you have a case of extensive bronchitis occurring as a 390 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
secondary affection in fever, in a young robust subject, with heat 
of skin, quickness of pulse, considerable powers of reaction, and 
dyspnoea, not produced by over secretion at an early period, you 
will be authorised in taking blood from the system generally. I 
say this, because I have, in several of such cases, employed vene- 
section with the best effects. But, as a general rule, I believe that, 
in cases of pulmonarv disease occurring in fever, local bleeding is 
preferable. You will always be able to give relief by leeching or 
cupping the chest; indeed, I have frequently seen the patient 
relieved by dry-cupping over the thorax to so great a degree that 
I look upon it as one of the most important measures you can 
adopt in the bronchitis or pneumonia of typhus. I have frequently 
removed a degree of congestion sufficient to cause manifest dul- 
ness, by this measure alone. By this proceeding, the congestion 
has often disappeared in twenty-four hours, and with wonderful 
relief to the patient. You may also apply blisters, and these 
valuable agents may be employed at an earlier period than in 
cases of ordinary bronchitis. If the stomach will bear it, you may 
give small doses of ipecacuanha or calomel, and Dover’s powders. 
Suppose you meet with a case of this kind at an advanced period 
of fever, and find that the patient is very low, has great dyspnoea 
and cough, and that the stethoscope informs you that there is a 
copious secretion into the bronchial tubes. Here you must be 
prompt and decided in the employment of your therapeutic means, 
for you have a very dangerous affection to contend with, and if 
relief be not quickly afforded, the patient will die of asphyxia. 
You must immediately have recourse to extensive counter-irrita- 
tion, and the use of the decoct, polygalse, with carbonate of ammo- 
nia, and the camphorated tincture of opium; and if the patient’s 
strength be much reduced, you must give wine with freedom, and 
light nutritious food. One of the most favourable circumstances 
connected with the use of wine in these cases, is the abatement of 
the frequency of the pulse. Great attention must be paid to the 
temperature of the surface. I have long been in the habit of order- 
ing the patients to be clothed in soft flannel, and I feel certain that 
this measure is one of the utmost utility. If after using wine you 
find that the patient’s pulse has come down, you may be sure that 
it was required, and that it will do good. Sometimes, during the 
existence of this condition of the lungs, a state of impending suffo- 
cation will occur, accompanied by tracheal rattle. Here the 
patient is in danger of perishing from a mechanical cause, and this 
may happen even at a time when he has not arrived at a state of 
great debility; in fact, while his pulse is still tolerably full, and 
his skin and extremities warm. It is in this stage that emetics 
have been recommended. When lecturing on chronic bronchitis, 
I gave the results of my experience on this point, and stated that, 
in many instances, powerful emetics, even though repeatedly 
administered, had failed to act on the stomach. The insensibility 
of the stomach here depends on various causes; on lesion of in- 
nervation, on asthenia of the stomach, produced by determination of FEVER 
391 
blood to another organ, and, as some think, on that condition which 
is observed to accompany the want of proper aeration of the blood. 
From whatever cause this insensibility proceeds, we frequently see 
that emetics, which in the ordinary state of the stomach exercise 
their full action, prove inefficient in many cases of this description. 
A scruple of ipecacuanha is given, then an emetic of sulphate of 
zinc, and, when this fails, an emetic of sulphate of copper, and 
these will not only fail in exciting emesis, but may also do a great 
deal of harm. Again, in many cases, even after vomiting has been 
produced, and the patient is, as it were, snatched from the jaws of 
death, we find that the same distressing symptoms return in the 
space of six or eight hours. Another emetic is then administered, 
and relief may be again obtained, but the dreaded state of suffoca- 
tion returns. We had a case in the Meath Hospital, in which free 
vomiting was produced four or five times, and yet the patient died 
afterwards of suffocation from the extent of the effusion into the 
air tubes. To a person who had not witnessed this case during 
its progress, the appearance of the patient after vomiming would 
not appear to indicate any thing alarming; yet the awful state of 
suffocation returned again and again, until emetics lost their power 
over the stomach, and the patient died asphyxiated. It is plain that 
if you can produce emesis you gain time for the administration of 
other remedies, and arrest the progress of the disease towards a 
fatal termination. This time, I need not tell you, must be employed 
actively and sedulously in the application of means calculated to 
remove the disease, and subdue the morbid state of the lung; and 
no one can deny the meed of praise to my enlightened friend, Dr. 
Mackintosh, for his bringing this subject before the profession. 
But it is only one of the many boons his vigorous mind has con- 
ferred upon medicine. In a case of this kind, my colleague, Dr. 
Graves, succeeded in arresting the disease by the application of 
moxa along the course of the eighth pair of nerves, in combination 
with other measures. In a late number of the Dublin Medical 
Journal he has handled this subject. In this paper (to which I 
would refer you) he has proposed the use of sulphate of quinine 
and opium in the form of injection, and gives the particulars of 
seme cases of impending suffocation, in which these remedies pro- 
duced very favourable results. He says that tonics and opium 
exercise a very powerful influence in arresting the super-secretion 
of the bronchial mucous membrane, and that it has been frequently 
observed in cases of ordinary catarrh, that these remedies, when 
injudiciously exhibited, have checked the expectoration. Now 
one great object in this disease is to prevent this excessive secretion 
which threatens life; and as our remedies for this purpose are, 
unfortunately, very scanty, any addition must be of great import- 
ance. Dr. Graves has given the particulars of three cases in which 
he tried opium and quinine in the form of injection. One of his 
patients wras a delicate female, who had got a violent attack of 
influenza, followed by enormous effusion into the bronchial tubes. 
In a few hours her strength became quite exhausted, her counte- 392 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
nance assumed a livid hue, and. to add to her sufferings, she had 
nausea and vomiting. An enema of thin starch, containing ten 
grains of sulphate of quinine and thirty drops of laudanum, was 
ordered to be given immediately. Shortly after the use of this, she 
fell asleep, her breathing became less laboured, and she awoke with 
considerable improvement in her strength; this patient recovered. 
Dr. Graves next details another case of the same description, where 
there were great debility, alarming dyspnoea, and a sense of impend- 
ing suffocation. In this case the quinine and opium were adminis- 
tered as before, and the patient recovered. In another case of a 
patient in the Meath Hospital, who had every symptom of approach- 
ing dissolution, the exhibition of the enema was followed by such 
good effects that on the next day she might be pronounced out of 
danger. I have not used this injection myself, but I think the 
principle on which Dr. Graves employs it is just, and, as far as a 
trial of it has been made, there is reason to hope for favourable 
results. At all events, we may look upon it as a valuable addition 
to our means of combating this terrible symptom. 
Now, with respect to the pneumonia of fever, I have, in the first 
place, to remark, that this affection, though less frequent than bron- 
chitis, is of equal importance. Suppose that, during the course of 
fever, your patient gets cough, hurried breathing, and perhaps 
some pain in the chest; he has dulness of sound extending over a 
considerable portion of the lung, and, on applying the stethoscope, 
you find crepitating rales and feebleness of respiration. In 
cases of this kind, the value and efficacy of treatment will mainly 
depend on the period of fever, the strength of the patient, and the 
nature of the preceding symptoms. The more the fever is of the 
inflammatory type, the earlier the period of the disease is, and the 
smaller the amount of prostration, the more favourable the prog- 
nosis. If the patient is of a robust constitution, the fever of short 
duration, and the prostration inconsiderable, you may venture on a 
single small bleeding, but this must be performed with caution, and 
always bearing in mind, that an attack of this kind requires very 
different treatment from the ordinary idiopathic pneumonia. We 
next proceed to the use of local bleeding, and of calomel and opium, 
if the stomach will bear it. It generally happens that the system 
will come under the influence of mercury in two or three days, 
but in some cases you will not be able to affect the mouth, and 
these you may look upon as the worst cases, and very likely to 
prove fatal. We often witness here a kind of struggle between the 
mercurial action and the disease. To-day the gums are slightly 
sore and the breath mercurial; to-morrow all this is gone, although 
the remedy has been steadily continued. Next day you will 
observe a slight return, and so on. In such a case as this, full 
ptyalism is almost never produced, and the disease is commonly the 
victor. I have only known two cases to recover out of a vast 
number in which we observed this circumstance. With respect to 
blisters, counter-irritation, diet, &e., the same rules apply here as 
to the catarrh of fever. Tartar emetic is altogether inadmissible in FEVER 
393 
the treatment of this kind of pneumonia; it can be used with safety 
in those cases only where free general bleeding may be employed, 
and this can never enter into the treatment of typhus, where gene- 
ral debility is ordinarily the most prominent symptom. Besides, 
there is in almost all these'cases a complication with gastro-enteric 
disease, and where this exists, the use of antimonial medicines is 
always dangerous. On this account we give a preference to the 
calomel and opium, assisted by blisters, stimulant expectorants, 
and a light nutritious diet to support the patient’s strength. When 
you find the skin pale and cool, the pulse weak and small, and the 
features shrunk, you should always give wine. This disease is 
generally very slow in resolving, the patient convalesces tediously, 
and requires to be constantly watched. 
We now come to the most important part of the analysis of the 
symptoms of fever, namely, those which have been termed gastric. 
In using the term gastric, I wish it to be understood as referring 
not merely to the stomach, but also to the whole digestive tube, the 
liver, and spleen. Of all the symptoms of fever, the gastric are 
the most frequent, the most numerous, the most remarkable for 
their extent, persistence, and insidious latency, and the most fre- 
quently connected with actual organic change. Of this proposition 
I think there cannot be the slightest doubt. If we look to the 
different parts of the system, we shall find that, of all others, the 
digestive tube is most liable to disease, whether we consider the 
typhus of this country, or the malignant fevers of warm climates. 
To undertake the treatment of fever, without an accurate know- 
ledge of the physiology and pathology of the digestive system, and 
the intimate connection between it and fever, would be nothing 
better than practising in the dark; and I feel perfectly convinced 
that it is to the want of this knowledge we are to attribute the 
ignorance, the empiricism, and the want of success, which have so 
long disgraced the treatment of fever. If you were to do nothing 
for years but study the pathology of the digestive system in fever, 
your time would be well and profitably employed, and you would 
have occasion, almost every day of your professional life, to con- 
gratulate yourselves on the importance of the knowledge you have 
obtained. There is no system so intimately connected with fever 
as the digestive, and this leads us to a consideration of what has 
been termed the physiological theory of fever, which has created 
such a sensation in modern times. It may not be amiss, therefore, 
to make a few observations on the rise and fall of the physiological 
doctrines, before we proceed to discuss the gastric symptoms of 
typhus. 
The physiological theory, as propounded by Broussais, may be 
considered under two general heads: first, those doctrines which 
apply to disease in general, and, secondly, those which apply to 
fever and its varieties. M. Broussais appeared before the medical 
world at a time when it was exceedingly natural that a man of 
his great talents should erect himself into the founder of a new 
school. Humoral pathology, which had been gradually falling into 394 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
disgrace, had already received a severe shock from the results of 
anatomical investigation ; and it was before the time of Broussais 
that the immortal Bichat had described the different tissues which 
enter into the composition of the body, and the division of nerves 
into those of animal and organic life. Pathological anatomy was 
advancing rapidly in its brilliant discoveries; and, as every day 
added to the mass of important facts bearing on the nature and seat 
of disease, Broussais announced that many affections, looked upon 
as essential by the old pathologists, could be distincty traced to a 
local cause; in fact, that a numerous class of diseases were reduci- 
ble to the phenomena of local inflammation. These discoveries 
were hailed with acclamation by a host of admiring disciples, and 
were expected to lead to the most splendid and important results. 
The captivating simplicity of a doctrine which attributed all dis- 
eases to changes in the solids, thus deriving additional support 
from the investigations of anatomy, and coinciding with the feel- 
ings of the time, could not fail in attracting a host of admiring fol- 
lowers. Besides, most persons were disgusted with the glaring 
absurdities which were put forward as part of the doctrines of the 
humoral school. Their pathology consisted almost exclusively of 
crude notions of certain changes in the fluids, which they termed 
alkalinity or acidity of humours, corruption of bile, inspissation and 
tenuity of blood, putrefaction and fermentation of fluids. These, 
with some strange ideas of the existence of peculiar unknown 
fluids in certain parts, as the spirits of the brain, the choler of the 
liver, &c., were the floating and obscure notions which preceded 
pathological anatomy. All the ingenious, the enquiring, and those 
who regarded not dogmas because they had been propounded by 
great names, became disgusted with the intangible obscurity and 
manifest absurdity of the doctrines of the humoral school; and 
embracing every new discovery in science which appeared calcu- 
lated to shed a better and a steadier light on the nature of disease, 
they embarked wdth ardour in the pursuit of pathological anatomy. 
As anatomy and pathology advanced, the healthy and then the 
diseased condition of the solids became the topics for investigation, 
the attention of medical men was turned from the speculations of 
humoralism to the study of known and perceptible alterations in 
the solids; and hence it was that attention became exclusively 
directed to the solid parts of the body. 
A little before this time, appeared the celebrated Dr. Brown, of 
Edinburgh, one of the most remarkable men of modern times, 
whether we consider his boldness, or his ingenuity in defending 
his doctrines. He declared that life was supported by stimulants, 
and that disease was referable to one or two states of the system of 
an opposite character—one of which he called sthenia, the other 
asthenia. Thus he divided all diseases into those of sthenia or 
excess, and of asthenia or deficiency of vitality. All diseases being 
thus reducible to one of two conditions, all treatment was reduced 
to the employment of general stimulation and general depletion ; 
for these terms applied not to the local disease, but to the state of FEVER 
395 
the whole economy. Bichat, however, demonstrated the separation 
in function and structure which exists among the various organs 
of the body; and M. Broussais, being fully aware of the untenable 
nature of some of the doctrines of the sthenic and asthenic theory, 
proceeded in forming his own doctrines, and applied the principles 
of Brown, not to the ichole economy, but to each separate organ and 
tissue. He declared that one part or organ might be in a state of 
asthenia, or, as he termed it, have a minus degree of vitality, at the 
same time that another organ was in a state of sthenia, and enjoy- 
ing a plus degree of vitality. He thus modified very considerably 
the theory of Brown, applying to each separate organ and tissue 
those terms which Brown had applied to the system generally. 
Brown thought that there could not be sthenia of one part and 
asthenia of the rest at the same time; Broussais declared that all 
diseases were referable to a plus or minus degree of vitality, and 
that either of these conditions might exist in any particular tissue 
or organ ; and that one part might be in a state of sthenia, while 
another part, or even the rest of the economy, might be at the same 
time in a state of asthenia, and vice versd. 
Disease, then, according to Broussais, consisted in an exaltation 
or depression of the vital action of the affected part; and, as symp- 
toms of disease were reducible to irregularity of function, and func- 
tion being the product of organs, and organs being the solids of the 
body, it followed that affections of the solids alone are the cause of 
all diseases, and therefore that the doctrine that fever is an essential 
disease or general affection of the system, not referable to disease of 
any of the solids, was wrong, and the cause of it was to be sought 
for in some changes occurring in the solids. Now, as inflammation 
of the digestive tube is one of the most constant lesions observed in 
fever, he took it as the pathological character of fever, and therefore 
concluded that fever is only symptomatic of gastro-enteric inflam- 
mation, and not in itself an original affection of the whole system, 
of the nature of which no one knew any thing. 
Such are the chief arguments of the physiological school. They 
contend that all the phenomena of fever are reducible to the symp- 
toms of local disease of the digestive tube, and the sympathetic 
effects produced by it on Various parts of the system. Many cir- 
cumstances contributed to render this theory plausible, and recom- 
mended it to the adoption of medical men. In the first place, there 
was the great similarity in symptoms, which is so frequently 
observed to exist between the ordinary idiopathic gastro-enteritis 
and typhus fever. In the next place, the constant occurrence of 
cases of idiopathic gastro-enteric inflammation, in which the 
accompanying fever, though purely symptomatic, bears a strong 
analogy to typhus. This resemblance of the fever of gastro-ente- 
ritis to typhus was one great cause of the theory being so well 
received. Another circumstance was the discovery of the fact, 
that of all systems the digestive is that which most intimately sym- 
pathises with, and produces the most striking effects on, the brain 
and nerves. To* give an example of this, if you compare the 396 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
inflammatory affections of different systems and organs, with 
respect to their tendency to produce prostration of strength, you 
will find that this tendency is produced by affections of the digestive 
system to a much greater degree than by those of any other. A 
patient may have extensive pleuritis, or pneumonia, or pericarditis, 
or even cerebritis, without any remarkable prostration; but let him 
get but a slight attack of gastro-enteric inflammation, and the pros- 
tration of strength becomes almost immediately a striking symptom 
of his disorder. Now in typhus, also, this prostration of strength 
is one of the most remarkable phenomena, and, as it has been gene- 
rally observed that the prostration of strength in typhus is propor- 
tioned to the amount of gastric derangement, the disciples of the 
physiological school were thus furnished with an additional argu- 
ment. A third circumstance was the known tendency of gastro- 
enteric disease to produce symptoms of morbid action in the 
respiratory and nervous systems. We find an infinite variety of 
these symptoms in typhus, and we know that in other cases they 
can be traced to the sympathy which attends irritation of the 
digestive apparatus. One of the most remarkable circumstances 
in typhus is the alteration of the fluids of the body. If you draw 
blood from the system, you will often find it of a dark colour, with- 
out any appearance of buff, that there is but little separation of 
serum, and that the clot is soft, without consistence,'and easily 
broken up. There are also various morbid alterations in the per- 
spiration, urine, and alvine discharges. Now, of all diseases, 
derangement of the digestive organs is the most likely to produce 
this alteration in the fluids. The digestive system is the main 
spring of the economy, the great alembic in which the materials 
for repairing the waste of the system are elaborated, the fountain 
from which the blood is supplied for all the various purposes of 
secretion. Now, if the digestive system be in a state of disease, 
and incapable of performing its functions in a perfect manner, it 
cannot furnish the materials of good or wholesome blood; and 
hence it is that the most remarkable alterations of the fluids of the 
body are observed in cases of gastro-enteric disease. A fourth cir- 
cumstance, in favour of the physiological theory, is the great fre- 
quency of symptomatic fever in warm climates; and it is well 
known, that, in these countries, the digestive system is much more 
liable than any other to the impressions of disease. Fifthly, the 
results of pathological anatomy seemed to give support to the 
opinion, that fever is symptomatic of gastro-enteric inflammation, 
for, in a vast number of cases, we find not only irritation but even 
extensive inflammation and ulceration of the mucous membrane of 
the digestive tube. Lastly, the results of treatment tended to give 
these doctrines addititional and, indeed, most important support. 
The founder of the physiological school claimed credit for his doc- 
trines, inasmuch as a practice, based on these doctrines, had been 
much more successful than that pursued by his predecessors. 
This admits of a twofold explanation. In the first place, as the 
theory of fever was founded on local inflammation, it followed of FEVER 
397 
necessity that the treatment should be antiphlogistic. Now, it is a 
well known fact, that the antiphlogistic treatment of fever is, on the 
whole, more successful than the stimulant. Here was one circum- 
stance, the change of practice from the old stimulant plan to the 
antiphlogistic, and consequently a greater degree of success. In 
the next place, was the remarkable efficacy of local antiphlogistic 
means, a practice for the introduction and inculcation of which the 
medical world is deeply indebted to Broussais. No one, I think, 
will venture to deny the great utility of local bleeding in the treat- 
ment of fever. But, though we must confess that it is one of the 
best remedies we can employ in a vast number of cases, still we 
do not regard it in the same point of view as the followers of 
Broussais, nor do we conclude that a fever is symptomatic, because 
leeching has been followed by favourable results. Local bleeding 
is of use, because it relieves or modifies a disease which has sprung 
up in the course of the fever, and which re-acts on the economy 
in proportion to its intensity, and the susceptibility of the patient; 
and the cessation of other symptoms, which frequently ensues on 
the application of leeches to the belly, is to be explained on the 
principle, that by removing an irritation, which powerfully re-acts 
on the system, and thereby impedes the efforts of nature, we 
reduce things to a state of simplicity, and favour the ordinary 
tendency of the disease to a critical termination: 
Such are the circumstances which have contributed to support 
and advance the theory of Broussais; circumstances which, I 
think, have not been sufficiently considered, or properly appreciated 
by those who have decried his doctrines and practice. On the 
other hand, it is true that this theory was formed too hastily, and 
defended too dogmatically. Happy would it be for mankind if it 
were true, for then we should have a key to the nature and treat- 
ment of the most extensive and fatal of all human affections. The 
great error of Broussais consisted in the hasty generalisation of the 
facts on which he based his doctrines; these were neither suffi- 
ciently connected, nor was their value sufficiently appreciated. 
Since the publication of his opinions, many facts have been brought 
forward ; and these of so strong a nature, as to induce men to take 
a different view of the subject, and to consider the gastro-enteric 
inflammation (so frequently observed in typhus) not as the cause 
and essence of the disease, but merely as one of the various second- 
ary lesions which arise during its progress ; that fever may occur 
without gastro-enteritis (which is the rarest cause), or with very 
little of it; that there is no constant relation between it and the 
extent of the disease; and, therefore, that a treatment, chiefly 
limited to the employment of local antiphlogistic means, is not 
founded on a rational view of the subject. 398 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
LECTURE XLIY. 
Different lesions in typhus fever—Absence of gastro-enteric symptoms—Cases by Bouil- 
laud, Andral, Louis, &c.—Andral’s arrangement of fevers—Louis’s opinion on the 
anatomical character of fever—Analogy of typhus with small-pox—Absence of pain 
in enteritis—Means for diagnosis—Variety of disease in serous tissues from typhus 
—Treatment of the digestive symptoms of typhus—Hiccup—Tympanitis in fever, 
treatment of—General treatment of fever—Conclusion of the course. 
To-day we have to consider the treatment of the gastric symp- 
toms which occur during the course of typhus. 
At our last meeting, I endeavoured to impress on your attention, 
that of all the lesions of typhus those which belong to the digestive 
system are the most remarkable, on account of their extent, variety, 
frequency of occurrence, and number of sympathetic relations ; and 
that, consequently, this was, perhaps, the most important part of 
our analysis of the phenomena of typhus. I spoke of the theory of 
Broussais, and showed that many circumstances tended to render 
that theory at least exceedingly plausible ; but that the progress of 
medicine had tended to shake the stability of the physiological doc- 
trines, as far as typhus is concerned, and to prove that, however 
extensive and frequent lesions of the intestinal canal may be, still 
they cannot by any means be looked upon as the first link in the 
chain of morbid action, nor typhus be considered as merely symp- 
tomatic of gastro-enteritis. If such were the fact, these lesions 
should exhibit an uniform constancy of occurrence, and their 
amount should be always proportioned to the severity of the symp- 
toms. We cannot recognise either of these characters in typhus. 
The symptoms are very seldom in proportion to the gastro-enteric 
affections, and they are not of constant occurrence. Indeed, cases 
of typhus have been recorded by medical writers, in which the 
phenomena of gastro-enteric inflammation were totally absent. 
You will find several cases of this description mentioned by Bouil- 
laud, Andral, and other practitioners of eminence ; and even Louis, 
who says that the anatomical character of fever seems to consist in 
organic derangement of the mucous glands of the intestines, 
acknowledges that he has met with cases of typhus without any 
gastro-enteric lesion. We may then, I think, freely admit the con- 
clusions which Andral has drawn from a most extensive analysis 
of the pathological characters of fever, that lesions of the digestive 
tube are not of constant occurrence, and that fever may exist inde- 
pendent of gastro-enteric disease; but, on the other hand, that in 
the majority of cases we meet with traces of more or less extensive 
derangement of the intestinal canal. If this be true, and I think 
there can be little doubt of it, it is quite sufficient to prove how 
important, how indispensable, must be the study of the digestive 
system in typhus. If you refer to the best practical treatises on 
fever, published in this country, you will meet with innumerable 
instances of the remarkable prevalence of gastro-intestinal disease 
in typhus; and in France so constantly have inflammation and TYPHUS FEVER. 
399 
ulceration of the mucous glands of the ileum, and other portions of 
the intestinal canal, been discovered, that Andral, in his last edition 
of the Clinique. Medicals, ranges fevers under the head of abdo- 
minal diseases. It is very probable that, in France, these second- 
ary lesions are more frequently met with than in this country, and 
this I freely admit; but I can say, that even here they are exceed- 
ingly common, and form a most important and prominent feature 
in the pathology of typhus. 
I need not tell you that the part most commonly affected is the 
mucous expansion of the digestive tube. The stomach and the 
lower third of the ileum, particularly the latter, are most liable to 
disease, and it is here we generally look for organic alterations of 
the bowels in fever. We find many cases of typhus without any 
disease of the stomach, or with lesions of a very trifling nature; 
but this observation does not apply by any means in an equal 
degree to the small intestine. Again, the morbid appearances of 
the stomach in this disease have not in them any thing special, or 
connected with the phenomena of typhus, and they exhibit very 
little difference in persons who have died of typhus and those who 
have not; but in the small intestines there is, under the same cir- 
cumstances, a very remarkable frequency and uniformity of lesion. 
Louis has stated it as his opinion, that the anatomical character of 
fever is inflammation of the intestinal mucous glands. AVhere 
gastro-enteric symptoms are present, we generally find, on dissec- 
tion, that the mucous membrane, particularly of the lower third of 
the ileum, is in various states of disease. In some cases, the lesion 
is confined to the mucous membrane itself, which becomes softened 
and unusually vascular; but, in the majority of instances, you will 
find both the mucous membrane and glands affected. The solitary 
and aggregate glands become enlarged, and appear to be increased 
in number. This, however, is not the case. Under the influence 
of the inflammatory process they become hypertrophied, and, being 
thus rendered prominent and distinct, vast numbers of them are 
easily seen, which, in the natural state, would have escaped the eye 
of the closest observer. This disease sometimes appears to affect 
the glands primarily, and has been termed exantkeme interne, 
from its resemblance to small-pox. It commences with increased 
vascularity and turgescence, followed by softening and ulceration. 
In the first accounts of this affection, it was supposed to be quite 
analogous to small-pox, and that the one was an eruption on the 
mucous surface of the bowels, as the other was an eruption on the 
skin. This opinion, however, has been disproved by the following 
facts:—In variola, we all know that there is a constant relation 
between the state of the cutaneous affection arid the period of fever. 
There is no such thing as this in inflammation of the intestinal 
mucous glands. In some advanced cases of fever, we find the 
glands only in the first stage of inflammation; while, in other 
cases, where fever has been of very brief duration, we find them in 
the last or ulcerative stage of the disease. These facts tend to inva- 
lidate the notion of there being an analogy between this affection 400 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
and small-pox, and shows that what has been looked upon as a 
pustular eruption affecting the surface of the intestinal tube, is 
nothing but an inflammatory state of its mucous glands, which 
may occur at any stage of typhus, and bears no relation to the par- 
ticular period of fever. 
With respect to the extent of this disease of the intestinal glands, 
there is considerable variety. In some patients we find it very 
extensive, and forming a large sheet of ulceration ; in others it is 
confined to a few small isolated patches. We may meet with it 
under its different phases of turgescence, softening, or ulceration; 
or we may have these three states co-existing in the same indi- 
vidual. 
It may be asked here, if this ulceration of the glands be a common 
occurrence in fever, how is it that persons will recover ? This is 
answered by the researches of pathological economy, which have 
shown that these ulcerations, even though numerous and exten- 
sive, are capable of taking on the process of cicatrisation and cure. 
This fact has been established by the discovery of numerous cica- 
trisations in the situation of the glands of those persons who 
recovered from fever and died of some other disease. Under these 
circumstances we find the mucous membrane of the intestine pre- 
senting numerous minute patches, covered by a fine membrane, 
destitute of villous processes, and resembling those cicatrices on 
the surface of the body, which point out the situation of portions 
of the skin which have been deprived of vitality. 
When speaking on the subject of enteritis, I drew your attention 
to a valuable observation in Dr. Cheyne’s report, that, in many 
cases of fever, what has been termed doubtful and imperfect con- 
valescence, depends on inflammation of the intestinal mucous 
glands. This leads us to the knowledge of a curious and import- 
ant fact, namely, that a crisis may take place and fever subside, and 
yet the disease of the digestive tube may still go on, and even ter- 
minate in the destruction of life. Circumstances analogous to this 
have been also observed in other diseases, in which we find the 
local affection remaining after the subsidence of the fever, by which 
it was accompanied or preceded. 
In speaking of enteritis, I drew your attention also to the occa- 
sional absence of all pain in cases where dissection proved the 
existence of extensive inflammation. This occurrence is still 
more remarkable in typhus. It has been often remarked, that 
idiopathic inflammation of the mucous glands is generally a pain- 
less and more or less latent affection. Now, if this be the case 
with idiopathi# disease, how much greater will be the chances of 
latency and absence of pain in the glandular derangement which 
occurs in typhus, where the general sensibility is impaired, and 
where every form of local inflammation is remarkable for the 
trifling amount of suffering it produces, and the insidious latency 
of its origin and progress. And hence it is that extensive disease 
may arise and proceed unchecked in its career to a fatal termina- 
tion, without ever attracting the notice of the physician, or eliciting TYPHUS FEVER. 
401 
a single expression of suffering, or even uneasiness, from the 
patient. But the absence of pain is no proof of the non-existence 
of this treacherous malady. I have said before, and I now repeat 
the expression, that inflammation of the intestinal glands may exist 
in its most deadly form without any manifestation of pain or dis- 
comfort on the part of the patient, which would indicate where the 
evil lurks, and teach us where we should apply the resources of 
our art for its palliation or removal. 
You will ask me, is there any thing capable of furnishing us 
with means of detecting this insidious affection'? There is. Some- 
times we find a degree of tenderness on making firm pressure over 
the region of the ileum, but this is by no means of constant occur- 
rence. But the most important aids towards forming a correct 
diagnosis are furnished by three symptoms, most commonly found 
in connection with these latent pathological changes. The first of 
these is great thirst without vomiting, and, generally speaking, a pre- 
ference for warm drinks. The next is early tympanitis. The last 
is the occurrence of diarrhoea. These are the symptoms generally 
observed in cases where disease predominates in the small intes- 
tines. Thirst, with a preference for warm drinks, is a very 
common symptom of this affection; and the occurrence of early 
tympanitis is, generally speaking, an ordinary accompaniment, 
and tends to throw much light on the nature of the disease. With 
respect to diarrhoea, it may be stated, as a general proposition, that, 
in the course of typhus, diarrhoea, when not critical, is one of the 
most positive indications of an inflammatory condition of some por- 
tion of the digestive tube. In many cases, diarrhoea does not 
appear until ulceration of the mucous membrane has taken place. 
Previous to the occurrence of ulceration, we have an increase of 
fever, with thirst, and perhaps some tenderness of the belly, and 
then diarrhoea sets in. There is nothing more common in hospital 
practice than to see a case of apparently simple essential fever 
going on without any particular abdominal symptom for ten or 
fifteen days, when it begins to change its character, diarrhoea sets 
in, and runs the patient down rapidly, and, on dissection, we find 
extensive ulceration of the small intestines.1 
I have told you that in cases of fever, where the digestive system 
is engaged, we very seldom meet with disease of the peritoneum, 
or other serous tissues. Still it is possible, and examples of it are 
occasionally observed. In some instances, where this inflammation 
of the mucous membrane and glands of the small intestines (or, 
as it has been termed, dothinenteritis) existed, we have seen peri- 
tonitis coming on at an advanced period of the disease. Now, this 
may occur by the direct transmission, or extension, of disease from 
the mucous to the serous surface, or it may arise from ulceration 
producing perforation of the three coats of the intestine, and effu- 
sion of its contents into the cavity of the peritoneum. A case of 
1 See, on the presumed distinctions between typhus and typhoid fevers, 
the “American Medical Intelligencer,” April 1, 1837, p. 10.—R. D. 402 
STOKES’s THEORY AND PRACTICE OF MEDICINE. 
this description is almost invariably fatal. Neither is this perfora- 
tion of the intestine an accident of such rare occurrence as might 
be supposed. Indeed, when we consider the frequency of dothin- 
enteritis, we are rather inclined to wonder that it is not more 
common. This, however, seems to be explained by recollecting, 
that these ulcers almost invariably open on the mucous surface of 
the intestine and spread laterally ; that they are generally superfi- 
cial, and have very little tendency to pass deep into the wall of the 
intestinal canal. Still a patient in typhus, labouring under dothin- 
enteritis, is in a very bad and precarious condition. A man in 
fever, with prostration of strength, thirst, tympanitis, and diarrhasa, 
is always in danger; for he may in a moment be seized with alarm- 
ing peritonitis, and sink in a few hours. Under these circum- 
stances, you may be pretty sure that he has been carried off by 
peritoneal inflammation, and you may make the diagnosis of per- 
foration of some part of the last twelve inches of the ileum. The 
truth and accuracy of this diagnosis we have confirmed in the 
Meath Hospital by numerous dissections. Its principle is founded 
on three circumstances: the pre-existence of symptoms of disease 
of the mucous glands; the sudden supervention of symptoms of 
peritonitis, without any thing to account for it; and the rapid sink- 
ing of the powers of life. I have made this diagnosis with success 
in ten cases, which occurred at the Meath Hospital, and in others 
in private practice. You will find a great deal of interesting 
matter on this subject in the Anatomico-Pathological Researches of 
Louis, who first made and established this diagnosis. I would 
also beg leave to refer you to my paper on Peritonitis, published in 
the London Cyclopaedia of Practical Medicine. 
We come now to the treatment of the digestive symptoms of 
typhus. We often find the patient complaining of thirst, with a 
desire in some cases for cold, in others for warm, drinks. As far 
as I have seen, the preference for cold drinks is most evident in 
cases where signs of irritation of the stomach exist, as tenderness 
of the epigastrium, nausea, and vomiting. One of the first observa- 
tions I shall make is, that, in all cases where there is great thirst, 
you should be cautious in the administration of stimulants. The 
circumstance of intense thirst always points out the existence of 
irritation in the stomach or intestines, or both, and this should 
make you very cautious (particularly in the early period of fever) 
in giving any stimulant, whether in the way of medicine, food, or 
drink. If the thirst be great, and accompanied by vomiting, the 
best thing you can do is to apply leeches, and this you will find 
productive of very great relief, particularly where there is epigastric 
tenderness. You may allow the patient also to drink cold water 
ad libitum. Many persons are afraid of doing this ; but it never 
does any harm, and is a great source of refreshment to the patient. 
We frequently give ice in cases of this description in the Meath 
Hospital. Against this practice, also, an outcry has been raised by 
some unthinking persons ; they say cold water, and more particu- 
larlarly ice, must be injurious, because we know that under cir- TYPHUS FEVER. 
403 
cumstance of fatigue, &c., their use has brought on a gastritis. 
This is a false argument. The circumstances are totally different, 
and the remedy in fever, with gastric irritation, has a wonderful 
value. If after the use of leeches, ice, and cold drinks, you find 
the disposition to vomit continuing, you will have recourse to the 
administration of opiates, and those best adapted for this purpose 
are the acetate or muriate of morphia, or the black drop. In cases 
of obstinate vomiting, the application of a blister to the epigastrium, 
and the sprinkling the raw surface with a small quantity of the 
acetate of morphia, will be found very useful. With respect to 
effervescing draughts, which are so commonly employed in cases 
of this description, I have already stated, when lecturing on gas- 
tritis, that their employment is very questionable, if not absolutely 
objectionable. They are very frequently rejected by the stomach, 
and the distension, which is produced by the evolution of gas, 
causes much distress and irritation. 
Another symptom, very often observed in connection with gas- 
tric derangement in fever, is hiccup, a symptom of which, in the 
great majority of cases, we know very little. In the early period 
of fever, I have found it co-exist with inflammation of the cardiac 
orifice of the stomach; in the advanced stage, as far as my expe- 
rience of it goes, it seems to be more connected with general lesion 
of the nervous system. With these views, we may divide the 
treatment of hiccup into two parts ; first, that which occurs in the 
early stage of fever, and, in the next place, that which comes on 
towards the close of the disease. In the former, we have found 
leeching, cold drinks, and abstinence, the best remedies; in the 
latter, anti-spasmodic and stimulant remedies appear to be more 
applicable. By reasoning, then, from experience, we find that 
hiccup, in the beginning of fever, demands local antiphlogistics; 
but in the latter periods, when there is profound adynamia, it may 
be treated with opiates, antispasmodics, and even stimulants. 
A very common symptom in fever is tympanitis. Here, again, I 
beg to refer you to my lecture on enteritis, as all I have said there 
on this point is equally applicable to the present case. Tympanitis 
sometimes occurs at an early, sometimes at an advanced, period of 
the disease. It is a symptom which is very often badly treated. 
Many practitioners, the moment they recognise its existence, and 
without ever enquiring into its cause, prescribe at once their 
favourite nostrum, turpentine, and bad consequences are too often 
the result. What generally takes place is this, that after the exhi- 
bition of turpentine the tympanitis disappears, but its removal is 
purchased at too dear a price. All the symptoms of fever, thirst, 
heat of skin, excitement of the vascular and nervous systems, are 
increased, and, what is still more annoying, the tympanitis returns, 
and is as bad as ever. The rule by which you should guide your 
practice in the treatment of tympanitis is this: if it occurs at an 
early period, when the skin is hot, the pulse quick, and the strength 
undiminished, it is a sign of irritation or inflammation of the 
mucous membrane, and is to be met by appropriate treatment. 404 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
Never employ stimulants for the removal of tympanitis occurring 
at an early period of fever. But in the advanced stage, where the 
general inflammatory symptoms have subsided, where the skin is 
cool, the pulse weak, and the strength reduced, then you may 
exhibit turpentine with decided advantage ; but as long as the con- 
dition of the patient requires and admits of local antiphlogistic 
treatment, never have recourse to it. 
Diarrhoea is another very common symptom in fever. I have 
told you before that diarrhoea, when not critical, may be looked 
upon as an unequivocal indication of disease of the mucous glands 
of the intestines. With respect to the period of its occurrence, we 
may have it either in the early or in the advanced stage of fever. 
When it makes its appearance at an early period of the disease, it 
should not be too hastily interfered with; for great danger has been 
found to result from stopping it at this time by the exhibition of 
astringent medicines. Bear this in mind. It is a common practice 
with some persons to prescribe astringents the moment diarrhoea 
appears. Now, this is founded on false notions of pathology. In 
cases of inflammatory disease, one of the principal modes which 
nature adopts in giving relief is, by super-secretion from the 
affected organ. Now, under such circumstances, you arrest a 
diarrhoea of this kind occurring at an early period, you do it at the 
risk of producing intense enteritis or effusion into the peritoneum. 
When it comes on at an early period, all you should do is to apply 
a few leeches to the belly, and give small doses of hydrarg. c. creta 
with Dover’s powders. You may also use mild anodyne injec- 
tions ; but in the treatment of this affection, always seek to arrest, 
not the disease but its cause. This is the true mode of proceeding. 
In the advanced period of fever, where the pulse is small and 
low, and the strength sinking, diarrhoea is a very alarming symp- 
tom ; for, if not speedily arrested, it will run the patient down in a 
very short time. Here, and here only, is the use of astringents 
demanded, and it is here that their beneficial effects are manifest. 
To arrest this dangerous symptom which is precipitating the case 
to a fatal termination, you must use opiates combined with astrin- 
gents, and you may give wine if necessary. 
From a consideration of the physiological characters of the 
digestive system—from the study of its pathological condition in 
fever—from a review of its form, structure, and functions, in 
health—and from the fact of its extraordinary liability to inflam- 
mation in fever, I think you will be prepared to admit, that the 
common practice of purging day after day, in typhus, must be pro- 
ductive of the worst consequences. I beg you will impress this 
firmly on your minds, for so universal has this practice been, that 
you will find it difficult not to be carried away by the tide of preju- 
dice, when you come to be engaged in the duties of your profession. 
A common practice has prevailed in these countries, and, indeed, 
still exists to a very great extent, of making the patient take purga- 
tive medicine every day; and this, I regret to say, is too often done 
even in cases where the surface of the small intestine presents 405 
TYPHUS FEVER. 
extensive patches of ulceration. Now, I will ask you, can any 
thing be so barbarous as this, or can it be exceeded in folly and 
mischief by the grossest acts of quackery? Here we have an organ 
in a state of high irritation, and exhibiting a remarkable excite- 
ment of its circulation ; and yet we proceed to apply stimulants to 
that organ, and to increase the existing irritation. Would it not 
be absurd, in a case of inflammation of the knee or elbow joint, to 
direct the patient to use constant exercise and motion? Would it 
not be very strange practice to apply irritants to a raw and exco- 
riated surface? Yet something equally absurd, and equally mis- 
chievous, is done by those who employ violent purgatives in a case 
of inflammation of the digestive tube in fever. This has been the 
great blot in the history of British practice. Calomel and black 
bottle, and even jalap, and aloes, and scammony. have been pre- 
scribed for patients labouring under severe and extensive dothin- 
enteritis. Morbid stools are discharged; and the more morbid 
they are, the more calomel and purgatives does the physician give 
to change their character, and bring them back to the standard of 
health. I want words to express the horrible consequences. Too 
often have I seen fever patients brought into the hospital with 
diarrhcea, hypercatharsis, and inflammation of the mucous mem- 
brane, from the use of purgatives, administered before their admis- 
sion. Practitioners will not open their eyes. They give purgatives 
day after day—a very easy practice, and one for which there are 
plenty of precedents—but it is fraught with the most dangerous 
consequences. I will freely admit, that the disciples of the school 
of Broussais have gone too far in decrying the use of laxatives 
altogether. But if they have lost hundreds by this error, British 
practitioners have killed thousands by an opposite plan of treat- 
ment. In cases of fever, where there is no decided symptom of 
gastro-enteric disease, there can be no objection to the use of laxa- 
tives if required, but they should always be of the mildest descrip- 
tion. You will gain nothing by violent purging in fever. Mild 
laxatives alone can be employed; and where there is any sign of 
intestinal irritation present, even these should be used with caution. 
There is one mode of opening the bowels which you may always 
have recourse to with advantage in fever, viz., the use of enemata. 
There is not the slightest doubt that, occasionally, accumulations 
of faecal matter will take place, and tend to keep up irritation, but 
they should always be removed with the least risk of producing 
bad consequences. To purge in fever, when intestinal irritation 
is present, is a practice opposed alike to theory and experience, and 
I have already stated that its results are most horrible. 
It generally happens, that in cases of severe fever, even where 
symptoms of gastro-enteric disease are still present, that a period 
will arrive when the patient’s strength must be supported by nutri- 
tious diet, wine, and other direct stimulants. Here the school of 
Broussais fell into a great practical error; their notion being that 
the fever was symptomatic of the gastro-enteritis, and not the 
gastro-enteritis of the fever, they followed a rigorous antiphlogistic 406 
STOKES’S THEORY AND PRACTICE OF MEDICINE. 
plan of treatment throughout the entire disease, and thus many of 
their patients died, not of gastro-enteritis, but of the debility and 
exhaustion brought on by protracted starvation. You should bear 
this in mind, and recollect that, even in health, a man cannot exist 
beyond a certain period without some kind of solid and nutritious 
aliment. In Dr. Paris’s work on Medical Jurisprudence, you will 
find an account of a nobleman, who starved himself to death, 
which took place about the twenty-first day. But how many 
fevers exceed this period? and can it be supposed that patients will 
survive, or be able to wrestle successfully with disease, unless their 
strength be supported by a certain quantity of nutritious aliment? 
It is decidedly a bad and erroneous practice to confine patients for 
weeks to the diete absolue ; to give them, in fact, scarcely any 
thing but gum-water throughout the course of a long and exhaust- 
ing disease. After the second week, you must look to the strength 
of your patient, and if you find this sinking, endeavour to support 
it by a mild nutritious diet; and if this will not be sufficient, you 
must have recourse to wine and stimulants. You may give nutri- 
ment and wine with advantage, even where you are still employ- 
ing local antiphlogistic means, supporting the system generally, 
while you are using measures to effect the removal of local disease. 
It would be impossible to lay down any rules with respect to the 
use of wine. Sometimes it will be required at an early, more gene- 
rally at an advanced, period of the disease. You may, however, 
adopt this rule as applicable to the greater number of fever cases, 
that as long as the patient’s strength and condition are such as to 
demand the use of antiphlogistic measures, you need not give wine. 
But when antiphlogistics are either no longer necessary, or when 
the patient’s strength will hardly admit of them, when the pulse 
falls, and the skin loses its morbid heat, then you may give wine, 
and in such cases it very often produces the most remarkably 
favourable effects. It matters not how quick the pulse may be at 
this period, for one of the first effects of wine is to diminish its fre- 
quency, if it agrees with the patient. Here we arrive at a very 
important fact—that recovery almost invariably takes place where 
the pulse falls after the use of wine; and this diminution in the 
frequency of the pulse not only affords good grounds for making a 
favourable prognosis, but also shows that we may persevere in the 
employment of wine with decided advantage. 
I feel certain that in these lectures many things have been 
imperfectly handled, and I know that many have been omitted 
altogether; but I knew this would be the case from the commence- 
ment, and that it could not be remedied. I thought, too, that it 
was much better to study a few subjects well than many super- 
ficially. I was convinced that the present mode of compressing 
into a limited course of lectures observations on all diseases, is a 
useless attempt, impracticable in its nature, and having a most 
injurious effect on medicine. This mode of teaching generates 
bad habits on the part of the teacher and the pupil; it makes the 
one satisfied with imparting, and the other satisfied with receiving, CONCLUSION. 
407 
imperfect and limited information. It is better, I repeat, to know a 
few things intimately than many things superficially. If you 
examine.the history of those men who have acquired the most" 
brilliant reputations in the world of science, you will find that it 
was not so much by the universality of their information, as by 
their profound knowledge of a few important subjects. 
In the present course of lectures, I have selected for my subject 
three great classes of disease, namely, those of the digestive, the 
respiratory, and the nervous systems, and, having done this, I have 
proceeded, to the consideration of fever. On these important affec- 
tions, I have endeavoured to communicate as much knowledge as 
my brief and limited space would allow. I have not touched on 
hydrophobia, tetanus, hysteria, and some other nervous diseases of 
less interest; neither did my time permit me to direct your atten- 
tion to the derangements of the circulating system, or cutaneous 
complaints. Still I do not regret this, for I feel satisfied that I have 
done you more justice by pursuing this plan, than if I had taken a 
hurried and unsatisfactory sketch of the long list of human 
maladies. 
It has been one of my principal objects in these lectures to avoid, 
as much as possible, taking up your time with literary disquisitions. 
I was anxious that every observation of mine should bear on some 
point of practical importance ; I wished to communicate, as far as 
my information went, the true principles of treatment, and I shall 
deem my exertions more than repaid, if I have succeeded in 
impressing any one useful practical precept. The length of time 
necessary for giving a full course on the theory and practice of 
medicine should be much greater than it is at present. If spared 
by Providence to give another course of lectures, it would be my 
earnest desire to adopt, if possible, a different mode of lecturing; to 
commence the subject of theoretical and practical medicine, and 
continue it through two, or, perhaps, three sessions, and to give 
minute and comprehensive lectures on all or the great majority of 
subjects which the ordinary courses on medicine certainly cannot 
comprise. It is only in this way that the whole of our knowledge 
on the present state of medical science can be made available. 
THE END. PATHOLOGICAL INDEX. 
Abscess, hepatic, 128 
Anatomy, pathological, importance of, 8 
Aneurism of the hepatic artery, 140 
Apoplexie foudroyante, 257 
Apoplexy, 246 
congestive, 248 
nervous, 182 
serous, 250 
simple, 249 
Arachnitis, 236 
cerebelli, case of, 214 
Brain, inflammation of the, 199 
— softening of the, 233 
Calculi, biliary, 113 
Cerebritis, 199 
Colic, flatulent, 96 
—— painters’, 177 
Colica pictonum, 177 
Convulsions, 238 
Delirium tremens, with acute gastritis, 42 
Diarrhoea, 81 
chronic, 87 
of phthisis, 86 
Digestive system, diseases of the, 19 
Diseases, local, remarks on, 13 
Doth inenteritis, 62, 70, 399 
Duodenitis, 59 
Dysentery, 88 
epidemic, 88 
Dyspepsia, 45 
Encephalitis, 199 
partial, 201 
Enteritis, 61 
Fatty matter discharged from the bowels, 
119 
Fever, 323 
continued, 359 
infantile remittent, 71 
intermittent, 333 
primary, 326 
secondary, 326 
typhus, 360 
Flatus in the intestines, 96 
Gall-bladder, distended, 137 
Gall-stones, 113 
Gastritis, 22 
acute, 24 
chronic, 44, 48 
Gastro-enteritis, follicular, 62, 70, 399 
Hrematemesis with acute gastritis, 42 
Hemicrania, 302 
Hepatic abscess, 128 
neuralgia, 156 
Hepatitis, 123 
acute, 123 
chronic, 147 
Hippocratists, 11 
Hydrocephalus, 241 
Hypochondriasis, 47 
Icterus infantum, 104 
Ileitis, 61 
Infantile remittent fever, 71 
Inflammation, erysipelatous, 22 
phlegmonous, 22 
of the vena porta, 154 
Intermittent fever, 333 
Intestines, large, diseases of the, 81 
small, diseases of the, 59 
Jaundice, 97 
from gall-stone, 113 
of infants, 104 
Jejunitis, 61 
Liver, inflammation of the, 123 
Magnetism, animal, 280 
Malaria, 344 
Medicine, mode of teaching, 15 
objects of, 3 
theory of, 2 
Meningitis, 199 
of the cerebellum, case of, 214 
Meteorism, 94 
Nervous system, diseases of the, 195 
Neuralgia, 300 
hepatic, 156 
Neuroses, 296 
Paralysis, 263 
Paralysie croissee, 263 
Paraplegia, 284 
Pathologico-anatomists, 11 
Peripneumonie des agonizans, 388 
Phrenology, remarks on, 207 
Poison, metallic, effects of, 178 
Puro-hepatitis, 126 
Ramollissement of the brain, 233 
Scrofula, 311 
Sero-hepatitis, 126 
Stomach, cancer of the, 58 
organic disease of the, 56 
Symptoms, meaning of, 7 
Tabes mesenterica, 68 
Tympanitis, 94 
Typhus fever, 360 
Worms, intestinal, 161 fiLfe, ' V  
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